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Stress Urinary Incontinence in Women (2/3)
- Stress urinary incontinence in women (1/3): definition and etiology
- Stress urinary incontinence (2/3): symptoms and diagnostic work-up
- Stress urinary incontinence (3/3): medical and surgical treatment
Signs and Symptoms of Stress Urinary Incontinence
The severity of stress incontinence is classified by Stamey:
- Grade 1: loss of urine with sudden increases of abdominal pressure: e.g. coughing, sneezing or laughing.
- Grade 2: loss of urine with lesser degrees of stress: e.g. walking or standing up.
- Grade 3: loss of urine without any relation to physical activity or position, e.g. while lying in bed.
Other symptoms: pelvic organ prolapse, urge symptoms (frequency, nocturia), residual urine or urinary retention, recurrent urinary tract infections.
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 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.
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.
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.
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.
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 anyway part of the treatment, it is not necessary to determine the karyopyknotic index.
- Bladder sonography: to measure residual urine, bladder wall thickness or reveal bladder anomalies.
- Vaginal or perineal ultrasound: can demonstrate the opening of the bladder neck under Valsalva provocation, this is a strong risk factor for stress incontinence.
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].
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 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 is indicated for the differential diagnosis of incontinence, frequency or dysuria. Specific signs of stress urinary incontinence do not exist.
Defecography or Dynamic 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.
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Deutsche Version: Belastungsinkontinenz der Frau