Determining and Evaluating Incontinence in the Office Setting

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.

Identifying Incontinence

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

• Overactive bladder also known as urge/frequency, detrusor instability, or detrusor hyperreflexia
• Overflow incontinence
• Stress incontinence/intrinsic sphincter deficiency/urethral instability
• Lower urinary tract bypass, including fistulas, diverticuli, and ectopic ureters
• Mixed incontinence

Initial Office Visit

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.

Diagnostic Protocol

• 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:

$150-$600

$318
$239
$212
$186
$212

10 minutes

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).
• 24 hr voiding diary or Urolog
• Stress test/pad test
• Behavioral modifications, dietary changes, timed voiding, pelvic floor exercises (Kegels), and oral and vaginal estrogen therapy as needed, are started.

Follow-up Visit: Urodynamics

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

Urodynamic Protocol (see Table 1)

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.

Therapeutic Options

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.

Summary

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.

References:

References

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