�UroToday.com - The incontinent patient is evaluated in order to make a presumptive diagnosing so that treatment can be offered. The evaluation begins with a history and a physical examination. The history focuses on the description of the patient's incontinence.
Although the history may define the patient's job it crataegus laevigata be shoddy. Urge incontinency may be triggered by activities such as coughing so that by history the patient would seem to get stress incontinence. A patient who only when complains of urge may also hold stress dissoluteness. Mixed self-gratification is very common with at least 65% of patients with stress self-gratification having associated urgency or urge incontinency. It crataegus laevigata be impossible to find out by history alone which is the more significant problem. Assessing the patient's bother and determining their expectations of treatment english hawthorn further guide how aggressive one needs to be both with the rating and the presentation of treatment options.
The of import parts of the physical exam ar an scrutiny of the abdomen and pelvis including a provocative stress screen. If the test is done resupine and thither is no leakage it should be repeated standing, as this will addition the patient's abdominal pressure. A uranalysis and a post-void rest (PVR) should be performed in all incontinent patients.
Incontinence questionnaires, voiding diaries, and tablet weight tests can provide more objective data than the history alone. Upper tract imaging is indicated in the patient with a history of hematuria and in patients with suspected hydroureteronephrosis. Other mental imagery may be useful to further assess other suspected pelvic pathology. Urodynamics ar performed to determine if the incontinency is due to bladder or urethral dysfunction or both, to assess if the patient has a storage or emptying job and lastly in an effort to identify patients whose upper tracts are at risk due to high vesica storage pressures.
The most common mental defectiveness of bladder function is detrusor over activity that causes urge incontinence. Detrusor over activity is defined as the inability to suppress nonvoluntary detrusor contractions during filling.1 A cystometrogram may fail to demonstrate whatever detrusor over activity in a patient who has urge incontinence by history. Any patients with symptoms of exhort incontinence by history should be presumed to have urge incontinency. The purpose of urodynamics is non to diagnose detrusor over activity simply to prove compliance, to diagnose stress incontinence, to rule extinct obstruction as a causal agent of either overflow or urge dissoluteness and to insure that the patient has a reasonable, safe, bladder capacity.
The diagnosing of stress incontinence is best made with measurement of the abdominal atmospheric pressure required to induce urinary loss, the Valsalva or abdominal news leak point pressure level and, or fluoroscopy. Stress incontinence is diagnosed if there is urethral loss of piss associated with an eL of abdominal pressure. Valsalva leak point pressure (VLPP) is secondhand to diagnose stress incontinency since it is ab pressure that is the expulsive force in stress incontinence. Measurement of the VLPP allows for quantification of the degree of urethral dysfunction. A normal urethra testament not leak at whatever pressure. A mobile urethra will leak at high abdominal pressures (>120 cm H2O) and a indisposed functioning intrinsic sphincter will leak at low pressures (
A pressure flow test is indicated in the patient in whom obstruction is suspected. Such patients would let in the patient who has had a prior procedure for stress incontinence, the patient with a turgid post evacuate residual or the patient role with pregnant prolapse and obstructive or irritative symptoms. No universally accepted definition of bladder outlet blockage in women exists. Usually bladder release obstruction is defined as high pressure-low flow. However since some women normally void with very low-pitched detrusor pressures it is difficult to define a high detrusor pressure in women. In patients with emptying problems or suspected neurogenic dysfunction an EMG may be indicated. Cystoscopy is indicated in the work up of some incontinent patients.
The valuation of the incontinent affected role consists of a history, a physical, urinalysis and a postvoid residual. Optional evaluative tests consist of a variety of urodynamic tests, tomography studies and cystoscopy.
References:
1. International Continence Society Committee on Standardization of Terminology of lour urinary tract function. Neurourol. Urodyn., 7; 1988, 403.
2. McGuire, E.J., Fitzpatrick, C.C., Wan, I., Bloom, D., Sanvordenker, J., Ritchey M., and Gormley, E.A., J Urol, Clinical assessment of urethral anatomical sphincter function. one hundred fifty: 1993, 1452.
Presented by: E. Ann Gormley, MD, FACS, at the Masters in Urology Meeting - July 31, 2008 - August 2, 2008, Elbow Beach Resort, Bermuda
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