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Upright exam key to stress urinary incontinence dx: essential part of good evaluation.

BIG SKY MONT. -- Examination of the patient in an upright position is a key component of a good office evaluation for stress urinary incontinence, and it's one many physicians overlook, Dr. Steven D. McCarus said at a meeting on ob.gyn., gynecologic ontology, and reproductive endocrinology.

"I'm amazed at how many patients say, 'Dr. Steve, I've never had anybody do that.' If you're doing pelvic floor corrective surgery, that's an extremely important part of the evaluation because you're going to pick up a high rectocele, an enterocele, a vaginal cuff prolapse, or an anterior enterocele. It takes 2 minutes. You've really got to do it," explained Dr. McCarus, chief of the division of gynecologic endoscopy at Florida Hospital Celebration Health in Orlando, Fla.

The preoperative office evaluation of a patient with stress urinary incontinence is aimed at determining which type of incontinence she has so the right operation can be selected. If, for example, she has a mixed mechanism involving a hypermobile urethra and intrinsic sphincteric deficiency, a transvaginal tape (TVT) procedure is really the way to go, because it addresses both mechanisms.

In this setting, the Butch retropubic bladder neck procedure is simply the wrong operation, he said.

Intrinsic sphincteric deficiency is the number one reason for failed Burch procedures in these patients. Indeed, the operation has a 54% failure rate in those women whose urinary incontinence is due wholly or in part to intrinsic sphincteric deficiency.

On the other hand, if office urodynamic testing shows the patient doesn't have intrinsic sphincteric deficiency and her" problem is solely urethral hypermobility, then a Burch or TVT procedure will yield equally good cure rates. The choice becomes one of the surgeon's preference.

"I work with a urogynecologist. Basically, I send my TVTs to her and I do all the laparoscopic Burches. I don't really want to deal with issues of tape eroding or getting infected or having a perforated bladder. I'll let her do that," Dr. McCarus said at the meeting, which was sponsored by the Geisinger Health System.

What he calls his "poor man's office evaluation" includes a history with a 7-day voiding diary and a more detailed 24-hour urination log.

The portion of the physical exam performed in the supine position includes the sterile Q-tip test, in which a cotton swab is placed in the urethrovesical junction and the patient performs a Valsalva maneuver--a greater than 30 degree deflection of the swab is a positive test for urethral hypermobility. Elevating the urethrovesical junction with two fingers and having the patient perform another Valsalva is another quick test for a hypermobile urethra.

"Also, when doing your exam with the patient in a supine position, look at the vaginal mucosa carefully, if you have loss of 'rugation' there's a good chance the patient has a lateral compartment defect, a paravaginal defect. You don't want to go in and correct a midline defect and leave a lateral compartment defect," he said.

It's after he has finished examining the patient in the supine position that he routinely has her stand and put one foot on the examination table for the upright exam looking for pelvic floor support defects.

Urine culture, a postvoid residual urine measurement, and simple urodynamic testing using a two- or three-chamber system are other essential parts of the office evaluation, added Dr. McCarus, who is also medical director of minimally invasive surgery at the Celebration Health women's center in Orlando.
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Title Annotation:Women's Health
Comment:Upright exam key to stress urinary incontinence dx: essential part of good evaluation.(Women's Health)
Author:Jancin, Bruce
Publication:Family Practice News
Geographic Code:1USA
Date:Apr 15, 2004
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