Timothy B. McKinney, MD

Urinary incontinence is         defined as the involuntary loss of urine that is objectively         demonstrated and is a social and hygienic problem. The condition may         effect up to 40% of women during the course of their lives and could be         present in as many as 20 million patients annually.[1]         

Urinary incontinence affects a person's         social, clinical, and psychological well being, causing depression and         isolation, and is the primary reason for institutionalizing many older         patients. It is believed that less than 50% of patients who have the         condition seek professional help and those who do, wait an average of 7         years.[2]

Currently, the most common method of         management is over-the-counter diapers. This reflects both an individual         reluctance to seek professional help, and the medical community's         inability to effectively diagnose and treat this condition in the early         stages. The cost of managing incontinence is growing along with the         aging population. In 1987 it was estimated at $10.3 billion annually,         while the most recent estimates place the cost nearer to $27 billion.[2]

The advent of urogynecology as a         specialty has greatly increased our understanding of many of the         underlying causes of incontinence. As a result, many improved diagnostic         and treatment choices are now available. A physician can select from a         broad spectrum of proven protocols and commercial devices to provide         effective incontinence services.

The underlying causes of incontinence         can be divided into 5 categories:

Overactive bladder also known as             urge/frequency, detrusor instability, or detrusor hyperreflexia

Stress incontinence/intrinsic             sphincter deficiency/urethral instability

Lower urinary tract bypass,             including fistulas, diverticuli, and ectopic ureters

The first steps in offering effective         incontinence treatment is to establish a qualitative diagnostic protocol         that allows for clear identification of the underlying causes. A typical         step-by-step diagnostic protocol begins by asking a series of questions,         reviewing patient history, a physical exam, and filling out a voiding         diary.

Questions: In addition to a personal             consultation, an initial intake questionnaire is the most effective             way to identify general conditions that may lead to a diagnosis.

History: Prior surgeries of pelvic             floor or incontinence, number of childbirths, medical diseases,             estrogen status, and medications. The correct diagnosis of genuine             urinary stress incontinence based purely on history is confirmed in             only 50-80% of patients. In contrast, a history of detrusor             instability is confirmed urodynamically in only 50% of patients.[2]             Therefore, one should not use history alone to diagnose the type of             urinary incontinence.

Physical exam: The anatomical             defects POP-Q, Q-tip test, neurological exam, U / A, Urine C&S,             cytology, and post-void residual evaluation (by ultrasound or             straight cath).             

Cystourethroscopy
                             Urodynamics
                                CMG:
                                EMG:
                                UPP:
                                URF:
                                VP:

$318
                             $239
                             $212
                             $186
                             $212

30 minutes
                             interpretation time only
                             5 minutes
                             5 minutes
                             5 minutes

Cystoscopy: The use of video             cystourethroscopy is a significant diagnostic tool in identifying             those patients with anatomical urethral and bladder pathologies.             Cystoscopy can be easily performed in the relaxed and dynamic states             in approximately 10 minutes. This procedure can enhance the             physician/patient relationship by adding a qualitative component to             their understanding of bladder conditions that can be discussed.             Reimbursement for the procedure is considerable (see Appendix             Table). Equipment is inexpensive (under $8,000), with costs being             recouped within a year, especially if used for other office             hysteroscopy procedures such as transvaginal hydrolaparoscopy (THL™),             implantable urethral bulking agents such as collagen, and most             recently, Durasphere™ (Advanced UroScience, Minneapolis, MN).

Behavioral modifications, dietary             changes, timed voiding, pelvic floor exercises (Kegels), and oral             and vaginal estrogen therapy as needed, are started.

With the advent of high quality,         low-priced office systems, urodynamics is another cost-effective         procedure for the office practitioner in evaluating the incontinent         patient. The key urodynamic study is the filling cystometrogram (CMG).         This test measures the change in bladder pressure in response to bladder         filling. It is also important in evaluating the sensory function of the         bladder. A CMG can detect up to 80% of patients with detrusor         instability, and it can detect an even higher percentage of genuine         stress incontinence.

New CMG protocols allow the physician         to easily perform differential diagnoses of stress incontinence etiology         that are associated with hypermobility and/or caused by a dysfunctional         urethra. This is accomplished through the Valsalva Leak Point Pressure         test and resting Urethral Closure Pressure Profile.


                 Table 1. Step by Step Protocol                 with
                 Urodynamic Equipment

With the bladder filled to 300 cc in         the upright position, a Valsalva is performed by the patient and         recorded pressures are made as leakage occurs. This number is called the         Valsalva leak point pressure. If the number is <65, the diagnosis of         Intrinsic Sphincter Deficiency (ISD) is made. Numbers from 65-100         represent a gray zone; >100 is a normal sphincter function by         extrapolation. Cough profile may also be of help in demonstrating stress         incontinence or cough-induced bladder instability.

An electromyogram (EMG) recorded         simultaneously during a CMG provides important data about the         neurological functioning of the continent mechanism. A multi-channel         urodynamics system such as the CIRCON® SURGITEK® OM™-5 Series         (Figure 1) offers the option of performing a sophisticated Urethral         Pressure Profile (UPP) using a dual sensor in the bladder and slowly         withdrawing the proximal transducer through the urethra and recording         pressures throughout the maneuver. This allows for a direct look at the         pathophysiology of the incontinent process. The drawback to this         parameter has been the poor reproducibility of the pressure transducer         catheters. However, new catheter technology is being developed to         resolve this issue.

Next, static and dynamic UPP are         performed. The static UPP measures the functional urethral length and         the maximum urethral closure pressure. A closure pressure of less than         20 mm H2O indicates intrinsic sphincter deficiency. The dynamic UPP         measures the pressure transmission ratios during coughing within the         functional urethral length simultaneously within the bladder and the         urethra. This ratio should always be greater than 1, if not, leakage         occurs. (See Editor's Note)

Uroflowometry (URF) and pressure flow         studies (VP) are also very useful in demonstrating abnormalities in         voiding patterns.

The management decision tree after a         thorough evaluation and accurate diagnosis should always begin with the         least invasive management. The nonsurgical options include: behavioral         modification, biofeedback/electrical stimulation, pelvic floor         exercises, supportive and occlusive mechanical devices, and         medical/pharmacological therapy.

Surgical management should include a         thorough reconstruction of all pelvic floor defects. At our institution         “site specific” correction of all endopelvic fascia defects is the         surgical choice. This procedure recreates normal anatomical         relationships, and can be accomplished either vaginally or         laparoscopically.

Other surgical procedures of choice         include retropubic urethropexy and TVT sling urethropexy.

                 Figure 1. CIRCON SURGITEK OM-5 Elite Urodynamic System

Most forms of urinary incontinence can         be diagnosed and treated effectively by OB/GYNs. Their understanding of         the pelvic floor structure and the trauma caused to it by childbearing         and aging, as well as the dedication to treating female pathologies         places them as the primary physician specialty to diagnose and treat the         incontinent patient.

Incorporating the management of         incontinence into one's practice should not require a large expenditure         of new capital or a redirecting of the commitment to the general         practice. Instead, managing incontinence can be easily incorporated into         the daily regimen, and could be a new source for growth and increased         revenue.

With the increase in physician         awareness, improvements in patient education, and advances in treatment         choices, OB/GYN practitioners have an excellent opportunity to offer         urinary incontinence management as part of their general practice. The         debate facing modern OB/GYN practices is not whether to offer         incontinence management at all, but to what extent should that service         be a part of one's practice.

1. Clinical Practice Guidelines Update: Urinary Incontinence in Adults. Rockville Md: Agency for Health Care Policy and Research, US Dept of Health and Human Services; 1989.    

2. Clinical Practice Guidelines Update: Urinary Incontinence in Adults. 1996.

Editor's Note: Dr. McKinney and his colleague, Dr. Sam Hassami, were awarded the 2000 ACOG/Upjohn urogynecology research award for their work on an objective Index of Severity for Incontinence using the formula (1-PTR) X urine leakage (grams) to quantitate incontinence and the success of subsequent therapies.

Dr. McKinney is a clinical professor, director of the fellowship program, department of OB/GYN, and chief, division of urogynecology & pelvic reconstructive surgery, University of Medicine & Dentistry of New Jersey, School of Osteopathic Medicine, in Stratford, NJ. He is also director, Kennedy Incontinence Center, in Sommerdale, NJ

Articles

Urinary incontinence is defined as the involuntary loss of urine that is objectively demonstrated and is a social and hygienic problem. The condition may effect up to 40% of women during the course of their lives and could be present in as many as 20 million patients annually.

Timothy B. McKinney, MD

Articles

Determining and Evaluating Incontinence in the Office Setting