1. Case Presentation-
Stress Urinary
Incontinence
Clerk 李翰泓 #9301

2. Patient’s information
Name: 李○郁
Chart number: 11285654
Age: 52 y/o
Gender: F
Occupation: Tour guide

3. Patient’s information (cont.)
● Past history:
1.LAVH for uterine myoma on 2012-03
2. UTI
3. Thalassemia, type unknown
4. Hypertension
● OB/GYN history:
o G3P2A1, CS, last menstruation: 2012-03, s/p LAVH
● Family history: noncontributory

4. History
● Tour guide for years
o Hold back urine and help carry heavy baggages
because of her job
● She suffers urinary tract infection frequently
o Especially during summer, almost every day in
summer vacation
o The symptoms are: urgency, low abdominal pain and
burning sensation during urination

5. History (Cont.)
● The patient has occasional urine leakage
after coughing or sneezing for years
● In the last 5 years, the patient has been
suffering from continuous urinary disorder
o Difficult urination, drippings after urination,
frequent urination (up to 1 time/0.5 hr)
o Most serious episode: all urine leak out after
coughing in a winter vacation
o Most of her colleagues suffer from similar disorder

6. Urodynamics exam (2014-04-09)
● Post void residual: 0 ml
● CMG: filling capacity: 364 ml, normal cystometrogram ,
leak with cough, first leakage at abdominal pressure 147
cmH2O, won’t leak after Valsalva
● UPP: Maximal urethral pressure of H51 cm2O, maximal
urethral closure pressure of 33 cmH2O, functional
urethral length of 30 mm
● Stress UPP: Negative pressure over whole urethra,
average transmission rate: 51%
● PAD test: 2-10 gram

7. Urodynamics exam (2014-04-09)
(Cont.)
● Uroflowmetry: Voided 430 ml over 53 sec, peak flow is
14 ml/sec, and the mean flow is 8 ml/sec
● Pressure flow study: First sensation at 168 ml, normal
desire at 249 ml, strong desire at 364 ml, urgency at 416
ml. Bladder infused volume 421 ml. The patient’s
voiding mechanism was accomplished by detrusor
contraction and valsalva effort. She did not silence after
her EMG
● Assessment: stress urinary incontinence

8. Operation
● Anterior repair:
o Anterior vaginal wall
longitudinal incision, close the
defect of pubocervical fascia
● TVT:
o Adjust tapes and curve needles
were inserted, the tape was
adjusted by compression test
under bladder 350 cc NS

9. Operational outcome
● Remove Foley on 2014-05-05, post op day
#3, re-on Foley due to urine retention
● Post void volume (2014-05-06, post op day
#4): 137 ml (morning), 0 ml (afternoon)
● Need adjustment or not?

10. Stress urinary
incontinence

11. Introduction
● Unintentional loss of urine
● Prompted by physical activity which may
increase abdominal pressure
o coughing, sneezing, running, heavy lifting
● Not related to psychological stress
● Age as the single largest risk factor
o Female is two times more common than male

12. Etiology
● Sphincter and pelvic muscle floor weakness
o Childbirth
o Prostate surgery
o Other
● Congenital weakness of bladder
● Urethral mucosa damage

13. Contributory factors
● Illness that cause chronic cough or sneeze
● Obesity
● Smoking - which cause frequent cough
● Excess consumption of caffeine or alcohol
● High impact activities for many years
● Hormone insufficiency

14. Symptoms & Signs
● More vulnerable for unintentional urine loss
when doing activities that would increase
abdominal pressure
o Could be both sign and symptom
● Usually in multiparous, elder women
● Frequency and urgency
o DDx from detrusor instability

15. Evaluation
● Mid Stream Urine (MSU)
● Uroflowmetry
o Detrusor muscle contractility and urinary tract
obstruction
o normal flow rate: 15 ml/sec
● Cystometry and video urethrography
o Evaluate urine leakage and detrusor instability
● Pad test

16. Genuine Stress
Incontinence
● This diagnosis can only be made via
uroflowmetry
o Urine leak during rise of intra-abdominal pressure
o Without detrusor muscle activity

17. Treatment
● Initial treatment
o Lifestyle
 Weight loss
 Dietary changes
o Behavioral therapy
 Bladder training
 Pelvic muscle exercise
 Biofeedback
 Cognitive therapy

18. Treatment (Cont.)
● Medications
o Duloxetine
 A SNRI, contraindicated in chronic liver disease patient
o Estrogen
 Vaginal estrogen instead of systemic usage, which may worsen it
o Other
 Alpha-adrenergic agent no longer recommended

19. Surgical intervention - 1
● Anterior colporrhaphy
o for patient with cystocele
● Endoscopic bladder neck suspension
o for patient with bladder neck and ureter
hypermobility
● Burch Colposuspension
o adhese the endopelvic fascia to Cooper’s ligament or
rectus muscle

20. Surgical intervention - 2
● Marshall-Marchetti-Krantz operation
● Left: MMK,
Right: Bruch
● MMK may not
cure cystocele

21. Surgical intervention - 3
● Tension-free vaginal tape

22. Surgical intervention - 4
● TVT v.s. TVT-O
o TVT for younger, active, and patient with internal
sphincter deficiency, which provide greater
supportive angle, and cause less pain to inguinal
area
o TVT-O for older, heavier and patient underwent
TVT, which is easier conducted, less likely to cause
bladder injury

23. Reference
1. http://www.glgacenter.com/images/tvt_02.jpg
2. http://wd.vghtpe.gov.tw/obgy/File/%E6%99%A8%E9%96%93%E6%95%
99%E5%AD%B8/16stress%20urinary%20incontinence.ppt
3. http://www.mayoclinic.org/diseases-conditions/stress-
incontinence/basics/definition/con-20027722
4. http://www.sciencedirect.com/science/article/pii/S0957584701902094
5. http://emedicine.medscape.com/article/452289-overview#a0156
6. Uptodate: Treatment and prevention of urinary incontinence in women
7. http://www.tcs.org.tw/profession/article/index_info.asp?med_id=81
8. http://www.surgeryencyclopedia.com/Ce-Fi/Colporrhaphy.html
9. http://www.atlasofpelvicsurgery.com/3BladderandUreter/2RetropubicUr
ethropexy/chap3sec2.html