Diagnosis of Urinary Incontinence
University of North Carolina, Chapel Hill, NC, USA.American family physician (Impact Factor: 2.18). 04/2013; 87(8):543-50.
Urinary incontinence is common, increases in prevalence with age, and affects quality of life for men and women. The initial evaluation occurs in the family physician's office and generally does not require urologic or gynecologic evaluation. The basic workup is aimed at identifying possible reversible causes. If no reversible cause is identified, then the incontinence is considered chronic. The next step is to determine the type of incontinence (urge, stress, overflow, mixed, or functional) and the urgency with which it should be treated. These determinations are made using a patient questionnaire, such as the 3 Incontinence Questions, an assessment of other medical problems that may contribute to incontinence, a discussion of the effect of symptoms on the patient's quality of life, a review of the patient's completed voiding diary, a physical examination, and, if stress incontinence is suspected, a cough stress test. Other components of the evaluation include laboratory tests and measurement of postvoid residual urine volume. If the type of urinary incontinence is still not clear, or if red flags such as hematuria, obstructive symptoms, or recurrent urinary tract infections are present, referral to a urologist or urogynecologist should be considered.
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ABSTRACT: Most cases of urinary incontinence in women fall under one of three major subtypes: urge, stress, or mixed. A stepped-care approach that advances from least invasive (behavioral modification) to more invasive (surgery) interventions is recommended. Bladder retraining and pelvic floor muscle exercises are first-line treatments for persons without cognitive impairment who present with urge incontinence. Neuromodulation devices, such as posterior tibial nerve stimulators, are an option for urge incontinence that does not respond to behavioral therapy. Pharmacologic therapy with anticholinergic medications is another option for treating urge incontinence if behavioral therapy is unsuccessful; however, because of adverse effects, these agents are not recommended in older adults. Other medication options for urge incontinence include mirabegron and onabotulinumtoxinA. Sacral nerve stimulators, which are surgically implanted, have also been shown to improve symptoms of urge incontinence. Pelvic floor muscle exercises are considered first-line treatment for stress incontinence. Noninvasive electrical and magnetic stimulation devices are also available. Alternatives for treating stress incontinence include vaginal inserts, such as pessaries, and urethral plugs. Limited or conflicting evidence exists for the use of medications for stress incontinence; no medications are approved by the U.S. Food and Drug Administration for this condition. Minimally invasive procedures, including radiofrequency denaturation of the urethra and injection of periurethral bulking agents, can be used if stress incontinence does not respond to less invasive treatments. Surgical interventions, such as sling and urethropexy procedures, should be reserved for stress incontinence that has not responded to other treatments.
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ABSTRACT: Object: Minimally invasive (MI) transforaminal lumbar interbody fusion (TLIF) has been demonstrated in previous studies to offer improvement in pain and function comparable to those provided by the open surgical approach. However, comparative studies in the obese population are scarce, and it is possible that obese patients may respond differently to these two approaches. In this study, the authors compared the clinical benefit of open and MI TLIF in obese patients. Methods: The authors conducted a retrospective cohort study based on review of electronic medical records at a single institution. Eligible patients had a body mass index (BMI) ≥ 30 kg/m(2), were ≥ 18 years of age, underwent single-level TLIF between 2007 and 2011, and outcome was assessed at a minimum 6 months postoperatively. The authors categorized patients according to surgical approach (open vs MI TLIF). Outcome measures included postoperative improvement in visual analog scale (VAS), Oswestry Disability Index (ODI), estimated blood loss (EBL), and hospital length of stay (LOS). Results: A total 74 patients (21 open and 53 MI TLIF) were studied. Groups had similar baseline characteristics. The median BMI was 34.4 kg/m(2) (interquartile range 31.6-37.5 kg/m(2)). The mean follow-up time was 30 months (range 6.5-77 months). The mean improvement in VAS score was 2.8 (95% CI 1.9-3.8) for the open group (n = 21) and 2.4 (95% CI 1.8-3.1) for the MI group (n = 53), which did not significantly differ (unadjusted, p = 0.49; adjusted, p = 0.51). The mean improvement in ODI scores was 13 (95% CI 3-23) for the open group (n = 14) and 15 (95% CI 8-22) for the MI group (n = 45), with no significant difference according to approach (unadjusted, p = 0.82; adjusted, p = 0.68). After stratifying by BMI (< 35 kg/m(2) and ≥ 35 kg/m(2)), there was still no difference in either VAS or ODI improvement between the approaches (both unadjusted and adjusted, p > 0.05). Complications and EBL were greater for the open group than for the MI group (p < 0.05). Conclusions: Obese patients experienced clinically and statistically significant improvement in both pain and function after undergoing either open or MI TLIF. Patients achieved similar clinical benefit whether they underwent an open or MI approach. However, patients in the MI group experienced significantly decreased operative blood loss and complications than their counterparts in the open group.
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ABSTRACT: Background Normal Pressure Hydrocephalus is a disease, which results from excess cerebral spinal fluid, it is often misdiagnosed for other degenerative diseases. Symptoms of Normal Pressure Hydrocephalus may be reversed with new treatment techniques such as shunting.AimsThe aim of this article is to review the pathophysiology of Normal Pressure Hydrocephalus, discuss how to distinguish it from other diseases and discuss treatment options, which show potential for treating Normal Pressure Hydrocephalus.Methods PubMed was used to conduct searches regarding the subject matter of this article.ResultsGait, dementia and urinary incontinence, which are also referred to as Adam's Triad, are typical associated with Normal Pressure Hydrocephalus. The pathophysiology of these conditions has been outlined in this article. Review articles have been outlined which discuss the potential certain shunt operations have to treat Normal Pressure Hydrocephalus.DiscussionThere are several known treatment options that have been successful when treating Normal Pressure Hydrocephalus. With the use of shunts to drain excess cerebral spinal fluid, it is possible to improve the patient's symptoms and thus improve their quality of life.Conclusion Normal Pressure Hydrocephalus should be considered when treating elderly patients that show signs of Adam's Triad. There are numerous types of treatment options available that show promise as to relieving some of the symptoms that are associated with Normal Pressure Hydrocephalus.
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