A%20Logical%20Approach%20to%20Clinical%20Problem%20Solving%20

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A Logical Approach to Clinical Problem Solving
An applied example on Urinary
Incontinence
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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

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Making the diagnosis

• Careful evaluation of the gathered data
• History
• Investigations
• Making a short list of Differential Diagnosis

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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

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Treating based on the stage

• PET at 32 weeks gestation
• Mild
• Severe
• Urinary Tract Infection
• Lower urinary tract
• Upper urinary tract

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Following the response to treatment / expectant
management

• Based on clinical judgment
• Based on laboratory testing
• Based on imaging techniques.

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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

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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

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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

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• 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

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• A 48-year old G3 P30 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 37C, 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?
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Bladder Control Problems

• Problems of
• Bladder Emptying
• Bladder Storage

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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
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Urinary Incontinence
Definition Urinary incontinence is uncontrolled
leakage of urine causing hygienic and social
problems.
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Urinary Incontinence is Common Among Older Adults
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Men
Women
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14
12
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Percentage of respondents in each age group
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6
4
2
0
5-14
15-24
25-34
35-44
45-54
55-64
65-74
75-84
gt85
Age (years)
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Bladder Storage Problems

• Overactive Bladder
• Stress Incontinence
• Mixed Incontinence
• Overflow Incontinence
• Fistulas

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Overactive Bladder
Urgency
Frequency
Urge incontinence
OVERACTIVE BLADDER
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Stress Incontinence
Stress incontinence occurs when a small amount of
urine escapes while the person coughs, sneezes,
laughs, jumps or lifts something heavy.
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Stress Incontinence
(b) Woman with stress incontinence
(a) Continent woman
External urethral sphincter
Sudden increase in intra-abdominal pressure
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Overflow Incontinence
Overflow incontinence happens when urine leaks
from an overfilled bladder.
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Overflow Incontinence
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Mixed Incontinence
Mixed incontinence occurs when a person has both
the symptoms of urge incontinence and stress
incontinence.
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Mixed Incontinence
Sudden increase in intra-abdominal pressure
Uninhibited detrusor contractions
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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

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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 .

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Approach

• Every woman is different
• Consider quality of life from the patients point
  of view
• History
• Voiding diary
• Quality of life assessment

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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 volumecompliance

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Bladder Pressure-Volume Relationship
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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

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Interpretation of Post-Void Residual

• PVR lt 50cc - Adequate bladder emptying
• PVR gt 150cc - Avoid bladder relaxing drugs
• PVR gt 200cc - Refer to Urology
• PVR gt 400cc - Overflow UI likely

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Peripheral Nerves in Micturition

• Parasympathetic (cholinergic) - Bladder
  contraction
• Sympathetic - Bladder Relaxation
• Bladder Relaxation (ß adrenergic)
• Sympathetic - Bladder neck and urethral
  contraction (a adrenergic)
• Somatic (Pudendal nerve) - contraction pelvic
  floor musculature

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Peripheral Nerves in Micturition
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Factors Associated with Bladder Control Problems

• Age
• Childbirth
• Gender
• Menopausal Status
• Surgery
• Lifestyle
• Medications
• Concomitant illnesses

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Potentially Reversible Causes

• D - Delirium
• I - Infection
• A - Atrophic vaginitis or urethritis
• P - Pharmaceuticals
• P - Psychological disorders
• E - Endocrine disorders
• R - Restricted mobility
• S - Stool impaction

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Medications That May Cause Incontinence

• Diuretics
• Anticholinergics - antihistamines,
  antipsychotics, antidepressants
• Seditives/hypnotics
• Alcohol
• Narcotics
• a-adrenergic agonists/antagonists
• Calcium channel blockers

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10 Warning Symptoms of Bladder Control Problems
1 Any leakage of urine
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10 Warning Signs of Bladder Control Problems
2 Leakage of urine, regardless of amount, on
coughing, sneezing, laughing or standing.
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10 Warning Signs of Bladder Control Problems
3 Leaking urine on the way to the toilet.
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10 Warning Signs of Bladder Control Problems
4 Bed wetting at any age over six years.
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10 Warning Signs of Bladder Control Problems
5 An urgent need to pass urine, being unable to
hold on.
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10 Warning Signs of Bladder Control Problems
6 Passing urine more frequently than 8 times a
day and only passing small amounts.
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10 Warning Signs of Bladder Control Problems
7 Blood in the urine.
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10 Warning Signs of Bladder Control Problems
8 Inability to urinate (retention of urine).
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10 Warning Signs of Bladder Control Problems
9 Pain when passing urine.
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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
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• A 48-year old G3 P30 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 37C, 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?
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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?

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• 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)

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Urodynamics

• Indications
• complicated incontinence
• Pre-op
• After failure of an anti-incontinence procedure

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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

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Cystometric Evaluation

• Simple
• After void, insert foley, measure PVR, lt50cc.
  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.

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Bladder Pressure-Volume Relationship
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Stable Bladder
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Detrusor Instability
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Genuine Stress Incontinence
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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
• lt60 cm H2O is ISD
• Urethral pressure profile
• Full bladder, catheter pulled along urethra
• Urethral closure pressure gt30 cm H20 nl, lt20 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

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Definition (based on urodynamic studies)

• Genuine Stress Urinary Incontinence
• (GSUI)
• involuntary loss of urine with a rise in
  intra-abdominal pressure in the absence of any
  rise in detrusor pressure
• Urethral hypermobility

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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

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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)

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Treatment Options

• Bladder training
• Patient education
• Scheduled voiding
• Positive reinforcement
• Pelvic floor exercises (Kegel Exercises)
• Biofeedback
• Caregiver interventions
• Scheduled toileting
• Habit training
• Prompted voiding

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Pharmacological Interventions

• Urge Incontinence
• Oxybutynin (Ditropan)
• Propantheline (Pro-Banthine)
• Imipramine (Tofranil)
• Stress Incontinence
• Phenylpropanolamine (Ornade)
• Pseudo-Ephedrine (Sudafed)
• Estrogen (orally, transdermally or transvaginally)

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Other Interventions

• Pessaries
• Periurethral bulking agents (periurethral
  injection of collagen, fat or silicone)
• Diapers or pads
• Chronic catheterization
• Periurethral or suprapubic
• Indwelling or intermittant

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Pessaries
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Indwelling Catheter
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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.
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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

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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

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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 Coopers
  ligament
• Paravaginal fascial repair
• Para-urethral vaginal wall suspended to the
  tendinous arc on the pelvic sidewall

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Bladder Neck Suspensions

• Pereyra
• Stamey
• Raz

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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

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Slings

• Materials
• Autologous fascia lata or rectus abdominis
• Homologous materials (cadaveric fascia lata)
• Synthetic

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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

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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

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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

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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

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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

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Comparative Outcomes
Procedure Category Retropubic Suspensions Transvaginal Suspensions Anterior Repair Sling Procedures
Cure/Dry _at_ 48mo 84 67 61 83
Cure/Dry/Improved_at_ 48mo 90 82 73 87
De-Novo Urgency 11 5 N/A 7
Retention (gt4wks) 5 5 N/A 8
Intraoperative Complications 2 2 1 3
Postoperative Complications 4 7 2 7
Death 5/10,000
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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

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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

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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

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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

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• Complaints of fullness, pressure
• Large bladder capacity
• Absence of uninhibited bladder contractions
• Treatment medical
• Cholinergics to increase tone and contractility
• Urecholine- bethanechol
• Prostigmine

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