Gynea Stuff

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  • Topic: Medical history, Physical examination, Urinary incontinence
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9/18/2009

CASE PRESENTATION #1
URINARY INCONTINENCE
Clinical Clerkship Lecture Series

Mrs. V.M.
44 year old female GTPAL 44004 referred
by her family doctor with urinary
by her family doctor with urinary
incontinence.
What questions would assist you in making
a diagnosis?

Urinary Incontinence - History
• Duration, severity, onset
• Aggravating and relieving factors
• Associations (eg. Cough, laugh, sneeze,
(eg Cough laugh sneeze
related to physical activity?)
• Urinary urgency, frequency
• ?pads
• Interfering with life—normal activities?

Urinary Incontinence - History





Obstetrical history
Menstrual history
Menopause
Other medical illnesses—diabetes, neurological
disorders, prior pelvic surgery
• Family medical history
• Vocational history--?heavy lifting
• Medication list

Urinary Incontinence - History









UTI, dysuria, hematuria
Nocturia
Enuresis
Small or large urinary losses
?continuous loss (WATT)
Weight changes
?prolapse symptoms
Fecal incontinence, constipation, diarrhea

Case #1 – Actual History
• Mrs. V.M.
44 year old female GTPAL 44004 with 6 year history of
progressive urinary loss with cough, laugh, sneezing and
exercise. Now needs pads. Interfering with life. Normal
lif
urinary frequency. Loss of small volumes only. No recent
urinary tract infections. Large babies delivered vaginally,
first required forceps and had associated tears. UI
worsened after last delivery. Has a sensation of pelvic
pressure. Still menstruating regularly. No associated
bowel symptoms or weight changes. Interested in your
advice—has heard about “pelvic exercises”.

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9/18/2009

Urtinary Incontinence – Physical
Examination
What aspects of the physical examination
are important to establishing diagnosis in
are important to establishing a diagnosis in
this patient?

Urinary Incontinence – Physical
Examination
• Vitals
• General physical exam
and neurological exam lower
• Back and neurological exam – lower
extremities
• Detailed pelvic exam
• Cough testing –lying, standing
• “Marshall-Bonney test” – urethral
hypermobility

Case #1 – Actual Physical
Findings

Urinary Incontinence - Diagnosis

• Mrs. V. M.
- normal vitals and general physical exam
- positive cough testing
cough testing
- hypermobile anterior vaginal wall
- MB test corrects loss
- well estrogenized
- anteverted, mobile uterus, no masses

What is your “provisional” diagnosis in this
is your provisional diagnosis in this
patient, based upon her history and physical
examination?

Provisional Diagnosis

Urinary Incontinence Investigations

“Genuine stress urinary incontinence”

Differential Diagnosis??

What investigations would you order or
investigations would you order or
consider to establish a diagnosis in this
patient?

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9/18/2009

Urinary Incontinence Investigations

Treatment Options

• Minimum:
- urine culture, R&M
- post-void residual
• Comprehensive—confirmatory:
- bloodwork (CBC, BUN, Cr, TSH, ?FSH)
- cystometrogram
- ? Multichannel urodynamics
- ? cystoscopy

What advice would you give this patient regarding
her new diagnosis?
(Consider the likely etiology, expected clinical
course and treatment choices for this condition.)

Urinary Incontinence –
Treatment Advice (Case #1)

Kegels Exercises!!
Exercises!!

Urinary Incontinence –
Treatment Options (Case #1)







Kegels, drill, timed toileting
Caffeine restriction
Judicious fluid intake
fluid intake
Medications—alpha-adrenergic stimulators
?pessaries
Surgery

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