Evaluation of Female Urinary Incontinence

, , University of Texas Medical School

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In This Article

The History

Assessing the onset and severity. Once leakage of urine is established as the problem, the clinician can assess the severity of the condition by asking about the number of pads the patient requires to protect clothing and the degree of activity impairment associated with the disorder. Urinary leakage may have a dramatic effect on lifestyle, and it may force an otherwise normal, active person to become reclusive as a result of malodor and sudden leakage of urine in public. The degree of distress experienced by those with incontinence varies. Although the goal of therapy is complete continence, subjective patient attitudes toward leakage influence the therapeutic approach.

In general, the onset of the disorder is not clearly related to any particular life event, but it is unusual for nulliparous, premenopausal women to complain of stress incontinence. Some women date their incontinence to a period after a particular vaginal delivery. The associations between parity,[1,2] vaginal delivery,[3] and incontinence are relatively well established.

When incontinence follows a particular surgical procedure, the onset may be better defined. For example, following a urethral suspension procedure, the patient may be aware of a stitch "giving way" and subsequently note recurrent stress incontinence. Menopause seems to be a time for the exacerbation of urinary symptoms, although the relationship is not direct.[4] In elderly women with stress incontinence, the symptoms may be of relatively short duration. Type III stress incontinence (discussed later in this article) is often found in this group.

Although incontinence is broadly divided by urethral or bladder causes, patients commonly have a combination of both causative factors. Symptoms of urgency, urge incontinence, and enuresis may be the only evidence that bladder dysfunction is a contributing cause of incontinence. Testing with a cystometrogram (CMG) for detrusor instability may be negative even in patients with urge incontinence.[5] If pure stress incontinence is present--related to either a hypermobile urethra or intrinsic sphincter deficiency--leakage generally does not occur at night (unless urethral function is extremely poor). Thus the presence of enuresis or nocturia suggests that the bladder, in addition to the urethra, may be contributing to the problem. Urge incontinence usually means that the detrusor is overactive even if the cystometrogram is negative.[5]

Irritative bladder symptoms, voiding dysfunction, sexual dysfunction, dysuria, stress incontinence, urge incontinence, and the sensation of a vaginal mass may be associated with genital prolapse.[6,7] In the presence of a large, prolapsing vaginal mass, clinical urinary incontinence may be completely masked.[7,8] When urethral dysfunction coexists with genital prolapse, urethral dysfunction should be identified and categorized prior to correction of the prolapse condition so that both can be repaired simultaneously. Also, if an enterocele or rectocele is overlooked on preoperative evaluation, these conditions are often exacerbated after stress incontinence surgery or correction of a cystocele, and they may manifest as significant postoperative problems.[9]

A thorough history of prior treatments for incontinence and the duration of their effect and degree of efficacy should be noted. Following failure of a single stress incontinence procedure, the most likely problem is recurrent urethral hypermobility-related stress incontinence. Following failure of more than 1 procedure, the probability of type III stress incontinence is much higher.[10] A past history of urethral surgery, particularly internal urethrotomy or transurethral bladder neck incision, may be associated with late onset of type III stress incontinence. Where multiple stress incontinence procedures have been performed, retropubic or periurethral scarring often makes any subsequent procedure more difficult.

Lifestyle and activity factors. It is important to determine a woman's exercise tolerance and the level of exercise that is typical or desirable for her. If she is a serious athlete, then a more robust operative approach (e.g., a sling) would be a better surgical approach than a needle suspension. If the patient's exercise tolerance is very poor, and activity causes cardiac or respiratory distress, treatment that causes relatively little cardiorespiratory disturbance (e.g., collagen or estrogen therapy) may be more appropriate.[11] The patient's availability for repeated treatment may also be an issue. A woman with a busy daytime job and/or young children, or one who lives a long distance from the site of treatment, may be better suited to a surgical treatment rather than injectable therapy or pelvic-floor exercises. Patients with chronic obstructive pulmonary disease (COPD) and those who smoke heavily are often better suited to undergo a sling procedure rather than a standard suspension. Intercourse-related incontinence may be the worst type of urinary incontinence.[12]

Current medications. Frequently, elderly patients are prescribed multiple drugs, many of which may have effects on urinary function. In an uncontrolled study, Gormley and colleagues[13] reported that patients taking calcium-channel blockers had the lowest incidence of incontinence, whereas those taking beta-blocking medication appeared to have the highest incidence. Medications that may exacerbate incontinence include diuretics (especially loop diuretics), sedatives, alpha-receptor-blocking agents such as prazosin, and other drugs.[14]

Coexistent health problems. Concomitant disorders such as diabetes, hypertension, COPD, and obesity have implications for anesthetic and surgical risk as well as for the choice of medication to treat incontinence. Diabetics may have autonomic neuropathy with diminished bladder sensation and poor detrusor contractility. These factors may contribute to the severity of the incontinence symptoms or may make common causes of incontinence more difficult to treat. For example, when a patient is treated with a sling for intrinsic sphincter deficiency, the added problem of an insensate, underactive detrusor may preclude the return of normal voiding function.

Systems review. A systems review evaluates the patient's fitness for surgery and the assessment of bowel function, which is of particular relevance when genital prolapse is present or suspected. A thorough neurological systems review and examination are also indicated.

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