Case Presentation-Stress Urinary Incontinence

Clerk 李翰泓 #9301

Patient’s informationName: 李○郁Chart number: 11285654Age: 52 y/oGender: FOccupation: Tour guide

Patient’s information (cont.)● Past history: 1.LAVH for uterine myoma on 2012-032. UTI3. Thalassemia, type unknown4. Hypertension

● OB/GYN history: o G3P2A1, CS, last menstruation: 2012-03, s/p LAVH

● Family history: noncontributory

History● Tour guide for years

o Hold back urine and help carry heavy baggages because of her job

● She suffers urinary tract infection frequentlyo Especially during summer, almost every day

in summer vacationo The symptoms are: urgency, low abdominal

pain and burning sensation during urination

History (Cont.)● The patient has occasional urine

leakage after coughing or sneezing for years

● In the last 5 years, the patient has been suffering from continuous urinary disordero Difficult urination, drippings after urination,

frequent urination (up to 1 time/0.5 hr)o Most serious episode: all urine leak out after

coughing in a winter vacationo Most of her colleagues suffer from similar

disorder

Urodynamics exam (2014-04-09)

● Post void residual: 0 ml● CMG: filling capacity: 364 ml, normal

cystometrogram , leak with cough, first leakage at abdominal pressure 147 cmH2O, won’t leak after Valsalva

● UPP: Maximal urethral pressure of H51 cm2O, maximal urethral closure pressure of 33 cmH2O, functional urethral length of 30 mm

● Stress UPP: Negative pressure over whole urethra, average transmission rate: 51%

● PAD test: 2-10 gram

Urodynamics exam (2014-04-09) (Cont.)● Uroflowmetry: Voided 430 ml over 53 sec, peak

flow is 14 ml/sec, and the mean flow is 8 ml/sec● Pressure flow study: First sensation at 168 ml,

normal desire at 249 ml, strong desire at 364 ml, urgency at 416 ml. Bladder infused volume 421 ml. The patient’s voiding mechanism was accomplished by detrusor contraction and valsalva effort. She did not silence after her EMG

● Assessment: stress urinary incontinence

Operation● Anterior repair:

o Anterior vaginal wall longitudinal incision, close the defect of pubocervical fascia

● TVT:o Adjust tapes and curve

needles were inserted, the tape was adjusted by compression test under bladder 350 cc NS

Operational outcome● Remove Foley on 2014-05-05, post op

day #3, re-on Foley due to urine retention

● Post void volume (2014-05-06, post op day #4): 137 ml (morning), 0 ml (afternoon)

● Need adjustment or not?

Stress urinary incontinence

Introduction● Unintentional loss of urine● Prompted by physical activity which

may increase abdominal pressureo coughing, sneezing, running, heavy lifting

● Not related to psychological stress● Age as the single largest risk factor

o Female is two times more common than male

Etiology● Sphincter and pelvic muscle floor

weaknesso Childbirtho Prostate surgeryo Other

● Congenital weakness of bladder● Urethral mucosa damage

Contributory factors● Illness that cause chronic cough or

sneeze● Obesity● Smoking - which cause frequent cough● Excess consumption of caffeine or

alcohol● High impact activities for many years● Hormone insufficiency

Symptoms & Signs● More vulnerable for unintentional

urine loss when doing activities that would increase abdominal pressureo Could be both sign and symptom

● Usually in multiparous, elder women● Frequency and urgency

o DDx from detrusor instability

Evaluation● Mid Stream Urine (MSU)● Uroflowmetry

o Detrusor muscle contractility and urinary tract obstruction

o normal flow rate: 15 ml/sec● Cystometry and video urethrography

o Evaluate urine leakage and detrusor instability

● Pad test

Genuine Stress Incontinence● This diagnosis can only be made via

uroflowmetryo Urine leak during rise of intra-abdominal

pressureo Without detrusor muscle activity

Treatment● Initial treatment

o Lifestyle Weight loss Dietary changes

o Behavioral therapy Bladder training Pelvic muscle exercise Biofeedback Cognitive therapy

Treatment (Cont.)● Medications

o Duloxetine A SNRI, contraindicated in chronic liver disease patient

o Estrogen Vaginal estrogen instead of systemic usage, which may

worsen ito Other

Alpha-adrenergic agent no longer recommended

Surgical intervention - 1● Anterior colporrhaphy

o for patient with cystocele● Endoscopic bladder neck suspension

o for patient with bladder neck and ureter hypermobility

● Burch Colposuspensiono adhese the endopelvic fascia to Cooper’s

ligament or rectus muscle

Surgical intervention - 2● Marshall-Marchetti-Krantz operation

● Left: MMK, Right: Bruch

● MMK may not cure cystocele

Surgical intervention - 3● Tension-free vaginal tape

Surgical intervention - 4● TVT v.s. TVT-O

o TVT for younger, active, and patient with internal sphincter deficiency, which provide greater supportive angle, and cause less pain to inguinal area

o TVT-O for older, heavier and patient underwent TVT, which is easier conducted, less likely to cause bladder injury

Reference1. http://www.glgacenter.com/images/tvt_02.jpg2. http://wd.vghtpe.gov.tw/obgy/File/%E6%99%A8%E9%96%93%E

6%95%99%E5%AD%B8/16stress%20urinary%20incontinence.ppt

3. http://www.mayoclinic.org/diseases-conditions/stress-incontinence/basics/definition/con-20027722

4. http://www.sciencedirect.com/science/article/pii/S0957584701902094

5. http://emedicine.medscape.com/article/452289-overview#a01566. Uptodate: Treatment and prevention of urinary incontinence in

women7. http://www.tcs.org.tw/profession/article/index_info.asp?med_id=

818. http://www.surgeryencyclopedia.com/Ce-Fi/Colporrhaphy.html9. http://www.atlasofpelvicsurgery.com/3BladderandUreter/2Retrop

ubicUrethropexy/chap3sec2.html