Three13 112 Evaluation and management of women with urinary incontinence and pelvic prolapse

Incontinence is the involuntary passage of urine. 

Stress incontinence - incontinence with any activity that increases intra-abdominal pressure. This is typically indicative of weakness in the urinary sphincter and can be seen in multiparous women, postmenopausal women, and men who have had a radical prostatectomy or another procedure affecting the outlet (aggressive transurethral resection of the prostate [TURP]). Treatment - increase the resistance of urinary outlet. 

Urge incontinence - involuntary passage of urine coincident with sensation of urinary urgency. This is often a symptom of severe overactive bladder, cystitis, or neurogenic bladder or may occur in patients with poorly compliant bladders. Treatment - relax bladder. 

Mixed urinary incontinence  - Stress + Urge Incontinence 

Continuous incontinence - independent of the urge to urinate or maneuvers associated with increased intra-abdominal pressure. associated with fistula, congenital (ectopic ureter) or totally incompetent sphincter


Pseudoincontinence - chronic vaginal discharge, labial fusion may result in retention of urine within the vaginal vault 

Overflow (false) incontinence - paradoxical incontinence, overflow incontinence occurs when the urinary volume within the bladder approaches and exceeds bladder capacity, resulting in an increase in intravesical pressure greater than urethral outlet resistance. This is likely to occur at night when the patient is less likely to guard against this incontinence. Guarding is a voluntary contraction of the pelvic floor muscles in an attempt to prevent urinary incontinence and can occur with any cause of urinary incontinence. Overflow incontinence can be resolved by treating the outflow obstruction, hence the paradoxical nature of this incontinence. 

Functional incontinence - patients may have intact bladder-outlet anatomy and physiology but may simply be unable to move in time to void such as hip fracture or dementia, that limits mobility or the ability to process information about bladder fullness

Enuresis

• Stress urinary incontinence
• • Symptoms with coughing, sneezing or exercise
• • No nocturia
• • Small-volume leakage on voiding diary (5–10 ml)
• • Positive cough stress test
• • Post-void residual volume of <50 ml

• Urgency urinary incontinence
• • Symptoms of urgency
• • Variable volume loss on voiding diary
• • Frequency and nocturia typical
• • Negative cough stress test
• • Post-void residual volume of <50 ml

• Mixed urinary incontinence
• • Symptoms with both physical activity and urgency
• • Variable volume loss on voiding diary
• • Positive cough stress test
• • Post-void residual volume of <50 ml

• • Grade 0 Incontinence without leakage
• • Grade 1 Incontinence with only severe stress, such as coughing, sneezing, and jogging
• • Grade 2 Incontinence with moderate stress, such as fast walk, going up and down the stairs
• • Grade 3 Incontinence with mild stress such as standing

Type 1 - incontinence due to loss of posterior urethrovesical angle alone 

Type 2 - Inconntinnence due to loss of posterior urethrovesical angle as well as urethral hypermobility 

Type 3 - Incontinence due to intrinsic sphincteric deficiency

• At rest the urethra makes an angle of 90-100 degrees with the base of the urinary bladder called the posterior urethrovesical angle.
• The urethra also makes an angle of less than 30 degrees with the vertical line.

• Done to objectify the evaluation of urethral mobility.
• The Q-tip is inserted into bladder through the urethra and the angle that the Q-tip moves from horizontal to its final position with straining is measured.
• Hypermobility is defined as a Q-tip angle of >30 degrees from horizontal.

• In the POP-Q system, which was created in an effort to provide objectivity to POP quantification, nine specific points of measurement are obtained in relation to the hymenal ring.
• 

• Six vaginal points labeled Aa, Ba, C, D, Ap, and Bp are measured during the Valsalva maneuver.
• Points above the hymen are considered negative, and points below
• the hymen are positive.
• The genital hiatus (gh) represents the size of the vaginal opening, and the perineal body (pb) represents the distance between the vagina and the anus.
• The total vaginal length (tvl) is measured by reducing the prolapse and measuring the depth of the vagina.

• The AUA guideline on the surgical treatment of female SUI stated that the following are the components of an initial evaluation of a woman with SUI who is desiring surgical intervention (Clinical Principle):
• - focused history, including assessment of bother (e.g., via validated questionnaire),
• - focused physical examination (including pelvic examination),
• - objective demonstration of SUI with a comfortably full bladder (e.g., cough or Valsalva stress test),
• - PVRU - PVR <50 represents adequate emptying and PVR >200 represents inadequate emptying, there is no consensus recommendation regarding the significance of PVR between 50-200cc. 
• - urinalysis

• Additional tests 
• - cystoscopy 
• - UDS - UDS may be omitted in the index patient when SUI is clearly demonstrated. In patients with significant POP, urodynamic study should be performed with and without POP reduction (e.g with sponge stick or pessary). In women with SUi, low MUCP and abdominal leak point pressure (ALPP) are often used as indicators of urethral dysfunction. Maximum Urethral Closure Pressure (MUCP) <20 cm H2O is indicative of type III SUI.

A one-hour pad test using a standardised exercise protocol and a diagnostic threshold of 1.4 g shows good specificity but lower sensitivity for symptoms of SUI and MUI. A 24-hour pad test using a threshold of 4.4 g is more reproducible but is difficult to standardise with variation according to activity level.

• Delerium
• Infection (urinary tract infection)
• Atrophic vaginitis/urethritis
• Psychological (e.g., severe depression, neurosis)
• Pharmacologic
• Excess urine production
• Restricted mobility
• Stool impaction

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