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Case History

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Image not available. A 33-year-old solicitor complains of highly embarrassing urinary incontinence. She has had two children in the past five years and has noticed slight leakage of urine when exercising, coughing or sneezing since midterm in her first pregnancy. Recently she has felt a dragging sensation when walking, and has had one episode of serious incontinence at work.

What are relevant questions and what should you examine for?

What are the conservative options?

What are the surgical options?

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Background

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Image not available. It has been estimated that 20%–30% of the female population experience involuntary leakage of urine. Urodynamic stress incontinence is defined as the involuntary loss of urine when the intravesical pressure exceeds the maximum urethral closure pressure in the absence of detrusor overactivity. The bladder neck and proximal urethra are intraabdominal organs, supported by the pubo-urethral ligaments. If the ligaments are damaged, or the pelvic floor sags, the proximal urethra slips through and leakage of urine can occur. Risk factors for stress urinary incontinence are shown in Table 36.1.

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Table Graphic Jump Location
Table 36.1Risk factors for stress urinary incontinence
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What are relevant questions and what should you examine for?

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History and examination should focus on the following.

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Questions to ask her:
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  • Is there any pain/blood when passing urine?

  • How often do you pass urine a day?

  • How often do you pass urine at night?

  • Do you wear a pad? How often do you change it?

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The examination should:
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  • Exclude a urinary tract infection/diabetes by testing urine

  • Exclude an abdominal or pelvic mass: investigate appropriately

  • Exclude a full bladder (urinary outflow obstruction)

  • Check for prolapse by asking the woman to bear down whilst examining her

  • Look at the tissues for atrophic vaginitis

  • Assess pelvic floor strength by asking the woman to grip on gloved finger in vagina

  • Include a full neurological examination if appropriate

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What are the conservative options?

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Conservative measures are used as first-line options, as they may help and do no harm. ...

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