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Urinary incontinence and ultrasound imaging.

In the United States, urinary incontinence (UI) is a common problem affecting an estimated 15 million people, with women affected twice as often as men. (1) Although not a life-threatening condition, urinary incontinence affects quality of life for women of all ages. The inconvenience and embarrassment of urinary incontinence causes women to retire prematurely from work and withdraw socially and sexually. Many incontinent women, fearful of a bladder accident, refuse to leave home or only go places where they know the locations of public bathrooms. For elderly women, incontinence is often the deciding factor between independent living and a nursing home. Nearly 60% of institutionalized patients have significant UI. (2)

Embarrassment compounded by the misconception that UI is both untreatable and an expected part of aging makes this problem grossly under-reported. Researchers estimate that fewer than 50% of women voluntarily reveal incontinence problems to their physician and less than 7% of clinicians include incontinence findings in patients' medical reports (Rebecca Hall, Ph.D., oral communication, October 20, 9003).

The economic impact of UI reflects the magnitude of this problem. Marketing experts believe that at least 1 out of 3 purchases of sanitary napkins is for incontinence problems and that women spend more than $1 billion per year Oil disposable incontinence products. (3,1) Medical economists estimate that the overall societal costs of UI exceed $16 billion per year; of that, more than $12 billion is attributed to incontinence in women. (5)

Overview of the Urinary Tract

The urinary system includes the kidneys, ureters, urinary bladder and the urethra. (See Fig. 1.) The kidneys remove metabolic waste products and return glucose, amino acids, water and other physiologically essential substances to the circulating blood plasma. Nearly 1200 mL of urine is produced each day as a by-product of this complex process. (6)

The ureters, which extend inferiorly from each kidney, direct the urine flow to the urinary bladder. An expandable balloon-like organ, the bladder is the temporary urine storage reservoir. The bladder wall contains 3 muscle layers that together form the detrusor muscle. Two sphincters, rings of muscle located on either side of the bladder neck, control urine flow through the urethra. A fully distended bladder can hold approximately 1 L of urine. (7)

Urination is a complicated process that involves both involuntary reflexes and voluntary or learned behaviors. Normally, the urge to urinate first appears when the bladder contains about 200 mL of urine. (7) Bladder filling stimulates stretch receptors in the bladder wall. This stimulation produces neurological signals that trigger the detrusor muscle to contract, increasing awareness of bladder pressure. Just like squeezing a balloon, detrusor muscle contractions elevate the pressure within the bladder. Eventually, the sensations associated with increasing bladder pressure signal that it is time to urinate.

Urination does not occur unless both sphincters relax and allow urine to leave the bladder through the urethra. Relaxing the external sphincter causes the internal sphincter to open automatically. Young children cannot control urine flow until they learn to control the external sphincter.

Certain conditions can cause involuntarily urine loss. These include:

* Pelvic floor changes.

* Urethral sphincter weakness.

* Urethral wall thinning.

* Disruptions in neurological brain-bladder communication.

Alter a normal urination or voiding, less than 10 mL of urine remains in the bladder. (7)

Overview of Urinary Incontinence

According to the International Continence Society, UI is "a condition where the involuntary, loss of urine is a social or hygienic problem and is objectively demonstrable." (8) This definition, however, does not indicate the complex physiological and behavioral aspects of urinary incontinence.

Risk arm Incontinence

Identifying risk factors is a research-intensive process involving large-scale cohort studies. Over the years researchers have identified the following UI risk factors:

* Female gender.

* Advanced age.

* Urinary tract infections.

* Poor mobility and ambulation.

* Dementia.

* White or Asian ethnicity.

* Smoking.

* Drinking beverages that contain caffeine.

* Forceps and vacuum-assisted births.

* Episiotomy.

* Abdominal resection for colorectal cancer.

* Hormone replacement therapy.

A recent study of 149 postmenopausal, nulliparous nuns revealed that 50% reported urinary incontinence. (9) Because these results are similar to findings in other groups of women, this study suggests that being female is probably the greatest risk factor for UI.

Types of Urinary Incontinence

Stress Incontinence

Stress incontinence occurs when coughing, sneezing, laughing, standing, lifting and other movements cause the abdominal muscles to put pressure on the bladder. Stress incontinence usually causes urine leakage or sometimes the loss of the bladder's entire contents. Anatomical changes are a common cause of stress incontinence. Sagging pelvic floor muscles make it difficult or impossible for bladder sphincter muscles to control the urine flow when abdominal muscles push against and compress the bladder. In women, the cause of stress incontinence is usually the weakening of bladder neck muscles, intrinsic sphincter deficiency (ISD) and urethral hypermobility (UH). Detrusor muscle activity is usually not a factor in stress incontinence.

UH is a condition where the urethra does not close properly. Weakened and stretched pelvic floor muscles that allow the bladder to sag within the pelvic cavity cause this type of stress incontinence. In the less severe condition, type I, the bladder neck does not close completely and the urethra is overly mobile. (10) Women who have type I incontinence leak small amounts of urine. In type II UH, the sphincters close the bladder neck and urethra. However, the amount of sagging alters the angle between the bladder body and the bladder neck. This alteration in anatomical geometry makes it difficult for the urethral sphincter to remain closed with increasing bladder pressure. (10) Sometimes the amount of sagging may cause the bladder and connecting tissues to bulge into the vaginal wall and form a cystocele. A cystocele is a bladder hernia.

The most severe form of stress incontinence is ISD. Sometimes called low-pressure urethra or drainpipe urethra, this condition occurs when previous incontinence surgery, radiation therapy, trauma (eg, childbirth and seatbelt injuries) and neurological disorders such as diabetes damage the bladder neck muscles. (11) Estimates of ISD frequency range from 11% of women seeking treatment for incontinence problems to nearly 50% of those referred by their primary care physicians to specialists who treat severe UI problems. (12)

Because urine leakage is more likely to happen when the bladder is full, many women adapt to stress incontinence by urinating more frequently. This behavior can cause overactive bladder or urge incontinence problems.

Urge

Urge incontinence is a condition in which bladder-brain miscommunication produces frequent and inappropriate detrusor muscle contractions. Detrusor instability causes women to have sudden and intense urges to urinate even when the bladder is not full. Also called overactive bladder or irritable bladder, this condition can cause bladder emptying during sleep and a gush of urine after drinking, touching water or even hearing running water. Defined as having to urinate more than 8 times during a 24-hour period or having to get up to urinate more than twice during the night, urge incontinence produces dietary and behavioral changes that can actually aggravate the problem. For example, restricting fluid intake leads to dehydration and constipation and increases the risk of stress incontinence. In attempts to stay dry, it is common for urge-incontinent women to go to the bathroom as frequently as every 30 minutes (Rebecca Rogers, M.D., oral communication, September 2003). For a comparison of stress and urge incontinence, see Table 1.

Mixed

Many women bare mixed incontinence, in which sagging pelvic floor muscles are the cause of urethral hypermobility and the compensating behaviors lead to urge incontinence. Because UH is a structural problem and urge incontinence is a neurological disorder, diagnosing and treating mixed incontinence requires a cross-disciplinary approach.

Overflow

Overflow incontinence, estimated to occur in 7% to 11% of elderly patients, is usually the result of obstructed urinary outflow or contractile dysfunction in which the detrusor muscle does not contract enough to expel urine. (2) The large residual urine volume results in bladder pressures that exceed bladder neck resistance capacity. The result is frequent urination urges and dribbling. In women, the usual causes of obstructed urinary outflow are bladder prolapse and fecal impaction. Neurological damage resulting from diabetes, multiple sclerosis and trauma are other common causes for overflow incontinence. Sometimes bladder surgery or the effects of medication and anesthesia can produce temporary or transient overflow incontinence.

Transient

There are many causes of transient incontinence. Medications, urinary tract infections, mental disturbances, restricted mobility and stool impaction all cause temporary urine leakage and urgency. (See Table 2.) Treating the infection or removing the impairment to normal urine flow control usually resolves this type of incontinence.

In younger women, pregnancy and delivery trauma is a frequent cause of transient incontinence. According to an early study, nearly 50% of women report urine leakage problems sometime during pregnancy. Incontinence reports peak at 38 weeks gestation. (13)

In a study to differentiate between transient and longer-lasting types of incontinence, researchers compared a group of more than 15 000 age-paired nulliparous and recently delivered women. Their research showed that about 10% of age-paired nulliparous women reported having had urine-leakage problems without ever having been pregnant. However, about 21% of study subjects reported incontinence problems after a vaginal delivery. A surprising finding was that only 16% reported similar problems after undergoing a cesarean delivery. (14) However, the authors stated that the benefits of having a cesarean delivery in terms of preserving continence do not outweigh the risks of that surgical procedure.

Other studies showed that 24% of women who experienced incontinence problems after a vaginal delivery and 5% of women who delivered by cesarean section reported having symptoms 3 months postpartum. This shows that for die majority of women pregnancy and birth-related incontinence problems are self-resolving. (13)

Patient Evaluation

Patient evaluation should include a thorough examination to identify the type of incontinence and its physiological or structural source. This includes a patient history, physical exam and clinical laboratory and diagnostic testing.

Medical History

Many physicians believe that the patient's medical history is the most important part of evaluating incontinence. Open-ended and well-directed questions help the clinician determine the cause of incontinence, as well as decide which diagnostic tests and treatments will benefit the patient. (See Table 3.) The duration and progression of incontinence symptoms may indicate the likelihood of successful treatment. (2) Prior abdominal surgeries and radiation treatments as well as diabetes, certain neurological disorders and frequent bladder infections may predispose or contribute to a patient's incontinence. Questions about childbirth experiences can reveal causes for ISD and types I and II stress incontinence.

Physical Examination

During the physical examination, the clinician looks for evidence that may help explain the patient's signs and symptoms. This will include a thorough examination of the patient's abdomen, rectum and urogenital areas to look for pelvic masses, evidence of reduced muscle tone and neurological causes of incontinence. Clinical laboratory tests and imaging examinations help clinicians discover conditions that can cause incontinence or complicate its diagnosis. Because strong urge sensations, frequent urination and incomplete voiding often accompany urinary tract infections, these symptoms may camouflage anatomic and neurologic causes of incontinence. Therefore, testing a urine sample for bacteria helps to differentiate bladder infection urgency from urgency that has anatomic and neuromuscular origins. Urinalysis also can reveal if impaired renal function, diabetes or a malignancy is the cause for the patient's incontinence symptoms.

Diagnosing Incontinence

Clinical testing procedures play a key role in helping clinicians tailor treatment strategies for UI. Some tests focus on measuring urine leakage; others provide a quantitative assessment of abnormal bladder contractions, bladder and urethral pressures and the effect of Valsalva maneuvers (eg, coughing and bearing down) on urine retention. In addition to helping identify the physiologic cause or causes of UI, diagnostic testing helps correlate the patient's subjective reports of urine leakage with quantitative measures.

The Pad Test

The patient wears a preweighed absorbent pad and after 1 or 2 hours removes the pad and seals it in a preweighed plastic bag. Weighing the pad at the office or clinic is a simple way to assess urine leakage.

Postvoid Residual

The postvoid residual is a measure of bladder emptying efficiency. The patient empties her bladder completely and then a physician or nurse uses a catheter to drain residual urine. A hand-held ultrasound instrument also can be used to determine the amount of retained urine. (See Fig. 2A and 2B.) A postvoid residual measurement of more than 200 mL indicates that overflow incontinence may be the source of the patient's bladder control problems. Many clinicians believe a postvoid residual of even 100 mL requires further evaluation. (15)

[FIGURE 2 OMITTED]

Urodynamic Testing

Clinicians use pressure and muscle activity sensors to evaluate the structural and neurological problems that contribute to UI. The pressure sensor detects and records changes in bladder pressure as a catheter fills the bladder with warm water or saline. The point at which the patient reports a strong urge to urinate is the bladder capacity. Normally this urge occurs at 400 to 600 mL of water. However, for women who have urge incontinence, bladder contractions and strong urge sensations can start at 200 mL of water or less (Peggy Griego, R.N., oral communication, October 2003).

The bladder leak point is another important diagnostic test. With urge incontinence, inappropriate bladder contractions squeeze water out of the partially filled bladder. However, leakage in the absence of bladder contractions indicates stress incontinence and the inability of the urinary sphincters to resist bladder pressure. Recording urethral pressure as the patient coughs, strains or changes position is another stress incontinence measure.

Pressure-flow studies constitute the final portion of the urodynamic evaluation. With sensors in place, the patient urinates. Determining the pressure required to urinate can suggest bladder outlet obstruction, a possible cause for frequent urination and dribbling. (15)

Video Urodynamics

Video urodynamics combines urodynamic bladder contraction and pressure data with medical imaging technology. Using contrast media-enhanced fluorometry or ultrasound, the clinician performs video urodynamics studies to correlate the size, shape and position of lower urinary tract structures with physiologic responses to bladder filling, Valsalva maneuvers and voiding.

There is some concern that contrast media, a liquid that is denser than water and saline solution and a potential bladder irritant, may cause detrusor instability. Therefore, introducing contrast media into the bladder may give a false-positive response for urge incontinence. (16) In spite of this potential drawback, many researchers believe video urodynamics is a powerful diagnostic tool that helps clinicians differentiate between ISD and type I and type II stress incontinence. (17)

Cystoscopy

Cystoscopy involves inserting a miniature camera contained within a catheter into the urethra and bladder. Viewing the images on a monitor allows the clinician to observe urethral and bladder neck responses to Valsalva maneuvers. Advancing the cystoscope into the bladder can reveal evidence of long-term bladder infections, bladder stones, interstitial cystitis and tumors.

Ultrasound

Ultrasound is a noninvasive and relatively inexpensive technology used to evaluate and screen for a variety of gynecological conditions, including pregnancy assessments, uterine fibroids, polyps and dysfunctional uterine bleeding. Because is uses sound waves to produce images, ultrasound does not have the safety concerns associated with x-radiation, contrast media and isotopes.

Clinicians already have hand-held ultrasound systems to assess postvoid residual urine volume and bladder capacity at the bedside. (See Fig. 2A and 2B) However, to meet more complex imaging needs, researchers are developing translabial and introital ultrasound (ie, between the labia at the vaginal opening) techniques to diagnose and evaluate urinary incontinence.

Hand-held Ultrasound Systems

Using bedside ultrasound systems decreases reliance on frequent catheterizations to measure postvoid residual urine volume. This technology is a noninvasive way to repeatedly assess patients who have or are at risk lot urinary retention and overflow incontinence. This includes patients who have weak detrusor muscle contractions resulting from diabetes, Parkinson disease and spinal cord injuries or who take medications that interfere with bladder emptying.

Some of the advantages of using hand-held ultrasound devices include:

* Patient acceptance.

* Lower incidence of bladder infections resulting from catheterization.

* Lower incidence of bladder infections resulting from urine retention.

* Helps patients void on an appropriate schedule.

* Can detect blocked catheters.

Although a cost-effective technology, hand-held ultrasound does have some drawbacks. These include:

* Requires specialized training for nursing staff.

* Can give inaccurate readings when patients are morbidly obese.

* Scar tissue, incisions, sutures and staples can affect ultrasound transmission and reflection.

Incontinence and Ultrasound Research

Medical researchers are developing new ways to use the ultrasound units commonly found in medical imaging facilities to detect incontinence-related pelvic floor and lower urinary tract structural changes. Some medical researchers and clinicians believe that, similar to the annual or biannual mammogram, a pelvic floor ultrasound examination may become an important gynecological screening tool. However, before a pelvic floor ultrasound can become part of a woman's annual exam, researchers must establish:

* Anatomical norms.

* Measurement technologies that provide reproducible results.

* Standardized patient preparation and positioning.

One of the outcomes of this research is the discovery that even among young, nulligravid and continent women there is a wide range of "normal" values for various pelvic floor structures at rest and with Valsalva maneuvers. (See Table 4.)

However, ultrasound studies show that funneling or widening of the proximal urethra during Valsalva maneuvers and urethral diverticula are some of the anatomical changes associated with incontinence. (18) (See Figs. 3, 4 and 5.) Ultrasound can also uncover many other incontinence-related tissue and structural changes that are not detectable during the routine gynecological exam. (See Table 5.)

[FIGURES 3-5 OMITTED]

Transducer placement is one of many important diagnostic variables. Transvaginal ultrasound, in which the sonographer places the transducer in the vagina, causes anatomical distortion and does not allow visualization of the urethra. According to many researchers, positioning the transducer introitally produces the best results. (18,19)

Patient preparation and placement can affect ultrasound results. Patients should come to the examination without just having voided. (18) Having a partially filled bladder makes it easier to see urethral funnelling.

Some researchers, claiming that patients with are positioned supine find it difficult to perform Valsalva maneuvers, recommend a semireclining position instead. (18) Although it is easier for patients to perform Valsalva maneuvers when standing, it is difficult to place and manipulate the transducer from below. However, other ultrasound researchers report that supine positioning does not compromise the patient's ability to perform Valsalva maneuvers (Rebecca Hall, Ph.D., oval communication, November 2003).

Treatment

Although some family practitioners and internists successfully treat UI, many patients opt to go to a specialist, such as a gynecologist or urologist. Treatment can range from simple dietary and behavioral changes to physical therapy, drugs, pessaries and surgery.

Behavior

Many behavioral changes can help patients limit incontinence problems or even overcome stress and rage incontinence. For example, dietary modifications can help prevent straining and pressure on the bladder and other pelvic support structures. Weight loss also helps relieve pelvic floor pressure. Limiting bladder irritants such as caffeine, alcohol and certain spices can reduce urge incontinence symptoms. In addition to other health benefits, encouraging patients to stop smoking can improve chronic coughing and Valsalva-related urine leakage. Keeping a bladder or voiding diary helps reveal patterns and behaviors that may contribute to incontinence problems. In a voiding diary patients should record:

* Number and time of bladder urges.

* Time of urine losses.

* Amount of urine lost.

* Number and time of voidings.

* Amount, time and type of beverages consumed. (20)

Patients who experience urine leakage or urgency void frequently to avoid accidents. This behavior, combined with the underlying causes of incontinence, can disrupt bladder-brain communication and worsen urge incontinence symptoms. Bladder drills or timed voidings are methods clinicians use to re-establish normal urination patterns. By following a schedule and gradually increasing the length of time between trips to the bathroom, patients can diminish urgency and leakage.

Physical Therapy

Physical therapy is another incontinence treatment option. Using biofeedback and other techniques, physical therapists help patients become more aware of pelvic floor muscles. This improves patients' ability to perform the pelvic floor exercises that improve muscle tone and bladder control. Electrostimulation therapy helps to reduce bladder contractions and urge incontinence symptoms.

Pessaries

Pessaries are flexible silicone rubber or latex ring-shaped devices that fit into the vagina and help support the uterus, vagina, bladder and rectum. Pessaries are an important incontinence management tool and offer a nonsurgical alternative for controlling a number of pelvic floor disorders. (See Table 6.) Good candidates for a pessary trial are pregnant women who are experiencing transient incontinence, women who want to explore nonsurgical alternatives and women for whom incontinence surgery is too risky or not likely to succeed. (21) In addition, pessaries are a good way for physically active women to manage exercise-induced stress incontinence. (22)

Pessaries compress the urethra against the upper posterior portion of the symphysis pubis and elevate the bladder neck. Together, these positional changes make the bladder neck sphincters better able to withstand bladder pressure and correct the angle between the bladder neck and the urethra. (21)

Pessaries come in many styles and sizes. The clinician must take into consideration the patient's physical requirements and comfort as well as the patient's ability to insert, remove and clean the pessary. Usually the largest pessary that fits comfortably while still allowing voiding is most effective at controlling stress incontinence. (See Fig. 6.)

[FIGURE 6 OMITTED]

Patients who wear a pessary must have regular follow-up visits so their health care provider can make sure the device fits properly and to check the vagina for irritation, pressure sores, infections and allergic reactions. Over time, patients may need a larger or differently shaped pessary to maintain continence.

Pharmaceutical Options

Many medications help women to control urge incontinence. Unfortunately, women who have stress incontinence currently do not have pharmaceutical treatment options. Clinicians once believed that estrogen therapy could reduce stress incontinence by improving sphincter muscle strength and pelvic floor muscle elasticity. However, recent research shows that some women who receive estrogen as part of hormone replacement therapy are actually at increased risk for urinary incontinence. (23) These results, presented at the 2003 annual meeting of the American College of Obstetricians and Gynecologists, underscore the controversy that surrounds the use of hormone replacement therapy to prevent or treat menopause-related problems. In the past, some clinicians recommended ephedrine, the active ingredient of many decongestants and cold medications, to improve stress incontinence. However, recent studies linking the use of this over-the-counter drug to hypertension, heart attacks, stroke, seizures and death make it an inappropriate choice. (24)

Drugs that help control urge incontinence include the antispasmodics that relax the detrusor muscle, the anticholinergics that block inappropriate bladder contractions and the tricyclic antidepressants that "paralyze" bladder smooth muscle. (25) All of these medications cause a variety of side effects that may include dry mouth, constipation, dizziness, increased heart rate and difficulty urinating. (See Table 7.)

Surgical Interventions

Patients and their physicians consider surgery when other treatments have not produced the desired level of control and when incontinence continues to negatively impact the patient's quality of life. Because incontinence surgery is elective, the decision is personal and subjective. For some patients, having surgery is their only hope for achieving continence. For others, dietary changes, weight loss, behavioral modification, pessaries or drug treatments do not produce an acceptable level of bladder control. Surgery is a treatment for stress incontinence and is not an effective treatment for urge incontinence.

There are many surgical incontinence treatment approaches. Some, such as bulking agents and tension-free transvaginal tape, are minimally invasive procedures. Others, many of which are retropubic procedures, are major surgery. Which procedure or combinations of procedures the surgeon uses depends on the underlying reasons for incontinence. For example, pelvic floor prolapse, a condition that often accompanies urinary incontinence, indicates the need for more invasive and extensive surgical strategies.

Bulking Agents

Surgically placed hulking agents are best used to help women who have a well-supported bladder and a stable urethra achieve continence. Currently there are 2 types of bulking agents: bovine collagen (a skin and bone protein) and carbon-coated beads. Research is underway to develop additional types of injectable bulking agents.

Similar to the way collagen injections remove facial wrinkles, bulking agent injections "fill in" the upper part of the urethra. This procedure helps control urine flow by narrowing the diameter of the bladder's neck.

While most often a hospital procedure, some physicians perform bulking agent injections in their office. After the patient has reached an appropriate sedation level, the physician inserts a cystoscope through the urethra and into the bladder to check for other bladder abnormalities. The gynecologist then inserts a needle containing either collagen or carbon-coated beads through the cystoscope and makes small injections on either side of the bladder neck. The bubble of injected material produces a localized swelling that helps the patient control urine flow.

Although collagen and carbon-coated bead injections are relatively simple procedures, there is some preoperative preparation. A few days before surgery, the patient has a urine test to make sure she does not have a urinary tract infection. A positive result requires treating the infection before the procedure.

Collagen injections require a little more preoperative preparation than carbon-coated bead injections. Because bovine collagen is not identical to human collagen, some patients are sensitive to it. About 4 weeks before the procedure, the physician or a nurse performs a skin test that indicates whether the patient is sensitive or allergic to collagen protein. Redness, swelling, tenderness and itching within 28 days of the test are signs of collagen allergy.

Transvaginal Tape

Tension-free transvaginal tape (TVT) is a relatively new method to help women with stress incontinence. Although more invasive than bulking agent injections, TVT is a comparatively noninvasive surgical procedure. TVT improves continence in women who have a hypermobile urethra, intrinsic sphincter deficiency or who have had less than optimal results from other surgeries.

The surgeon makes 2 very small abdominal incisions located just above the pubic bone. A third incision in the vagina provides access to the urethra. Using a pair of guiding needles, the surgeon threads a ribbon of polypropylene mesh fabric through the vaginal incision. The surgeon positions the ribbon-carrying needles so the fabric cradles the urethra as the needles emerge through the abdominal incisions. Supporting the middle section of the urethra helps the sphincter stay closed when the patient coughs or sneezes, preventing involuntary urine loss.

The surgeon does not stitch or tack the support material to structurally stable tissues or bone. Rather, the rough-textured mesh provides support by increasing friction, which decreases organ movement. Over time, the natural deposition of collagen in and around the polypropylene mesh helps permanently anchor the support ribbon.

Although the TVT technique does not help all patients, it does oilier many advantages. Unlike more invasive incontinence surgeries, TVT is an outpatient procedure that takes less than 1 hour to perform. Although the patient can undergo a TVT procedure with general anesthesia, using only local anesthesia and light sedation allows the patient to respond to directions and cough when asked. This helps the surgeon position the support tape in a way that benefits the patient most.

TVT surgery is not an appropriate remedy for all women. It is not recommended for young women who are still growing, women who are or who plan to become pregnant or for women who must take blood-thinning drugs such as heparin or coumadin. Preoperative preparation is minimal for a TVT procedure and includes urinalysis to test for a urinary tract infection and, it appropriate, a pregnancy test.

Retropubic Procedures

Some causes of incontinence require more complex surgery. The stretching of tissues that surround the urethra causes urethral mobility when the bladder neck falls down and away from the pubic bone. Urethral mobility tends to widen the tipper part of the urethra and make it difficult ]or the sphincter to control urine flow. Treating stress incontinence resulting from urethral mobility requires the surgeon to enter the pelvic cavity through either the abdomen or the vagina. Some techniques require large abdominal incisions; others use laparoscopes and small abdominal incisions.

To limit urethral movement and establish a better angle between the bladder and the bladder neck, the surgeon uses the tissues on both sides of the urethra to lift the urethra into a better position. Several well-placed stitches between this tissue and the ligaments above it provide a hammock of support.

Abdominal vs laparoscopic incontinence surgery is a controversial topic. Some surgeons find that using strictly abdominal methods gives better long-term results. Other surgeons have very good results using laparoscopic techniques.

Patients who have severe stress incontinence require more than bladder neck stabilization to achieve bladder control. To help these patients, the surgeon may have to create new bladder support with a bladder support sling. Based on the combination of incontinence problems, the surgeon decides which type of support material will work best. The support sling may be a ribbon of tissue harvested from the abdomen or leg, specially preserved cadaver tissue or synthetic materials.

Incontinence and the Medical Imaging Facility

Many of the patients examined in medical imaging facilities have UI. While few of these patients voluntarily reveal their situation, open-ended questioning can provide information that allows the radiologic technologist to adjust procedures and accommodate patient needs. Questions such as, "Would you like to schedule a bathroom break during the procedure?" or "Would you prefer to wear street clothes or a hospital gown?" will often elicit further information.

Incontinence can affect patient positioning, the ability to tolerate confinement in the magnetic resonance (MR) chamber and the technologist's ability to get artifact-free images. Patients who have stress incontinence may be reluctant to get into positions that put pressure on their bladder and urinary sphincter. Patients who have urge incontinence may have an easier time undergoing lengthy or confining medical imaging procedures if they use the bathroom just prior to their examination. Knowing the expected length of the procedure is another factor that can help urge incontinent patients feel more comfortable.

While many preprocedural questionnaires ask patients about indwelling hardware, few make specific reference to vaginal pessaries. Vaginal pessaries cause anatomical distortions. Therefore, patients should remove or have their pessary removed before undergoing lower abdomen medical imaging procedures. It is safe for patients to wear pessaries while undergoing MR procedures. (26) However, pessaries can interfere with the quality of MR imaging.

Conclusion

Although the past decade has seen remarkable progress in incontinence diagnosis and treatment, fewer than 50% of patients sell-report incontinence problems to their health care providers. It also is astounding that few clinicians include incontinence findings in patient medical reports. This implies that the majority, of patients and health care providers believe incontinence is a normal and untreatable part of the aging process.

While advanced age and female gender are significant incontinence risk factors, incontinence is not a normal condition. Therefore, it is important that patients and health care providers learn to think of UI in the same way as a debilitating "bad back" or "sore knee."

Because of heavy advertising, most people are aware of urine absorbency, products and drugs that limit overactive bladder symptoms. However, many patients and health care providers do not know that other simple treatments, such as dietary and behavioral changes, pessaries and physical therapy, can relieve and even cure stress and urge incontinence in the majority of patients.

Although it is important that clinicians explore the simple solutions first, some patients will require more invasive procedures to regain continence. However, even for these patients, there is a spectrum of treatments that range from bulking agent injections to surgically implanted bladder slings.

Ongoing research in translabial and introital ultrasound promises to provide methods that sonographers can use to image pelvic floor disorders. The ability to screen women for pelvic floor disorders will remove the need for self-reporting, give medical significance to urinary incontinence and open opportunities for preventive care and treatment.
Table 1
Comparison of Stress Incontinence and Urge Incontinence

                Stress Incontinence      Urge Incontinence

Symptoms        Laughing, coughing and   Frequent urges to urinate,
                sneezing cause           nocturia, loss of entire
                involuntary loss of      bladder contents
                small amounts of urine

Physical Exam   Hypermobile urethra      Variable
                Hypomobile urethra

Treatment       Physical therapy         Behavioral modification
                Diet                     Physical therapy
                Surgery                  Diet
                                         Pharmaceutical

Table 2

Some Types of Medications That Contribute
To Incomplete Bladder Emptying

Anticholinergics

Antispasmodics

Tricyclic antidepressants

Antipsychotics

Antiparkinsonian

Calcium channel blockers *

Narcotic analgesics *

Anesthetic agents

Recreational drugs

* When combined with other agents

Source: Karch AM. Lippincott's Nursing Drug Guide.
Philadelphia, Pa: Lippincott-Raven; 1997.

Table 3
Medical History Questions for Women Undergoing Incontinence Evaluation

Positive response to having:      Provides information concerning:

Small urine losses                Potential for overflow and
                                    stress incontinence
Moderate and large urine losses   Potential for detrusor
                                    overactivity
Urine losses with coughing,       Potential for stress
  sneezing                          incontinence
Urgency and frequent need to      Detrusor overactivity
  void
Weak urine stream, straining to   Bladder outlet obstruction and
  void                              overflow incontinence
Work and lifestyle changes        Subjective perception of
                                    incontinence
Use of absorbent products         Quantitative perception of
                                    incontinence
Multiple or difficult             Potential for stress
  childbirths                       incontinence
Diabetes, multiple sclerosis,     Conditions that may predispose
  pelvic and abdominal              or contribute to incontinence
  surgeries, radiation
  treatment

Table 4
Range of Normal Pelvic Organ Parameters - Translabial Ultrasound *

                    Mean    Standard
Parameter           Value   Deviation   Range

Posterior           114     10.6        90[degrees] to 30[degrees]
urethrovesical
angle
--resting

Posterior           145     23.3        100[degrees] to 180[degrees]
urethrovesical
angle
--Valsalva

Urethral rotation   32.1    23.5        0[degrees] to 90[degrees]

Bladder neck        17.3    8.8         1.2 to 40.2 mm
mobility
Cystocele descent   13.7    9.4         30.3 to -10 mm ([dagger])

Uterine descent     31.5    13.4        59 to 0 mm

Rectal descent      8.6     16.1        54 to -22 mm

* Adapted from: Dietz HP. Role of perineal sonography in the
evaluation of patients with stress urinary incontinence. The
Australian and New Zealand Journal of Obstetrics and Gynecology.
2003;43(1):54.

([dagger]) Negative values correspond to movement below the
symphysis pubis.

Table 5
Voiding Problems and Related Ultrasound Findings (18)

Voiding problem                      Ultrasound finding

Recurrent urinary tract infections   Urethral and bladder diverticula,
                                     postvoiding residual volume,
                                     foreign bodies such as bladder
                                     stones and sutures

Urgency and frequency                Urethral and bladder diverticula,
                                     bladder wall masses, foreign
                                     bodies, fibroids, funneling of
                                     the upper urethra

Painful urination and intercourse    Urethral diverticula,
                                     intrauterine device

Urge incontinence                    Bladder wall thickening greater
                                     than 5 mm

Stress incontinence                  Upper urethral funneling,
                                     urethral hypermobility, fixed or
                                     hypomobile urethra, no pelvic
                                     floor reactivity

Table 6
Gynecologic Conditions Amenable
To Pessary Management

Cystocele
Enterocele
Preoperative management
Rectocele
Stress urinary incontinence
Uterine prolapse
Vaginal vault prolapse

Table 7
Some Medications for Urge Incontinence

                                                      Some Side
Drug Class        Examples          Mode of Action    Effects

Anticholinergic   Propantheline     Block in-         Dizziness,
                                    appropriate       drowsiness,
                                    bladder           blurred vision
                                    contractions

Antispasmodic     Oxybutynin        Relax smooth      Headache, dry
                  (Ditropan)        muscle            mouth, consti-
                  Tolterodine                         pation, dry
                  (Detrol)                            eyes
                  Flavoxate
                  (Urispas)
                  Dicyclomine
                  (Bentyl)

Tricyclic         Imipramine        Inhibit or        Dizziness, dry
antidepressants   Doxepin           paralyze          mouth, craving
                                    smooth muscle     for sweets,
                                                      weight gain

Calcium channel   Tolterodine                         Dizziness,
blockers                                              drowsiness,
                                                      blurred vision


References

(1.) Urinary incontinence in women. Available at: http://kidney.niddk.nih.gov/kudiseases/pubs /uiwomen/index.htm. Accessed November 15, 2003.

(2.) Geriatric medicine--urinary incontinence. Available at: www.mayo.edu/geriatrics-rst /Incont.html. Accessed January 4, 2002.

(3.) Nichols A, Albaugh J. The management of urinary incontinence. Available at: http://nsweb .nursingspectrum.com/ce/ce128.htm. Accessed September 30, 2003.

(4.) Diagnosing and treating urinary incontinence. HealthSmart Quarterly, Newsletter: Albuquerque, NM: The University of New Mexico Health Sciences Center: Fall 2003.

(5.) Wilson L. Annual direct costs of urinary incontinence. Obstet Gynecol. 2001;98(3):398-406.

(6.) Fischbach F. A Manual of Laboratory and Diagnostic Tests. 6th ed. Philadelphia, Pa: Lippincott: 2000.

(7.) Martini, F. Fundamentals of Anatomy and Physiology. 4th ed. Upper Saddle Rive, NJ: Prentice Hall: 1998.

(8.) Consensus Statement of the First International Conference for the Prevention of Incontinence. Available at: www.continence-foundation.org.uk /in-depth/prevention-of-incontinence.php. Accessed November 3, 2003.

(9.) Buchsbaum GM. Prevalence of urinary incontinence and associated risk factors in a cohort of nuns. Obstet Gynecol. 2002;100(2):226-229.

(10.) What is stress incontinence and its causes? Available at: www.ucdmc.ucdavis. edu/ucdhs/health/a-z/50UrinaryIncontinence /doc50stress.html. Accessed September 27, 2003.

(11.) Horbach NS, Ostergard DR. Predicting intrinsic urethral sphincter dysfunction in women with stress urinaryincontinence. Obstet, Gynecol. 1994;84:188.

(12.) Rogers R. Anatomy and pathophysiology of urinary incontinence. Presentation at the Conference on Urinary Incontinence, Albuquerque, NM, December 13, 2002.

(13.) Goldberg R. Ever Since I Had My Baby. New York, NY: Three Rivers Press; 2003.

(14.) Rortevit G. Urinary Incontinence after vaginal delivery or cesarean section. N Engl J Med. 2003:348(10):900-907.

(15.) Urodynamic testing. National Kidney and Urologic Diseases Information Clearing House. Available at: http://kidney.niddk.nih.gov/kudiseases/pubs /urodynamic. Accessed October 2, 9003.

(16.) Sullivan J, Lewis P, Howell S, Shepard A, Abrams P. Does contrast media affect the results of urodynamics? Available at: www.continet.org/publications /1999/informally/urodynamics/331.htm. Accessed: September 6, 2003.

(17.) Lane TM, Shah PJR. Valsalva leak point pressure in the evaluation of stress urinary incontinence. Available at: www.brazjurol.com.br/pdf /lane_420_425.pdf. Accessed September 9, 2003.

(18.) Tunn R, Petri E. Introital and transvaginal ultrasound as the mare tool in the assessment of urogenital and pelvic floor dysfunction: an imaging panel and practical approach. Ultrasound Obstet Gyneco. 2003;22:205-213.

(19.) Hall R. Ultrasound: Evaluation of the Urethra and Anal Sphincter. Presented at: Identifying and Treating Pelvic Floor Disorders Following Childbirth: A Guide tar Evaluation and Treatment of Incontinence and Pelvic Organ Prolapse. Albuquerque, NM: November 7, 2003.

(20.) Bladder diary instructions. Patient information sheet. Women's Health Urogynecology Center, University of New Mexico Health Sciences Center, Albuquerque, New Mexico.

(21.) Viera A, Pettigrrew-Larkins A. Practical use of the pessary. American Family Physician. Available at: www.aafp.org/afp/20000501/2719.html. Accessed September 29, 2003.

(22.) Nygaard I, Delancy JO, Arnsdorf L, Murphy E. Exercise and incontinence. Obstet Gynecol. 1990;75:848-851.

(23.) Latest HERS report links HRT to increased risk for urinary incontinence. Available at: www.medscape .com/viewarticle/453299?WebLogicSession=P3jHfM47 BozSj23xkjrwgylfSAlwcQOHN1qA5I1aFfW6gMQW9x 4S|1596364421381855934/184161395/6/7001/7001/ 7002/7002/7001/-1. Accessed September 29, 2003.

(24.) Ephedrine legal advice. Available at: www .ephedrine-ephedra.com. Accessed September 29, 2003.

(25.) Urge incontinence. Medlineplus. Available at: www.nlm.nih.gov/medlineplus/ency/article /001270.htm. Accessed September 29, 2003.

(26.) MRI safety. Available at: www.stmichaelshospital .com/content/programs/medical_imaging/mri /mri_safety.asp. Accessed November 15, 2003.

Janet Yagoda Shagam, Ph.D., is a microbiologist with more than 25 years of experience teaching college-level biology, medical and environmental microbiology and chemistry. Dr. Yagoda Shagam, an award-winning freelance medical and science writer, has written numerous professional articles, peer-reviews research articles, case studies for BioQuest and the American Society for Microbiology and has given presentations to various clinical, community, national and international professional organizations. In addition, Dr. Yagoda Shagam serves on several editorial boards and is the New Mexico Regional Director and the Southwest Director-at-Large for the American Medical Writers Association.

The author wishes to thank the clinical staff of the Women's Health Urogynecology Center at the Health Science Center; University of New Mexico, for their time and willingness to let her observe and photograph diagnostic procedures. Special thanks go to Rebecca Hall, Ph.D., for reviewing the manuscript and providing ultrasound images, Rebecca Rogers, M.D., for being a constant and patient information source, Peggy, Gurule, B.S.N., RN, for explaining urodynamic diagnostics and Ellen Craig; M.S., RN, CNM, for explaining pessaries and the pessary fitting procedure. The author also acknowledges the generosity of the urogynecology patients who allowed her to intrude into very personal and intimate space.
Directed Reading Continuing Education Quiz

Urinary Incontinence
And Ultrasound Imaging

To receive Category A continuing education credit for this Directed
Reading, read the preceding article and circle the correct response
to each statement. Choose the answer that is most correct based on
the text. Transfer your responses to the answer sheet on Page 295
and then follow the directions for submitting the answer sheet to
the American Society, of Radiologic Technologists. You also may
take Directed Reading quizzes online at www.asrt.org.

* Your answer sheet for this Directed Reading must be received
in the ASRT office on or before this date.

1. Urinary incontinence is a normal and expected
part of aging.

a. trim
b. false

2. The structures that direct the flow of urine to the
bladder are the:

a. detrusor muscles.
b. urinary sphincters.
c. kidneys.
d. ureters.

3. Bladder filling directly causes:

a. coughing.
b. detrusor muscle contractions.
c. stretch receptor stimulation.
d. external urinary sphincter relaxation.

4. Which research indicates being female is probably
the greatest risk factor for urinary incontinence?

a. pregnancy trauma study
b. vaginal vs cesarean section study
c. postvoid residual study
d. postmenopausal, nulliparous nun study

5. The most severe form of stress incontinence is:

a. mixed.
b. type I.
c. type II.
d. intrinsic sphincter deficiency.

6. Behavioral changes resulting from stress incontinence
can produce:

a. transient incontinence.
b. pelvic floor prolapse.
c. urge incontinence.
d. overflow incontinence.

7. Signs and symptoms of urge incontinence
include:

a. sudden and intense urges to urinate.
b. small urine leaks when coughing or laughing.
c. inability to stop urine flow midstream.
d. obstructed urinary outflow.

8. Overflow incontinence occurs in what percentage
of elderly patients?

a. 2 to 3
b. 4 to 6
c. 7 to 11
d. 12 to 15

9. In a study that paired nulliparous and recently
delivered women, what percentage of subjects
reported continence problems after a vaginal
delivery?

a. 10
b. 16
c. 21
d. 24

10. What does the postvoid residual volume measure?

a. urinary leakage
b. bladder emptying efficiency
c. bladder capacity
d. the effect of Valsalva maneuvers

11. When using a catheter to fill the bladder, the
point at which the patient reports a strong urge
to urinate is the:

a. bladder capacity.
b. bladder emptying efficiency.
c. bladder leak point.
d. postvoid residual.

12. -- is a type of study that correlates the
size, shape and position of urinary tract structures
with physiological responses.

a. Cystoscopy
b. Video urodynamics
c. A pressure flow study
d. The pad test

13. Health care providers use hand-held ultrasound
devices to:

a. measure the postvoid residual urine volume.
b. diagnose bladder infections.
c. demonstrate a hypermobile urethra.
d. measure detrusor muscle instability.

14. Advantages of the hand-held ultrasound device
described in the article include all of the following
except that it:

a. is not affected by scar tissue, sutures or staples.
b. reduces incidence of bladder infections
resulting from catheterization.
c. has good patient acceptance.
d. can detect blocked catheters.

15. Some researchers believe that the best position of
the transducer for examining the urinary system is:

a. transvaginally.
b. transrectally.
c. transabdominally.
d. introitally.

16. The purpose of bladder drills or timed voidings is
to help patients:

a. avoid accidents.
b. re-establish normal urination patterns.
c. strengthen the urinary sphincter.
d. control Valsalva maneuvers.

17. Pessaries help patients manage:

a. urge incontinence.
b. stress incontinence.
c. postvoid residual problems.
d. bladder infections.

18. In addition to behavior modification, --
also help (helps) patients control urge incontinence.

a. transvaginal tape
b. bulking agents
c. medications that relax the detrusor muscle
d. medications that relax tire urethral sphincter

9. Collagen and carbon-coated bead injections:

a. stabilize the pelvic floor.
b. relax the detrusor muscle.
c. narrow the bladder neck diameter.
d. prevent urethral funneling.

20. For women who have a hypermobile urethra or
intrinsic sphincter deficiency, -- is (are) a
relatively noninvasive treatment option.

a. bulking agents
h. transvaginal tape
c. retropubic procedures
d. laparoscopy
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Title Annotation:Directed Reading
Author:Shagam, Janet Yagoda
Publication:Radiologic Technology
Date:Mar 1, 2004
Words:7255
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