genitourinary disorders
Urinary Incontinence in Adults
Evaluation of Urinary Incontinence in Adults
Most patients, embarrassed to mention incontinence, do not volunteer information about it, although they may mention related symptoms (eg, frequency, nocturia, hesitancy). All adults should therefore be screened with a question such as “Do you ever leak urine?”. Clinicians should not assume that incontinence is irreversible just because it is long-standing. Also, Urinary Retention must be excluded before treatment for detrusor overactivity is started. Most patients are embarrassed to mention incontinence, so ask all adults about incontinence. History focuses on duration and patterns of voiding, bowel function, drug use, and obstetric and pelvic surgical history. A voiding diary can provide clues to causes. Over 48 to 72 hours, the patient or caregiver records volume and time of each void and each incontinent episode in relation to associated activities (especially eating, drinking, and drug use) and during sleep. The amount of urine leakage can be estimated as drops, small, medium, or soaking; or by pad tests (measuring the weight of urine absorbed by feminine pads or incontinence pads during a 24-hour period). If the volume of most nightly voids is much smaller than functional bladder capacity (defined as the largest single voided volume recorded in the diary), the cause is a sleep-related problem (patients void because they are awake anyway) or a bladder abnormality (patients without bladder dysfunction or a sleep-related problem awaken to void only when the bladder is full). Of men with obstructive symptoms (hesitancy, weak urinary stream, intermittency, feeling of incomplete bladder emptying), about one third have detrusor overactivity without actual obstruction. Urgency or an abrupt gush of urine without warning or without preceding increase in intra-abdominal pressure (often called reflex or unconscious incontinence) typically indicates detrusor overactivity. Neurologic, pelvic, and rectal examinations are the focus. Neurologic examination involves assessing mental status, gait, and lower extremity function and checking for signs of peripheral or autonomic neuropathy, including Orthostatic Hypotension . Neck and upper extremities should be checked for signs of cervical spondylosis or stenosis. The spinal column should be checked for evidence of prior surgeries and for deformities, dimples, or hair tufts suggesting neural tube defects. Innervation of the external urethral sphincter, which shares the same sacral roots as the anal sphincter, can be tested by assessing: Perineal sensation Volitional anal sphincter contraction (S2 to S4) The anal wink reflex (S4 to S5), which is anal sphincter contraction triggered by lightly stroking perianal skin The bulbocavernosus reflex (S2 to S4), which is anal sphincter contraction triggered by pressure on the glans penis or clitoris However, the absence of these reflexes is not necessarily pathologic. can identify atrophic vaginitis and Urethritis , urethral hypermobility, and pelvic floor weakness with or without pelvic organ prolapse. Pale, thin vaginal mucosae with loss of rugae indicate atrophic vaginitis. Urethral hypermobility can be seen during coughing when the posterior vaginal wall is stabilized with a speculum. A cystocele, an enterocele, a rectocele, or uterine prolapse suggests can identify Fecal impaction , rectal masses, and, in men, prostate nodules or masses. Prostate size should be noted but correlates poorly with outlet obstruction. Suprapubic palpation and percussion to detect bladder distention are usually of little value except in extreme acute cases of Urinary stress testingcan be done on the examination table if stress incontinence is suspected; this method has a sensitivity and specificity of>90%. The bladder must be full; a patient sits upright or close to upright with the legs spread, relaxes the perineal area, and coughs vigorously once: Immediate leakage that starts and stops with the cough confirms stress incontinence. Delayed or persistent leakage suggests detrusor overactivity triggered by the cough. If cough triggers incontinence, the maneuver can be repeated while the examiner places 1 or 2 fingers inside the vagina to elevate the urethra (Marshall-Bonney test); incontinence that is corrected by this maneuver may respond to surgery. Results can be false-positive if patients have an abrupt urge to void during the test. Results can be false-negative if patients do not relax, the bladder is not full, the cough is not strong, or a large cystocele is present (in women). In women with large cystoceles, the test should be repeated with the patient supine and the cystocele reduced, if possible Urinalysis, urine culture Serum bloodureanitrogen (BUN), creatinine Postvoid residual volume Sometimes urodynamic testing for estimation of protein-free calcium levels) if the voiding diary suggests Polyuria , electrolytes if patients are confused, and vitamin B12 levels if clinical findings suggest a neuropathy. Postvoid residual volumeshould be determined by catheterization or ultrasonography (preferred). Postvoid residual volume plus voided volume estimates total bladder capacity and helps assess bladder proprioception. A volume<50 mL is normal;<100 mL is usually acceptable in patients>65 but abnormal in younger patients; and>100 mL may suggest detrusor underactivity or outlet obstruction. Urodynamic testingis indicated when clinical evaluation combined with the appropriate tests is not diagnostic or when abnormalities must be precisely characterized before surgery. Cystometrymay help diagnose urge incontinence, but sensitivity and specificity are unknown. Sterile water is introduced into the bladder in 50-mL increments using a 50-mL syringe and a 12- to 14-F urethral catheter until the patient experiences urgency or bladder contractions, detected by changes in fluid level in the syringe. If<300 mL causes urgency or contractions, detrusor overactivity and urge incontinence are likely. Peak urinary flow rate testingwith a flow meter is used to confirm or exclude outlet obstruction in men. Results depend on initial bladder volume, but a peak flow rate of<12 mL/sec with a urinary volume of≥200 mL and prolonged voiding suggest outlet obstruction or detrusor underactivity. A rate of≥12 mL/sec excludes obstruction and may suggest detrusor overactivity. During testing, patients are instructed to place their hand on their abdomen to check for straining during urination, especially if stress incontinence is suspected and surgery is contemplated. Straining suggests detrusor weakness that may predispose patients to postoperative retention. In cystometrography,pressure-volume curves and bladder sensation are recorded while the bladder is filled with sterile water; provocative testing (withbethanecholor ice water) is used to stimulate bladder contractions. Electromyography of perineal muscleis used to assess sphincter innervation and function. Urethral, abdominal, and rectal pressures may be measured. usually done with voiding Cystourethrography , can correlate bladder contraction, bladder neck competency, and detrusor-sphincter synergy, but equipment is not widely available. 