Management of urinary incontinence in postmenopausal women: An EMAS clinical guide. 360(5):481-90. Int Urogynecol J Pelvic Floor Dysfunct. Urethral hypermobility is important, as well as intrinsic sphincter deficiency and the pathophysiology of stress urinary incontinence. Edward David Kim, MD, FACS is a member of the following medical societies: American Society for Reproductive Medicine, American Urological Association, Sexual Medicine Society of North America, Society for Male Reproduction and Urology, Society for the Study of Male Reproduction, Tennessee Medical AssociationDisclosure: Serve(d) as a speaker or a member of a speakers bureau for: Endo. Urinary Incontinence in Women. Neurourol Urodyn. Is intrinsic sphincter deficiency a complication of simple hysterectomy?. Some practitioners have the patient arrive with a full bladder, measure the volume voided, and then catheterize the patient to obtain a postvoid residual measurement. 166(6 Pt 1):1835-40; discussion 1840-4. Incontinence occurs off the top of a chronically over-filled bladder. Gordon D, Groutz A, Ascher-Landsberg J, Lessing JB, David MP, Razz O. Double-blind, placebo-controlled study of magnesium hydroxide for treatment of sensory urgency and detrusor instability: preliminary results. Without effective treatment, urinary incontinence can have an unfavorable outcome. [Medline]. The cost of treating urinary incontinence in United States alone is $16.3 billion, 75% of which is spent on treatment of women. 2007 Nov. 110(5):1034-40. 1999 Mar. Short-term tests have the advantage of convenience and assured compliance. 2016 Sep 7. Int Urogynecol J Pelvic Floor Dysfunct. It can severely, adversely affect a person’s quality of life (QoL) (McCarthy, 2009). A detailed pelvic floor examination should be performed for signs of pelvic organ prolapse. Patients with symptoms of an overactive bladder are aware of the intense need to void but are unable to hold back urine. [Medline]. [26] Cerebrovascular disease doubles the risk for urinary incontinence in older women. [46], Howard et al described functional and morphologic differences in the urethral sphincteric and support system of nulliparous black and white women. [Medline]. In addition, the following points regarding the clinical presentation should be sought when obtaining the history: Severity and quantity of urine lost and frequency of incontinence episodes, Duration of the complaint and whether problems have been worsening, Triggering factors or events (eg, cough, sneeze, lifting, bending, feeling of urgency, sound of running water, sexual activity/orgasm), Constant versus intermittent urine loss and provocation by minimal increases in intra-abdominal pressure, such as movement, changes in position, and incontinence with an empty bladder, Associated frequency, urgency, dysuria, pain with a full bladder, and history of urinary tract infections (UTIs), Concomitant symptoms of fecal incontinence or pelvic organ prolapse, Coexistent complicating or exacerbating medical problems, Obstetrical history, including difficult deliveries, grand multiparity, forceps use, obstetrical lacerations, and large babies, History of pelvic surgery, especially prior incontinence procedures, hysterectomy, or pelvic floor reconstructive procedures, Lifestyle issues, such as smoking, alcohol or caffeine abuse, and occupational and recreational factors causing severe or repetitive increases in intra-abdominal pressure. Patients experience a sense of incomplete emptying, slow-flowing urine, and urinary dribbling. [52] However, hypermobility is present in most cases of stress incontinence. [Medline]. The clinical presentation of urinary incontinence can be varied in many respects. People with incontinence often live with this condition for 6-9 years before seeking medical therapy. [Medline]. Wojcik LJ, Kaplan GW. Although the ultimate well-being of a patient with urinary incontinence depends on the precipitating condition, urinary incontinence itself is easily treated and prevented by properly trained health care personnel. Patients describe continuous dribbling of urine and typically require a high volume of pad use. A badly compromised perineal body may be short and consist of mostly skin with little or no underlying muscle. Abrams P, Cardozo L, Khoury S, et al, Eds. 2011 Jan 12. [Medline]. Menopause. The change in angle when the swab is deflected upward with maximal strain, indicated by the arc of the wooden end of the swab, is measured with a goniometer or estimated visually. Bladder Neck Plication Stitch: A Novel Technique During Robot-Assisted Radical Prostatectomy to Improve Recovery of Urinary Continence. [Medline]. [Medline]. Urinary stress incontinence among obese women: review of pathophysiology therapy. Curr Med Res Opin. 2007 Mar. With improvement in information technology, well-trained medical staff, and advances in modern medical knowledge, patients with incontinence should not experience the morbidity and mortality of the past. 2008 Mar 6. Surgical options for urge incontinence are limited and have a high morbidity. Kuismanen K, Sartoneva R, Haimi S, et al. 2013 Jan. 166(1):107-10. Daneshgari F, Imrey PB, Risendal B, Dwyer A, Barber MD, Byers T. Differences in urinary incontinence between Hispanic and non-Hispanic white women: a population-based study. The theory is best appreciated and understood with the help of illustrations and diagrams showing directional force vectors. Generally, this represents a significant breech in the storage capabilities of the bladder or urethra. Neurourol Urodyn. Urodynamic study records abdominal leak point pressure (ALPP) of 55 cm H2O, consistent with ISD. 2006 Feb. 175(2):601-4. [Medline]. [Full Text]. Women with normal pelvic anatomy should have a resting cotton-swab angle of 0° with respect to the floor. Kelleher CJ, Cardozo LD, Khullar V, Salvatore S. A new questionnaire to assess the quality of life of urinary incontinent women. This study points out that bladder neck procedures need not be performed if potential incontinence has been ruled out, even if bladder neck hypermobility is present. Assessing comfort, safety, and patient satisfaction with three commonly used penile compression devices. Petros PE, Woodman PJ. Am J Med. Serati M, Braga A, Cattoni E, Siesto G, Cromi A, Ghezzi F, et al. Spinal cord lesions can alter sympathetic and parasympathetic tone, resulting in urinary incontinence. Share cases and questions with Physicians on Medscape consult. 1994 May. Castillo PA, Espaillat-Rijo LM, Davila GW. 1998 May. 2000 Feb. 163(2):531-4. The Marshall test is performed by placing an index finger and the second finger on either side of the bladder neck, to support the proximal urethra. [Medline]. Paik SH, Han SR, Kwon OJ, Ahn YM, Lee BC, Ahn SY. Studies of the pathophysiology of idiopathic detrusor instability: the physiological properties of the detrusor smooth muscle and its pattern of innervation. Detrusor overactivity. Urinary incontinence in the Netherlands: Prevalence and associated risk factors in adults. Mishra GD, Barker MS, Herber-Gast GC, Hillard T. Depression and the incidence of urinary incontinence symptoms among young women: Results from a prospective cohort study. [Medline]. 2017. Classification of urinary incontinence into types allows the clinician to make an educated guess at a particular anatomic abnormality that warrants further investigation. But most of those women would not desire treatment for that incontinence; urine leakage might occur during a fit … Jensen JK, Nielsen FR Jr, Ostergard DR. Aging, hypoestrogenism, chronic connective tissue strain due to primary loss of muscular support, activities or medical conditions resulting in long-term repetitive increases in intra-abdominal pressure, and other factors can contribute. 2016 Oct 6. Medscape Medicine News. In multiple sclerosis (MS), demyelinating plaques in the frontal lobe or lateral columns can produce lower urinary tract disorders. Eur Urol. 193 (5):1572-80. [Full Text]. [Medline]. [16] In addition, during stress maneuvers, the urethra did not rotate and descend as a single unit; rather, the posterior urethral wall moved farther than the anterior wall. Br J Urol. Staskin D, Frankel J, Varano S, Shortino D, Jankowich R, Mudd PN Jr. Once-Daily Vibegron 75 mg for Overactive Bladder: Long-Term Safety and Efficacy From a Double-Blind Extension Study of the International Phase 3 Trial (EMPOWUR). It can range from being a minor problem to something that greatly affects your daily life. 2015 May. Obstet Gynecol. Outcome measures and definition of cure in female stress urinary incontinence surgery: a survey of recent publications. Nygaard et al examined the prevalence of symptomatic pelvic floor disorders in women in the United States and found no difference among non-Hispanic whites (16%), Hispanics (15.9%), non-Hispanic blacks (13.8%), and other races (15%). J Endourol. 2017 Oct 24. 2016 Nov. 33 (11):1528-1535. 54(6):M299-303. Tumors of the superior medial frontal lobe, spinal cord tumors above the conus medullaris, and cervical spondylosis can cause detrusor hyperreflexia. J Urol. In diagnosing occult incontinence, the goal is to avoid new-onset incontinence following surgical correction of prolapse. The patient stands upright with feet shoulder-width apart. Next, attention is turned to the posterior vaginal wall. An estimated 50-70% of women with urinary incontinence fail to seek medical evaluation and treatment because of social stigma. [Medline]. Clinical Case, You are being redirected to 79(6):865-78. Diabet Med. Pharmacologic and Nonpharmacologic Treatments for Urinary Incontinence in Women: A Systematic Review and Network Meta-analysis of Clinical Outcomes. Reflex incontinence is due to neurologic impairment of the central nervous system. Med Clin North Am. 367(19):1803-13. Although it is more common in older women, it can affect younger women as well. Am J Med. A simple analogy is that of a garden hose (urethra) running over a pavement surface (anterior endopelvic connective tissue). This tool may be a valuable adjunct to pretherapy and posttherapy assessment, as well as valuable in comparing the quality of life impact of different urodynamic diagnoses. Long-term tests are conducted under normal living conditions for 24-48 hours. The urethra is then compressed shut against the firm support provided by the anterior vaginal wall and associated endopelvic connective tissue sheath. When obtaining a clinical history, determining whether the problem is a social and/or hygienic problem and the degree of disability attributable to the incontinence also is important. [Full Text]. [Medline]. 2005 Feb 23. Saint S, Elmore JG, Sullivan SD, Emerson SS, Koepsell TD. The individual is instructed to perform specific activities such as coughing, running in place, bending and lifting, and hand washing. [Guideline] O'Reilly N, Nelson HD, Conry JM, Frost J, Gregory KD, Kendig SM, et al. Int Urogynecol J Pelvic Floor Dysfunct. Other signs of a diverticulum might include tenderness and purulent or watery discharge upon compression. Prevalence and severity of undiagnosed urinary incontinence in women. [Medline]. A suburethral mass should raise suspicion for a urethral diverticulum. A Female Pelvic Medicine and Reconstructive Surgery fellowship is now accredited as a subspecialty by the American Board of Obstetrics and Gynecology (ABOG) and the American Board of Urology (ABU). Sensation of the perineum and perianal area should be tested with a soft touch and light prick. Metastatic carcinoma can cause epidural spinal cord compression. Eur Urol. The authors believe that the primary abnormality in detrusor overactivity is at the detrusor muscle level with an increased capacity for spontaneous myogenic contractile activity and spread of electrical activity from cell to cell, resulting in tetanic contractions. He also has a small bladder capacity (50 mL) due to chronic bladder outlet obstruction. Obstet Gynecol. Serati M, Braga A, Cattoni E, Siesto G, Cromi A, Ghezzi F, et al. Part of the difficulty has been in defining the degree, quantity, and frequency of urine loss necessary to qualify as pathologic, with varying definitions among studies. 169 (5):320-328. Some children may become so preoccupied with activities that voiding is delayed until capacity is reached and accidents result. 2001 Jan. 97(1):116-20. 317 (24):2493-2501. N Engl J Med. Some patients with stress incontinence have urine leakage into the proximal urethra that may, at first, trigger sensory urgency and/or bladder contractions, which initially are suppressible. Then, gently pull back on the cotton swab until the cotton is snug against the bladder neck. [Medline]. One study found that in patients with stress incontinence, a representative and reproducible measure of incontinence episodes and mean daily voids can be obtained with a 3-day diary. Am J Obstet Gynecol. [Medline]. N Engl J Med. [Medline]. Petros PE, Woodman PJ. Eur J Clin Nutr. Evidence from animals to humans. Appell RA, Sand P, Dmochowski R, Anderson R, Zinner N, Lama D, et al. It is not a normal part of aging or something that you just have to live with. 2016 Oct 4. Urinary frequency, urgency, and nocturia complement urge incontinence symptom complex. [Medline]. The anatomic support of the urethra may be normal. 2000 May. Detrusor dysfunction may consist of impaired contractility, detrusor overactivity, or both. This research found that 93% of patients with stress incontinence displayed funneling of the proximal urethra with straining, and half of those individuals also showed funneling at rest. Honda M, Kimura Y, Tsounapi P, Hikita K, Saito M, Takenaka A. A clear understanding of the current concepts, pathophysiology, and typical symptoms of voiding dysfunction and pure nocturnal enuresis usually allows the clinician to distinguish these troublesome but benign problems from true underlying pathological conditions of the urinary tract. Edward David Kim, MD, FACS Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center A pad test is a useful adjunct to the patient's history and physical examination. [Medline]. 9(3):140-4. A 2009 survey of women in a managed care population found that the prevalence of undiagnosed urinary incontinence was 53% in the preceding year. J Urol. Peripheral nerve disease such as diabetic peripheral neuropathy can cause urinary incontinence through a contractile dysfunction of the bladder. Vitamin D and incident urinary incontinence in older adults. Relevant complicating or exacerbating medical problems may include the following: Chronic obstructive pulmonary disease (COPD). 358(10):1029-36. 316 (13):1366-1374. Part the labia if the tissue is touching the wooden shaft of the swab because this may impair movement during straining. Urinary incontinence is a symptom that can be the result of various causes which include anatomic, physiologic, and pathologic factors affecting the urinary tract. The pelvic floor examination is an integral part of the incontinence evaluation. A study that used receiver-operating characteristic analysis of the swab test found that the optimal cut-off point for the change in angle from resting to straining was 30° or more, which had a sensitivity of 82% and a specificity of 54%. Urinary incontinence affects up to 7% of children older than 5 years, 10-35% of adults, and 50-84% of the elderly persons in long-term care facilities. The following points regarding the clinical presentation should be sought when obtaining the history: Relevant complicating or exacerbating medical problems may include the following: Medications that may be associated with urinary incontinence include the following: Successful treatment of urinary incontinence must be tailored to the specific type of incontinence and its cause. The speculum is then disarticulated, and a single blade examination is performed, inspecting the anterior vaginal wall during straining with the posterior wall retracted. Consequently, the prevalence of urinary incontinence reported in the literature is varied. 2017 Jun 27. [Medline]. [Medline]. [Medline]. Jul 9 2014. Exp Ther Med. [3], Stress: Urine leakage associated with increased abdominal pressure from laughing, sneezing, coughing, climbing stairs, or other physical stressors on the abdominal cavity and, thus, the bladder The pubocervicovesical or anterior endopelvic connective tissue in the area of the bladder neck is attached to the back of the pubic bone, the arcus tendineus fascia pelvis, and the perineal membrane. Clinicians should prioritize urinary incontinence detection, identify and treat modifiable factors, incorporate patient preference into evaluation and treatment, initiate conservative and medica … Urinary Incontinence in Women: A Review JAMA. [52]. Evaluation of Female Urinary Incontinence Medscape Womens Health. Behavioral therapy with or without biofeedback and pelvic floor electrical stimulation for persistent postprostatectomy incontinence: a randomized controlled trial. [Medline]. [Medline]. [1] Costs associated with UI have been estimated at $5 billion per year. Pad testing can be used if the history strongly suggests stress incontinence, stress test findings are negative, and detrusor instability is ruled out. Primary incontinence disorders generally are due to congenital structural disorders, including ectopic ureter, exstrophy, epispadias, and patent urachus. [Medline]. Typically, patients with cervical cord lesions manifest detrusor hyperreflexia. Both indwelling catheters and intermittent catheterization have a range of potential complications (see Treatment). In addition to urinary tract infection, conditions such as bladder cancer, bladder stones, and foreign bodies can irritate the bladder, resulting in involuntary bladder contractions and incontinence. Ann Intern Med. Characteristically, patients with stress incontinence display immediate loss of a few drops to a brief squirt of urine. Although data concerning urinary incontinence in people of different races are sparse, reports are emerging that race may play an important role in the prevalence and likelihood of reporting of incontinence. (See the images below.). [41], Sears et al reported that, among patients with incontinence, urge incontinence was more common in black women (51.5%), whereas stress incontinence was statistically significantly more common in white women (66.2%). [Medline]. Delancey JO, Ashton-Miller JA. Then, the patient is instructed to squeeze the examining fingers, and the levator strength can be appreciated. The extrapyramidal system is believed to have an inhibitory effect on the micturition center; theoretically, loss of dopaminergic activity in this area could result in loss of detrusor inhibition. Relationship Between Central Obesity, General Obesity, Overactive Bladder Syndrome and Urinary Incontinence Among Male and Female Patients Seeking Care for Their Lower Urinary Tract Symptoms. Stones or neoplasms may also result in incontinence due to obstruction. 2018 Sep 4. 2005 Mar. Ann Intern Med. [Medline]. [15] Normally, an acute increase in intra-abdominal pressure applies a downward force to the urethra. 2008 Sep 17. Gastroenterology. Appell RA, Sand P, Dmochowski R, Anderson R, Zinner N, Lama D, et al. [Medline]. In addition, a disorder of the spinal cord or central nervous system (CNS) may be the major etiologic factor in some cases. The uroflow pattern is without abnormality, producing a bell-shaped curve without any abdominal straining. Neurourol Urodyn. 2016 Oct 4. Int Urogynecol J Pelvic Floor Dysfunct. The levator muscles are palpated, and the resting tone is noted. 2009 Nov. 122(11):1037-42. [Medline]. J Urol. [Full Text]. OnabotulinumtoxinA vs Sacral Neuromodulation on Refractory Urgency Urinary Incontinence in Women: A Randomized Clinical Trial. The cotton swab test is used to assess urethral mobility in women. 18(4):359-64. [Medline]. A less common cause of stress incontinence is intrinsic sphincter deficiency, which can result from the aging process, pelvic trauma, surgery (eg, hysterectomy, [Medline]. Observation of leakage during Valsalva maneuver or cough denotes a positive test result. Anatomical assessment of the bladder outlet and proximal urethra using ultrasound and videocystourethrography. Nazir T, Khan Z, Barber HR. September 19, 2013. Using a cotton swab, the anal wink pelvic floor reflex can be elicited by stroking laterally to the anal canal. Int Urogynecol J Pelvic Floor Dysfunct. The patient then is asked to strain. Chutka DS, Fleming KC, Evans MP, Evans JM, Andrews KL. In this situation, the entire contents of the bladder are lost rather than a few drops of urine. Chaikin DC, Groutz A, Blaivas JG. PLoS One. Neurourol Urodyn. New ambulatory surgical methods using an anatomical classification of urinary dysfunction improve stress, urge and abnormal emptying. BJU Int. Test-retest reliability of the cough stress test in the evaluation of urinary incontinence. Duckett JR, Aggarwal I, Patil A. Duloxetine treatment for women awaiting continence surgery. 2010 Jul. Obstet Gynecol. The racial distribution of female pelvic floor disorders in an equal access health care system. Labrie J, Berghmans BL, Fischer K, Milani AL, van der Wijk I, Smalbraak DJ, et al. [4, 5] Urge urinary incontinence is involuntary leakage accompanied by or immediately preceded by urgency. One mechanism is reflex, or voluntary, closure of the pelvic floor. Only 5% of incontinent individuals in the community and 2% in nursing homes receive appropriate medical evaluation and treatment. For patient education information, see Incontinence & Overactive Bladder Health Center and Incontinence in Men. Note the presence of multiple uninhibited detrusor contractions (phasic contractions) that is generating 40- to 75-cm H2O pressure during the filling cystometrogram (CMG). Nygaard I, Holcomb R. Reproducibility of the seven-day voiding diary in women with stress urinary incontinence. Black women demonstrated a 29% higher average urethral closure pressure during a maximum pelvic muscle contraction. Each pad is preweighed and then weighed again after use by the patient at home, or, alternatively, the pad is placed in an airtight plastic bag and weighed later by the clinician. Additional causes of urethral dysfunction include pelvic radiation or neurologic injury, including myelomeningocele. [Medline]. Surgery versus physiotherapy for stress urinary incontinence. This increased interest is arising among basic scientists, clinical researchers, and clinicians. Efficacy and Safety of OnabotulinumtoxinA in Patients with Urinary Incontinence Due to Neurogenic Detrusor Overactivity: A Randomised, Double-Blind, Placebo-Controlled Trial. J Am Geriatr Soc. 2017 Oct 24. 2011 Jun. Incontinence worsens during high-impact sports activities such as golf, tennis, or aerobics. 2010 Feb. 26(2):253-61. 95 (4):580-6. 63(5):872-8. [39, 26]. Her uroflow rate is low (1 mL/s), detrusor pressure is high (42 cm H2O), and the EMG recording is elevated. [Medline]. 2011 Sep 23. Morgan JL, O'Connell HE, McGuire EJ. For discussion of this topic, see the article Overactive Bladder. Wallner LP, Porten S, Meenan RT, O'Keefe Rosetti MC, Calhoun EA, Sarma AV, et al. Relative obstruction develops because of mechanical factors, dynamic factors, and detrusor alterations. Urinary incontinence (UI) is a common problem affecting up to two thirds of all women. Nov 2006;17(6):563-5. 1997 Mar-Apr. Fedorkow DM, Sand PK, Retzky SS, Johnson DC. 2001 Apr. McFall S, Yerkes AM, Bernard M, LeRud T. Evaluation and treatment of urinary incontinence. 2015 Aug. 81 (4):456-61. [55] If the initial diagnosis was mixed incontinence, stress leakage was demonstrated on a second cough stress test 80% of the time. BJU Int. Krause P, Fuhr U, Schnitker J, Albrecht U, Stein R, Rubenwolf P. Pharmacokinetics of intravesical versus oral oxybutynin in healthy adults: results of an open label, randomized, prospective clinical study. Thus, phasic contractions are suppressed. 2018 Oct 28. Other studies do not support this theory, however. Patients with coexisting pelvic organ prolapse may report dyspareunia, vaginal pain upon ambulation, and a bulging sensation in the vagina. Lai HH, Helmuth ME, Smith AR, Wiseman JB, Gillespie BW, Kirkali Z, et al. Urinary incontinence. Medications that may be associated with urinary incontinence include the following: Angiotensin-converting enzyme (ACE) inhibitors. 2002 Anticholinergic therapy vs. onabotulinumtoxina for urgency urinary incontinence. Adult incontinence treatment and OAB … Anticholinergic therapy vs. onabotulinumtoxina for urgency urinary incontinence. Wein AJ, Rackley RR. N Engl J Med.
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