Gynecology [URINARY INCONTENINCE]

Stress Incontinence
With multiple or large births the cardinal ligament gets bladder Abdominal pressure (à) is
stretched. This weakens the pelvic floor and the bladder falls into translated to both sphincter and
the vagina - a high-grade cystocele. So the sphincter of the bladder
vagina
bladder falls into the vagina, while most of the bladder remains in
the abdomen. In a normal patient abdominal pressure is translated
to both the bladder and the sphincter; the patient has to relax the
sphincter to void. In a cystocele, as abdominal pressure increases
it’s translated to the bladder but not the sphincter. Thus, there’s
loss of urine with any increase in abdominal pressure (cough,
sneeze, tennis) but no loss any other time. The diagnosis is made
Abdominal pressure (à) is
clinically: cystocele can be seen on exam (physical) and there
translated to bladder only
will be a rotation of the urethra by more than 30o on the Q-Tip causing leak
Test. No additional testing is required. Treatment begins with
attempts to strengthen the pelvic floor using pessaries and will
eventually require surgery (Burch, MMK, or anterior vaginal
repair).
Normal Pressure-Volume Cystometry
This is the only form of urinary incontinence that is unique to Notice that pressure increases naturally
women. All others can be found in both men and women. as volume increases

Pressure
Motor Urge or Hypertonic
The normal bladder fills with urine. At around 250cc there’s the
urge to void. 500cc plus and it begins to hurt. The bladder does
not contract until the patient relaxes the sphincter and chooses to
void. In motor urge incontinence there are random detrusor
muscle contractions that occur at any time, randomly, and at all Volume
volumes. The patient can sense (urge) the contraction (motor) and
will have involuntary loss of urine day and night with frequent,
Motor Urge Cystometry
insuppressible urges. The diagnosis can often be made clinically Spastic contractions at all
though cystometry will demonstrate contractions at all volumes. volumes, low and high.
All other testing (urinalysis, urine culture, physical exam) are
normal. Quell these contractions with antispasmodics such as
Solifenacin or other anti-muscarinic drugs such as oxybutynin or
Pressure
propantheline.

Overflow or Hypotonic
Lesions of the spine or nerves of any kind (trauma, diabetic
neuropathy, multiple sclerosis) can induce overflow
incontinence. The patient loses sensory feedback indicating
Volume
fullness, and can’t sense the urge to void. The patient may lose
the motor outputs that initiate bladder contractions, even if the
sensation of fullness is intact. Either way, the bladder gets
massively distended - filled with urine. Eventually, the intrinsic
Overflow Cystometry
stretch of the bladder muscles contracts against massive pressure.
No contractions occur, urine
A small amount of urine dribbles out, decreasing the pressure to leaks only at high volumes, at
just under critical. As the kidneys filter more urine the volume very high pressures
slightly increases to just over the critical pressure - more urine
leaks. Then there’s a constant balance of “just too
Pressure

Volume

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 Gynecology [URINARY INCONTENINCE]

much” and “just under enough” where the patient has involuntary
loss of urine day and night without the urge or ability to void.
Additionally, the bladder never empties. Physical exam,
urinalysis, and urine culture are normal. Cystometry
demonstrates absent detrusor contractions and an always full
bladder. To treat the condition we either need to induce
contractions with bithanechol with timed voids or use regular
and scheduled catheterization to relieve the pressure. Some
patients may have permanent foley or suprapubic catheters in
place.

Irritative Bladder
Some kind of inflammation (stones, infection, tumor) irritates
the lining of the bladder and produces contractions. Unlike
hypertonic, they’re suppressible. The patient will present with the
typical symptoms of urinary inflammation (i.e. a UTI): urgency,
frequency, and dysuria. A urinalysis will show WBC. If
leukocyte esterase, nitrates, or bacteria are seen it’s infectious and
a culture will speciate the organisms. If not, cytology will help
confirm or reject cancer. The medicine section has lectures
dedicated to UTI, Kidney Stones, and cancer. Essentially,
infection gets antibiotics, stones get passed, lithotripsy or
nephrostomy depending on their size, and cancers need surgery.
Be able to recognize the symptoms of irritative bladder in
OB/GYN and know that no cystometry is needed; U/A and Urine
culture are sufficient for the diagnosis.

Fistula
Fistulas are epithelialized connections between one organ and
another. One such fistula can be from the bladder to any other
organ such as the vagina, rectum, or skin. Fistulas are caused by
inflammatory disease (such as Crohn’s) or with radiation
exposure (as in cancer treatment). There’s a permanent
connection without valve or sphincter between the bladder and
the connected organ. Thus there’s a constant and continuous
leak of urine day and night. The dye tampon test can be used to
determine if there’s a fistula or not. Dye injected into the bladder
will appear on a tampon in the vagina or rectum (or visually seen
leaking from the skin) indicating the fistulous tract. Surgical
repair is curative - a LIFT procedure, a fistulotomy.

Path Urine Nocturnal Patient Diagnosis Treatment

Stress Big babies Cough, Sneeze, No Cystocele Q-Tip Test Pessary
Incontinence Multiple Births Tennis Surgery
Motor Urge Detrusor Random Yes Insuppressible urges Cystometry Anti-Ach
Hypertonic Instability Day and Night medications
Overflow Spinal Lesions Dribble, Yes Involuntary loss, bladder Cystometry Bethanecol
Hypotonic Neuro dysfxn Day and Night never empties
Irritative Stones, Cancer U/F/D No Urgency, Frequency, Urinalysis Antibiotics
Bladder Infection, Dysuria Urine Culture Surgery
Fistula Radiation, Constant Leak Yes Constant leak Tampon Test Surgery,
Cancer, Crohn Fistulotomy

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