Epidemiology (EPINCONT study, approx. 30,000 Norwegian women):
- Severity of incontinence increases with age
- 1 in 4 women have experience incontinence, but only 1 in 15 had symptoms of significant incontinence.
- 26% of women with incontinence consulted their doctor.
- 54% of women with severe incontinence consulted their doctor.
- 64% of women with worsening incontinence, or who were "bothered" by their symptoms consulted their doctor.
Workup:
General Approach:
- H&P, urinalysis
- Voiding diary and pad test. (document timing and volume of voids for at least 24 hrs, also document how many pads per day).
- Urodynamics, if not clearly stress urinary incontinence.
Bennett:
Only order urodynamics if it will change your treatment plan.
If primary urge incontinence, then try one or two meds before considering urodynamics.
If primary stress incontinence, try pelvic PT, pessaries before urodynamics, but don't do surgery until urodynamics is completed.
*When choosing a type of sling:
- TVT: use if there is known pelvic pain or if pt has ISD.
- TOT: on bimanual before surgery, make sure obturator muscle is not already tender.
Phelps:
- History - stress vs urge symptoms, etc...
- Patient empties bladder to leave urinalysis.
- Place foley to check post-void residual
- Leave foley in and place 60ml syringe with plunger removed.
- 60ml are poured into syringe to bladder at a time.
- A rise is the level of fluid in the syringe is a sign of detrusor instability.
- Back fill bladder with 250ml for cough test.
Lawrence:
- History - stress vs urge symptoms, etc...
- Have patient empty bladder for urinalysis.
- Straight cath for post-void residual and check for urethral hypermobility (valsalva with straight cath in, and >30 degrees from horizontal is positive)
*Does not do the cough test
Urodynamics:
Normal Uroflow:
- Volume greater than 200 mL over 15 to 30 seconds
- Maximum flow rate greater than 15 mL/sec (after correction for artifact)
- Continuous single curve (as opposed to short spikes) of flow
*Flow rates less than 15 mL/sec may indicate outlet obstruction, detrusor weakness, or significant Valsalva effort during voiding. An acontractile detrusor is unable to initiate a contraction and will lead to overflow incontinence.
- Women younger than 25 have a mean maximum urethral closure pressure of 90 cm H2O, while women older than 64 have a mean of 65 cm H2O.
- Leak point pressure below 60 cm H2O to confirm the diagnosis of intrinsic sphincter deficiency.
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Urinary Urgency:
- Bladder training instructions
Effect of selected medicines and other agents on bladder function