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Advances in Urogynecology


Practical Evaluation of the Incontinent Woman

Martina Mutone, MD; Sandra R. Valaitis, MD

Urinary incontinence is a medical condition affecting many women to some degree, especially among the elderly. Indeed, one in nine American women, or 11%, will undergo surgical treatment for incontinence or prolapse in their lifetime.1 Estimates reveal that urinary incontinence is much more prevalent than other common chronic diseases such as diabetes, hypertension, and depression.2,3 Health care costs in the United States for treating incontinence have been estimated at $25 billion per year.4 Urinary incontinence most often occurs in postmenopausal women, but may also be seen in premenopausal patients. Studies have demonstrated large increases in both the absolute numbers of women affected and the percentage of the aging population during the twentieth century. It is estimated that by the year 2030, 20% of the US population will be older than 65 years.5 The number of women who will present to OB/GYNs for treatment of urinary incontinence and other pelvic-floor disorders is therefore likely to reach epidemic proportions.

Many women are reluctant to seek evaluation or treatment for incontinence, often because of a belief that it is a natural consequence of childbirth or aging. One report by Burgio et al6 revealed that only 38% of older women address their incontinence issues with their physician. There are also social implications of incontinence that cause discomfort or embarrassment for patients, leading to feelings of isolation. It is important to properly diagnose women who suffer from urinary incontinence, because most will respond favorably to appropriate treatment.

The physical symptoms associated with the involuntary leakage of urine have significant effects on quality of life. Patients with incontinence may alter their drinking and toileting habits or curtail their exercise routines or social engagements because of their condition. These changes can have negative effects on physical and emotional health. An objective assessment of quality of life is therefore important in evaluating incontinence treatments. Standardized, validated quality-of-life questionnaires have been developed for this purpose, and are often used in research studies investigating the effectiveness of different therapeutic modalities.7

TYPES OF INCONTINENCE

The most common types of incontinence are listed in Table 1.8 Stress urinary incontinence is associated with urine loss exacerbated by exertion or activities that suddenly increase intra-abdominal pressure. This is the most common form of incontinence in women. In one review of 48 studies, it affected 49% of study participants.9 The underlying problem in this condition is the inability of the urethral sphincter to maintain a positive pressure differential in the face of a sudden increase in intra-abdominal pressure. This may be due to compromise in the integrity of the striated muscle of the urethral sphincter or the smooth muscle and/or connective tissue supporting the urethra, injury to the perineal branch of the pudendal nerve, or a combination of these factors.


View this table

 Table 1. Common Types of Urinary Incontinence

Severe urethral dysfunction resulting in significant stress incontinence symptoms with minimal physical activity is termed intrinsic sphincter deficiency (ISD), and has been associated with specific urodynamic criteria. Although a standardized definition for this condition has not yet been established, it is generally accepted that ISD is present when leakage is observed at low Valsalva leak-point pressures, when the maximum urethral closure pressure is below 20 cm of water, or urethroscopically, when the bladder neck appears open at rest.

Urge incontinence occurs most commonly in elderly women. With this condition, the patient will complain of urinary leakage accompanied by an uncontrollable urge to void. In a major review study,9 approximately 22% of participants suffered from this condition. Less frequently seen types of incontinence include functional and bypass incontinence. The former refers to urine loss due to the patient’s inability to physically move to the toilet or to cognitively recognize the need to empty her bladder when it is full. Bypass incontinence refers to patients who may have an anatomic problem caused by iatrogenic or congenital factors affecting the integrity of the urinary tract, such as a fistula, ectopic ureter, or urethral diverticulum.

RISK FACTORS

There are a multitude of factors that can increase a woman’s risk of experiencing urinary incontinence during her lifetime (Table 2). Some conditions related to chronically increased intra-abdominal pressure or vaginal birth can also increase the risk of developing pelvic organ prolapse.8 Patients who suffer from connective tissue disorders that cause the production of defective types of collagen and elastin may also be at greater risk for developing pelvic support problems and urinary incontinence.10,11 The importance of both over-the-counter and prescription pharmaceuticals affecting urethral and bladder function cannot be stressed enough. For instance, changing the type of antihypertensive agent an incontinent woman takes may have a very positive effect on her bladder function. Although infrequently used to treat hypertension, a-adrenergic blocking agents may predispose patients to stress incontinence, while commonly used diuretics often exacerbate symptoms of urinary frequency. Some common medications and substances that can have an adverse effect on bladder function are included in Table 3. This is only a partial list, however, and it is worthwhile for the clinician to review the patient’s medications and their potential side effects in detail to ascertain whether any of them could be exacerbating her urinary symptomatology.


View this table

 Table 2. Risk Factors for Incontinence

View this table

 Table 3. Medications/Substances Affecting Urinary Tract Function

An issue that has recently come under great debate is how vaginal birth affects the continence mechanism and pelvic organ support, and whether primary cesarean delivery is protective. There are numerous articles in the recent literature relating the development of urinary and fecal incontinence to trauma from vaginal birth, especially operative delivery, and suggesting a protective role for cesarean delivery.12-14 However, women who undergo cesarean delivery may still develop urinary incontinence and pelvic support problems later in life, so the protective potential of this intervention remains unclear. Other factors related to pregnancy itself or exposure to various environmental and medical conditions can also contribute to the development of incontinence.14,15 Further investigation is necessary to gain a better understanding of how pregnancy itself may affect the continence mechanism, regardless of the mode of delivery.

HISTORY

When asking a patient about her incontinence complaints, it is important to consider both the risk factors and the duration and severity of her symptoms. A majority of women will delay seeking treatment for incontinence for an average of 5 years, reflecting the social isolation and embarrassment these patients experience.16 In addition, many women may feel that their symptoms are merely a reflection of the aging process. Nonetheless, urinary incontinence has been shown to negatively affect quality of life, and women with incontinence have significantly higher rates of depression than those who are not incontinent.17,18 A review of any surgical procedures (especially previous anti-incontinence procedures) and the obstetric, gynecologic, and medical history is invaluable for identifying risk factors. A review of symptoms including pulmonary function, defecatory difficulties (eg, chronic constipation, fecal incontinence), and neurologic symptoms may identify other confounding factors.

A useful tool for evaluating the incontinent woman is a voiding diary (Figure 1). This provides the practitioner with not only a baseline objective measurement of the patient’s symptoms, but also an idea of her habits. The diary can be used again to objectively see how the patient is responding to treatment and how a change in habits (eg, fluid intake) affects her urinary symptoms.


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 Figure 1. Sample of a completed voiding diary


EXAMINATION

In examining the incontinent patient, the clinician should not only focus on the pelvic examination to rule out masses and delineate the degree of pelvic organ support, but also assess the patient’s mental status, overall fitness and mobility, and the presence of lower-extremity edema (Table 4). Examining the patient in an erect as opposed to supine position is more likely to provide a better assessment of the degree of associated pelvic organ prolapse. An evaluation of pelvic floor tone may detect weakness of the levator ani musculature and provide a way to teach the patient how to correctly perform pelvic floor (Kegel) exercises to help alleviate her symptoms.


View this table

 Table 4. Physical Examination

During the pelvic examination, cotton-swab (Q-tip) testing and a postvoid residual volume measurement can be performed to obtain further data regarding urethral support and the adequacy of voiding. The presence of a negative cotton-swab test (ie, deflection of the distal end of the swab by less than 30û from the horizontal, indicating no bladder neck hypermobility) accompanied by stress incontinence has been associated with a 50% failure rate for retropubic urethropexy.19 Also, if stress incontinence is identified during an empty-bladder supine stress test, which attempts to elicit incontinence from a patient who has recently voided and who is laying in the supine position, the patient may be more likely to be suffering from ISD.20,21 Thus, these simple tests can indicate which patients may be more suitable for treatment with bulking agents or a sling procedure.

Rectal examination can aid the clinician in determining the tone of the anal sphincter and detecting fecal impaction, which has been associated with urinary incontinence in patients with impaired mobility.22 A focused neurologic examination may identify a central or peripheral neuropathic process contributing to the patient’s complaints. Testing of lower-extremity motor strength, sensation in S2, S3, and S4, deep-tendon reflexes, and sacral reflex activity (with an anal wink or bulbocavernosus reflex) may help to detect a neurologic abnormality. However, an inability to elicit an anal wink or bulbocavernosus reflex may occur in 20% of normal women.23

URODYNAMIC TESTING

Symptoms of urinary incontinence may be objectively evaluated using various types of urodynamic tests. The most basic urodynamic test is cystometry, which detects a rise in bladder pressure and the sensations that occur with filling.24 Simple cystometry to provide information about potential changes in bladder pressure during filling can be performed in the office with basic equipment. Using a flexible urethral catheter attached to a valveless syringe, the bladder is slowly filled in retrograde fashion while the meniscus serves as a column manometer. A detrusor contraction results in an increase in bladder pressure, which is visually evident as a change in the meniscus level. A limitation of simple cystometry is that if the column of water rises during filling, it may be difficult to discern whether this is due to a change in intra-abdominal or detrusor pressure. The specificity of this test may be increased by using multichannel recording to estimate intra-abdominal pressure and subtracting it from bladder pressure to give a "true" detrusor pressure. Complex multichannel (subtracted) cystometry incurs additional time and expense compared with "eyeball" urodynamics, and involves specialized equipment and technical expertise. The detection of stress incontinence on simple cystometry has been shown to have an 82% positive predictive value for urodynamic stress incontinence on complex subtracted cystometry, with similar findings for urge incontinence relative to detrusor overactivity.25 Therefore, many patients with uncomplicated incontinence may be satisfactorily evaluated using simple office techniques.

Another test that can be used to verify and quantify incontinence is the perineal pad test and its variations. A pad worn by the patient is weighed before and after a defined testing period, and the change in weight is used to estimate the volume of urine lost. The testing period may include provocative maneuvers to elicit incontinence, such as physical activities to increase intra-abdominal pressure or putting the patient’s hands into running water. Both short-term office and long-term home testing is possible. The pad test may be augmented by the use of oral pyridium to color the urine, increasing the ability to discriminate urine from other body fluids such as sweat or vaginal discharge. Quantitative cutoffs to define incontinence have not been established due to overlap between incontinent patients and controls.26 However, pad testing may be valuable in situations where other objective tests are negative or the history is inconclusive. Again, the limitation with this method is that a positive pad test does not specifically identify the cause of the incontinence (eg, stress or urge).

Patients without urinary incontinence symptoms who require surgery for advanced pelvic organ prolapse may also benefit from preoperative urodynamic evaluation. Studies of urethrovesical pressure dynamics have shown that patients with significant prolapse have a continence mechanism related to urethral obstruction by the prolapse.27 Urodynamic testing, with reduction of prolapse by a pessary, speculum blade, large swabs, or ring forceps has therefore been advocated for clinically continent patients with advanced prolapse to detect "occult" incontinence that could manifest postoperatively.28 The practice of performing a bladder neck support procedure in conjunction with prolapse surgery in patients with occult incontinence is now in common use; clinical trials to evaluate the efficacy of this practice are currently in progress.

Complex urodynamic testing consists of specific physiologic studies designed to evaluate bladder and urethral function. This includes studies of bladder storage (cystometry, urethral pressure profilometry) and emptying (uroflowmetry, instrumented pressure-flow studies) functions. Normal bladder and urethral function is characterized by relaxation and accommodation of the detrusor muscle and tonic contraction of the urethral sphincter complex during bladder filling, and detrusor contraction that is preceded by urethral sphincter relaxation during voiding. These reflexes are peripherally mediated through the spinal cord, with central input from descending cortical pathways. Bladder storage and emptying disorders that result from disruption of this system, either centrally or peripherally, are amenable to evaluation by complex urodynamic tests.

In the evaluation of the patient with a disorder of bladder function, urodynamic testing has two purposes. The first is to verify and quantify the patient’s symptoms. Urinary incontinence is a symptom, a sign, and a condition. A complaint of stress incontinence (the symptom) must be objectively confirmed (the sign) prior to performing surgical treatment. Patients’ symptoms have been shown to correlate poorly with findings on complex urodynamic studies.29 Of particular importance is the symptom of pure stress incontinence, which has a positive predictive value of only 74% for the urodynamic diagnosis of stress incontinence.30 The second aim of testing is to determine the most appropriate therapy; treatments differ depending on the type of incontinence. An accurate diagnosis of stress incontinence is essential prior to performing bladder neck surgery, as the presence of detrusor overactivity will significantly worsen surgical outcome.31,32

There is controversy regarding the type of testing that is needed to achieve these goals, and how the role of complex urodynamics compares with that of basic office evaluation. For most tests, sensitivity and specificity are determined by comparing the results of the test against a standard. Short of surgical treatment outcome, however, there exists no "gold standard" against which complex urodynamic findings may be compared. Because clinical symptoms have a poor predictive value for urodynamic diagnosis, it has been suggested that urodynamics should be performed in most or all patients prior to definitive therapy.29,30 However, if the urodynamic diagnosis does not correlate with the surgical outcome, the testing may have little clinical relevance. To date, there have been insufficient scientific data to determine whether urodynamic testing affects clinical outcomes after incontinence treatment.33 A recent study using decision- analysis modeling suggested that for women with both pelvic organ prolapse and urinary incontinence, routine performance of complex urodynamic tests prior to surgery does not improve cure rates, and is therefore not cost-effective.34 This conclusion applied only to women who were already surgical candidates because of pelvic organ prolapse. The role of complex urodynamic testing in predicting therapeutic outcome for incontinence has not been studied in clinical trials. This would require a large number of subjects with random allocation to management based on urodynamic findings versus standard management based on history, physical examination, and basic tests, with final treatment result as the primary outcome.

Controversy notwithstanding, it is clear that complex urodynamic studies provide valuable information to help guide the management of selected patients with disorders of bladder storage and emptying. The tests are limited by invasiveness, expense, time requirements, lack of reproducibility,35 and the absence of data proving that they alter treatment outcome. The Agency for Health Care Policy and Research has established practice guidelines for clinicians regarding the appropriate use of specialized urodynamic testing.8 Patients may be directed to surgical treatment without complex urodynamic testing if they meet criteria consistent with a low risk of surgical failure (ie, a complaint of primary, isolated, pure stress incontinence symptoms, along with demonstration of normal voiding function and a hypermobile urethra). Patients with complicating factors should undergo specialized testing prior to definitive treatment. Table 5 lists indications for referral to a specialist for complex urodynamic evaluation.


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 Table 5. Indications for Complex Urodynamic Testing


Conclusion

Given the prevalence of urinary incontinence in the general population, its predominance in elderly women, and the large cohort of the population ("baby boomers") reaching the postmenopausal years, it is anticipated that physicians who provide health care for women will see increasing numbers of patients who suffer from urinary incontinence complaints. A basic knowledge of the common causes of incontinence, and an understanding of a practical approach to the evaluation of these patients (Figure 2), will help the clinician to more effectively manage these distressing symptoms, providing relief to the patients who suffer from urinary incontinence.


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 Figure 2. Assessment and treatment algorithm for urinary incontinence



Martina Mutone, MD, is clinical assistant professor, Division of Female Pelvic Medicine and Reconstructive Surgery, Indiana University/Methodist Hospital, Indianapolis; and Sandra R. Valaitis, MD, is associate clinical professor of Obstetrics and Gynecology, Indiana University, Indianapolis.

References
  1. Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 1997;89(4):501-506.
  2. Optima Educational Solutions, Inc. Emerging concepts in the clinical management of stress urinary incontinence. Available at:http://www.critical-breakthroughs.com/main.php?nextlink =storybody&dispid =1422. Accessed January 20, 2004.
  3. Thom D. Variation in estimates of urinary incontinence prevalence in the community: effects of differences in definition, population characteristics, and study type. J Am Geriatr Soc. 1998;46(4):473-480.
  4. Moore KH, Hay DM, Imrie AE, Watson A, Goldstein M. Oxybutinin hydrochloride (3mg) in the treatment of women with idiopathic detrusor instability. Br J Urol. 1990;66(5): 479-485.
  5. US Bureau of the Census. Statistical Abstract of the United States 1996. Washington, DC: US Bureau of the Census; 1996:15-16.
  6. Burgio KL, Ives DG, Locher JL, Arena VC, Kuller LH.Treatment seeking for urinary incontinence in older adults. J Am Geriatric Soc. 1994;42(2):208-212.
  7. Uebersax JS, Wyman JF, Shumaker SA, McClish DK, Fantl JA. Short forms to assess life quality and symptom distress for urinary incontinence in women: the Incontinence Impact Questionnaire and the Urogenital Distress Inventory. Neurourol Urodyn. 1995;14(2):131-139.
  8. Agency for Healthcare Research and Quality (Agency for Health Care Policy and Research). Clinical Practice Guideline Update. Quick Reference Guide for Clinicians. Rockville, MD: Agency for Health Care Policy and Research; AHCPR Pub. No. 96-0686, March 1996.
  9. Hampel C, Wienhold D, Benken N, Eggersmann C, Thuroff JW. Definition of overactive bladder and epidemiology of urinary incontinence. Urology. 1997;50(6A Suppl):4-14.
  10. Norton P, Baker J, Sharp H, Warenski J. Genitourinary prolapse: relationship with joint mobility. Neurourol Urodyn. 1990;9:321-322.
  11. Landon CR, Smith ARB, Crofts CE, Trowbridge A. Biomechanical properties of connective tissue in women with stress incontinence of urine. Neurourol Urodyn. 1989;8:369-370.
  12. Foldspang A, Mommsen S, Djurhuus JC. Prevalent urinary incontinence as a correlate of pregnancy, vaginal childbirth, and obstetric techniques. Am J Public Health. 1999;8992): 209-212.
  13. Sultan AH, Kam MA, Hudson CN. Pudendal nerve damage during labour: prospective study before and after childbirth. Br J Obstet Gynaecol. 1994;101(1):22-28.
  14. Rortveit G, Daltveit AK, Hannestad YS, Hunskaar S. Urinary incontinence after vaginal delivery or cesarean section. N Engl J Med. 2003;348(10):900-907.
  15. Thorp JM, Norton PA, Wall LL, et al. Urinary incontinence in pregnancy and the puerperium: a prospective study. Am J Obstet Gynecol. 1999;181(2):266-273.
  16. Norton PA, MacDonald LD, Segwick PM, Stanton SL. Distress and delay associated with urinary incontinence, frequency and urgency in women. Br Med J. 1988;297(6657): 1187-1189.
  17. Van der Vaart CH, de Leuw JR, Roovers JP, Heintz AP. The effect of urinary incontinence and overactive bladder symptoms on quality of life in young women. Br J Urol Int. 2002;90(6):544-549.
  18. Nygaard I, Turvey C, Burns TL, Crischilles E, Wallace R. Urinary incontinence and depression in middle-aged United States women. Obstet Gynecol. 2003;101(1):149-156.
  19. Bergman A, Koonings PP, Ballard CA. Negative Q-tip test as a risk factor for failed anti-incontinence surgery. J Reprod Med. 1989;34(3):156-160.
  20. Lobel RW, Sand PK. The empty supine stress test as a predictor of intrinsic urethral sphincter dysfunction. Obstet Gynecol. 1996;88(1):128-132.
  21. McLennan MT, Bent AE. Supine empty stress test as a predictor of low Valsalva leak pressure. Neurourol Urodyn. 1998;17(2):121-127.
  22. Resnick NM, Yalla SV, Laurino E. The pathophysiology of urinary incontinence among institutionalized elderly persons. N Engl J Med. 1989;320(1):1-7.
  23. Klutke JJ, Bergman A. Guide to investigation of the incontinent patient. In: Ostergard R, Bent AE, eds. Urogynecology and Urodynamics. Theory and Practice, ed 4. Baltimore: Williams and Wilkins; 1996;94.
  24. Abrams P, Cardozo L, Fall M, et al. The standardization of terminology of lower urinary tract function: report from the Standardization Subcommittee of the International Continence Society. Neurourol Urodyn. 2002;21(2):167-178.
  25. Wall LL, Wiskind AK, Taylor PA. Simple bladder filling with a cough stress test compared with subtracted cystometry for the diagnosis of urinary incontinence. Am J Obstet Gynecol. 1994;171(6):1472-1479.
  26. Ryhammer AM, Djurhuus JC, Laurbery S. Pad testing in incontinent women: a review. Int Urogynecol J. 1999;10(2): 111-115.
  27. Richardson DA, Bent AE, Ostergard DR. The effect of uterovaginal prolapse on urethrovesical pressure dynamics. Am J Obstet Gynecol. 1983;146(8):901-905.
  28. Rosenzweig BA, Pushkin S, Blumenfeld D, Bhatia NN. Prevalence of abnormal urodynamic test results in continent women with severe genitourinary prolapse. Obstet Gynecol. 1992; 79(4):539-542.
  29. Summitt RL Jr, Stovall TG, Bent AE, Ostergard DR. Urinary incontinence: correlation of history and brief office evaluation with multichannel urodynamic testing. Am J Obstet Gynecol. 1992;166(6 pt 1):1835-1844.
  30. Weidner AC, Myers ER, Visco AG, Cundiff GW, Bump RC. Which women with stress incontinence require urodynamic evaluation? Am J Obstet Gynecol. 2001;184(2):20-27.
  31. Stanton SL, Cardozo L, Williams JE, Ritchie D, Allan V. Clinical and urodynamic features of failed continence surgery in the female. Obstet Gynecol. 1978;51(5):515-520.
  32. Colombo M, Zanetta G, Vitobello D, Milani R. The Burch colposuspension for women with and without detrusor overactivity. Br J Obstet Gynaecol. 1996;103(3):255-260.
  33. Glazener CM, Lapitan MC. Urodynamic investigations for management of urinary incontinence in adults. Cochrane Database of Systematic Reviews. 3:CD003195, 2002.
  34. Weber AM, Walters MD. Cost-effectiveness of urodynamic testing before surgery for women with pelvic organ prolapse and stress urinary incontinence. Am J Obstet Gynecol. 2000; 183(6):1338-1347.
  35. Brubaker L, Benson J, Clark A, et al. Multichannel urodynamics have limited reproducibility. Proceedings of the Eighteenth Annual Meeting of the American Urogynecologic Society; September 25-28, 1997, Tucson AZ.

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