a logical approach to clinical problem solving & an applied example on urinary incontinence

A Logical Approach to Clinical A Logical Approach to Clinical Problem SolvingProblem Solving

& & An applied example on An applied example on

Urinary IncontinenceUrinary Incontinence

4 Steps to Clinical Problem Solving

• Making the Diagnosis

• Assessing the severity and/ or stage of the

disease

• Rendering a treatment based on the stage

of the disease

• Following the patient response to treatment

Making the diagnosis

• Careful evaluation of the gathered data:– History

– Investigations

• Making a short list of Differential Diagnosis

Involving in many instances:-GIGO-Putting the pieces of the puzzle in their right place

Assessing the severity and / or stage of the Disease• Determining how bad the disease is

• Sometimes there is no ‘mild or severe’ yet the disease may be in itself a risk for another condition:– Bacterial vaginosis

Treating based on the stage

• PET at 32 weeks gestation– Mild– Severe

• Urinary Tract Infection– Lower urinary tract – Upper urinary tract

Following the response to treatment / expectant management

• Based on clinical judgment

• Based on laboratory testing

• Based on imaging techniques.

However when you are solving a case on paper, it is a bit different…

• 7 questions need to be answered– What is the most likely diagnosis?– What should be your next step?– What is the most likely mechanism for this process?– What are the risk factors for this condition?– What are the grade / severity and possible

complications of this disease process?– What is the best therapy? Is there an alternative

therapy (ies)?– How would you confirm the diagnosis

What is the most likely diagnosis?

• Means : The most common cause– Data presented may be confirming the

diagnosis– Or they may be leading to another cause

What should be your next step?

• Depends on how much information is

provided:

– If enough: you will make the diagnosis

Stage the disease and treat accordingly

– No enough information More diagnostic tests

– If he is providing treatment then the next step will

be to follow the response

• What is the likely mechanism for this process?– The pathophysiology of the disease itself– The disease may lead to another or to a complication

• What are the risk factors for this disease process?– Are they present in the context– Do they mandate further testing / investigations.

• What is the best therapy?– Do NOT jump to treatment on intuition– The treatment should be tailored according to:

• Stage/ severity of the disease• The best possible alternative according to the patient characteristics

• How would you confirm the diagnosis?– Making the point and concluding the story

• A 48-year old G3 P3+0 woman complains of a 2-year history of loss of urine 4-5 times each day, typically occurring 2-3 seconds after coughing, lifting or sneezing, additionally, she notes dysuria and an urge to void during these episodes. These events causes her embarrassment and interferes with her daily activities. She is otherwise in good health.

• A urine culture 1 month ago was negative.• On examination,

– she is slightly obese, the BP is 130/80 and the HR is 80bpm and regular with a temp of 37˚C, her breast examination is normal and so were her abdominal examination.

– A midstream urinalysis is unremarkable.

What is your next step?What is the most likely Diagnosis?What is the best initial treatment?

Bladder Control Problems

Problems of:

• Bladder EmptyingBladder Emptying

• Bladder StorageBladder Storage

Bladder Emptying Problems

Image source: Virginia Urology Center

• Urinary Retention– Obstruction from within– Obstruction from outside– Stretch attenuation of the urethra – Bladder neck obstruction– Angulation of the urethra– Neurogenic causes [reflex from pain, retention

with overflow]

Urinary Incontinence

Definition:

Urinary incontinenceUrinary incontinence is uncontrolled leakage of urine causing hygienic and social problems.

Urinary Incontinence is Common Among Older Adults

Men

Women

18

16

14

12

10

8

6

4

2

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5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 >85Age (years)

Bladder Storage Problems

• Overactive Bladder

• Stress Incontinence

• Mixed Incontinence

• Overflow Incontinence

•Fistulas

Overactive Bladder

Frequency

OVERACTIVE BLADDER

UrgencyUrge

incontinence

Stress Incontinence

Stress incontinenceStress incontinence occurs when a small amount of urine escapes while the person coughscoughs, sneezessneezes, laughslaughs, jumpsjumps or lifts lifts something heavysomething heavy.

Stress Incontinence

(a) Continent woman (b) Woman with stress incontinence

Externalurethral

sphincter

Sudden increase in intra-abdominal pressure

Overflow Incontinence

Overflow incontinenceOverflow incontinence happens when urine leaks from an overfilled bladderoverfilled bladder.

Mixed Incontinence

Mixed incontinenceMixed incontinence occurs when a person has both the symptoms of urge incontinenceurge incontinence and stress stress incontinenceincontinence.

Mixed Incontinence

Sudden increase in intra-abdominalpressure

Uninhibited detrusorcontractions

Prevalence

• 8-51% in community

• At least 50% in nursing homes

• 25% suffer from severe incontinence

• Greatest in older women and increases with age

• Incontinence 6-10x greater in women than in men

Impact on quality of life

• Significant worldwide health problem

• Affects 16 million women in US

• Cost of diagnosing and managing UI exceed $26 billion annually in US

• Adult diaper sales $5-6 billion/yr

• Great social impact as well

• Leaking depression stop exercise gain weight and so on ….

Approach

• Every woman is different

• Consider quality of life from the patient’s point of view

• History

• Voiding diary

• Quality of life assessment

Normal Bladder Function

• Functional urethra is intra-abdominal

• Increased abdominal pressure transmitted equally to bladder and urethra

• With increased stress urethro-vesical junction responds to stress by closing tight

• Bladder is a voluntary smooth muscle

• Inherent ability to maintain low pressure with filling-increase in volume:compliance

Bladder Pressure-Volume Relationship

Anatomy of Micturition

• Detrusor muscle

• External and Internal sphincter

• Normal capacity 300-600cc

• First urge to void 150-300cc

• CNS control– Pons - facilitates– Cerebral cortex - inhibits

• Hormonal effects - estrogen

Interpretation of Post-Void Residual

• PVR < 50cc - Adequate bladder emptying

• PVR > 150cc - Avoid bladder relaxing drugs

• PVR > 200cc - Refer to Urology

• PVR > 400cc - Overflow UI likely

Peripheral Nerves in Micturition

• Parasympathetic (cholinergic) - Bladder contraction

• Sympathetic - Bladder Relaxation– Bladder Relaxation (β adrenergic)– Sympathetic - Bladder neck and urethral

contraction (α adrenergic)

• Somatic (Pudendal nerve) - contraction pelvic floor musculature

Peripheral Nerves in Micturition

Factors Associated with Bladder Control Problems

• Age• Childbirth• Gender• Menopausal Status• Surgery• Lifestyle • Medications• Concomitant illnesses

Potentially Reversible Causes

D - Delirium

I - Infection

A - Atrophic vaginitis or urethritis

P - Pharmaceuticals

P - Psychological disorders

E - Endocrine disorders

R - Restricted mobility

S - Stool impaction2

Medications That May Cause Incontinence

• Diuretics

• Anticholinergics - antihistamines, antipsychotics, antidepressants

• Seditives/hypnotics

• Alcohol

• Narcotics

• α-adrenergic agonists/antagonists

• Calcium channel blockers

10 Warning Symptoms of Bladder Control Problems

#1

Any leakageleakage of urine

#2

Leakage of urine, regardless of amount, on coughingcoughing, sneezingsneezing, laughinglaughing or standing.standing.

10 Warning Signs of Bladder Control Problems10 Warning Signs of Bladder Control Problems

#3

Leaking urine on the wayway to theto the toilet.toilet.


#4

Bed wetting at any age over six years.over six years.


#5

An urgent need to pass urine, being unable to hold onunable to hold on.


#6

Passing urine more frequently than 8 8 times a daytimes a day and only passing small small amountsamounts.


#7

BloodBlood in the urine.


#8

InabilityInability to urinate (retention of urine).


#9

PainPain when passing urine.


#10

Progressive weaknessweakness of the urinary stream or a stream that stops and stops and startsstarts instead of flowing out smoothly.

Image source: Malaysian Urological Association


• A 48-year old G3 P3+0 woman complains of a 2-year history of loss of urine 4-5 times each day, typically occurring 2-3 seconds after coughing, lifting or sneezing, additionally, she notes dysuria and an urge to void during these episodes. These events causes her embarrassment and interferes with her daily activities. She is otherwise in good health.

• A urine culture 1 month ago was negative.• On examination,

– she is slightly obese, the BP is 130/80 and the HR is 80bpm and regular with a temp of 37˚C, her breast examination is normal and so were her abdominal examination.

– A midstream urinalysis is unremarkable.

What is your next step?What is the most likely Diagnosis?What is the best initial treatment?

What is your next step?

• Answer the question: What type of incontinence Does she have?– Perform cystometry

• Conduct a pelvic examination:– Will the presence of proplase alter your

decision regarding therapy?

• The Q-tip cotton swab test has been used as a simple means of identifying patients with hypermobility of the urethrovesical junction.

• A sterile Q-tip lubricated with xylocaine gel is placed in the urethra but not through the internal sphincterand the patient is asked to bear down. – If the Q-tip moves up more than 30°, the test is

considered positive, and the patient may benefit from surgery

• This means that the pressure in the bladder was transmitted to the Q-tip (i.e. exceeded the closing urethral pressure)

Urodynamics

• Indications– “complicated” incontinence– Pre-op– After failure of an anti-incontinence procedure

Urodynamics

• Components (a combo of any listed below)– Cystometry – study of bladder fxn– Pressure-flow study – bladder fxn during void– Videourodynamics– Uroflowmetry (study of flow rates) & PVR– Electromyography (EMG)– Urethral Pressure Profilometry– Ambulatory Urodynamics

Cystometric Evaluation• Simple

– After void, insert foley, measure PVR, <50cc. Attach syringe to foley, instill sterile saline. Normal first desire ~200cc.

– Observe column of saline, unusual waves suggest detrusor dyssynergia.

– Maximum bladder capacity ~500 cc.– Remove ~250 cc, remove foley, ask to cough,

loss of urine suggests GSI.

Bladder Pressure-Volume Relationship

Stable Bladder

Detrusor Instability

Genuine Stress Incontinence

Studies• Cystometry

• Compliance, fd 90-150ml, nd 200-300ml, sd 400-550 ml, true subtracted detrusor pressures

• Valsalva leak point pressure• Amount of intraabdominal pressure needed to leak• <60 cm H2O is ISD

• Urethral pressure profile• Full bladder, catheter pulled along urethra• Urethral closure pressure >30 cm H20 nl, <20 is ISD

• Uroflow• Rate and pattern of urine flow• Peak flow 20-30 ml/sec

• Pressure flow test• Details voiding mechanism, obstructive dysfunction, poor contractility• Voiding detrusor pressure 10-30 cm H20 is nl

• Electromyography• Electrical activity of pelvic floor musculature• Timing and degree of muscle relaxation impacts voiding mechanism

Definition (based on urodynamic studies)

Genuine Stress Urinary Incontinence

(GSUI)

• involuntary loss of urine with a rise in intra-abdominal pressure in the absence of any rise in detrusor pressure

• Urethral hypermobility

Helpful hints• Stress induced detrusor instability

– May be confused with GSI– See loss of urine after cough, but delayed – Bladder overactive after stress

• Incontinence may only be seen in standing position

• Correction of the cystocele may produce incontinence – UVJ is slightly kinked with cystocele and

correction may reveal the econdition

Treatment Options

• Reduce amount and timing of fluid intake

• Avoid bladder stimulants (caffeine)

• Use diuretics judiciously (not before bed)

• Reduce physical barriers to toilet (use bedside commode)

1

Treatment Options• Bladder training

– Patient education– Scheduled voiding– Positive reinforcement

• Pelvic floor exercises (Kegel Exercises)

• Biofeedback

• Caregiver interventions– Scheduled toileting– Habit training– Prompted voiding

Pharmacological Interventions

• Urge Incontinence– Oxybutynin (Ditropan)– Propantheline (Pro-Banthine)– Imipramine (Tofranil)

• Stress Incontinence– Phenylpropanolamine (Ornade)– Pseudo-Ephedrine (Sudafed)– Estrogen (orally, transdermally or transvaginally)

Other Interventions

• Pessaries

• Periurethral bulking agents (periurethral injection of collagen, fat or silicone)

• Diapers or pads

• Chronic catheterization– Periurethral or suprapubic– Indwelling or intermittant

Pessaries

Indwelling Catheter

Surgery?• Bonney test: Gentle support of bladder neck during

exam and asking patient to cough again

• If continent, surgical repair is likely to be successful

• Surgical repairs aim at elevation of bladder neck and

correction of the pubovesical fascia tears

Surgery is reported to “cure” 4 out of 5 cases, but success rate drops to 50% after 10 years.

Surgical Procedures

• Six basic surgical themes– Bladder buttress operations (anterior repair,

etc)– Retropubic operations (Burch, MMK, etc)– Bladder neck suspensions (Raz, Stamey,

Pereyra, etc)– Sling procedures (TVT, PV Sling, etc)– Periurethral Injections– Artificial urinary sphincter

Bladder Buttress

• Post-op continence rates are lower when compared to other procedures

• Still in use for correction of cystocele and can be performed in conjunction with other incontinence procedures

Retropubic Operations

• Marshall Marchetti Krantz (MMK) cystourethropexy – 1949– Para-urethral vaginal wall suspended to symphisis pubis

• Burch colposuspension – 1961– Para-urethral vaginal wall suspended to Cooper’s

ligament

• Paravaginal fascial repair– Para-urethral vaginal wall suspended to the

tendinous arc on the pelvic sidewall

Bladder Neck Suspensions

• Pereyra

• Stamey

• Raz

Sling Procedures

• Suburethral sling is a strip of material that is tunneled underneath the bladder neck and/or proximal or midurethra and then attached to above structures such as rectus fascia or pelvic sidewall to create a posterior support, or “hammock effect” to the bladder neck and proximal urethra

• Initially used for ISD (intrinsic sphincter deficiency), but now used for all kinds GSI

Slings

• Materials– Autologous fascia lata or rectus abdominis– Homologous materials (cadaveric fascia lata)– Synthetic

Slings

• Types of slings– Traditional suburethral (rectus abdominis)

sling– Minimally invasive suburethral slings

• Transvaginal bone-anchored sling (In-Fast, Vesica)

• Tension free vaginal tape (TVT) – only sling placed at the midurethra

• Initial results are encouraging, but long-term results are lacking

TVT Operative Technique• Abdominal incisions made• Vaginal wall incision made• Paraurethral dissection performed• Trocar with tape advanced through vaginal incision,

urogenital diaphragm, and retropubic space until its tip is brought out to the abdominal incision

• Cystoscopy• Trocar and tape pulled through, tension is adjusted,

and plastic sheath is removed• Abdominal and vaginal incisions are closed

Periurethral Bulking Injection

• Indicated for patients with stress incontinence who have:– Medical conditions that make them unfit for

surgery– A history of partially successful treatment and

wish to avoid more invasive procedures– Particularly indicated in patients with ISD

Periurethral Bulking Injections

• Purpose is to bulk up the tissue at the bladder neck in order to increase urethral closure pressure

• Bulking agents– Collagen*– Silicone– Teflon– Fat *– Durasphere* (carbon beads in a carrier gel)

*FDA approved bulking agents

Artificial Urinary Sphincter

• Indicated mainly in patients who have undergone recurrent previous surgery for GSI and have ISD

• Few reports on this as first-line treatment, so results are difficult to interpret.

• As high as 92% continence rate, but also a high revision rate of 17%

Comparative OutcomesProcedure Category

Retropubic Suspensions

Transvaginal Suspensions

Anterior Repair

Sling Procedures

Cure/Dry @ 48mo84%67%61%83%Cure/Dry/Improved@ 48mo

90%82%73%87%

De-Novo Urgency11%5%N/A7%Retention (>4wks)5%5%N/A8%Intraoperative Complications

2%2%1%3%

Postoperative Complications

4%7%2%7%

Death5/10,000

Urge IncontinenceUrge Incontinence

• Loss of urine associated with uncontrollable urge to void

• Uninhibited, involuntary detrusor contractions• Pressure-volume relation out of balance• Also called unstable bladder

• Frequency• Urgency• nocturia

• Chronic irritation due to infection, irritation or tumors

Treatment

• Primarily medical• Most commonly anticholinergics

– Ditropan – oxybutynin chloride– Detrol– Imipramine– Levbid, cytospaz – hyoscyamine sulphate– Tolterodine (detrusitol)

• Side effects- dry mouth, constipation etc.• Behavioral

– Bladder retraining– Pelvic-floor rehabilitation

Mixed IncontinenceMixed Incontinence

• Some degree of both stress and urge

• More difficult to treat

• Need to do complex urodynamic studies to determine major component

• Precisely predict success with surgery

• Surgery may worsen the urge component

• Properly counsel patient


• Neurogenic bladder– Multiple sclerosis, spinal cord lesions, stroke– Diabetis– Trauma– Radical hysterectomy

• Normal innervation absent or damaged• Loss of vesical reflexes and emptying

sensation• Overdistended bladder with overflow

• Complaints of fullness, pressure

• Large bladder capacity

• Absence of uninhibited bladder contractions

• Treatment – medical– Cholinergics to increase tone and

contractility• Urecholine- bethanechol• Prostigmine

a logical approach to clinical problem solving & an applied example on urinary incontinence

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