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Urinary Incontinence and Prolapse

Probably more than 17 million Americans have this problem. Half of all nursing home patients are affected by urinary incontinence and may are in the nursing home because of their urinary incontinence. When you are doing an evaluation for urinary incontinence or prolapse, you have certain goals that you want to establish. In simple evaluations and even when I am seeing a patient for the first time, what I am basically trying to do is establish urge incontinence and stress.

Simple components of this whole evaluation were established in a careful review done by the Agency for Health Care Policy and Research, which I believe is now called the Agency for Health Care Quality and Research. That included a history and physical examination; you can't get away from those things; and only the diagnostic tests of the post void residual and the urinalysis to initiate therapy. There are certainly some more details behind the history and physical exam, and we will go a little bit beyond post void residual and urinalysis.

Additional tests that are frequently done include uroflowmetry and simple cystometry, cystoscopy and then multichannel urodynamics with voiding studies as well as storage studies and stress incontinence testing.

The goals of history are basically to quickly identify reversible causes of incontinence, whether it is from drug interaction, such as using an alpha blocker, or incontinence that has been augmented by diuretic use, a simple quality of life impact assessment, but overall when we are trying to diagnose urge and stress incontinence, study after study seems to indicate that whenever you are doing a detailed history there are limitations to identifying true stress or urge incontinence as compared to urodynamic findings. This certainly does not negate the importance of the history and I would say that it is impossible to treat somebody effectively without a good history. You can use the history to serve as a guide for focus of your evaluation and treatment.

There are many different questionnaires available. Our office questionnaire, as many of our office questionnaires are, encompasses four or five pages. Certainly, not all of that is devoted to urinary symptoms, but in many ways, they could be. Questions that relate to stress incontinence are certainly very obvious: Do you leak urine when you cough, laugh or sneeze? Urge incontinence symptoms would be stated; Do you have an uncomfortably strong need to urinate and do not reach the toilet in time? How many times a day do you urinate ? Increased frequency would certainly be a sign of the overactive bladder, more predisposed to urge incontinence. And then quantifying the amount of urine leakage by quantifying pad use. Questions of this nature are the mainstay of the history and of course, you also want to get into other factors in terms of their medical history . These could include medical problems that involve diuretic use or use of alpha blockers that could easily reduce urethral tone and predispose to stress incontinence. Overall, as I said, we are trying to do the job of distinguishing urge and stress incontinence.

The clinical assessment of pelvic support involves a straightforward breakdown of anterior, posterior and apical compartments. The anterior defects, as we all well know, are cystocele, paravaginal defect and the assessment of urethral support, or apex support relative to uterine prolapse or vaginal apex descent from a post hysterectomy vaginal vault prolapse type of enterocele. Posterior vaginal wall defects can be actually high enterocele, rectocele and the capacious vaginal outlet with perineal laxity.

For the technique of examination, we want to evaluate the degrees of relaxation at rest as well as with maximal straining. Actually, the most important information is with maximal straining or cough. I will examine patients in the standing position frequently; I think I am in the minority when it comes to that, but at the start of each examination, before the patient gets on the table, I will do a standing cough stress test. I will pretty much not have them void before the examination, as I go right to some simple bladder testing as part of my examination. I will take them with whatever bladder volume they have, do a rigorous standing cough stress test and observe for urinary leakage and also observe for any prolapse that may be obstructing leakage or obstructing urination. In many ways, I think this is more easily identifiable than after someone is laying down. Arguably, that is not necessary, but I do find it informative and if you are already doing a standing cough stress test, you can at least see if there is an obstructing bulge. If you have a negative cough stress test and you have a large bulge through the introitus, or at least a prominent one, it may be important to reduce that bulge by holding the apex up, and I do like to do that right at the start of the examination. I would use either a proctoswab, one of those large Q-tip type rectal swabs, or the posterior blade of a speculum to hold the apex up and do another cough stress test with the prolapse reduced to look for occult stress incontinence or even occult increased stress incontinence.

When inspecting the introitus, you will assess the estrogen status and also the inflammatory status of the tissues and get a good look at the urethral meatus for similar findings. The speculum is placed directly in to visualize the apex and then you would withdraw the speculum to about the mid vagina. As you withdraw the speculum, you frequently have the patient bear down to assess how far down that apex is going to come as you remove support from it. In that way, you can judge your actual apex descent, independent of possibly obscuring anterior or posterior wall descent. You replace a single blade of the speculum against the posterior wall of the vagina and assess anterior support under straining. Paravaginal assessment is actually something that I find is done differently by different people. I tend to like to use, at least in my office, a ring forceps to elevate the paravaginal areas and see how much prolapse I am going to reduce as I do that. Even with well supported nascent paravaginal tissue, you can get a ring forceps in there and really kind of push things up and hold the urethra up and give yourself the impression that you are correcting a large paravaginal defect, which is correcting the full sweep.