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Types of incontinence and clinical assessment
TYPES OF INCONTINENCE
Types of incontinence and clinical assessment Brenda Kelly Jhuma Bhaumik Simon Jackson
Urinary incontinence is defined as a condition in which involuntary loss of urine is objectively demonstrable and causes social or hygienic problems.1 The International Continence Society recommends urinary incontinence should be further defined in terms of symptoms, signs, urodynamic observations and condition as a whole.2
Types of urinary incontinence The three most common forms of urinary incontinence are: • stress incontinence • urge incontinence • mixed incontinence, a combination of stress and urge incontinence. The symptoms, signs and urodynamic observations associated with these types of urinary incontinence are outlined in Figure 1. Less common forms of female urinary incontinence include overflow, continuous and reflex incontinence. Overflow incontinence is the involuntary loss of urine associated with overdistension of the bladder resulting from inefficient bladder emptying. It may occur because of poor detrusor contractility, bladder outlet obstruction or a combination of both. Continuous incontinence results from a fistula between the ureter, bladder or urethra and the vagina, or an ectopic ureter opening into the vagina or urethra. Reflex incontinence is defined as the loss of urine due to detrusor hyperreflexia and/or involuntary urethral relaxation in the absence of sensation and is not usually associated with the desire
Brenda Kelly is a Specialist Registrar in Obstetrics and Gynaecology at the John Radcliffe Hospital, Oxford, UK. After qualifying from the University of Edinburgh, she trained in obstetrics and gynaecology in London and Oxford. Current research interests include extracellular matrix biology. Jhuma Bhaumik is a Clinical Research Fellow at the John Radcliffe Hospital, Oxford, UK. She qualified from the University of Calcutta and trained in obstetrics and gynaecology in London. Her research interests include urogynaecology and pelvic-floor reconstructive surgery. Simon Jackson is a Consultant Gynaecologist at the John Radcliffe Hospital, Oxford, UK. He qualified from Oxford University and trained in obstetrics and gynaecology at Bristol. His research interests include researching quality of life and connective tissue metabolism.
WOMEN’S HEALTH MEDICINE 2:6
5
© 2005 The Medicine Publishing Company Ltd
TYPES OF INCONTINENCE
Types of urinary incontinence Type of urinary incontinence
Symptoms
Signs
Urodynamic observations
Stress incontinence
Involuntary leakage on effort or exertion, or on sneezing or coughing
Observation of involuntary leakage from the urethra, synchronous with exertion/ effort or sneezing/coughing
Urodynamic stress incontinence is involuntary leakage of urine during increased abdominal pressure in the absence of a detrusor contraction
Urge incontinence
Involuntary leakage accompanied by, or immediately preceded by, urgency
Not defined
Urgency is the sudden compelling desire to void during cystometry Detrusor overactivity is due to detrusor involuntary contractions during filling cystometry
Mixed incontinence
Involuntary leakage associated with urgency and also with effort, sneezing or coughing
Not defined
The urodynamic observation of both urodynamic stress incontinence and detrusor overactivity incontinence during the same test is mixed incontinence
1
study methodology and design, for example, in the population of women studied and definitions of urinary incontinence used. Methods of data collection include postal questionnaires, personal and telephone interviews, each of which have limitations as well as advantages, which should be borne in mind when interpreting data. It is widely believed that women under-report symptoms and severity because of shame, embarrassment and ignorance regarding treatment options. The EPINCONT study (Figure 2) remains one of the largest prevalence studies to date.6 The prevalence rates were similar to those reported by Minassian and colleagues in a recent literature review.7 However, in the EPINCONT study, women were not clinically assessed using urodynamics. Prevalence studies, in which urodynamic evaluation has additionally been performed, confirm stress incontinence as the major type of urinary incontinence in women.8–10 Although mixed incontinence is reported in relatively high numbers in epidemiology surveys, it emerges that most of these women are eventually diagnosed with stress incontinence when urodynamic assessment is performed.10
to micturate. This is highly suggestive of underlying neurological pathology.
Prevalence of incontinence There has been wide variation in the reported prevalence of urinary incontinence. Estimates range from 8.5% to 83% of women.3–5 This wide variation in prevalence partly reflects differences in
The EPINCONT study • Evaluated prevalence of urinary leakage in an unselected female population aged 20 years or more by postal questionnaire with an additional validated severity index (used to assess severity of incontinence). • 25% of the 27,936 women had urinary leakage. • Almost 7% described significant incontinence (defined as moderate or severe incontinence).
Prevalence of type of urinary incontinence reported Age: in addition to prevalence of incontinence increasing with increasing age, the type of urinary incontinence differs with age, with stress incontinence most common amongst younger women aged 25–49 years and prevalence decreases with increasing age.6 In older women, mixed incontinence is the most prevalent type of urinary incontinence. This is considered to be largely due to the increase in urge symptoms which are seen with age.
stress incontinence (50%)
mixed incontinence (32%)
Clinical assessment History History-taking in women complaining of urinary incontinence needs to be thorough and systematic. It should aim to differentiate between symptoms of stress incontinence, urgency and urge incontinence and to assess factors that may predispose to these problems (Figures 3 and 4). The clinician should also be alert to symptoms that prompt specialist referral and assessment (Figure 5).
other (4%)
urge incontinence (14%) 2
WOMEN’S HEALTH MEDICINE 2:6
6
© 2005 The Medicine Publishing Company Ltd
TYPES OF INCONTINENCE
History-taking in female urinary incontinence: symptoms Particular questions may help to further differentiate between symptoms of stress incontinence, urgency and urge incontinence. Example question
Underlying disorder
When you pass water, can you hold or do you have to go immediately?
Urgency
Do you ever leak when you have a desire to pass urine and before you can reach the toilet?
Urge incontinence
Do you ever leak when you cough, sneeze, exercise, lift heavy objects, walk or run, or during sexual intercourse?
Stress incontinence
How often do you pass urine from the time you wake in the morning to the time you go to sleep?
Daytime frequency – more than seven voids per day indicate an overactive bladder
How many times are you woken from your sleep because you need to pass urine?
Nocturia – arousal from sleep more than once at night to void may be suggestive of an overactive bladder
3
Questionnaires: inviting women to complete a questionnaire prior to the consultation may provide a useful starting point as well as overcoming some of the embarrassment many women experience in discussing incontinence issues. These self-completed questionnaires are not subject to doctor bias and several examples of wellvalidated questionnaires have been published previously, including the Bristol female lower urinary tract symptoms questionnaire.11
a failure to associate fluid intake with urine output. The average daily adult intake is 1.5–2.0 litres and excessive fluid consumption is a common cause of urinary frequency. Caffeine-containing drinks such as tea, coffee and cola, are known bladder stimulants and an understanding of this fact can allow patients to manage their own urinary symptoms without the need for any other intervention. Documenting this information can be accomplished by completing a frequency volume chart or urinary diary (Figure 6; also see below).
Fluid intake: it is also important to enquire about fluid intake. Patients are often unaware of the fluid volume they consume and excessive consumption is often the result of erroneous advice and
Examination Abdominal examination should be performed to exclude any masses and urinary retention. In addition, a pelvic examination is carried out to assess genital prolapse (e.g. cystocele, uterovaginal prolapse), pelvic masses and pelvic floor strength and tone. Assessment of pelvic floor tone is essential as weak pelvic floor musculature can contribute to stress urinary incontinence and may substantially improve with appropriate physiotherapy without recourse to specialist referral and surgery. A simple way to evalu-
History-taking in female urinary incontinence: predisposing factors Obstetric history • Number of pregnancies • Length of labour • Mode of delivery • Birthweight • Episiotomies Gynaecological history • Menopausal status • Hormone replacement therapy • Hysterectomy/operations for prolapse Medical history • Respiratory disorders/chronic cough • Diabetes • Obesity • Multiple sclerosis • Previous pelvic irradiation: cystitis, fistulae formation • Constipation Drug history • Diuretics • Antidepressants • Anticholinergics
Symptoms and findings that should prompt specialist referral Urinary symptoms • Significant bladder pain • Persistent haematuria • Difficulty in voiding urine • Recurrent urinary tract infections Clinical history/findings • Significant genital prolapse • Underlying gynaecological pathology • Previous failed conservative therapy • Contraindications to empirical therapy (e.g. antimuscarinic preparations in glaucoma) • Previous urinary tract surgery 5
4
WOMEN’S HEALTH MEDICINE 2:6
7
© 2005 The Medicine Publishing Company Ltd
TYPES OF INCONTINENCE
Frequency/volume chart A frequency/volume chart can be used as part of the initial clinical assessment. The patient is instructed to record how much they drink in ml and when (In), and to measure urine passed in a small jug (Out). A cross placed in the column marked ‘Wet’ denotes an episode of urinary incontinence. A line is placed on the chart at the time the patient goes to bed so that a record can be obtained of nocturia as well as daytime frequency. In the example shown, the patient’s primary complaint was of urgency with occasional urge incontinence. A review of her chart on the day shown indicates that the likely cause of this is excessive fluid intake during the day.
Date: am
Date: 1
Time
Date: 2
Date: 3
Date: 4
5
In
Out Wet
In
Out Wet
In
Out Wet
In
Out Wet
In
Out Wet
In
Out Wet
In
Out Wet
In
Out Wet
In
Out Wet
In
Out Wet
1 2 3 4 5 6 7 8 9 10 11 12 pm 1 2 3 4 5 6 7 8 9 10 11 12 Total 3590
6
ate pelvic floor strength/tone is to place an index finger 4 cm to 6 cm inside the vagina, positioned at 4 o’clock and 8 o’clock and ask the patient to squeeze her pelvic floor muscles. Muscle tone can be then be graded according to the modified Oxford scale (grades 1–5).12
kept by the patient of their fluid intake (both volume and time), volume of micturitions and frequency of incontinence (Figure 6). In order to be representative, it is usually kept over a number of days. The urinary diary can also be used as a baseline for monitoring women undergoing bladder retraining.
Additional investigations Several basic investigations of urinary incontinence can be initiated in primary care. Urinalysis: it is essential to perform dipstick urinalysis. Urine should be screened for infection using multistix that test for nitrites, blood and leucocytes. The finding of haematuria should prompt further investigation and in the absence of infection should prompt specialist referral to exclude urinary tract neoplasia.
Quality of life: assessing the impact of urinary incontinence on the patient’s quality of life is important and can be facilitated by asking the woman to complete a disease-specific quality of life questionnaire, such as, the King’s Health Questionnaire.13 In addition to providing a valid and reliable instrument for the assessment of quality of life in women with urinary incontinence, these questionnaires can be useful in evaluating the impact of new treatments of urinary incontinence. Quality-of-life assessment is discussed further on pages 1–3.
Urinary diary: women should also be invited to keep a frequency volume or urinary diary. In its simplest form, this is a paper record
Urodynamic investigations (e.g. uroflowmetry, cystometry) are not always required (Figure 7).
WOMEN’S HEALTH MEDICINE 2:6
8
© 2005 The Medicine Publishing Company Ltd
TYPES OF INCONTINENCE
Indications for urodynamic investigations
REFERENCES 1 Bates P, Bradley W E, Glen E et al. The standardization of terminology of lower urinary tract function. J Urol 1979; 121: 551–4. 2 Abrams P, Cardozo L, Fall M et al. The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourol Urodyn 2002; 21: 167–78. 3 Yarnell J W, Voyle G J, Richards C J, Stephenson T P. The prevalence and severity of urinary incontinence in women. J Epidemiol Community Health 1981; 35: 71–4. 4 Diokno A C, Brock B M, Brown M B, Herzog A R. Prevalence of urinary incontinence and other urological symptoms in the noninstitutionalized elderly. J Urol 1986; 136: 1022–5. 5 Brocklehurst J C. Urinary incontinence in the community – analysis of a MORI poll. BMJ 1993; 306: 832–4. 6 Hannestad Y S, Rortveit G, Sandvik H, Hunskaar S. A community-based epidemiological survey of female urinary incontinence: the Norwegian EPINCONT study. Epidemiology of Incontinence in the County of Nord-Trondelag. J Clin Epidemiol 2000; 53: 1150–7. (This paper outlines one of the largest prevalence studies of urinary incontinence to date.) 7 Minassian V A, Drutz H P, Al Badr A. Urinary incontinence as a worldwide problem. Int J Gynaecol Obstet 2003; 82: 327–38. 8 Sandvik H, Hunskaar S, Vanvik A, Bratt H, Seim A, Hermstad R. Diagnostic classification of female urinary incontinence: an epidemiological survey corrected for validity. J Clin Epidemiol 1995; 48: 339–43. 9 Carey M P, Dwyer P L, Glenning P P. The sign of stress incontinence – should we believe what we see? Aust N Z J Obstet Gynaecol 1997; 37: 436–9. 10 Weidner A C, Myers E R, Visco A G, Cundiff G W, Bump R C. Which women with stress incontinence require urodynamic evaluation? Am J Obstet Gynecol 2001; 184: 20–7. 11 Jackson S, Donovan J, Brookes S, Eckford S, Swithinbank L, Abrams P. The Bristol Female Lower Urinary Tract Symptoms questionnaire: development and psychometric testing. Br J Urol 1996; 77: 805–12. 12 Laycock J, Schussler B, Norton P, Stanton S L, eds. Pelvic floor re-education. 2.2, Clinical evaluation of pelvic floor, 1st edn. London: Springer-Verlag, 1994. 13 Kelleher C J, Cardozo L D, Khullar V, Salvatore S. A new questionnaire to assess the quality of life of urinary incontinent women. Br J Obstet Gynaecol 1997; 104: 1374–9. 14 Cardozo L, Drutz H P, Baygani S K, Bump R C. Pharmacological treatment of women awaiting surgery for stress urinary incontinence. Obstet Gynecol 2004; 104: 511–19. (This trial double-blind, randomized, placebo-controlled study was the first to assess the efficacy of duloxetine for women with severe stress urinary incontinence. This serotonin/ norepinephrine reuptake inhibitor is also used in the treatment of depression.) 15 Kelleher C. Investigation and treatment of lower urinary tract dysfunction. Curr Obstet Gynaecol 2003; 13: 342–9.
(see also pages 15–19) • Failure of empirical treatment • Mixed symptoms precluding empirical treatment • Before surgery for stress incontinence 7
On the basis of the clinical assessment, women may be commenced on conservative treatment. Women with stress urinary incontinence can be referred to physiotherapy for advice on pelvic-floor exercises (page 29) and/or commenced on a drug such as duloxetine (page 33).14 Those patients whose primary symptoms of urgency/urge incontinence suggest an uncomplicated overactive bladder may improve with reducing caffeine intake, bladder training and/or anticholinergics to suppress unstable bladder contractions.15 Cystometry involves measuring the pressure/volume relationship of the bladder during filling and voiding. It is a objective test of bladder function which can provide a pathophysiological explanation of the patient’s symptoms. For a more detailed description of urodynamic evaluation and interpretation, see pages 15–19.
CONFLICT OF INTERESTS Simon Jackson is a medical adviser for Lilly Pharmaceuticals.
WOMEN’S HEALTH MEDICINE 2:6
9
© 2005 The Medicine Publishing Company Ltd
Types of incontinence and clinical assessment Brenda Kelly Jhuma Bhaumik Simon Jackson
Urinary incontinence is defined as a condition in which involuntary loss of urine is objectively demonstrable and causes social or hygienic problems.1 The International Continence Society recommends urinary incontinence should be further defined in terms of symptoms, signs, urodynamic observations and condition as a whole.2
Types of urinary incontinence The three most common forms of urinary incontinence are: • stress incontinence • urge incontinence • mixed incontinence, a combination of stress and urge incontinence. The symptoms, signs and urodynamic observations associated with these types of urinary incontinence are outlined in Figure 1. Less common forms of female urinary incontinence include overflow, continuous and reflex incontinence. Overflow incontinence is the involuntary loss of urine associated with overdistension of the bladder resulting from inefficient bladder emptying. It may occur because of poor detrusor contractility, bladder outlet obstruction or a combination of both. Continuous incontinence results from a fistula between the ureter, bladder or urethra and the vagina, or an ectopic ureter opening into the vagina or urethra. Reflex incontinence is defined as the loss of urine due to detrusor hyperreflexia and/or involuntary urethral relaxation in the absence of sensation and is not usually associated with the desire
Brenda Kelly is a Specialist Registrar in Obstetrics and Gynaecology at the John Radcliffe Hospital, Oxford, UK. After qualifying from the University of Edinburgh, she trained in obstetrics and gynaecology in London and Oxford. Current research interests include extracellular matrix biology. Jhuma Bhaumik is a Clinical Research Fellow at the John Radcliffe Hospital, Oxford, UK. She qualified from the University of Calcutta and trained in obstetrics and gynaecology in London. Her research interests include urogynaecology and pelvic-floor reconstructive surgery. Simon Jackson is a Consultant Gynaecologist at the John Radcliffe Hospital, Oxford, UK. He qualified from Oxford University and trained in obstetrics and gynaecology at Bristol. His research interests include researching quality of life and connective tissue metabolism.
WOMEN’S HEALTH MEDICINE 2:6
5
© 2005 The Medicine Publishing Company Ltd
TYPES OF INCONTINENCE
Types of urinary incontinence Type of urinary incontinence
Symptoms
Signs
Urodynamic observations
Stress incontinence
Involuntary leakage on effort or exertion, or on sneezing or coughing
Observation of involuntary leakage from the urethra, synchronous with exertion/ effort or sneezing/coughing
Urodynamic stress incontinence is involuntary leakage of urine during increased abdominal pressure in the absence of a detrusor contraction
Urge incontinence
Involuntary leakage accompanied by, or immediately preceded by, urgency
Not defined
Urgency is the sudden compelling desire to void during cystometry Detrusor overactivity is due to detrusor involuntary contractions during filling cystometry
Mixed incontinence
Involuntary leakage associated with urgency and also with effort, sneezing or coughing
Not defined
The urodynamic observation of both urodynamic stress incontinence and detrusor overactivity incontinence during the same test is mixed incontinence
1
study methodology and design, for example, in the population of women studied and definitions of urinary incontinence used. Methods of data collection include postal questionnaires, personal and telephone interviews, each of which have limitations as well as advantages, which should be borne in mind when interpreting data. It is widely believed that women under-report symptoms and severity because of shame, embarrassment and ignorance regarding treatment options. The EPINCONT study (Figure 2) remains one of the largest prevalence studies to date.6 The prevalence rates were similar to those reported by Minassian and colleagues in a recent literature review.7 However, in the EPINCONT study, women were not clinically assessed using urodynamics. Prevalence studies, in which urodynamic evaluation has additionally been performed, confirm stress incontinence as the major type of urinary incontinence in women.8–10 Although mixed incontinence is reported in relatively high numbers in epidemiology surveys, it emerges that most of these women are eventually diagnosed with stress incontinence when urodynamic assessment is performed.10
to micturate. This is highly suggestive of underlying neurological pathology.
Prevalence of incontinence There has been wide variation in the reported prevalence of urinary incontinence. Estimates range from 8.5% to 83% of women.3–5 This wide variation in prevalence partly reflects differences in
The EPINCONT study • Evaluated prevalence of urinary leakage in an unselected female population aged 20 years or more by postal questionnaire with an additional validated severity index (used to assess severity of incontinence). • 25% of the 27,936 women had urinary leakage. • Almost 7% described significant incontinence (defined as moderate or severe incontinence).
Prevalence of type of urinary incontinence reported Age: in addition to prevalence of incontinence increasing with increasing age, the type of urinary incontinence differs with age, with stress incontinence most common amongst younger women aged 25–49 years and prevalence decreases with increasing age.6 In older women, mixed incontinence is the most prevalent type of urinary incontinence. This is considered to be largely due to the increase in urge symptoms which are seen with age.
stress incontinence (50%)
mixed incontinence (32%)
Clinical assessment History History-taking in women complaining of urinary incontinence needs to be thorough and systematic. It should aim to differentiate between symptoms of stress incontinence, urgency and urge incontinence and to assess factors that may predispose to these problems (Figures 3 and 4). The clinician should also be alert to symptoms that prompt specialist referral and assessment (Figure 5).
other (4%)
urge incontinence (14%) 2
WOMEN’S HEALTH MEDICINE 2:6
6
© 2005 The Medicine Publishing Company Ltd
TYPES OF INCONTINENCE
History-taking in female urinary incontinence: symptoms Particular questions may help to further differentiate between symptoms of stress incontinence, urgency and urge incontinence. Example question
Underlying disorder
When you pass water, can you hold or do you have to go immediately?
Urgency
Do you ever leak when you have a desire to pass urine and before you can reach the toilet?
Urge incontinence
Do you ever leak when you cough, sneeze, exercise, lift heavy objects, walk or run, or during sexual intercourse?
Stress incontinence
How often do you pass urine from the time you wake in the morning to the time you go to sleep?
Daytime frequency – more than seven voids per day indicate an overactive bladder
How many times are you woken from your sleep because you need to pass urine?
Nocturia – arousal from sleep more than once at night to void may be suggestive of an overactive bladder
3
Questionnaires: inviting women to complete a questionnaire prior to the consultation may provide a useful starting point as well as overcoming some of the embarrassment many women experience in discussing incontinence issues. These self-completed questionnaires are not subject to doctor bias and several examples of wellvalidated questionnaires have been published previously, including the Bristol female lower urinary tract symptoms questionnaire.11
a failure to associate fluid intake with urine output. The average daily adult intake is 1.5–2.0 litres and excessive fluid consumption is a common cause of urinary frequency. Caffeine-containing drinks such as tea, coffee and cola, are known bladder stimulants and an understanding of this fact can allow patients to manage their own urinary symptoms without the need for any other intervention. Documenting this information can be accomplished by completing a frequency volume chart or urinary diary (Figure 6; also see below).
Fluid intake: it is also important to enquire about fluid intake. Patients are often unaware of the fluid volume they consume and excessive consumption is often the result of erroneous advice and
Examination Abdominal examination should be performed to exclude any masses and urinary retention. In addition, a pelvic examination is carried out to assess genital prolapse (e.g. cystocele, uterovaginal prolapse), pelvic masses and pelvic floor strength and tone. Assessment of pelvic floor tone is essential as weak pelvic floor musculature can contribute to stress urinary incontinence and may substantially improve with appropriate physiotherapy without recourse to specialist referral and surgery. A simple way to evalu-
History-taking in female urinary incontinence: predisposing factors Obstetric history • Number of pregnancies • Length of labour • Mode of delivery • Birthweight • Episiotomies Gynaecological history • Menopausal status • Hormone replacement therapy • Hysterectomy/operations for prolapse Medical history • Respiratory disorders/chronic cough • Diabetes • Obesity • Multiple sclerosis • Previous pelvic irradiation: cystitis, fistulae formation • Constipation Drug history • Diuretics • Antidepressants • Anticholinergics
Symptoms and findings that should prompt specialist referral Urinary symptoms • Significant bladder pain • Persistent haematuria • Difficulty in voiding urine • Recurrent urinary tract infections Clinical history/findings • Significant genital prolapse • Underlying gynaecological pathology • Previous failed conservative therapy • Contraindications to empirical therapy (e.g. antimuscarinic preparations in glaucoma) • Previous urinary tract surgery 5
4
WOMEN’S HEALTH MEDICINE 2:6
7
© 2005 The Medicine Publishing Company Ltd
TYPES OF INCONTINENCE
Frequency/volume chart A frequency/volume chart can be used as part of the initial clinical assessment. The patient is instructed to record how much they drink in ml and when (In), and to measure urine passed in a small jug (Out). A cross placed in the column marked ‘Wet’ denotes an episode of urinary incontinence. A line is placed on the chart at the time the patient goes to bed so that a record can be obtained of nocturia as well as daytime frequency. In the example shown, the patient’s primary complaint was of urgency with occasional urge incontinence. A review of her chart on the day shown indicates that the likely cause of this is excessive fluid intake during the day.
Date: am
Date: 1
Time
Date: 2
Date: 3
Date: 4
5
In
Out Wet
In
Out Wet
In
Out Wet
In
Out Wet
In
Out Wet
In
Out Wet
In
Out Wet
In
Out Wet
In
Out Wet
In
Out Wet
1 2 3 4 5 6 7 8 9 10 11 12 pm 1 2 3 4 5 6 7 8 9 10 11 12 Total 3590
6
ate pelvic floor strength/tone is to place an index finger 4 cm to 6 cm inside the vagina, positioned at 4 o’clock and 8 o’clock and ask the patient to squeeze her pelvic floor muscles. Muscle tone can be then be graded according to the modified Oxford scale (grades 1–5).12
kept by the patient of their fluid intake (both volume and time), volume of micturitions and frequency of incontinence (Figure 6). In order to be representative, it is usually kept over a number of days. The urinary diary can also be used as a baseline for monitoring women undergoing bladder retraining.
Additional investigations Several basic investigations of urinary incontinence can be initiated in primary care. Urinalysis: it is essential to perform dipstick urinalysis. Urine should be screened for infection using multistix that test for nitrites, blood and leucocytes. The finding of haematuria should prompt further investigation and in the absence of infection should prompt specialist referral to exclude urinary tract neoplasia.
Quality of life: assessing the impact of urinary incontinence on the patient’s quality of life is important and can be facilitated by asking the woman to complete a disease-specific quality of life questionnaire, such as, the King’s Health Questionnaire.13 In addition to providing a valid and reliable instrument for the assessment of quality of life in women with urinary incontinence, these questionnaires can be useful in evaluating the impact of new treatments of urinary incontinence. Quality-of-life assessment is discussed further on pages 1–3.
Urinary diary: women should also be invited to keep a frequency volume or urinary diary. In its simplest form, this is a paper record
Urodynamic investigations (e.g. uroflowmetry, cystometry) are not always required (Figure 7).
WOMEN’S HEALTH MEDICINE 2:6
8
© 2005 The Medicine Publishing Company Ltd
TYPES OF INCONTINENCE
Indications for urodynamic investigations
REFERENCES 1 Bates P, Bradley W E, Glen E et al. The standardization of terminology of lower urinary tract function. J Urol 1979; 121: 551–4. 2 Abrams P, Cardozo L, Fall M et al. The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourol Urodyn 2002; 21: 167–78. 3 Yarnell J W, Voyle G J, Richards C J, Stephenson T P. The prevalence and severity of urinary incontinence in women. J Epidemiol Community Health 1981; 35: 71–4. 4 Diokno A C, Brock B M, Brown M B, Herzog A R. Prevalence of urinary incontinence and other urological symptoms in the noninstitutionalized elderly. J Urol 1986; 136: 1022–5. 5 Brocklehurst J C. Urinary incontinence in the community – analysis of a MORI poll. BMJ 1993; 306: 832–4. 6 Hannestad Y S, Rortveit G, Sandvik H, Hunskaar S. A community-based epidemiological survey of female urinary incontinence: the Norwegian EPINCONT study. Epidemiology of Incontinence in the County of Nord-Trondelag. J Clin Epidemiol 2000; 53: 1150–7. (This paper outlines one of the largest prevalence studies of urinary incontinence to date.) 7 Minassian V A, Drutz H P, Al Badr A. Urinary incontinence as a worldwide problem. Int J Gynaecol Obstet 2003; 82: 327–38. 8 Sandvik H, Hunskaar S, Vanvik A, Bratt H, Seim A, Hermstad R. Diagnostic classification of female urinary incontinence: an epidemiological survey corrected for validity. J Clin Epidemiol 1995; 48: 339–43. 9 Carey M P, Dwyer P L, Glenning P P. The sign of stress incontinence – should we believe what we see? Aust N Z J Obstet Gynaecol 1997; 37: 436–9. 10 Weidner A C, Myers E R, Visco A G, Cundiff G W, Bump R C. Which women with stress incontinence require urodynamic evaluation? Am J Obstet Gynecol 2001; 184: 20–7. 11 Jackson S, Donovan J, Brookes S, Eckford S, Swithinbank L, Abrams P. The Bristol Female Lower Urinary Tract Symptoms questionnaire: development and psychometric testing. Br J Urol 1996; 77: 805–12. 12 Laycock J, Schussler B, Norton P, Stanton S L, eds. Pelvic floor re-education. 2.2, Clinical evaluation of pelvic floor, 1st edn. London: Springer-Verlag, 1994. 13 Kelleher C J, Cardozo L D, Khullar V, Salvatore S. A new questionnaire to assess the quality of life of urinary incontinent women. Br J Obstet Gynaecol 1997; 104: 1374–9. 14 Cardozo L, Drutz H P, Baygani S K, Bump R C. Pharmacological treatment of women awaiting surgery for stress urinary incontinence. Obstet Gynecol 2004; 104: 511–19. (This trial double-blind, randomized, placebo-controlled study was the first to assess the efficacy of duloxetine for women with severe stress urinary incontinence. This serotonin/ norepinephrine reuptake inhibitor is also used in the treatment of depression.) 15 Kelleher C. Investigation and treatment of lower urinary tract dysfunction. Curr Obstet Gynaecol 2003; 13: 342–9.
(see also pages 15–19) • Failure of empirical treatment • Mixed symptoms precluding empirical treatment • Before surgery for stress incontinence 7
On the basis of the clinical assessment, women may be commenced on conservative treatment. Women with stress urinary incontinence can be referred to physiotherapy for advice on pelvic-floor exercises (page 29) and/or commenced on a drug such as duloxetine (page 33).14 Those patients whose primary symptoms of urgency/urge incontinence suggest an uncomplicated overactive bladder may improve with reducing caffeine intake, bladder training and/or anticholinergics to suppress unstable bladder contractions.15 Cystometry involves measuring the pressure/volume relationship of the bladder during filling and voiding. It is a objective test of bladder function which can provide a pathophysiological explanation of the patient’s symptoms. For a more detailed description of urodynamic evaluation and interpretation, see pages 15–19.
CONFLICT OF INTERESTS Simon Jackson is a medical adviser for Lilly Pharmaceuticals.
WOMEN’S HEALTH MEDICINE 2:6
9
© 2005 The Medicine Publishing Company Ltd