72

Evaluation and Management of Men with Urinary Incontinence

Hashim Hashim; Paul Abrams

Questions

1.Which of the following is the definition of stress urinary incontinence?

a.Leakage of urine with urgency

b.Leakage of urine with an increase in intra-abdominal pressure

c.Leakage of urine while asleep

d.Leakage of urine with urgency and effort

e.Leakage of urine without being aware of it

2.Initial assessment of men with urinary incontinence includes all of the following EXCEPT:

a.flow test.

b.invasive urodynamics.

c.frequency/volume chart.

d.urinalysis.

e.quality-of-life questionnaire.

3.Which of the following is NOT a treatment for urgency urinary incontinence (UUI)?

a.Bladder training

b.Pelvic floor muscle training

c.Antimuscarinics

d.Duloxetine

e.Botox

4.Which of the following is NOT a treatment for stress urinary incontinence in men?

a.Pelvic floor muscle training

b.Penile clamp

c.Antimuscarinics

d.Male sling

e.Artificial urinary sphincter

5.Which of the following is NOT measured by the International Prostate Symptom Score (AUA-SI)?

a.Urgency

b.Frequency

c.Nocturia

d.Incontinence

e.Straining

Answers

1.b. Leakage of urine with an increase in intra-abdominal pressure.

Leakage of urine with urgency is known as urgency urinary incontinence. Leakage of urine while asleep is nocturnal enuresis. Leakage of urine on urgency and effort is mixed urinary incontinence, and leakage of urine without being aware of it is insensible urinary incontinence.

2.b. Invasive urodynamics. Men with urinary incontinence should be assessed with noninvasive baseline investigations including a flow test, frequency/volume chart or bladder diary, urinalysis to exclude infection and blood in the urine, and a quality-of-life questionnaire to assess the impact of the incontinence on quality of life. Invasive urodynamics, including filling cystometry and pressure flow studies, is reserved after failure of conservative and medical therapies and when it will alter the management of the patient.

3.d. Duloxetine. Bladder training, pelvic floor muscle training, and antimuscarinics are first-line treatments of patients with UUI. If these fail, then patients can be treated with cystoscopic intra-detrusor botulinum toxin-A injections. Duloxetine is a serotonin, norepinephrine reuptake inhibitor that has been licensed for the treatment of stress urinary incontinence in women, and not UUI.

4.c. Antimuscarinics. Antimuscarinics are licensed for the treatment of overactive bladder syndrome and not stress urinary incontinence.

5.d. Incontinence. The IPSS or American Urological Association Symptom Index assesses three storage symptoms (urgency, frequency, nocturia), three voiding symptoms (intermittency, weak stream, straining), and one

postmicturition symptom (incomplete emptying). It does not assess for urinary incontinence.

Chapter review

1.In men, stress incontinence is usually a consequence of prostatectomy.

2.When enuresis occurs later in life, one should suspect high-pressure chronic urinary retention.

3.A 3-day bladder diary is extremely useful in evaluating urinary incontinence.

4.Patients receiving Botox should be warned of the risk of urinary retention and the possible need for intermittent catheterization.

5.Postmicturition incontinence is treated by pelvic floor muscle training and urethral milking.

6.Men with urinary incontinence should be assessed with noninvasive baseline investigations including a flow test, frequency/volume chart or bladder diary, urinalysis to exclude infection and blood in the urine, and a quality of life questionnaire to assess the impact of the incontinence on quality of life.

7.The IPSS or AUA-SI assesses three storage symptoms (urgency, frequency, nocturia), three voiding symptoms (intermittency, weak stream, straining), and one postmicturition symptom (incomplete emptying).

73

Urodynamic and Video-Urodynamic

Evaluation of the Lower Urinary

Tract

Victor W. Nitti; Benjamin M. Brucker

Questions

1.Indications for urodynamic studies (UDS):

a.are supported by high-quality, level 1 evidence for most conditions.

b.are better defined for men than for women.

c.are best defined by the clinician who has clear-cut reasons for performing the study and will use the information obtained to guide treatment.

d.are of little value in assessing a patient with neurogenic lower urinary tract dysfunction.

e.are only useful in women when incontinence is seen clinically.

2.The American Urological Association/Society for Urodynamics and Female Urology Urodynamics Guideline findings and recommendations:

a.are all supported by level 1 or 2 evidence.

b.do not apply to patients with neurogenic lower urinary tract dysfunction.

c.are intended to assist the clinician in the appropriate selection of urodynamic tests, following evaluation and symptom characterization.

d.include recommendations on standardization of urodynamic equipment.

e.do not consider expert opinion.

3.Which of the following tests assesses bladder compliance?

a.Cystometrogram

b.Micturitional urethral pressure profile

c.Postvoid residual volume

d.Voiding pressure flow study

e.Electromyogram

4.Detrusor pressure:

a.can be measured directly via a transurethral catheter.

b.should remain low (near zero) during bladder filling.

c.rises abruptly and does not return to baseline with detrusor overactivity.

d.rises before the external sphincter relaxes in normal voluntary micturition.

e.is obtained by adding the abdominal pressure to the vesicle pressure.

5.Detrusor overactivity (DO):

a.is synonymous with overactive bladder.

b.is necessary to make a diagnosis of urodynamic bladder outlet obstruction.

c.can be seen on UDS of asymptomatic men and women.

d.is commonly associated with renal deterioration.

e.is a diagnosis made based on history alone.

6.The hallmark of bladder outlet obstruction is:

a.incomplete bladder emptying.

b.low pressure–low flow voiding dynamics.

c.high pressure–low flow voiding dynamics.

d.impaired detrusor contractility.

e.elevated postvoid residual.

7.The external urethral sphincter should normally:

a.relax with an involuntary bladder contraction in a neurologically normal person.

b.relax prior to a voluntary detrusor contraction in a neurologically normal person.

c.progressively relax while the bladder fills.

d.always contract when the detrusor contracts.

e.contract during urination in a neurologically normal person.

8.Videourodynamics (VUDS):

a.is the most precise measure of lower urinary tract function and should be used in all cases in which UDS is to be performed.

b.is required to assess obstruction in a man.

c.is the procedure of choice for documenting bladder neck dysfunction in

men and women.

d.is impractical to perform in spinal cord–injured patients.

e.is needed to confirm detrusor overactivity.

9.Urethral function tests such as abdominal leak point pressure (ALPP) and maximum urethral closure pressure (MUCP):

a.can precisely define intrinsic sphincter deficiency (ISD).

b.should be done routinely before all surgery for stress incontinence.

c.are the most important part of the UDS assessment of women with stress urinary incontinence.

d.should not be used as a single factor to grade the severity of incontinence.

e.can only be performed during ambulatory urodynamics.

.Which of the following conditions/factors may result in inaccurate measurement of bladder compliance?

a.Prior radiation to the pelvis

b.Use of fluid-filled urodynamic catheters

c.Presence of vesicoureteral reflux

d.Bladder outlet obstruction

e.History of genitourinary (GU) tuberculosis (TB)

.According to the Functional Classification System, the symptom of stress incontinence can be classified as:

a.failure to store secondary to an overactive bladder outlet.

b.failure to store secondary to an overactive bladder.

c.failure to store secondary to an underactive bladder outlet.

d.failure to empty secondary to an underactive bladder outlet.

e.failure to empty secondary to an overactive bladder outlet.

.During multichannel urodynamics, what is the best measure that allows the clinician to look for abdominal straining occurring during micturition?

a.Rectal or vaginal catheter pressure

b.Bladder catheter pressure

c.Uroflow pattern

d.Electromyogram activity and uroflow velocity

e.Postvoid residual

.For women with stress incontinence, UDS has its most useful role in which of the following scenarios?

a. In women who are considering surgical correction who also have urgency incontinence symptoms or difficulty emptying the bladder