A Logical Approach to Clinical
Problem Solving
&
An applied example on
Urinary Incontinence
4 Steps to Clinical Problem Solving
• Making the Diagnosis
• Assessing the severity and/ or stage of the
disease
• Rendering a treatment based on the stage
of the disease
• Following the patient response to treatment
Making the diagnosis
• Careful evaluation of the gathered data:
– History
– Investigations
Involving in many instances:
-GIGO
-Putting the pieces of the puzzle in their
right place
• Making a short list of Differential Diagnosis
Assessing the severity and / or
stage of the Disease
• Determining how bad the disease is
• Sometimes there is no ‘mild or severe’ yet
the disease may be in itself a risk for
another condition:
– Bacterial vaginosis
Treating based on the stage
• PET at 32 weeks gestation
– Mild
– Severe
• Urinary Tract Infection
– Lower urinary tract
– Upper urinary tract
Following the response to
treatment / expectant management
• Based on clinical judgment
• Based on laboratory testing
• Based on imaging techniques.
However when you are solving a
case on paper, it is a bit different…
• 7 questions need to be answered
– What is the most likely diagnosis?
– What should be your next step?
– What is the most likely mechanism for this process?
– What are the risk factors for this condition?
– What are the grade / severity and possible
complications of this disease process?
– What is the best therapy? Is there an alternative
therapy (ies)?
– How would you confirm the diagnosis
What is the most likely diagnosis?
• Means : The most common cause
– Data presented may be confirming the
diagnosis
– Or they may be leading to another cause
What should be your next step?
• Depends on how much information is
provided:
– If enough: you will make the diagnosis
Stage the disease and treat accordingly
– No enough information
More diagnostic tests
– If he is providing treatment then the next step will
be to follow the response
• What is the likely mechanism for this process?
– The pathophysiology of the disease itself
– The disease may lead to another or to a complication
• What are the risk factors for this disease process?
– Are they present in the context
– Do they mandate further testing / investigations.
• What is the best therapy?
– Do NOT jump to treatment on intuition
– The treatment should be tailored according to:
• Stage/ severity of the disease
• The best possible alternative according to the patient characteristics
• How would you confirm the diagnosis?
– Making the point and concluding the story
• A 48-year old G3 P3+0 woman complains of a 2-year history
of loss of urine 4-5 times each day, typically occurring 2-3
seconds after coughing, lifting or sneezing, additionally, she
notes dysuria and an urge to void during these episodes.
These events causes her embarrassment and interferes with
her daily activities. She is otherwise in good health.
• A urine culture 1 month ago was negative.
• On examination,
– she is slightly obese, the BP is 130/80 and the HR is 80bpm and
regular with a temp of 37˚C, her breast examination is normal
and so were her abdominal examination.
– A midstream urinalysis is unremarkable.
What is your next step?
What is the most likely Diagnosis?
What is the best initial treatment?
Bladder Control Problems
Problems of:
• Bladder Emptying
• Bladder Storage
Bladder Emptying Problems
• Urinary Retention
– Obstruction from within
– Obstruction from outside
– Stretch attenuation of the urethra
– Bladder neck obstruction
– Angulation of the urethra
– Neurogenic causes [reflex from pain, retention
with overflow]
Image source: Virginia Urology Center
Urinary Incontinence
Definition:
Urinary incontinence is uncontrolled leakage
of urine causing hygienic and social
problems.
Urinary Incontinence is Common
Among Older Adults
Percentage of respondents
in each age group
18
16
Men
Women
14
12
10
8
6
4
2
0
5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 >85
Age (years)
Bladder Storage Problems
• Overactive Bladder
• Stress Incontinence
• Mixed Incontinence
• Overflow Incontinence
•Fistulas
Overactive Bladder
Urgency
Urge
incontinence
Frequency
OVERACTIVE BLADDER
Stress Incontinence
Stress incontinence occurs when a small
amount of urine escapes while the person
coughs, sneezes, laughs, jumps or lifts
something heavy.
Stress Incontinence
(a) Continent woman
(b) Woman with stress
incontinence
External
urethral
sphincter
Sudden increase in intra-abdominal pressure
Overflow Incontinence
Overflow incontinence happens when
urine leaks from an overfilled bladder.
Overflow Incontinence
Mixed Incontinence
Mixed incontinence occurs when a
person has both the symptoms of
urge incontinence and stress
incontinence.
Mixed Incontinence
Sudden increase
in intra-abdominal
pressure
Uninhibited detrusor
contractions
Prevalence
• 8-51% in community
• At least 50% in nursing homes
• 25% suffer from severe incontinence
• Greatest in older women and increases with age
• Incontinence 6-10x greater in women than in men
Impact on quality of life
• Significant worldwide health problem
• Affects 16 million women in US
• Cost of diagnosing and managing UI exceed
$26 billion annually in US
• Adult diaper sales $5-6 billion/yr
• Great social impact as well
• Leaking depression stop exercise gain
weight and so on ….
Approach
• Every woman is different
• Consider quality of life from the patient’s
point of view
• History
• Voiding diary
• Quality of life assessment
Normal Bladder Function
• Functional urethra is intra-abdominal
• Increased abdominal pressure transmitted
equally to bladder and urethra
• With increased stress urethro-vesical junction
responds to stress by closing tight
• Bladder is a voluntary smooth muscle
• Inherent ability to maintain low pressure with
filling-increase in volume:compliance
Bladder Pressure-Volume
Relationship
Anatomy of Micturition
•
•
•
•
•
Detrusor muscle
External and Internal sphincter
Normal capacity 300-600cc
First urge to void 150-300cc
CNS control
– Pons - facilitates
– Cerebral cortex - inhibits
• Hormonal effects - estrogen
Interpretation of Post-Void Residual
• PVR < 50cc - Adequate bladder emptying
• PVR > 150cc- Avoid bladder relaxing drugs
• PVR > 200cc- Refer to Urology
• PVR > 400cc- Overflow UI likely
Peripheral Nerves in Micturition
• Parasympathetic (cholinergic) - Bladder
contraction
• Sympathetic - Bladder Relaxation
– Bladder Relaxation (β adrenergic)
– Sympathetic - Bladder neck and urethral
contraction (α adrenergic)
• Somatic (Pudendal nerve) - contraction pelvic
floor musculature
Peripheral Nerves in Micturition
Factors Associated with
Bladder Control Problems
• Age
• Childbirth
• Gender
• Menopausal Status
• Surgery
• Lifestyle
• Medications
• Concomitant illnesses
Potentially Reversible Causes
D
I
A
P
P
E
R
S
- Delirium
- Infection
- Atrophic vaginitis or urethritis
- Pharmaceuticals
- Psychological disorders
- Endocrine disorders
- Restricted mobility
- Stool impaction
2
Medications That May Cause Incontinence
• Diuretics
• Anticholinergics - antihistamines,
antipsychotics, antidepressants
• Seditives/hypnotics
• Alcohol
• Narcotics
• α-adrenergic agonists/antagonists
• Calcium channel blockers
10 Warning Symptoms of
Bladder Control Problems
#1
Any leakage of urine
10 Warning Signs of
Bladder Control Problems
#2
Leakage of urine,
regardless of amount,
on coughing, sneezing,
laughing or standing.
10 Warning Signs of
Bladder Control Problems
#3
Leaking urine on the
way to the toilet.
10 Warning Signs of
Bladder Control Problems
#4
Bed wetting at any
age over six years.
10 Warning Signs of
Bladder Control Problems
#5
An urgent need to
pass urine, being
unable to hold on.
10 Warning Signs of
Bladder Control Problems
#6
Passing urine more
frequently than 8
times a day and only
passing small
amounts.
10 Warning Signs of
Bladder Control Problems
#7
Blood in the urine.
10 Warning Signs of
Bladder Control Problems
#8
Inability to urinate
(retention of urine).
10 Warning Signs of
Bladder Control Problems
#9
Pain when
passing urine.
10 Warning Signs of
Bladder Control Problems
#10
Progressive
weakness of the
urinary stream or a
stream that stops and
starts instead of
flowing out smoothly.
Image source: Malaysian Urological Association
• A 48-year old G3 P3+0 woman complains of a 2-year history
of loss of urine 4-5 times each day, typically occurring 2-3
seconds after coughing, lifting or sneezing, additionally, she
notes dysuria and an urge to void during these episodes.
These events causes her embarrassment and interferes with
her daily activities. She is otherwise in good health.
• A urine culture 1 month ago was negative.
• On examination,
– she is slightly obese, the BP is 130/80 and the HR is 80bpm and
regular with a temp of 37˚C, her breast examination is normal
and so were her abdominal examination.
– A midstream urinalysis is unremarkable.
What is your next step?
What is the most likely Diagnosis?
What is the best initial treatment?
What is your next step?
• Answer the question: What type of
incontinence Does she have?
– Perform cystometry
• Conduct a pelvic examination:
– Will the presence of proplase alter your
decision regarding therapy?
• The Q-tip cotton swab test has been used as
a simple means of identifying patients with
hypermobility of the urethrovesical junction.
• A sterile Q-tip lubricated with xylocaine gel is
placed in the urethra but not through the
internal sphincterand the patient is asked to
bear down.
– If the Q-tip moves up more than 30°, the test is
considered positive, and the patient may benefit
from surgery
• This means that the pressure in the bladder was
transmitted to the Q-tip (i.e. exceeded the closing
urethral pressure)
Urodynamics
• Indications
– “complicated” incontinence
– Pre-op
– After failure of an anti-incontinence procedure
Urodynamics
• Components (a combo of any listed below)
– Cystometry – study of bladder fxn
– Pressure-flow study – bladder fxn during void
– Videourodynamics
– Uroflowmetry (study of flow rates) & PVR
– Electromyography (EMG)
– Urethral Pressure Profilometry
– Ambulatory Urodynamics
Cystometric Evaluation
• Simple
– After void, insert foley, measure PVR, <50cc.
Attach syringe to foley, instill sterile saline.
Normal first desire ~200cc.
– Observe column of saline, unusual waves
suggest detrusor dyssynergia.
– Maximum bladder capacity ~500 cc.
– Remove ~250 cc, remove foley, ask to cough,
loss of urine suggests GSI.
Bladder Pressure-Volume
Relationship
Stable Bladder
Detrusor Instability
Genuine Stress Incontinence
Studies
• Cystometry
• Compliance, fd 90-150ml, nd 200-300ml, sd 400-550 ml, true subtracted
detrusor pressures
• Valsalva leak point pressure
• Amount of intraabdominal pressure needed to leak
• <60 cm H2O is ISD
• Urethral pressure profile
• Full bladder, catheter pulled along urethra
• Urethral closure pressure >30 cm H20 nl, <20 is ISD
• Uroflow
• Rate and pattern of urine flow
• Peak flow 20-30 ml/sec
• Pressure flow test
• Details voiding mechanism, obstructive dysfunction, poor contractility
• Voiding detrusor pressure 10-30 cm H20 is nl
• Electromyography
• Electrical activity of pelvic floor musculature
• Timing and degree of muscle relaxation impacts voiding mechanism
Definition (based on urodynamic studies)
Genuine Stress Urinary Incontinence
(GSUI)
• involuntary loss of urine with a rise in intraabdominal pressure in the absence of any
rise in detrusor pressure
• Urethral hypermobility
Helpful hints
• Stress induced detrusor instability
– May be confused with GSI
– See loss of urine after cough, but delayed
– Bladder overactive after stress
• Incontinence may only be seen in standing
position
• Correction of the cystocele may produce
incontinence
– UVJ is slightly kinked with cystocele and
correction may reveal the econdition
Treatment Options
•
•
•
•
Reduce amount and timing of fluid intake
Avoid bladder stimulants (caffeine)
Use diuretics judiciously (not before bed)
Reduce physical barriers to toilet (use
bedside commode)
1
Treatment Options
• Bladder training
– Patient education
– Scheduled voiding
– Positive reinforcement
• Pelvic floor exercises (Kegel Exercises)
• Biofeedback
• Caregiver interventions
– Scheduled toileting
– Habit training
– Prompted voiding
Pharmacological Interventions
• Urge Incontinence
– Oxybutynin (Ditropan)
– Propantheline (Pro-Banthine)
– Imipramine (Tofranil)
• Stress Incontinence
– Phenylpropanolamine (Ornade)
– Pseudo-Ephedrine (Sudafed)
– Estrogen (orally, transdermally or transvaginally)
Other Interventions
• Pessaries
• Periurethral bulking agents (periurethral
injection of collagen, fat or silicone)
• Diapers or pads
• Chronic catheterization
– Periurethral or suprapubic
– Indwelling or intermittant
Pessaries
Indwelling Catheter
Surgery?
• Bonney test: Gentle support of bladder neck during
exam and asking patient to cough again
• If continent, surgical repair is likely to be successful
• Surgical repairs aim at elevation of bladder neck and
correction of the pubovesical fascia tears
Surgery is reported to “cure” 4 out of 5 cases,
but success rate drops to 50% after 10 years.
Surgical Procedures
• Six basic surgical themes
– Bladder buttress operations (anterior repair,
etc)
– Retropubic operations (Burch, MMK, etc)
– Bladder neck suspensions (Raz, Stamey,
Pereyra, etc)
– Sling procedures (TVT, PV Sling, etc)
– Periurethral Injections
– Artificial urinary sphincter
Bladder Buttress
• Post-op continence rates are lower when
compared to other procedures
• Still in use for correction of cystocele and
can be performed in conjunction with other
incontinence procedures
Retropubic Operations
• Marshall Marchetti Krantz (MMK)
cystourethropexy – 1949
– Para-urethral vaginal wall suspended to symphisis pubis
• Burch colposuspension – 1961
– Para-urethral vaginal wall suspended to Cooper’s
ligament
• Paravaginal fascial repair
– Para-urethral vaginal wall suspended to the
tendinous arc on the pelvic sidewall
Bladder Neck Suspensions
• Pereyra
• Stamey
• Raz
Sling Procedures
• Suburethral sling is a strip of material that is
tunneled underneath the bladder neck and/or
proximal or midurethra and then attached to
above structures such as rectus fascia or pelvic
sidewall to create a posterior support, or
“hammock effect” to the bladder neck and
proximal urethra
• Initially used for ISD (intrinsic sphincter
deficiency), but now used for all kinds GSI
Slings
• Materials
– Autologous fascia lata or rectus abdominis
– Homologous materials (cadaveric fascia lata)
– Synthetic
Slings
• Types of slings
– Traditional suburethral (rectus abdominis)
sling
– Minimally invasive suburethral slings
• Transvaginal bone-anchored sling (In-Fast,
Vesica)
• Tension free vaginal tape (TVT) – only sling placed
at the midurethra
• Initial results are encouraging, but long-term
results are lacking
TVT Operative Technique
•
•
•
•
Abdominal incisions made
Vaginal wall incision made
Paraurethral dissection performed
Trocar with tape advanced through vaginal
incision, urogenital diaphragm, and retropubic
space until its tip is brought out to the
abdominal incision
• Cystoscopy
• Trocar and tape pulled through, tension is
adjusted, and plastic sheath is removed
• Abdominal and vaginal incisions are closed
Periurethral Bulking Injection
• Indicated for patients with stress
incontinence who have:
– Medical conditions that make them unfit for
surgery
– A history of partially successful treatment and
wish to avoid more invasive procedures
– Particularly indicated in patients with ISD
Periurethral Bulking Injections
• Purpose is to bulk up the tissue at the bladder
neck in order to increase urethral closure
pressure
• Bulking agents
–
–
–
–
–
Collagen*
Silicone
Teflon
Fat *
Durasphere* (carbon beads in a carrier gel)
*FDA approved bulking agents
Artificial Urinary Sphincter
• Indicated mainly in patients who have
undergone recurrent previous surgery for
GSI and have ISD
• Few reports on this as first-line treatment,
so results are difficult to interpret.
• As high as 92% continence rate, but also a
high revision rate of 17%
Comparative Outcomes
Procedure
Category
Retropubic
Suspensions
Transvaginal Anterior
Suspensions Repair
Sling
Procedures
Cure/Dry @ 48mo
84%
67%
61%
83%
Cure/Dry/Improved
@ 48mo
90%
82%
73%
87%
De-Novo Urgency
11%
5%
5%
5%
N/A
N/A
7%
8%
Intraoperative
Complications
2%
2%
1%
3%
Postoperative
Complications
4%
7%
2%
7%
Death
5/10,000
Retention (>4wks)
Urge Incontinence
• Loss of urine associated with uncontrollable
urge to void
• Uninhibited, involuntary detrusor contractions
• Pressure-volume relation out of balance
• Also called unstable bladder
• Frequency
• Urgency
• nocturia
• Chronic irritation due to infection, irritation or
tumors
Treatment
• Primarily medical
• Most commonly anticholinergics
– Ditropan – oxybutynin chloride
– Detrol
– Imipramine
– Levbid, cytospaz – hyoscyamine sulphate
– Tolterodine (detrusitol)
• Side effects- dry mouth, constipation etc.
• Behavioral
– Bladder retraining
– Pelvic-floor rehabilitation
Mixed Incontinence
• Some degree of both stress and urge
• More difficult to treat
• Need to do complex urodynamic
studies to determine major component
• Precisely predict success with surgery
• Surgery may worsen the urge
component
• Properly counsel patient
Overflow Incontinence
• Neurogenic bladder
– Multiple sclerosis, spinal cord lesions,
stroke
– Diabetis
– Trauma
– Radical hysterectomy
• Normal innervation absent or damaged
• Loss of vesical reflexes and emptying
sensation
• Overdistended bladder with overflow
• Complaints of fullness, pressure
• Large bladder capacity
• Absence of uninhibited bladder
contractions
• Treatment – medical
– Cholinergics to increase tone and
contractility
• Urecholine- bethanechol
• Prostigmine