Clinical Evaluation of Urinary Incontinence

Abstract

Pelvic organ prolapse is the downward descent of the pelvic floor organs and has a prevalence of 3%-6% and can even reach to 50% if defined by a vaginal examination. The anatomical concepts of pelvic diaphragm, lateral attachment of vagina to arcus tendineus fascia pelvis, and intrinsic and extrinsic sphincter control mechanisms are elaborated. The anatomic and physiological mechanisms of autonomic and voluntary control of continence are discussed. The clinical and urodynamic tests and their implications in guiding the management are explained. Finally, uroflowmetry, cystometry, urethral pressure profile, postvoid urine measurement, leak point pressure (LPP) test, video urodynamic tests, and electromyography studies of pelvic floor are discussed as an integral part of the assessment.

Keywords: Electromyography; physiopathology pelvic floor; stress; urethra; urinary bladder; urinary catheterization; urinary incontinence; urinary retention; urination disorders; urodynamic.

Figure 1

(a) Pelvic diaphragm viewed from below. (b) Muscles of pelvic wall: Lateral view. (c) Coronal section of pelvis. (d) Anatomical supports of bladder neck and urethra

Figure 2

Graphic representation of various uroflow patterns. (a) Superflow commonly seen with reduced urethral flow resistance. (b) Intermittent multiple peak pattern. (c) Intermittent interrupted pattern. (d) Abnormal flow rate characteristic of detrusor outlet obstruction

Figure 3

Recording of multichannel cystometry. (a) In a person with normal detrusor function, the detrusor pressure remains at zero or rises slightly while collecting urine, even at the maximum capacity. (b) In a person with normal detrusor function, cough and other maneuvers are seen as sharp rise and fall, with equal transmission to bladder and abdominal channels. There is no rise in detrusor pressure. (c) In a person with normal voiding pattern the detrusor pressure rises as the bladder contracts to empty. There is little or no rise in abdominal pressure during voiding (unless the person strains)

Figure 4

Demonstration of urgency and/or urinary leakage coincident with increased detrusor pressure in multiple channel cystometry in a neurologically intact patient defines the diagnosis of detrusor instability

Figure 5

Maximal urethral closure pressure is measured by urethral pressure profile while a pressure sensor is gradually withdrawn from the urethra

Figure 6

Videourodynamics of bladder and urethra can assess both the anatomy and physiology of urinary tract

Figure 7

Electromyography study can assess functional tone as well as the response to treatment (muscle strengthening exercises and neuromodulation)[32]