20 CHAPTER 1 Preliminary investigation

Urinary incontinence in adults

Definitions

Urinary incontinence (UI): involuntary loss of urine that is objectively demonstrable and is of social and/or hygienic concern (international Continence Society definition).

Stress urinary incontinence (SUI): urine loss associated with increased intra-abdominal pressure such as exertion, coughing, or sneezing. A diagnosis of urodynamic SUI is made during filling cystometry when there is involuntary leakage of urine during a rise in abdominal pressure (induced by coughing), in the absence of a detrusor contraction.

Urge urinary incontinence (UUI): sudden uncontrollable urgency, leading to leakage of urine.

Overactive bladder (OAB): urinary urgency, with or without urge incontinence, usually with frequency and nocturia, in the absence of causative infection or pathological conditions.

Overflow incontinence: increased residual or chronic urinary retention leads to urinary leakage from bladder overdistention.

Total incontinence: the continuous leakage of urine.

Functional incontinence: loss of urine related to deficits of cognition and mobility.

Mixed urinary incontinence (MUI): a combination of SUI and UUI.

•Both UUI/OAB and MUI require a perception of urgency by the patient.

•25% of women aged >20 years have UI, of whom 50% have SUI, 10–20% have pure UUI, and 30–40% have MUI.

•UI impacts psychological health, social functioning, and quality of life.

Significance of SUI and UUI

SUI occurs in women as a result of bladder neck/urethral hypermobility and/or neuromuscular defects causing intrinsic sphincter deficiency (sphincter weakness incontinence). As a consequence, urine leaks whenever urethral resistance is exceeded by an increased abdominal pressure occurring during exercise or coughing, for example.

In women, obesity, childbirth, and cystocele/uterine prolapse are common causes. In men, prostate surgery (radical prostatectomy, TURP) can result in incompetence or weakness of the external sphincter.

UUI may be due to bladder overactivity (formerly known as detrusor instability) or, less commonly, to a pathological process that irritates the bladder (infection [UTI, vaginitis, pelvic inflammatory disease], tumor [urological, gynecological], urolithiasis) or neuropathy (multiple sclerosis, CNS neoplasms, stroke). The correlation between urodynamic evidence of bladder overactivity and the sensation of urgency is poor, particularly in patients with MUI.

Symptoms resulting from involuntary detrusor contractions may be difficult to distinguish from those due to sphincter weakness. Furthermore,

URINARY INCONTINENCE IN ADULTS 21

in some patients, detrusor contractions can be provoked by coughing, thus distinguishing leakage due to SUI from that due to bladder overactivity can be very difficult. For the diagnosis of OAB, no cause can be identified.

Other types of incontinence

While SUI and especially UUI do not specifically allow identification of the underlying cause, some types of incontinence may allow a specific diagnosis to be made.

•Bed wetting in an elderly man suggests high-pressure chronic retention.

•Total incontinence suggests a fistulous communication between the bladder (usually) and vagina (e.g., due to surgical injury at the time of hysterectomy or C-section) or, rarely, the presence of an ectopic ureter draining into the vagina (in which case the urine leak

is usually low in volume, but lifelong). Total disruption of the internal and external sphincter in men and women can also cause total incontinence.

Diagnosis and management of incontinence

A basic history and physical exam along with urinalysis may identify the cause. In women, a pelvic exam must be performed (cystocele, urethral diverticulum).

Residual urine determination and urinary flow rates can be used to diagnose retention or outflow obstruction. Good flow rate with minimal postvoid residual suggests sphincteric incontinence.

•Urodynamic studies are useful where the history does not clearly indicate the cause.

•Cystometrogram measures bladder compliance, sensations, and detrusor responses to filling. It is particularly useful with urgency and urge incontinence. Documentation of detrusor hyperreflexia or detrusor instability has important therapeutic implications.

•Valsalva leak point pressure determines the intra-abdominal pressure at which urine leaks. A low leak point pressure implies intrinsic sphincter deficiency (ISD).

•Videourodynamic studies are advanced testing if basic evaluation not informative.

Further reading

Anger JT. Saigal CS. Stothers L. Thom DH. Rodriguez LV. Litwin MS (2006). Urologic Diseases of America Project. The prevalence of urinary incontinence among community dwelling men: results from the National Health and Nutrition Examination survey. J Urol 176(5):2103–2108.

Atiemo HO, Vasavada SP (2006). Evaluation and management of refractory overactive bladder.

Curr Urol Rep 7:370–375.

Wein AJ, Rackley RR (2006). Overactive bladder: a better understanding of pathophysiology, diagnosis, and management. J Urol 175:S5–S10.

22 CHAPTER 1 Preliminary investigation

Genital symptoms

Scrotal pain

Pathology within the scrotum

•Epididymitis, orchitis, epididymo-orchitis

•Torsion of the testicles

•Torsion of testicular appendages

•Testicular tumor (usually painless)

Referred pain

•Ureteric colic

•Inguinal hernia

•Nerve root irritation or entrapment (ilioinguinal or genitofemoral)

Testicular torsion

Ischemic pain is severe and often accompanied by nausea and vomiting. Torsion presents with sudden onset of pain in the hemiscrotum, sometimes waking the patient from sleep. It may radiate to the groin and/or flank. There is sometimes a history of mild trauma to the testis in the hours before the acute onset of pain.

Similar episodes may have occurred in the past, with spontaneous resolution of the pain (suggesting torsion or spontaneous detorsion). The testis is very tender. It may be high-riding (lying at a higher than normal position in the testis) and may lie horizontally due to twisting of the cord.

Torsion of testicular appendage

Pain is usually not as severe as testicular torsion, and onset can be more gradual, not usually associated with nausea/vomiting.

Epididymitis, orchitis, epididymo-orchitis

These conditions have similar presenting symptoms to those of testicular torsion. Tenderness is most commonly localized to the epididymis. Isolated orchitis is rare today. Untreated epididymitis may involve the testicle secondarily with massive swelling and diffuse tenderness. See p. 33 for advice on attempting to distinguish torsion from epididymo-orchitis.

Testicular tumor

Only 20% of patients present with testicular pain, and most often after minor trauma.

Acute presentations of testicular tumors

•Testicular swelling may occur rapidly (over days or weeks). An associated (secondary) hydrocele is common. A hydrocele, especially in a young person, should always be investigated with an ultrasound to determine whether the underlying testis is normal.

•Rapid onset (days) of testicular swelling can occur. Very rarely, patients present with advanced metastatic disease (high-volume disease in the retroperitoneum, chest, and neck, causing chest, back, or abdominal pain or shortness of breath).

GENITAL SYMPTOMS 23

•Approximately 10–15% of testis tumors present with signs suggesting inflammation (i.e., signs suggesting a diagnosis of epididymo-orchitis—a tender, swollen testis, with redness in the overlying scrotal skin and a fever).

Priapism

Priapism is painful, persistent, prolonged erection of the penis not related to sexual stimulation (see causes in Chapter 12). It can be associated with pharmacological therapies (oral and intracavernosal) for erectile dysfunction. Recurrent or “stuttering” priapism episodes are recurrent but of limited duration. There are two broad categories—low flow (most common) and high flow.

Low-flow (“ischemic”) priapism is due to hematological disease (hemoglobinopathies, sickle cell anemia, thalassemia) or infiltration of the corpora cavernosa with malignant disease, or it is medication related. The corpora cavernosa are very rigid and painful because the corpora are ischemic.

High-flow priapism is due to perineal trauma, which creates an arteriovenous fistula. There is less pain and rigidity.

Diagnosis is usually obvious from the history and examination. Characteristically, the corpora cavernosa are rigid and the glans is flaccid. In low-flow priapism of the erect penis is very tender. Examine the abdomen for evidence of malignant disease and perform a digital rectal examination to examine the prostate. If necessary, corporal blood gas can be used to sort ischemic priapism (pO2 < 30 mmHg, pCO2 > 60 mm Hg, pH < 7.25) from non-ischemic priapism (pO2 > 90 mmHg, pCO2 < 40 mmHg, pH > 7.4).