Urinary incontinence and pelvic organ prolapse
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Pelvic organ prolapse (POP) and stress urinary incontinence (SUI) coexist in up to 80 percent of women with pelvic floor dysfunction [1]. While these conditions are often concurrent, one may be mild or asymptomatic, which makes selection of the optimal surgical procedure(s) challenging. Prolapse repair can unmask urinary incontinence in previously continent women or worsen existing SUI symptoms [2].
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Urinary incontinence and pelvic organ prolapse
- 1. Urinary Incontinence and Pelvic Organ Prolapse PRESENTED BY: MUKESH SAH, MD POST-GRADUATE MEDICAL INTERN GOODSAM MEDICAL CENTER
- 2. Urinary Incontinence and Pelvic Organ Prolapse Epidemiology 10-20%, aged 15-64 years 30-40%, > 60 years 50%, long-term care facility * Iselin, CE and Webster, GD: Urol Clin N Amer 1998 † Samuelsson, EC, et al.: Am J Obstset Gyencol 1999 ‡ Suback, LL, et al.: Obstet Gynecol 2001 Females patients comprise 40% of a general urology practice 50%, > 50 years of age 30-50%, lifetime prevalence 354,962 operations/year, US data (1997) Urinary incontinence * Pelvic Organ Prolapse † ‡
- 3. How Many People Have Incontinence? 13 million Americans of all ages suffer from urinary incontinence Women account for nearly 85%
- 4. What Is Incontinence? Incontinence is the unintentional release of urine Embarrassing; unpredictable condition; it can cause women to: Avoid an active lifestyle Shy away from social situations Constantly search for the nearest bathroom Become too embarrassed to talk to their doctor
- 5. Urinary Incontinence A Hidden Condition * Two-thirds of patients are symptomatic for 2 years before seeking treatment 30% of patients who seek treatment receive no assessment Nearly 80% are not examined * Survey conducted by Gallup Group (European Study Patients self-manage by voiding frequently, reducing fluid intake and wearing pads
- 6. Urinary Incontinence Barriers to Treatment Patient misconceptions and fears “Normal part of aging” “Not severe or frequent enough to treat” “Too embarrassing to discuss” “Treatment won't help”
- 7. Are There Different Types of Incontinence?
- 8. Classification of Incontinence Symptom Categories * Stress incontinence Urge incontinence Unconscious incontinence Continuous leakage Nocturnal enuresis Post-void dribble Extra-urethral incontinence Geriatric incontinence
- 9. Screening and Diagnosis of Overactive Bladder Assess history, symptoms, and test results Establish a diagnosis “Do you have bladder problems that are troublesome or do you ever leak urine?” YES
- 10. Past History Medical History Diabetes mellitus GI complaints/Constipation Neurological disorders Prior CVA Multiple sclerosis Parkinson’s disease Surgical Incontinence and prolapse surgery, hysterectomy Radical pelvic surgery (prostatectomy, APR) Spinal surgery Bladder outlet procedures
- 11. Obstetrical/Gynecological Number of children (vaginal or cesarean) Vaginal deliveries Number Large birth weight Forceps delivery Menopausal status Estrogen replacement
- 12. SUI Subjective Data Precipitating events Minimal provocation: quiet walking, bending Moderate provocation: coughing, sneezing Significant provocation: strenuous exercise Magnitude of stress incontinence Drops v. complete void Frequency of episodes Type of pads used: liners, maxipads or diapers How many used daily Changed when wet, damp or dry (changed by habit)
- 13. Urge Incontinence Triggers “Key in the door”, hand washing Rising from the seated position Coughing, walking, jumping “Urge Syndrome” symptoms Frequency Nocturia Urgency Urge incontinence
- 14. OAB and Stress Incontinence Differential Diagnosis Symptom Assessment History and Physical Examination Abrams P, Wein AJ. The Overactive Bladder: A Widespread and Treatable Condition. Erik Sparre Medical AB; 1998. Symptoms Overactive bladder Stress incontinence Urgency (strong, sudden desire to void) Yes No Frequency with urgency (>8 times/24 h) Yes No Leaking during physical activity; eg, coughing, sneezing, lifting No Yes Amount of urinary leakage with each episode of incontinence Large (if present) Small Ability to reach the toilet in time following an urge to void Often no Yes Waking to pass urine at night Usually Seldom
- 15. Urinary Incontinence Differential Diagnosis * Condition Detrusor overactivity Causes Idiopathic Neurogenic UTI Bladder cancer Outlet obstruction Condition Urethral hypermobility ISD Causes Pelvic floor relaxation Prior pelvic surgery Neurogenic Stress Urge
- 16. Physical Examination Abdominal prior surgical scars distended bladder obesity Back/Spine skeletal deformities scars from trauma/surgery tuft of hair, skin dimple Neurological mental status sensory function motor function reflex integrity
- 17. Pelvic Examination Moderately full bladder Components Visual inspection Speculum exam Assessment of pelvic floor strength Bimanual exam
- 18. Pelvic Examination Inspection Labia Signs of estrogenization Introitus Atrophy/stenosis Posterior injury from childbirth Perineum Wide perineum or posteriorly displaced anus may indicate weakened perineal body/pelvic muscle atrophy
- 19. Speculum Examination Systematic Anterior vaginal wall and urethra Vaginal apex Posterior vaginal wall Valsalva/strain or cough Stage Baden-Walker (halfway down v. POPQ)
- 20. Anterior Compartment Urethral or bladder decent +/- Q-tip test Incontinence (Quantity relative to valsalva) Cystocele Lateral defect • Corrected by replacing the lateral fornices to the sidewall (using ring forceps) Central defect • Smooth surfaced (loss of rugae) herniation not corrected by lateral replacement
- 21. Vaginal Apex and Posterior Compartment Position of cervix or vaginal cuff Cervical descent with straining Cervical mucosal appearance Rectocele Bulge close to the introitus generally Confirm with simultaneous DRE Graded similar to cystocele Enterocele Bulge generally higher in vault Bidigital rectovaginal exam essential
- 22. Objective Data Voiding diary Pad weight test Laboratory tests Cystourethroscopy Urodynamics Eyeball urodynamics Multichannel urodynamics
- 23. Voiding Diary (3-5 days) Date, time and volume of each void Record of each incontinent episode time amount precipitating cause of leakage
- 24. Pad Weight Test Only truly objective measure of incontinence 1ml urine roughly equals 1gm Weight of wet pad minus sample dry pad 24-hour test best for urge and stress incontinence 1-hour pad test standardized by ICS good measure of SUI
- 25. Laboratory Evaluation Urine analysis and culture BUN and creatinine Hematuria Cytology Upper tract evaluation (IVP or CT) Cystoscopy
- 26. Cystoscopy Urethra Urethritis (shaggy, erythematous, painful mucosa), atrophy (pale), diverticulum, FB Stricture Bladder Outlet (contracture, BPH) Neoplasia Ureteral orifice (location and number) Diverticuli Calculi and foreign bodies
- 27. Urodynamics * Not generally required in most patients with uncomplicated incontinence * Erickson and Davies, AUA update series, 1999 (11) In neurologically intact patients, one can proceed with noninvasive empiric therapy if history, physical and urinalysis do not suggest serious pathology
- 28. Urodynamics * Indications Initial tests inconclusive Prior corrective surgery for incontinence Prior radical pelvic surgery or radiotherapy Neurologic disorder Mixed stress/urge with unclear relative contribution
- 30. Behavioral Modificatio n Education Delayed Voiding Timed Voiding Reinforcement Pelvic Floor Exercises Management of Urinary Incontinence Behavioral Modifications
- 31. Urge Incontinence Rule-out neurological disorders Radicular pain Paresthesias Muscle weakness Diminished sensation Ocular symptoms (MS) Bladder outlet obstruction Risk factors for TCC of the bladder
- 32. Distribution of Muscarinic Receptors
- 34. THANK YOU