Evaluation History Enquire about LUTS (storage or voiding symptoms); triggers for incontinence (cough, sneezing, exercise, position, urgency); frequency and severity of symptoms. Establish risk factors (abdominal/pelvic surgery or radiotherapy; neurological diseases; obstetric and gynaecological history; medications). A validated patient completed questionnaire may be helpful (IPSS, FLUTS, Kings Health, SF36 QOL).
Physical examination Women Perform a pelvic examination in the supine, standing, and left lateral position with a Sim's speculum. Ask the patient to cough or strain, and inspect for vaginal wall prolapse (cystocele, rectocele, enterocele), uterine or perineal descent, and urinary leakage (stress test). Urethral hypermobility is assessed with the Q-tip test. A lubricated cotton-tipped applicator is introduced through the urethra to bladder neck level. Hypermobility is defined as a resting or straining angle of >30° from horizontal.
Both sexes Examine the abdomen for a palpable bladder (indicating urinary retention). A neurological examination should include assessment of anal tone and reflex, perineal sensation, and lower limb function.
Investigation - Bladder diaries: record the frequency and volume of urine voided, incontinent episodes, pad usage, fluid intake, and degree of urgency. Alternatively, pads can be weighed to estimate urine loss (pad testing). - Urinalysis: can exclude UTIs. Blood tests, X-ray imaging, cystoscopy: indicated for persistent or severe symptoms, bladder pain, and voiding difficulties. - Screening tests: flowmetry measures the pressure of urine voided. A low rate indicates bladder outflow obstruction or reduced bladder contractility. The volume of urine remaining in the bladder after voiding (post-void residual) is also useful (<50ml is normal; >200ml is abnormal; 50 - 200ml requires clinical correlation). - Urodynamic investigations: cystometry can measure the minimal pressure at which leakage occurs on straining (abdominal leak point pressure). Pressures >90 - 100cmH2O suggest SUI and hypermobility, <60cmH2O suggests ISD. Videourodynamics can visualize movement of the proximal urethra and bladder neck, and establish the precise aetiology of UI. It can also identify relevant anatomical or neurological abnormalities and risk factors for the development of upper tract deterioration. - Sphincter electromyography (EMG): measures electrical activity from striated muscles of the urethra or perineal floor, and provides information on synchronization between bladder muscle (detrusor) and external sphincter.
Causes and pathophysiology Risk factors - Predisposing factors - gender (female > males) - race (Caucasian > Afro-Caribbean) - genetic predisposition - neurological disorders (spinal cord injury, stroke, MS, Parkinson's disease) - anatomical disorders (vesicovaginal fistula, ectopic ureter, urethral diverticulum) - childbirth - anomalies in collagen subtype - pelvic, perineal, and prostate surgery (radical hysterectomy; radical prostatectomy; TURP) leading to pelvic muscle and nerve injury - radical pelvic radiotherapy
Pathophysiology The underlying aetiology for UI can only be absolutely determined by urodynamic studies. Causes include: Bladder abnormalities Detrusor overactivity is a urodynamic observation characterized by involuntary bladder muscle (detrusor) contractions during the filling phase of the bladder, which may be spontaneous or provoked, and can consequently cause urinary incontinence. The underlying cause may be neurogenic, where there is a relevant neurological condition, or idiopathic, where there is no defined cause. Low bladder compliance is characterized by a decreased volume to pressure relationship, where there is a high increase in bladder pressure during filling due to alterations in elastic properties of the bladder wall, or changes in muscle tone (secondary to myelodysplasia, spinal cord injury, radical hysterectomy, interstitial or radiation cystitis).
Sphincter abnormalities In females there may be functional abnormalities of urethral hypermobility and/or intrinsic sphincter deficiency (ISD). These are the main causes of SUI.
Urethral hypermobility is due to a weakness of pelvic floor support causing a rotational descent of the bladder neck and proximal urethra during increases in intra-abdominal pressure. If the urethra opens concomitantly, there will be urinary leaking.
Intrinsic sphincter deficiency (ISD) describes an intrinsic malfunction of the sphincter, regardless of its anatomical position, which is responsible for type III SUI. Causes include inadequate urethral compression (previous urethral surgery; ageing; menopause; radical pelvic surgery; anterior spinal artery syndrome) or deficient urethral support (pelvic floor weakness; childbirth; pelvic surgery; menopause). In males, the urethral sphincter may be damaged after prostatic or pelvic surgery (TURP; prostatectomy).
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