Stress urinary incontinence - case and brief

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  • 2014-04-09
  • Stress urinary incontinence - case and brief

    1. 1. Case Presentation- Stress Urinary Incontinence Clerk 李翰泓 #9301
    2. 2. Patient’s information Name: 李○郁 Chart number: 11285654 Age: 52 y/o Gender: F Occupation: Tour guide
    3. 3. Patient’s information (cont.) ● Past history: 1.LAVH for uterine myoma on 2012-03 2. UTI 3. Thalassemia, type unknown 4. Hypertension ● OB/GYN history: o G3P2A1, CS, last menstruation: 2012-03, s/p LAVH ● Family history: noncontributory
    4. 4. History ● Tour guide for years o Hold back urine and help carry heavy baggages because of her job ● She suffers urinary tract infection frequently o Especially during summer, almost every day in summer vacation o The symptoms are: urgency, low abdominal pain and burning sensation during urination
    5. 5. History (Cont.) ● The patient has occasional urine leakage after coughing or sneezing for years ● In the last 5 years, the patient has been suffering from continuous urinary disorder o Difficult urination, drippings after urination, frequent urination (up to 1 time/0.5 hr) o Most serious episode: all urine leak out after coughing in a winter vacation o Most of her colleagues suffer from similar disorder
    6. 6. Urodynamics exam (2014-04-09) ● Post void residual: 0 ml ● CMG: filling capacity: 364 ml, normal cystometrogram , leak with cough, first leakage at abdominal pressure 147 cmH2O, won’t leak after Valsalva ● UPP: Maximal urethral pressure of H51 cm2O, maximal urethral closure pressure of 33 cmH2O, functional urethral length of 30 mm ● Stress UPP: Negative pressure over whole urethra, average transmission rate: 51% ● PAD test: 2-10 gram
    7. 7. Urodynamics exam (2014-04-09) (Cont.) ● Uroflowmetry: Voided 430 ml over 53 sec, peak flow is 14 ml/sec, and the mean flow is 8 ml/sec ● Pressure flow study: First sensation at 168 ml, normal desire at 249 ml, strong desire at 364 ml, urgency at 416 ml. Bladder infused volume 421 ml. The patient’s voiding mechanism was accomplished by detrusor contraction and valsalva effort. She did not silence after her EMG ● Assessment: stress urinary incontinence
    8. 8. Operation ● Anterior repair: o Anterior vaginal wall longitudinal incision, close the defect of pubocervical fascia ● TVT: o Adjust tapes and curve needles were inserted, the tape was adjusted by compression test under bladder 350 cc NS
    9. 9. Operational outcome ● Remove Foley on 2014-05-05, post op day #3, re-on Foley due to urine retention ● Post void volume (2014-05-06, post op day #4): 137 ml (morning), 0 ml (afternoon) ● Need adjustment or not?
    10. 10. Stress urinary incontinence
    11. 11. Introduction ● Unintentional loss of urine ● Prompted by physical activity which may increase abdominal pressure o coughing, sneezing, running, heavy lifting ● Not related to psychological stress ● Age as the single largest risk factor o Female is two times more common than male
    12. 12. Etiology ● Sphincter and pelvic muscle floor weakness o Childbirth o Prostate surgery o Other ● Congenital weakness of bladder ● Urethral mucosa damage
    13. 13. Contributory factors ● Illness that cause chronic cough or sneeze ● Obesity ● Smoking - which cause frequent cough ● Excess consumption of caffeine or alcohol ● High impact activities for many years ● Hormone insufficiency
    14. 14. Symptoms & Signs ● More vulnerable for unintentional urine loss when doing activities that would increase abdominal pressure o Could be both sign and symptom ● Usually in multiparous, elder women ● Frequency and urgency o DDx from detrusor instability
    15. 15. Evaluation ● Mid Stream Urine (MSU) ● Uroflowmetry o Detrusor muscle contractility and urinary tract obstruction o normal flow rate: 15 ml/sec ● Cystometry and video urethrography o Evaluate urine leakage and detrusor instability ● Pad test
    16. 16. Genuine Stress Incontinence ● This diagnosis can only be made via uroflowmetry o Urine leak during rise of intra-abdominal pressure o Without detrusor muscle activity
    17. 17. Treatment ● Initial treatment o Lifestyle  Weight loss  Dietary changes o Behavioral therapy  Bladder training  Pelvic muscle exercise  Biofeedback  Cognitive therapy
    18. 18. Treatment (Cont.) ● Medications o Duloxetine  A SNRI, contraindicated in chronic liver disease patient o Estrogen  Vaginal estrogen instead of systemic usage, which may worsen it o Other  Alpha-adrenergic agent no longer recommended
    19. 19. Surgical intervention - 1 ● Anterior colporrhaphy o for patient with cystocele ● Endoscopic bladder neck suspension o for patient with bladder neck and ureter hypermobility ● Burch Colposuspension o adhese the endopelvic fascia to Cooper’s ligament or rectus muscle
    20. 20. Surgical intervention - 2 ● Marshall-Marchetti-Krantz operation ● Left: MMK, Right: Bruch ● MMK may not cure cystocele
    21. 21. Surgical intervention - 3 ● Tension-free vaginal tape
    22. 22. Surgical intervention - 4 ● TVT v.s. TVT-O o TVT for younger, active, and patient with internal sphincter deficiency, which provide greater supportive angle, and cause less pain to inguinal area o TVT-O for older, heavier and patient underwent TVT, which is easier conducted, less likely to cause bladder injury
    23. 23. Reference 1. http://www.glgacenter.com/images/tvt_02.jpg 2. http://wd.vghtpe.gov.tw/obgy/File/%E6%99%A8%E9%96%93%E6%95% 99%E5%AD%B8/16stress%20urinary%20incontinence.ppt 3. http://www.mayoclinic.org/diseases-conditions/stress- incontinence/basics/definition/con-20027722 4. http://www.sciencedirect.com/science/article/pii/S0957584701902094 5. http://emedicine.medscape.com/article/452289-overview#a0156 6. Uptodate: Treatment and prevention of urinary incontinence in women 7. http://www.tcs.org.tw/profession/article/index_info.asp?med_id=81 8. http://www.surgeryencyclopedia.com/Ce-Fi/Colporrhaphy.html 9. http://www.atlasofpelvicsurgery.com/3BladderandUreter/2RetropubicUr ethropexy/chap3sec2.html

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