Dr. med. Dirk Manski



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Stress Urinary Incontinence in Women (2/3)

Signs and Symptoms of Stress Urinary Incontinence

The severity of stress incontinence is classified by Stamey:


Other symptoms: pelvic organ prolapse, urge symptoms (frequency, nocturia), residual urine or urinary retention, recurrent urinary tract infections.

Diagnostic Work-Up

History:

Ask for micturition symptoms, the severity of incontinence (pad usage), degree of bother, previous surgery, number of vaginal deliveries, medications (e.g. alpha blocker, clonidine), neurological and urological diseases. Ask for symptoms of pelvic prolapse, bowel symptoms and symptoms of sexual dysfunction.

Urine analysis:

Urine sediment and urine culture (best using urine collected by catheterization) to exclude the presence of a urinary tract infection.

Quantification of Stress Urinary Incontinence:

A micturition diary with documentation drinking habits, incontinence episodes and voided volumes may help to quantify the severity and bother of stress urinary incontinence. A time period of 24–48 hours is usually sufficient.

Pad test for quantification of SUI:

A weighted pad is used after filling the bladder to minimum 50% of its capacity. The patient should perform defined provocation exercises (stair climbing, jumping, coughing ....), then the pad is weighted again.

Physical Exam:

A complete physical exam is done including a neurological examination, a pelvic and rectal examination in lithotomy position. Important pathological findings are: cystocele, rectocele, quantification of pelvic organ prolapse (using the grading system of the ICS), decreased anal sphincter tonus, lack of anal or genital reflexes, observation of stress urinary incontinence while coughing or Valsalva provocation.

Q-tip test:

The cotton swab or Q-tip test uses a sterile, lubricated cotton or dacron swab, which is inserted into the urethra just until to the end of the urethra/beginning of the trigonum of the bladder. The patient is asked for a Valsalva provocation. If the angle of the Q-tip rotates more than 30 degrees, a urethrovesical hypermobility is probable.

Marshall-Bonney test:

The Marshall-Bonney test tries to anticipate the clinical effect of a suspension operation in relation to cure urinary incontinence: using the index and middle fingers, the paraurethral tissue is lifted and the patient is asked for coughing or Valsalva provocation with a full bladder.

Karyopyknotic index:

The karyopyknotic index (vaginal swab and cytology) helps to identify an estrogen deficit, which may adversely affect stress urinary incontinence (e.g. atrophy of urethral mucosa). If topical estrogen therapy is part of the treatment, it is not necessary to determine the karyopyknotic index.

Ultrasound Imaging:

Voiding Cysturethrography:

VCUG is important to image cystocele, hypermobile urethra, rotation of the urethra and opening of the bladder neck under stress, and to exclude other forms of incontinence (extraurethral incontinence). In urinary incontinence, VCUG is performed using the lateral projection [VCUG performed for stress urinary incontinence].

figure lateral voiding cysturethrography in female urinary incontinence  

Fig. voiding cysturethrography in female stress urinary incontinence: after reaching the functional bladder capacity, lateral projection VCUG with and without Valsalva maneuver in double exposure technique (two shots on the same X-ray film) is done. Apart from a slight vertical descent (x → y), imaging reveals an opening of the bladder neck (white → black line). With kind permission of Dr. R. Gumpinger, Kempten.

Urodynamic Examination:

Urodynamic examination is the gold standard to diagnose the cause for urinary incontinence. It remains controversial, whether all patients should receive urodynamic studies before surgical treatment for stress urinary incontinence. The demonstration of stress incontinence can be achieved by a urethral pressure profile and by measurement of the Valsalva leak point pressure (VLPP). It is sometimes not possible to proof stress urinary incontinence with urodynamic testing due to the presence of the measurement catheter. The measurement of the Valsalva leak point pressure (VLPP) may also be performed without the catheter and the abdominal pressure is detected with the rectal probe.

Valsalva leak point pressure (VLPP): a Valsalva maneuver is performed until urine leakage and the intra-abdominal and intravesical pressures are measured. Some consider values > 60 cm H2O normal.

Cystoscopy:

Cystoscopy is indicated for the differential diagnosis of incontinence, frequency or dysuria. Specific signs of stress urinary incontinence do not exist.

Defecography or MRI imaging of the pelvic floor:

Defecography or MRI imaging of the pelvic floor may reliable image cystocele, rectocele, enterocele or prolapse under stress. The pubo-coccygeal line is often specified as a reference point.







Index: 1–9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z



References

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Laparoscopic colposuspension for urinary incontinence in women.
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Gilling, P. J.; Wilson, L. C.; Westenberg, A. M.; McAllister, W. J.; Kennett, K. M.; Frampton, C. M.; Bell, D. F.; Wrigley, P. M. & Fraundorfer, M. R.
A double-blind randomized controlled trial of electromagnetic stimulation of the pelvic floor vs sham therapy in the treatment of women with stress urinary incontinence.
BJU Int, 2009, 103, 1386-1390


Latthe, P. M.; Singh, P.; Foon, R. & Toozs-Hobson, P.
Two routes of transobturator tape procedures in stress urinary incontinence: a meta-analysis with direct and indirect comparison of randomized trials.
BJU Int, 2010, 106, 68-76


Liedl u.a. 2005 LIEDL, B. ; SCHORSCH, I. ; STIEF, C.:
[The development of concepts of female (in)continence. Pathophysiology, diagnostics and surgical therapy].
In: Urologe A
44 (2005), Nr. 7, S. W803–18; quiz W819–20

Petros, P. E. & Ulmsten, U. I.
An integral theory of female urinary incontinence. Experimental and clinical considerations.
Acta Obstet Gynecol Scand Suppl, 1990, 153, 7-31.


Quek, P.
A critical review on magnetic stimulation: what is its role in the management of pelvic floor disorders?
Curr Opin Urol, 2005, 15, 231-235


Ward, K. L.; Hilton, P.; K., U. & Group, I. T. T.
Tension-free vaginal tape versus colposuspension for primary urodynamic stress incontinence: 5-year follow up.
BJOG, 2008, 115, 226-233


Viktrup u.a. 2004 VIKTRUP, L. ; SUMMERS, K. H. ; DENNETT, S. L.:
Clinical practice guidelines for the initial management of urinary incontinence in women: a European-focused review.
In: BJU Int
94 Suppl 1 (2004), S. 14–22


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