ISSUES IN UROGYNECOLOGY
| THE MINIMUM WORK-UP OF URINARY INCONTINENCE —Dee E. Fenner, MD, Harold A. Furlong Professor
of Obstetrics and Gynecology and Director, Division of Gynecology, Department of Obstetrics and Gynecology,
University of Michigan Medical School, Ann Arbor
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| Current observations and future projections: 50% to 75% of women complain of urine leakage at some
point in lifetime; leading cause of nursing home placement; significant impact on quality of life; considered
chronic condition with morbid sequelae; increased demand for care of pelvic floor disorders over next 30 yr—
30 to 39 yr of age, 1.7 consults per 1000 woman-years; 70 to 79 yr of age, 18.6 consults per 1000 woman-
years
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| Standardization of terminology of lower urinary tract function (International Continence Society):
symptom—subjective complaint of patient; sign—objective finding by health care provider, including simple
means to verify or quantify symptoms (cough stress test, voiding diary); urodynamic observations—
associated with signs or symptoms and/or urodynamic evidence of relevant pathologic processes; every patient
with incontinence does not require full urodynamic evaluation
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| Case 1: woman 36 yr of age, gravida 2, para 2, presents with symptoms of stress incontinence since delivery of
last child; denies urgency, frequency, or nocturia; wears absorbent pad at all times; supine empty stress test positive;
postvoid residual (PVR) volume 35 mL; clinical considerations—does patient need urodynamic studies
before surgery? does patient need simple single-channel study? does patient require multichannel study or fluorourodynamics
(FUDS)? are there other objective signs of incontinence that might help guide management?
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| Minimal work-up based on Agency for Health Care Policy and Research (AHCPR) guidelines: history,
physical examination, urinalysis, and voiding diary (frequency of urination, en route loss, stress incontinence,
nocturia, insensible loss, and fluid intake); consider transient causes (bladder infection, new
medication); evaluation mnemonic—postvoid residual, urinalysis, diary, stress test (PuADS); helpful in guiding
patient evaluation; stress test—note whether bladder full or empty, position of patient; objective sign
must be evident before considering surgery
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| Role of urodynamic testing in diagnosis and classification of urinary incontinence: data show good
sensitivity for stress incontinence, but specificity poor; urodynamic testing not useful for diagnosing urge or
mixed incontinence; 10% of patients with urinary symptoms have normal cystometry; multichannel studies
not always done, but may be warranted for some patients
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| Case 1 conclusions: patient does not need urodynamic studies before surgery; simple cystometry may be useful;
patient does not require multichannel study or FUDS; patient’s positive stress test objective sign; speaker
opines surgery appropriate for this patient
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| Case 2: woman, 66 yr of age, with urinary incontinence for 15 yr with worsening symptoms of urgency and
stress incontinence; status postvaginal hysterectomy and anterior and/or posterior colporrhaphy 30 yr ago;
PVR 60 mL; urethra appears fixed on examination
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| Candidates for further testing (AHCPR guidelines): if symptoms do not match clinical findings; before considering
expensive therapy or first-line treatment failure; if patient has significant prolapse (concern with function
of lower urinary tract), previous incontinence surgery, neurologic conditions (multiple sclerosis or spinal cord lesions),
or microscopic hematuria (rule out malignancy); data show urodynamic testing not beneficial in diagnosing
detrusor instability; among patients with symptoms of stress urinary incontinence, 10% did not have genuine
stress incontinence confirmed by urodynamic testing
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| Does type of surgery matter? increasing data show traditional midurethral sling effective for intrinsic
sphincter dysfunction (ISD); patients at risk for ISD have—previous incontinence surgery; leaking with any
movement; previous radical pelvic surgery; fixed urethrovesical junction; evidence of sacral nerve damage
with fecal incontinence; study looking at cost-effectiveness of preoperative testing for stress incontinence
showed urodynamic testing did not improve effectiveness of treatment (based on idea that further urodynamic
testing not necessary if sling procedure planned)
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| Case 2 conclusions: urodynamic studies warranted (because patient has symptoms of stress and urge incontinence);
multichannel study or FUDS may be helpful in assessing bladder function, but may not change surgical
management (data show tension-free vaginal tape [TVT] procedure effective with urge incontinence 60%
of time); objective signs—positive stress test or continuous leakage
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| Case 3: woman, 65 yr of age, presents with stage 3 prolapse; first noticed something “dropped” 5 yr ago; denies
urinary incontinence; clinical considerations—history and physical examination, urinalysis, voiding diary,
stress test, and PVR
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| History: intake or standardized questionnaire useful; important to ask patient if she has ever experienced urine
leakage; about one-third of patients had urine leakage before prolapse worsened (prolapse possibly kinking off
urethra or buttressing urethra); evaluate hormone status; evaluate pelvic floor muscles—bulbocavernosus muscle
reflex or anal wink; place 2 fingers in vagina to evaluate strength of pelvic floor muscles; look for substitution
with abdominal gluteal muscles; about one-third of women unable to do Kegel contractions; functional stop
test—counsel patient to do only once to ensure they are performing Kegel exercise correctly; performing routinely
can interfere with normal urinary reflexes; PVR—urinary retention common in patient with stage 3 prolapse;
may resolve with correction of prolapse; no standard for PVR (normal generally <100 mL 20 min after
voiding; add 10 mL for every decade of life >50 yr of age); Q-tip test—no longer standard test in work-up of urinary
incontinence; hypermobility of urethrovesical junction must be documented before urethropexy
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| Urodynamic testing: cost-effectiveness compared to office evaluation—population dependent; in specialty
practice, most likely beneficial; urodynamic testing not necessary in most uncomplicated cases of urinary incontinence;
single-channel cystometrography helpful in establishing objective findings; normal cystometry—
first sensation to urinate usually felt with 150 mL; most women able to hold 400 to 500 mL (may decrease
with aging); indications for urodynamic testing—uncertain diagnosis; patient not satisfied with initial treatment;
surgery planned in complicated patient; comorbid condition (neurologic condition); does urodynamic
testing change management?—urine leakage occurs when bladder pressure overcomes urethral pressure, regardless
of cause (urethra not functioning properly); Colpopexy and Urinary Reduction Efforts (CARE) clinical
trial—showed significantly lower frequency (50%) of stress incontinence in group that underwent Burch colposuspension,
compared to women who did not have Burch procedure, at 3 mo postoperatively
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| Case 3 conclusions: urodynamic testing recommended if vaginal reconstructive surgery planned; most likely,
testing not warranted if abdominal sacrocolpopexy planned; multichannel study depends on surgery; look for
objective signs of stress incontinence (positive stress test, continuous leakage with cough)
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| Case 4: woman, 48 yr of age, complains of leakage, urgency, frequency, and nocturia; leaks en route to toilet;
significant impact on quality of life; patient’s symptoms suggestive of urge incontinence; employ PaUDS evaluation
initially; urodynamic studies not warranted (low sensitivity and specificity); treatment based on symptoms
recommended; if patient unresponsive, consider testing
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| Cystoscopy: not used as part of work-up; useful in evaluating hematuria or visualization of foreign object, eg,
suture in bladder
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| Conclusion: most patients can be treated following good history (severity of symptoms and impact on life), physical
examination (prolapse, pelvic floor muscle strength), urinalysis, voiding diary, stress test, and PVR; urodynamic
testing utilized only if it will change management
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| THE IMPACT OF PREGNANCY AND DELIVERY ON URINARY FUNCTION —Roger P. Goldberg, MD,
Assistant Professor, Northwestern University Feinberg School of Medicine, Chicago, IL
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| Introduction: 50% of women have involuntary urine leakage by 40 yr of age; childbirth monumental physical
event—anatomic mismatch between bony pelvis and size of fetus at delivery; extraordinary pressures of fetal
head against side wall of pelvis and long and difficult labors play role in incontinence after childbirth; defects
in levator ani seen after vaginal birth
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| Study data: Frances (1960)—did first prospective pregnancy study looking at incontinence during pregnancy,
and data showed markedly high prevalence of women reporting leaking with coughing and sneezing during
pregnancy; 38% had persistent mild stress urinary incontinence (SUI) after childbirth, and 9% had severe SUI
after childbirth; persistence of SUI may be caused by neurologic injury; Snooks (1984)—showed vaginal delivery
associated with delayed pudendal nerve conduction, and conduction delay worsened after certain aspects
of vaginal birth; conduction delay not seen with cesarean delivery; concluded pudendal conduction
returned to normal for 60% of women 2 mo postpartum; in 5-yr follow-up study, Snooks showed pudendal
neuropathy progressively worsened over time, with ≈36% of women developing stress incontinence; neuromuscular
injury—injury to pelvic floor followed by temporary improvement; within 5 yr, persistent abnormalities
become evident in many women; urodynamic studies—showed urethral closure pressures, urethral
functional length, and intrinsic sphincteric function appear to worsen after vaginal birth; bladder neck
changes—Peschers et al showed bladder neck descent during Valsalva significantly increased after vaginal
delivery in primiparas and multiparas but not after cesarean delivery; 92% risk for long-term SUI 5 yr later in
women with incontinence 3 mo after vaginal delivery; 10-fold higher risk for persistent SUI with forceps delivery;
Viktrup (1992)—looking at immediate postpartum SUI, found ≈13% of women had urinary leakage;
rate reduced to 3% 1 yr postpartum; Viktrup follow-up data (2001) showed SUI in 19% of women without
problem 5 yr earlier
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| Incontinence and delivery mode: population-based studies indicate higher relative risk for stress incontinence
with vaginal birth, compared to cesarean birth; observational studies involving mothers of multiples
showed cesarean delivery protective against SUI by 2-fold; Epidemiology of Incontinence (EPINCONT)
study showed vaginal delivery group in general appeared to have higher rates of SUI; in general, incontinence
complex issue; some women experience urinary leakage before or after menopause, regardless of mode of obstetric
delivery; Goldberg et al showed woman with >2 births at >4-fold higher risk for SUI, regardless of delivery
mode; however, urge incontinence not associated with delivery mode, but with number of deliveries
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| Elective cesarean delivery: >90% in other countries; controversial issue politically and ethically; 31% of female
British obstetricians/gynecologists surveyed stated they would choose elective cesarean delivery because
of risk for pelvic injury; benefits—speaker opines 2 to 3 times less likelihood of SUI in younger
women; obstetric issues play lesser role with aging; prolapse less likely; reduced perineal and rectal injury;
downside—physical and psychologic disadvantages and economic concerns
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Suggested Reading
Abrams P et al: The standardization of terminology in lower urinary tract function: report from the standardization
sub-committee of the International Continence Society. Urology 61(1):37, 2003; Brubaker L et al: Abdominal
sacrocolpopexy with Burch colposuspension to reduce urinary stress incontinence. N Engl J Med
354(15):1557, 2006; Colli E et al: Are urodynamic tests useful tools for the initial conservative management of
non-neurogenic urinary incontinence? A review of the literature. Eur Urol 43(1):63, 2003; Goldberg RP et al:
Delivery mode is a major environmental determinant of stress urinary incontinence: results of the Evanston-Northwestern
Twin Sisters Study. Am J Obstet Gynecol 193(6):2149, 2005; Goldberg RP et al: Urinary incontinence
among mothers of multiples: the protective effect of cesarean delivery. Am J Obstet Gynecol 188(6):1447, 2003;
Luber KM et al: The demographics of pelvic floor disorders: current observations and future projections. Am J
Obstet Gynecol 184(7):1496, 2001; Peschers U et al: Changes in vesical neck mobility following vaginal delivery.
Obstet Gynecol 88(6):1001, 1996; Snooks SJ et al: Injury to innervation of pelvic floor sphincter musculature
in childbirth. Lancet 2(8402):546, 1984; Weidner AC et al: Which women with stress incontinence require
urodynamic evaluation? Am J Obstet Gynecol 184(2):20, 2001.
Educational Objectives
| The goal of this program is to improve the management of urinary incontinence. After hearing and assimilating
this program, the clinician will be better able to:
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 | 1. Cite 4 components (evaluation mnemonic) of the minimal work-up for urinary incontinence.
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| 2. List the conditions in which urodynamic testing is indicated for urinary incontinence.
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| 3. Assess patients with urinary incontinence and determine which patients would benefit from urodynamic
testing.
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| 4. Summarize the anatomic reasons why vaginal birth places a woman at risk for pelvic floor disorders.
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| 5. Discuss study data associating urinary incontinence with vaginal delivery.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose
relevant financial relationships within the past 12 months that might create any personal conflicts of interest.
Any identified conflicts were resolved to ensure that this educational activity promotes quality in health
care and not a proprietary business or commercial interest. For this issue, the faculty reported nothing to disclose.
Acknowledgements
Dr. Fenner was recorded at the Annual Clinical Update in Obstetrics and Gynecology, sponsored by the University of
Michigan Medical School, held March 9-10, 2006, in Ann Arbor, MI; Dr. Goldberg was recorded at Advances in
Urogynecology and Reconstructive Pelvic Surgery, sponsored by Northwestern University’s Feinberg School of
Medicine and The Evanston Continence Center, held June 8-10, 2006, in Chicago, IL. The Audio-Digest Foundation
thanks the speakers and the sponsors for their cooperation in the production of this program.
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