What can a woman who is having urinary leakage
with urgency or cough or stress expect when she goes
to the doctor's office? The basic diagnostic evaluation
needed for urinary incontinence must determine whether
or not the loss of urine falls into one of several
categories:
stress incontinence - produced by
any intraabdominal straining such as coughing or straining
urge incontinence - leakage caused
by the bladder detrusor muscle contracting involuntarily
or causing a very small bladder capacity
mixed incontinence - a combination
of the above two types
overflow incontinence - in which
the bladder is distended and has somewhat lost sensation
of fullness so that when it just gets overfilled,
the bladder muscle contracts on its own.
other types such as a fistula (hole) in the bladder
or the ureter tubes coming into the bladder, or spinal
cord or brain problems affecting the bladder nerves.
There have been published guidelines for the basic
work-up of this urinary loss by the Agency for Health
Care Planning and Research (AHCRP) but studies have
shown that work-up developed by experts may misclassify
incontinence by as much as 30%. A recent quarterly
report, Vol. XVIII, No 2, 1999, from the American
Urogynecologic Society by Steven Swift MD, Basic evaluation
of the incontinent female presents us with the answers
to several questions about this subject.
Can I tell from my symptoms, i.e., when and
how I lose urine, what type of incontinence I have?
Symptoms can give a hint as to what type of incontinence
is present but overall, symptoms are not accurate
enough to make the diagnosis alone. Questions the
doctor will ask are included below:
Diagnostic category Questions the doctor may ask
stress Do you lose urine when you cough, sneeze. or
laugh suddenly?
stress Do you lose urine when you stand up, sit down
or bend over?
type III stress (intrinsic urethral insufficiency)
Do you have almost continuous loss with any little
movement?
urge/ type III stress Is there a history of radiation
treatment to pelvis?
urge Do you get the urge to void and not get to the
bathroom in time?
urge Do you have a history of neurological diseases/trauma/strokes?
urge or overflow Do you lose urine suddenly without
any warning or straining?
obstruction/ detrusor-sphincter dyssynergia Do you
have difficulty voiding?
overflow Do you wet the bed at night and are unaware
of it?
overflow/continuous Do you have a history of previous
surgery on urethra/bladder?
overflow / obstruction Do you fail to empty your bladder
completely?
continuous Do you stay wet all the time without any
urge to void?
*indicates cystoscopy needed Do you have frequent
(>3 per year) urinary tract infections?
*indicates cystoscopy needed Do you have blood in
your urine?
*indicates cystoscopy needed Do you have pain when
you void?
*indicates cystoscopy needed Do you urinate very frequently
(>14 per 24 hours)?
* indicates there may be a mechanical, irritative
disease in the bladder causing incontinence
What are some of the risk factors for developing urine
leakage?
Certain medications can cause incontinence such as
alpha-adrenergic blockers used for hypertension. Examples
would be:
prazosin (Minipress®, Minizide®)
terazosin (Hytrin®)
doxazosin (Cardura®)
Diuretics do not cause incontinence but they certainly
can worsen it just as too much caffeine or too many
fluids each day can aggravate symptoms. Smooth muscle
relaxants such as Valium®, Klonopin®, and
Xanex® also can worsen urinary leakage by relaxing
the external urethral sphincter.
Other risk factors for incontinence include cigarette
smoking, constipation, obesity, and strenuous physical
activity. Most women who have stress incontinence
have undergone vaginal childbirth But childbirth does
not always lead to incontinence in later life.
What does the doctor check for on examination?
The general physical exam looks for any evidence
of heart failure because when excess fluid in the
legs is mobilized at night or lying down, this volume
of fluid can contribute to nighttime voiding and urgency.
A focused exam of the nerves is done, especially if
there is any history or neurological injury, trauma
or stroke.
On pelvic exam, the doctor will ask you to cough
with a fairly full bladder to see if leaking is observed.
While this may be embarrassing for you, it is a necessary
test and the doctor is used to having urine leak and
spray. The pelvic exam is done to check for associated
relaxation of the anterior vaginal bladder wall (cystocoele),
the posterior vaginal rectal wall (rectocoele) , the
sides of the vagina (paravaginal defect), and the
end of the vagina (prolapse or enterocoele). After
that, the doctor may put a Q-tip (cotton tipped applicator)
in the urethra using a little xylocaine gel to numb
it. Then you will be asked to strain down to see if
the tip of it moves up by more than 30 degrees. If
it does, this may indicate the bladder neck drops
down with straining and this may contribute to losing
urine with straining and be treatable with surgery.
Will I have to have a catheter put in my
bladder?
Yes you may. There are several reasons a catheter
may be used. One is to get a sample of urine for culture.
This is especially needed if you have a history of
frequent urinary tract infections. It is commonly
done after you have been asked to void to see if you
are able to completely empty the bladder. Also, at
the time of your office exam or perhaps at a later
visit, a catheter may be used to put fluid in the
bladder and measure the bladder pressure during a
cystometrogram. This is needed to make sure you are
not having "bladder spasms" or uninhibited
bladder detrusor contractions. If you do have them,
that may explain urgency symptoms of having to void
frequently. Finally a cystoscopy may need to be done
if you are having any symptoms suggestive of infection,
stones, or interstitial cystitis. The cystoscopy is
like a catheter being put in the bladder except a
cystoscope is used to look inside. The cystoscope
is about the same size as a catheter.
What tests other than the physical and pelvic
exam will I need to have?
The doctor may ask you to fill out a voiding calendar
to record how much you drink and how often and how
much urine is lost. This can tell the severity of
your leakage and also if you are drinking too much
or too little fluids. Finally, the doctor may want
you to have complex urodynamic studies in which the
bladder, the urethral muscles and the capacity and
sensation of the bladder are measured using a catheter
and pressure transducer placed into the bladder. These
studies are sometimes done routinely, but they are
especially needed if you have any history of spinal
cord or neurological problems, very frequent urgency
symptoms, loss of urine with just minimal movement
or exertion, or a past history of bladder repair surgery
that is now not successful
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