URINARY INCONTINENCE APPROACH

HISTORY
Age, Parity
Analysis of Incontinence: Duration, frequency, amount
Precipitating factors
3Ps: Position, Protection, Problem
Progression
Urinary Diary
Association
Irritative sx (Freq, Urgency, Nocturia) urge
Obstructive sx (Poor stream, Incomplete void, Straining) overflow
Recurrent UTI urge
Past Obs Hx: Mode of Delivery. Instrumental?, Prolonged 2 nd stage? Baby birth W8.
Past Gynea Hx: Sx of Prolapse, Pelvic surgery, Hx of malignancy, Hx of radiotherapy
PHYSICAL EXAM
General Look
Abdominal Exam
Respiratory Exam
Neurological exam Mental status, Gait, Lower extremity, Perineal sensation & reflexes.
Pelvic Exam
Pelvic floor muscle tone
Stress test - >90% diagnostic for stress inc
Cotton swab @ Q-tip test
INVESTIGATIONS
1. Urine analysis & culture
2. Urodynamic studies
a. Non-invasive methods:
i. Uroflowmetry
ii. Volume-frequency chart
iii. Ultrasound: Residual Volume, Urethral cyst, Diverticulation of urethra
iv. EMG by surface electrodes
b. Invasive methods
i. Cystometry
ii. Urethral Pressure Profilometry
iii. RV by Catheter
iv. EMG by needle electrodes
3. Ultrasound
4. VCU
5. IVU. Indication: Hematuria, Neuropathic bladder, Uterovaginal fistula.

6. Cystourethroscopy. Indication: Reduced bladder capacity, Short hx (<2yrs) of urgency

& frequency, Persistent UTI, High suspicion of tumors or stone.
7. MRI
UROFLOWMETRY
Normal flow curve: Bell shaped
Normal flow rate >15ml/sec
Normal voidal volume >150ml
CYSTOMETRY
Indications
1. Previous unsuccessful continency
surgery
2. Mixed incontinence
3. Voiding disorder
4. Neuropathic bladder

Normal Values
Residual Volume >50ml
1st Desire to Void: 150-200ml
Bladder Capacity: 400-600ml
Detrusor Pressure (Filling phase):
<15cmH20
Detrusor Pressure (Voiding phase): 4070cmH20
No leakage when coughing

MANAGEMENT
A. CONSERVATIVE
Success rate 40-60%. Mainstay in Stress Inc.
Stop smoking, alcohol, caffeine. Kegel exercise.
Intravaginal device to support bladder neck & urethra.
B. MEDICAL
Mild-Moderate Stress Incontinence
Alpha-Agonist
Pseudoephedrine
Phenylpropanolamine

Urge Incontinence
Anticholinergic Drugs
Oxybutynin chloride
Tolterodine
TCA: Imipramine

C. SURGICAL [Stress Incontinence]

Colposuspension

Tension-free Vaginal Tape (TVT)