Evaluation of Stress Urinary Incontinence

Article No. 6

Evaluation of Stress Urinary Incontinence

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INTRODUCTION

Urinary incontinence (UI), according to the International Continence Society, is defined as the involuntary loss of urine. The most commonly recognized subtypes of UI are stress urinary incontinence (SUI), urge urinary incontinence (UUI), and mixed urinary incontinence (MUI).

History taking & Examination: To categorize as SUI, UUI /overactive bladder syndrome (OAB), MUI or overflow UI and to help understand the underlying cause and identify factors that may impact treatment decisions:

• Duration
• Most bothersome one
• Frequency
• Precipitants
• Other factors: previous pelvic surgeries, comorbid conditions, current medications, for her urinary problems or some other indications, symptoms of pelvic organ prolapse, defecatory dysfunction, pelvic pain and sexual dysfunction
• Medical, neurological, obstetric and gynaecological history

Examination:

• General and abdominal examination to rule out enlarged bladder or other abdominal mass. Careful assessment of oestrogen status and any associated genitourinary prolapse; and Pelvic floor assessment with digital examination of the rectum and vagina.
• A cough stress test: Any leakage of urine with coughing vigorously; with bladder empty or filled, with patient supine or standing; is considered positive test. Interpretation: A positive empty supine stress test indicative of intrinsic sphincter deficiency.
• Hypermobility: Quantify the degree of hypermobility by measuring the angle of deflection from horizontal of the swab inserted into the urethra during cough or Valsalva maneuver. Interpretation: When urine leakage occurs without urethral hypermobility intrinsic sphincter deficiency is suspected.

 

 

Other Modalities for Diagnosis:

1. Patient questionnaires
2. Voiding diaries
3. The pad test
4. Urinalysis with urine culture sensitivity
5. Post-voiding residual volume: Amount of urine that remains in the bladder after voiding. Both bladder outlet obstruction and detrusor underactivity contribute to the development of PVR.
6. Imaging: To understand the anatomical and functional abnormalities
7. Urodynamics: Determines the functional status of the bladder and urethra

• Uroflowmetry : A free-flow void into a recording device, quantifying the volume of urine passed, the maximum (Qmax) and average rate of urine flow (Qave), voiding time, flow time and time to maximum flow .Qave in women usually ranges from 17 to 24 ml/s.
• Pressure flow studies (PFS) –Voiding Cystometry : Detrusor pressure is measured during controlled bladder filling and subsequent voiding with measurement of flow rate.
• Videourodynamics: Involves use of contrast medium instead of saline, to assess position and mobility of bladder neck in addition.
• Ambulatory Urodynamics:Functional test of the lower urinary tract, using natural filling and reproducing the patient’s everyday activities; Indication: as in neurogenic lower urinary tract dysfunction

Normal urodynamic parameters in women

 

 

Urethral Pressure Studies

1. Leak point pressures : Detrusor leak point pressure (DLPP)- lowest detrusor pressure at which urine leakage occurs in absence of either detrusor contraction or increased abdominal pressure
   Abdominal leak point pressure (ALPP) or Valsalva leak point pressure (VLPP)- intravesical pressure at which urine leakage occurs due to increased abdominal pressure in the absence of a detrusor contraction -measurement of urethral function or outlet competence.
2. Urethral Pressure Profilometry (UPP)- continuous fluid pressure needed to just open a closed urethra. Maximum urethral pressure (MUP)- maximum pressure of the measured profile                             
   Maximum urethral closure pressure (MUCP)- maximum difference between urethral pressure and intravesical pressure

 

 

3. Urodynamics should not be routinely carried out when offering conservative treatment for UI and with defined clinical diagnosis of pure stress UI.

Indications: when findings may change the choice of surgical treatment

prior to surgery for UI

symptoms of OAB

history of previous surgery

suspicion of voiding difficulty

Guidelines on indications for urodynamics are not widely implemented, resulting in practice variation in workup of women with UI.

At present, the urodynamic outcomes hardly influence the choice of treatment.

Stress testing with reduction of the prolapse should be done in women with high grade pelvic organ prolapse but without the symptom of SUI.

Conclusion

UI is a common symptom that can affect women of all ages, with a wide range of severity and nature. Hence extent and interpretation of its evaluation must be with a defined protocol- identify the type of incontinence, understand its effect on the quality of life and expectations from the treatment, associated problems, and thorough and effective counseling so that a consensus is met as regards the treatment to be planned.

Today’s necessity is to perform more studies on current diagnostic modalities like urodynamic investigation and how to combine different diagnostic modalities in a way to to create a more uniform algorithm for UI and make evaluation less cumbersome and easy to access.