The Basic Evaluation of Urinary The Basic Evaluation of Urinary IncontinenceIncontinence

Educational ObjectivesEducational Objectives

After this presentation, the participant should be After this presentation, the participant should be able to perform an initial evaluation of a woman able to perform an initial evaluation of a woman with urinary incontinence.with urinary incontinence.

This lecture will enable the participant to choose This lecture will enable the participant to choose appropriate urodynamic tests and understand appropriate urodynamic tests and understand the purpose and limitations of each.the purpose and limitations of each.

After this session the clinician will understand After this session the clinician will understand which patients require more advanced testing.which patients require more advanced testing.

What is Urinary Incontinence?What is Urinary Incontinence?

The loss of urine beyond the patients‘ The loss of urine beyond the patients‘ control which is of social or hygienic control which is of social or hygienic significance to the patient. significance to the patient.

Types of Urinary IncontinenceTypes of Urinary Incontinence

Stress Urinary IncontinenceStress Urinary Incontinence

A. Urethral Hyper mobilityA. Urethral Hyper mobility

B. Intrinsic Sphincteric DeficiencyB. Intrinsic Sphincteric Deficiency

• Urge incontinenceUrge incontinence

• Mixed incontinenceMixed incontinence

Pathophysiology of Stress Pathophysiology of Stress Urinary IncontinenceUrinary Incontinence

Urethral Urethral hypermobilityhypermobility– Displacement of Displacement of

urethra during urethra during sudden increase in sudden increase in abdominal pressureabdominal pressure

– Decreases pressure Decreases pressure transmissiontransmission

Hypermobile UrethraHypermobile Urethra

GSUI:GSUI:Intrinsic Sphincteric DeficiencyIntrinsic Sphincteric Deficiency

Weak urethral sphincterWeak urethral sphincter

With or without urethral hypermobilityWith or without urethral hypermobility

Risk: Prior incontinence surgeryRisk: Prior incontinence surgery

Presentation: severe, recurrent Presentation: severe, recurrent incontinenceincontinence

Urge IncontinenceUrge Incontinence

13%

12%13%

62%USI (stress)DO (urge)MixedOther

UI Symptoms Do Not Equate to UI Symptoms Do Not Equate to

Underlying ConditionsUnderlying Conditions

Adapted from: Weidner AC, et al. Am J Obstet Gynecol. 2001;184(2):20-27.

4 out of 5 women with incontinence have stress symptoms (pure or combined with urge)

3 out of 4 have urodynamic stress incontinence (USI) as proven by urodynamic testing (pure or combined with detrusor overactivity [DO])

12%

33%

4%

51%StressUrgeMixedOther

Symptoms Underlying Condition

Treatment of IncontinenceTreatment of Incontinence

Stress urinary incontinence 1.Urethral Stress urinary incontinence 1.Urethral hyper mobility -- Conventional hyper mobility -- Conventional

Surgery Surgery

2. Intrinsic Sphincter Deficiency-- Sling2. Intrinsic Sphincter Deficiency-- Sling CollagenCollagen

Urge incontinence ----- drugsUrge incontinence ----- drugs

Mixed incontinence ---- Symptoms? Mixed incontinence ---- Symptoms?

Treatment FailuresTreatment Failures

The vast majority of treatment failures, The vast majority of treatment failures, whether medical or surgical, result not whether medical or surgical, result not from poorly performed therapy, but a from poorly performed therapy, but a poorly chosen therapy.poorly chosen therapy.

Urodynamic evaluation can help you Urodynamic evaluation can help you choose the proper therapychoose the proper therapy

Question?Question?

Should I operate on this patient without Should I operate on this patient without urodynamic studies?urodynamic studies?

The real question: The real question:

Do I understand Do I understand the patient’s problem well enough to the patient’s problem well enough to formulate a reasonable treatment plan?formulate a reasonable treatment plan?

DefinitionDefinition

Urodynamic testing is the dynamic study Urodynamic testing is the dynamic study of the transport, storage, and evacuation of the transport, storage, and evacuation of urine by the urinary tract.of urine by the urinary tract.

The tests range from simple studies to The tests range from simple studies to sophisticated software programs and high-sophisticated software programs and high-tech video imaging.tech video imaging.

Purpose of UrodynamicsPurpose of Urodynamics

Urodynamics should provide a better Urodynamics should provide a better understanding of the pathophysiology understanding of the pathophysiology contributing to the patient’s symptoms, contributing to the patient’s symptoms, rather than generate a list to validate rather than generate a list to validate surgical indications.surgical indications.Urodynamic data is objectiveUrodynamic data is objectiveThe patients symptoms are subjectiveThe patients symptoms are subjectiveOur evaluations should consider both the Our evaluations should consider both the subjective and objective informationsubjective and objective information

The Evaluation of The Evaluation of

Urinary Stress Incontinence (many Urinary Stress Incontinence (many years ago)years ago)

Abdominal Hysterectomy—MMK or BurchAbdominal Hysterectomy—MMK or Burch

Vaginal Hysterectomy-----Anterior repairVaginal Hysterectomy-----Anterior repair

Evaluation of Urinary IncontinenceEvaluation of Urinary Incontinence

HistoryHistory

Physical examinationPhysical examination

Voiding diaryVoiding diary

Post void residualPost void residual

Stress testStress test

Urinalysis, Urine cultureUrinalysis, Urine culture

Q-tip testQ-tip test

Urodynamic testing ? (simple or sophisticated?)Urodynamic testing ? (simple or sophisticated?)

Transient Causes of Urinary Transient Causes of Urinary Incontinence (DIAPPERS)Incontinence (DIAPPERS)

DeliriumDeliriumInfectionInfectionAtrophic vaginitisAtrophic vaginitisPharmacologicPharmacologicPsychologicalPsychologicalEndocrineEndocrineRestricted mobilityRestricted mobilityStool ImpactionStool Impaction

AHCPR guidelines for basic AHCPR guidelines for basic evaluationevaluation

History of urine loss with physical activityHistory of urine loss with physical activityVoiding diary demonstrates normal voiding habits (8 or Voiding diary demonstrates normal voiding habits (8 or less voids per day, and 2 or less voids per night)less voids per day, and 2 or less voids per night)No history or findings suggestive of neurological No history or findings suggestive of neurological abnormalitiesabnormalitiesNo previous anti-incontinence or radical pelvic surgeryNo previous anti-incontinence or radical pelvic surgeryNormal post void residual (less than 100cc)Normal post void residual (less than 100cc)Pelvic examination demonstrating urethral hyper mobility Pelvic examination demonstrating urethral hyper mobility Not pregnantNot pregnant

AHCPR Guidelines

Tx: Behavioral, Pharmacological or Both

History, Physical UA, Voiding Diary

Transient Causes

“DIAPPERS”Management

Stress Test & PVR

Failed

Stress Test (-)

PVR Normal

Further Testing*

Stress Test (-)

PVR Elevated Urge Incontinence

Stress Test (+)

PVR Normal

Stress IncontinenceTx: Behavioral, Pharmacological or Surgery

History Requiring Further History Requiring Further EvaluationEvaluation

Recurrent urinary tract infectionsRecurrent urinary tract infectionsContinuous (non-episodic) incontinenceContinuous (non-episodic) incontinencePainful or frequent voids (more than 8 per day or Painful or frequent voids (more than 8 per day or 2 per night)2 per night)Greater than 4,000 ml 24 hr. voided volumeGreater than 4,000 ml 24 hr. voided volumeHistory consistent with neurological diseaseHistory consistent with neurological diseaseFailed incontinence proceduresFailed incontinence proceduresGreater than 65 years of ageGreater than 65 years of ageDiabetes MellitusDiabetes MellitusRadical Pelvic surgery or radiation therapyRadical Pelvic surgery or radiation therapy

Voiding Diary Helps Assess Voiding Diary Helps Assess HistoryHistory

Fluid intakeFluid intake– Time, type, amountTime, type, amount

Urine outputUrine output– Time, amountTime, amount

Urine leakageUrine leakage– Time, amountTime, amount– Precipitating events (cough, sneeze, exercise, sex, etc.)Precipitating events (cough, sneeze, exercise, sex, etc.)– Associated symptoms (urgency, dysuria, etc.)Associated symptoms (urgency, dysuria, etc.)

Pad usagePad usage– Number, typeNumber, type

Voiding DiaryVoiding Diary

Helpful for documenting and measuring the severity and Helpful for documenting and measuring the severity and timing of the incontinencetiming of the incontinenceOne week record is highly reliable for measuring urinary One week record is highly reliable for measuring urinary frequency, nocturia, and number of incontinent episodes, frequency, nocturia, and number of incontinent episodes, but is not reliable for diagnosing the type of incontinence.but is not reliable for diagnosing the type of incontinence.Further evaluation needed if:Further evaluation needed if:

* output greater than 4,000 cc/24 hours* output greater than 4,000 cc/24 hours * more than 8 voids per day or 2 per night* more than 8 voids per day or 2 per night

(Wyman, Obstet Gynecol,1998)(Wyman, Obstet Gynecol,1998)

TimeTime Amount Amount VoidedVoided ActivityActivity Leakage*Leakage*

(0-3 scale)(0-3 scale)

Urge Urge Present Present (yes/no)(yes/no)

Fluid IntakeFluid IntakeAmount/TypeAmount/Type

6:506:50AMAM 425 mL425 mL Getting Getting up/breakfastup/breakfast 00 YesYes 16 oz. coffee16 oz. coffee

6 oz. orange juice6 oz. orange juice

7:457:45 150 mL150 mL Leaving for workLeaving for work 00 SlightSlight ……

8:208:20 350 mL350 mL At workAt work 00 YesYes 8 oz. coffee8 oz. coffee

9:109:10 …… CoughCough 22 YesYes ……

9:159:15 300 mL300 mL WorkingWorking 00 YesYes 10 oz. water10 oz. water

12:2512:25PMPM 275 mL275 mL Working/at lunchWorking/at lunch 00 YesYes 8 oz. water8 oz. water

2:452:45 400 mL400 mL Bending Bending 11 YesYes 4 oz. water 4 oz. water

5:305:30 250 mL250 mL Leaving workLeaving work 00 YesYes ……

6:306:30 125 mL125 mL Exercise classExercise class 22 SlightSlight 12 oz. water12 oz. water

7:457:45 …… DinnerDinner 00 NoNo 4 oz. wine, 8 oz. 4 oz. wine, 8 oz. waterwater

8:208:20 375 mL375 mL At homeAt home 00 YesYes 4 oz. water4 oz. water

10:5010:50 250 mL250 mL Getting ready for Getting ready for bedbed 00 YesYes ……

Urine Voiding DiaryUrine Voiding Diary

*Leakage: 0=no leakage; 1=drops; 2=wet underwear or light pad; 3=soaked pad or clothing.

UrinalysisUrinalysis

BacteriuriaBacteriuria

HematuriaHematuria

PyuriaPyuria

GlycosuriaGlycosuria

ProteinuriaProteinuria

Physical ExaminationPhysical Examination

Further Evaluation needed:Further Evaluation needed:

FistulaFistula

DiverticulaDiverticula

Severe Pelvic Organ ProlapseSevere Pelvic Organ Prolapse

Large Pelvic massLarge Pelvic mass

Neurological abnormalitiesNeurological abnormalities

Markedly decreased muscle strengthMarkedly decreased muscle strength

Neurological EvaluationNeurological Evaluation

Cranial nervesCranial nervesMuscle strengthMuscle strengthDeep tendon reflexesDeep tendon reflexesSensory functionSensory functionSacral cord integritySacral cord integrity

Up to 25% of patients with MS or Parkinsonism present Up to 25% of patients with MS or Parkinsonism present with urinary incontinence.with urinary incontinence.

(Galloway,1983)(Galloway,1983)Any neurological abnormalities should receive further Any neurological abnormalities should receive further

evaluationevaluation

Other Basic TestsOther Basic Tests

Cotton swab testCotton swab test– Demonstrates Demonstrates

urethral urethral hypermobilityhypermobility

Q-TIP TESTQ-TIP TEST

Most consider a greater than 30 degrees Most consider a greater than 30 degrees change as positivechange as positive

Sensitivity for USI ----- 80%Sensitivity for USI ----- 80%

Specificity for USI ----- 42%Specificity for USI ----- 42%

(Tapp, Ob Gyn, Jan 2005)(Tapp, Ob Gyn, Jan 2005)

Other Basic TestsOther Basic Tests

Postvoid residualPostvoid residual

Post Void Residual (PVR)Post Void Residual (PVR)

Consensus is that PVR of less than 50 cc Consensus is that PVR of less than 50 cc is normalis normal

AHCPR recommends multi channel AHCPR recommends multi channel urodynamics for a PVR of greater than urodynamics for a PVR of greater than 100 cc100 cc

Most experts consider greater than Most experts consider greater than 200 cc PVR definitely abnormal200 cc PVR definitely abnormal

Stress TestStress Test

A classical sign—observation of leakage on A classical sign—observation of leakage on coughing coughing International Continence Society no longer International Continence Society no longer requires a positive stress test for the diagnosis requires a positive stress test for the diagnosis of urinary incontinenceof urinary incontinence““Can use information from frequency volume Can use information from frequency volume charts, pad tests, and validated symptom and charts, pad tests, and validated symptom and quality of life questionnaires to verify and quality of life questionnaires to verify and quantify symptoms”quantify symptoms”

( International Continence Society,2003)( International Continence Society,2003)

Cough Stress TestCough Stress Test

Most perform it with at least 300cc fluid in Most perform it with at least 300cc fluid in the bladderthe bladder

The greater the bladder volume, the lower The greater the bladder volume, the lower the Valsalva leak point pressure.the Valsalva leak point pressure.

(Miklos,1995)(Miklos,1995)

How Valid is the Stress test?How Valid is the Stress test?

92% sensitivity for urodynamic SUI92% sensitivity for urodynamic SUI

56% specificity for urodynamic SUI56% specificity for urodynamic SUI

68% positive predictive value68% positive predictive value

89% negative predictive value 89% negative predictive value

(Weidner 2001)(Weidner 2001)

(Most consider a negative stress test an indication for (Most consider a negative stress test an indication for further testing)further testing)

Eyeball cystometryEyeball cystometry– Detects bladder (?) Detects bladder (?)

contractions and contractions and compliance, residual compliance, residual urine, and determines urine, and determines bladder capacitybladder capacity

– Precedes stress testPrecedes stress test

Can not determine Can not determine detrusor or urethral detrusor or urethral pressurepressure

Urodynamic TestingUrodynamic Testing

Simple CystometrySimple Cystometry

Although simple office cystometry was left out Although simple office cystometry was left out from the AHCPR recommendations, many feel it from the AHCPR recommendations, many feel it should be considered an essential part of the should be considered an essential part of the basic evaluation of the incontinent patient, basic evaluation of the incontinent patient, because it plays a vital role in the diagnosis of because it plays a vital role in the diagnosis of both stress incontinence and detrusor both stress incontinence and detrusor overactivity (instability).overactivity (instability).

Bergman (1989) found simple urodynamics Bergman (1989) found simple urodynamics sufficient to establish a diagnosis in 75-80 % of sufficient to establish a diagnosis in 75-80 % of patients in his study.patients in his study.

Simple Cystometry

Equipment for Simple CystometryEquipment for Simple Cystometry

500cc sterile saline (body temperature)500cc sterile saline (body temperature)

Foley catheter (indwelling?)Foley catheter (indwelling?)

60 cc Foley tipped syringe60 cc Foley tipped syringe

Graduated beakerGraduated beaker

Cheap stop watchCheap stop watch

““Hat” insert for commodeHat” insert for commode

Sequence of Simple CystometrySequence of Simple Cystometry

Timed void (with stop watch)Timed void (with stop watch)

Post void residual (catheterized specimen Post void residual (catheterized specimen for urinalysis or culture if needed)for urinalysis or culture if needed)

Empty supine testEmpty supine test

Filling cystometryFilling cystometry

Provocative testingProvocative testing

Cough stress test (can be repeated)Cough stress test (can be repeated)

Timed VoidingTimed Voiding

Meet patient in clinic with full bladder (hers)Meet patient in clinic with full bladder (hers)Have patient void as she normally does and time Have patient void as she normally does and time from start to finish (including interruptions).from start to finish (including interruptions).Measure voided volume in the “hat”Measure voided volume in the “hat”Normal voiding flow rates range between 12 and Normal voiding flow rates range between 12 and 20 ml/sec (Abrams1988)20 ml/sec (Abrams1988)Fantyl (1982) recommended further testing for Fantyl (1982) recommended further testing for those having average flow rates below 15cc/secthose having average flow rates below 15cc/secMost recommend further studies for average Most recommend further studies for average flow rates below 10 cc/secflow rates below 10 cc/sec

Empty Supine TestEmpty Supine Test

The test is performed by having the patient perform a The test is performed by having the patient perform a Valsalva’s maneuver while in the supine position with Valsalva’s maneuver while in the supine position with 100-200cc fluid in the bladder. 100-200cc fluid in the bladder.

Any leakage is considered a positive testAny leakage is considered a positive test

Lobel (1996) found a positive test to have a 70 % Lobel (1996) found a positive test to have a 70 % sensitivity and a 90% negative predictive value for sensitivity and a 90% negative predictive value for detecting urethral closure pressures below 20 cm water.detecting urethral closure pressures below 20 cm water.Hsu (1999) found a similar correlation with Valsalva Leak Hsu (1999) found a similar correlation with Valsalva Leak point Pressures of under 100 cm water .point Pressures of under 100 cm water .A positive empty supine test is an indication for multi A positive empty supine test is an indication for multi channel testing to rule out Intrinsic Sphincter Deficiencychannel testing to rule out Intrinsic Sphincter Deficiency

Filling CystometryFilling Cystometry

First sensation ----150ccFirst sensation ----150ccFirst urge to void ----200-300ccFirst urge to void ----200-300ccMax capacity --- 400-500ccMax capacity --- 400-500ccCompliance -- resting pressure < 8cm Compliance -- resting pressure < 8cm No uninhibited pressure rises > 15 cm No uninhibited pressure rises > 15 cm

Any abnormalities are indication for further Any abnormalities are indication for further testingtesting

SummarySummary

A thorough, thoughtful evaluation to include a A thorough, thoughtful evaluation to include a history, physical, voiding diary, and simple history, physical, voiding diary, and simple urodynamics will enable the physician to urodynamics will enable the physician to understand the pathophysiology of a patient’s understand the pathophysiology of a patient’s symptoms sufficiently to formulate a reasonable symptoms sufficiently to formulate a reasonable course of therapy in most cases.course of therapy in most cases.

However, the clinician must recognize the However, the clinician must recognize the findings which will require further evaluation to findings which will require further evaluation to include multi channel urodynamic testing. include multi channel urodynamic testing.