Factors Discriminating Between Genuine Stress and Mixed Incontinence Patricia A. Burns
PhD, RN, FAAN
Associate Professor and Director Nurse Practitioner Program, School of Nursing, State University of New York. Buffalo
Thomas H. Nochajski
PhD
Research Scientist, Research Institute on Alcoholism Buffalo, New York
Kevin Pranikoff
MD
Associate Professor, Department of Urology, State University of New York, Buffalo
Nurse practitioners (NP) are often confronted with female clients who describe various types of urine loss symptoms. To establish an accurate diagnosis and therapeutic intervention, it is important for the NP to identify the etiology of the urine loss complaint. The purpose of the study is to compare symptoms and physical findings that differentiate between the urodynamic diagnoses of genuine stress incontinence (GSI) and mixed incontinence (MI) in 135 clinical trial subjects: 123 diagnosed as GSI and 12 as MI. These subjects participated in a randomized controlled clinical trial to investigate the efficacy of biofeedback and pelvic floor exercises for incontinence treatment. Data were analyzed for significant differences between these two groups on urologic and gynecologic symptoms, pelvic muscle relaxation, vaginal mucosa, vaginal electromyograph readings, urodynamic parameters, and quantified measure of urine loss. One-way analysis of variance (ANOVA) showed significant difference in nocturnal and diurnal voidings and urine loss immediately after sensing the urge to void in the MI and GSI subjects. Chi-square analyses found a significantly decreased incidence of poor vaginal tone and atrophic vaginal mucosa in the MI group as compared to the GSI group. The MI group also lost significantly more urine than did the GSI group on the hand wash maneuver of the perineal pad test. Although the sample size of MI subjects was small, these results show that a noninvasive history and physical examination can differentiate between urologic diagnoses. This approach provides a cost-effective expedient protocol to aid the NP in establishing a differential diagnosis between genuine stress and mixed incontinence.
T h e International Continence Society defines urinary incontinence as a condition where involuntary loss of urine becomes a social or hygienic problem (Abrams, Blaivas, Stanton, & Andersen, 1988). For those afflicted it can be frustrating, embarrassing, and socially stigmatizing. Few acknowledge serious disruption of their domestic or social lives and consequently neglect to seek medical attention. Furthermore, if attention is sought they are often ignored or told i t is a consequence of aging (Willington, 1975). ~
~~
Address correspondence and reprint requests to Patricia A. Burns, PhD, RN, FAAN, 806 Kimball Tower School of Nursing, SUNY at Buffalo, Buffalo, NY 14214. Funded by a cooperative agreement (UOI AG0526001) from the National Institute of Aging and the Center for Nursing Research.
VOLUME 4, NUMBER 1, JANUARY-MARCH, 1992
Gender differences have been found in the prevalence of incontinence with rates of 37.7%in females compared to 18.9%in males (Diokno, Brock, Brown, & Herzog, 1986; Milne, 1976). Almost 38% of the female sample ( n = 1, 145)in the Medical, Epidemiological, and Social Aspects of Aging (MESA) study reported urine loss symptoms, with the greatest percentage (55.3%) reporting mixed stress and urge incontinence (Diokno et al., 1986). Stress incontinence is defined as an involuntary loss of urine during increased intra-abdominal pressure without evidence of detrusor contraction. This leakage can result from pelvic relaxation secondary to vaginal childbirth, decreased estrogen during menopause, increased abdominal pressure with conditions such as obesity, or physiologic functions such as straining with 15
bowel movements, coughing, sneezing, laughing, and running (Ouslander, Kane, Vollmer, & Menezes, 1985). Urge incontinence, or detrusor instability, is a condition characterized by involuntary bladder contractions during bladder filling. This will usually cause symptoms of frequency, urgency, and nocturia; often the person feels the urge to pass urine, but cannot control micturition (Neeson & Stockdale, 1981). The diagnoses of mixed incontinence (MI) is given when the client has symptoms of stress and urge incontinence. Differential diagnostic procedures of incontinence (i.e., physiologic monitoring of the lower urinary tract [urodynamic evaluation]) have been considered by some to be essential in determining an accurate urologic diagnosis (Jarvis, Hall, Stamp, Millar, & Johnson, 1980). Other investigators consider a urodynamic procedure as invasive and unnecessary (Kaufman, 1979). Cantor and Bates (1980) found that a careful history of stress incontinent individuals was sufficient to establish a urologic diagnosis, and further invasive investigation should be reserved for clients having symptoms of nocturia, nocturnal enuresis, and/or urge incontinence. The purpose of this paper is to identify factors-either subjective reports or objective measures-that differentiate between subjects diagnosed as having genuine stress incontinence (GSI) or MI. These differential factors could provide a database for nurse practitioners (NP) to establish an incontinence diagnosis based on history and physical findings. Comparisons are presented between GSI and MI subjects across a variety of characteristics, including demographics, history of urine loss, nocturia, prior surgical procedures, and physiologic findings.
METHODS Subjects were recruited for a clinical trial to test the efficacy of a behavioral treatment for stress incontinence in ambulatory females. Of 1,042 volunteers who responded to various newspaper advertisements and other recruitment methods, 135 met study criteria (Burns, Nochajski, Clesse-Desotelle, & Pranikoff, 1990). The major reasons for exclusion were urine loss attributed to urgency (n = 202), information seekers (n = 195), canceled appointments (n = 72), less than three urine losses per week (n = 47), and refusal of random assignment (n = 23). Subjects between the ages of 55 and 78 were processed into the clinical trial through three screening procedwes. Female volunteers were initially screened in a telephone interview to assure that clients were (a) experiencing urine loss symptoms, (b) agreeable to
16
randomization, and (c) available for the entire trial and 6-month follow-up visits. Eligibility was again assessed at a second screening by an NP who performed a physical and pelvic examination. Subjects were required to meet the following criteria: (a) able to produce a urine loss with stress maneuvers (i.e., cough, bear down, heel bounce), (b) record a minimum of three losses on a 7-day urinary diary, and (c) achieve a mini-mental score of 23 or greater. At the third and final screening a urodynamic evaluation was performed using a DANTEC 2 100 Urodynamic System recorder (DANTEC Electronics, Allendale, New Jersey). This included cystometries, urethral pressures, and profilometries that were obtained in supine and standingpositions. Subjects with obstructive uropathy or with a urinary residual greater than 50 cc were excluded. Urodynamic diagnoses of the included study subjects identified 123 women as stress incontinent and 12 as having MI. All study subjects were then randomized in blocks of 12 into a biofeedback group, pelvic floor exercise group, or control group. HISTORY AND PHYSICAL EXAMINATION The history and physical examination performed by an NP evaluated the urine loss problem and determined if the subjects met study criteria. The nature of the incontinence was obtained by study subjects logging their urine loss episodes on a 24-hour diary. Records were kept of the following urinary activities: (a) time of normal voids, (b) time of urine loss episodes, and (c) type of activity associated with urine loss (i.e., coughing, sneezing, laughing, etc.) throughout the 8 weeks of treatment and again 2 weeks before the 3- and 6-month follow-up visits. Physical examinations were performed on all subjects to determine (a) the presence and degree of pelvic relaxation (cystoceles and rectoceles), (b) atrophic vaginitis, (c) vaginal muscle tone, and (d) presence of urine loss with stress maneuvers. The following grading criteria were used to determine the degree of pelvic relaxation: (a) first degree-the appearance of slight deviation, (b) second degree-protrusion at the introitus, and (c) third degree-protrusion beyond the introitus (Neeson 8c Stockdale, 1981). Atrophic vaginitis was diagnosed as pale vaginal mucosa with decreased rugae and/or localized areas of vaginitis in the posterior fornix and around the urethral orifice (Neeson & Stockdale, 19811. Vaginal muscle tone was assessed during pelvic examination by instructing the subject to squeeze around the examiner’s finger as tightly as possible. The strength of the muscle was measured on a 4-point subjective scale with zero equaling an absence of muscle contraction and 4 being full pressure anteriorly and posteriorly around the examining finger. Stress
JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS
incontinenre was induced by having the subjects drink 400 cc of water approximately 45 minutes before being asked to cough or bear down in either a supine and/or standing position.
ELECTROMYOGRAPH READINGS Elrctromyograph recordings were obtained using a J & J M53 Electromyograph machine and a D-200 Digital Integrator (Bio-Medical Instruments, Warren, Michigan) to record the vaginal muscle activity as measured in microvolts by a vaginal probe o r perineometer (Burns, Marecki, Dittmar, & Bullough, 1985). A computer recorded the 1-second readings of the subjects’ pelvic muscle contraction as the subjects performed quick and sustained pelvic floor exercises. These were displayed as a line graph on the computer monitor, and then the numerical scores were printed. Electromyograph measures for the quick contractions were obtained at 1-second intervals during a 3-second time span. Subjects relaxed between contractions for 10 seconds or until they resumed a baseline relaxation reading. This procedure was repeated five times with an average of the five, peak, quick contractions comprising the quick electromyograph measure. Pearson correlations of the five, peak measures had a mean of .90 with a range of .83 to .93. The sustained electromyograph score was derived by taking the average of the peak and four subsequent contraction readings. As with the quick contraction readings, an average of 5 scores comprised the final measure. Pearson correlations o f the five sustained measures again showed statistical consistency with a mean of .89 and a range of .78 to .95.
URODYNAM IC EVALUAT10N T h e urodynamic methods, definitions, and units conformed to the standards recommended by the International Continence Society (Abrams et al., 1988). The procedure began with uroflometry and measurement of residual urine. Subjects with obstructive uropathy defined as uroflow less than 15 cc per second ( n = 5) or a residual greater than 50 cc ( n = 5) were eliminated from the study and referred for appropriate treatment. Maximal urethral pressure (MUP) was measured during a pelvic muscle contraction in the lithotomy position. Static urethral closure pressure profilometry (UCPP), which is the pressure differential between urethra and bladder, was performed with the bladder empty and full in the lithotomy position and again full in the standing position. Dynamic UCPP was also accomplished in the latter two positions. Cystometry was performed in the lithotomy position with room temperature water delivered at 50 cc per minute via peristaltic pump. An additional standing
VOLUME 4, NUMBER 1, JANUARY-MARCH, 1992
position with heel bouncing and running water provocation was employed if detrusor instability was not identified i n the supine position. A diagnosis of GSI was made if the subjects lost urine with coughing and/or straining on physical examination in either the supine or erect position, or demonstrated detrusor stability on cystometrogram with or without a loss of urethral closure pressure on dynamic UCPP. Mixed urinary incontinence was diagnosed when subjects (a) lost urine while performing stress maneuvers on physical examination; (b) evidenced detrusor instability o n cystometrogram, defined as uninhibited contractions of greater than 10 cm H20; and (c) lost urethral closure pressure on dynamic UCPP. Even though the study attempted to recruit mainly GSI individuals, 12 of the 135 subjects were found on urodynamic evaluation to have MI.
QUANTIFICATION OF URINE LOSS An objective quantification of urine loss was obtained using a modification developed by Fantl, Harkins, Wyman, Choi, & Taylor, (1987) of the technique described by (Sutherst, Brown, & Shawer, 1981). Patients were filled to bladder capacity with sterile normal saline at room temperature using a 16F catheter. Filling ceased when subjects reported a full bladder and the filling volume recorded. T w o preweighed absorbent pads were secured against the perineum and held in place with the patients’ undergarments. T h e subject was then asked to walk a 50-yard distance at her own pace, stair climb, produce a series of coughs, heel-bounce, and assume sitting and standing positions. Each maneuver was performed five consecutive times. On completion of this portion of the test, the pads were replaced with a second set of preweighed pads. Finally, the subjects were requested to perform a hand wash under running water for 1 minute. T h e perineal pads were again removed and weighed using a Port-0-Gram Ohaus Electronic Scale (minimal unit: 0.1 gm) (Ohaus Scale, Florham, New Jersey).
RESULTS T h e following measures, vaginal muscle tone, presince or absence of atrophic vaginitis, previous pelvic surgeries, degree of pelvic relaxation (cystoceles, rectoceles), history and type of urine loss, urodynamic parameters, electromyograph readings, and urine losses as measured by the perineal pad test, were analyzed using Chi-square and one-tailed Fisher’s exact tests for the categorical variables and one-way ANOVA for the continuous variables. T h e authors recognize that the discrepancy i n size of subgroups is large, a n d
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TABLE 1. HISTORY OF SELF-REPORTS OF URINE LOSS AND NORMAL VOIDS BY DIAGNOSTIC GROUP Incontinent and Urinary History
History of Urine Loss Number of years with urine loss Years condition has worsened Number of weekly losses Self-Reports of Urine Loss Cough Bowel movement Rising up from sitting Rising from bed Sneeze Bending down Lifting objects Exercising Sitting Laughing Sleeping Voids Normal Voiding Nocturnal voids Diurnal voids
Genuine Stress Incontinence ( n = 123)
Mixed Incontinence ( n = 12)
i f S D
%fSD
12.3 f 11.7 1.9 f 2.6 16.9 f 16.1
1 3 . 0 f 11.3 3.9 f 6.8 21.4 It 13.1
3.0 f 2.1 f 2.0 f 1.7 f 1.5 f 0.6 f 0.6 f 0.6 f 0.4 f 0.3 f 0.3 f 0.9 f
6.5 3.2 4.2 3.2 2.8 1.3 1.5 1.6 1.8 1.0 1.5
1.0
2.0 f 1.0 5.1 f 2.0
1.9 f 2.7 f 2.6 f 1.0f 1.6 f 1.3f 1.6 f 0.8 f 0.2 f 0.3 f 0.3 f 1.7f
2.9 5.6 3.1 1.3 2.8 1.7 2.6 1.4 0.6 0.7 0.9 1.1**
2 . 9 f 1.1' 6.6 f 1.9*
Note. SD = standard deviation. ' p < .05. **p < .01.
generalizability of these findings is limited. However, the Fisher's test was employed as a more stringent analysis of a 2-X-2 table. When the ANOVA homogeneity of variance tests were nonsignificant, the pooled variance tests were used. Separate variance contrasts were used when variances differed significantly. The sociodemographic characteristics for the two subgroups, GSI and MI, showed that subjects were predominately white and married. Also, the ages of the two subgroups did not differ significantly between the GSI group (62.31 f 5.89) and MI group (64.17 f 6.77). INCONTINENCE HISTORY The comparative figures for symptoms associated with urine loss are shown in Table 1. The number of years the two groups suffered from the problem were relatively equivalent. Also, although not significant (t's Il.O), i t is interesting to note that the GSI group indicated fewer years for length of time the condition worsened and also indicated fewer weekly losses. When considering the types of urine losses experienced, of ,greatest interest is the relative patterns of losses that occurred for the two groups in the week before the urodynamic evaluation. It can be seen that the GSI group experienced more losses for coughing and rising from bed, whereas the MI group frequently reported greater losses when having a bowel movement, bending down, lifting objects, and rising from sitting positions. 18
Subjects were also asked if they lost urine with symptoms previously described as attributable to detrusor instability or urge incontinence. In validating the diagnosis these results revealed that the loss of urine after sensing the urge to void was reported significantly more often in those subjects with MI than those with GSI ( F (1,133)= 7.06, p < .01). Diurnal (6 a.m. to 10 p.m.) and nocturnal (10 p.m. to 6 a.m.) voids were analyzed to determine if women with an urge component to their urine loss problem (MI group) differed in their nocturnal voiding patterns. The results yielded significant differences for nocturnal ( F (1,132) = 5.13, p < .03) and diurnal ( F (1,132) = 6.40, p < .02) voids. The diurnal and nocturnal voids were greater in the MI group. GYNECOLOGIC FACTORS Table 2 presents the gynecologic findings of female subjects and the differentiation between diagnostic groups. Comparisons were made between the presence of cystoceles and rectoceles, atrophic vaginitis, and vaginal muscle tone for both diagnostic categories. There was a significant difference for vaginal muscle tone (X* [df = 1, n = 1351 = 3.86, p < .05), with the GSI group demonstrating a larger percentage of poor muscle tone (Table 2) than the MI group (82.1% vs. 58.3%,respectively). Similarly, the presence of atrophic vaginitis was increased in the GSI group (52%) as
JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS
TABLE 2. OBSTETRlCAL/GYNECOLOGlCAL/URODY NAMIC/ELECTROMYOGRAPHFINDINGS BY DIAGNOSTIC GROUP Variables
Pelvic Changes Poor vaginal muscle tone Presence of atrophic vaginitis Urethral suspension Hysterectomy Cystocele Grade 1 Grade 2 Grade 3 Rectocele Grade 1 Grade 2 Grade 3 Obstetrical Historya Pregnancies Vaginal deliveries Urodynamic Parameters Bladder capacityb Functional urethral lengthc Urethral closure pressurec Electromyographd Sustained contraction Ouick contraction
Genuine Stress Incontinence ( n = 123) n
%
101 64 31 52 91 66 24 1 52 44 7 1
82.1 52.0 25.2 42.3 74.0 53.7 19.5 0.8 42.3 35.8 5.7 0.8
Mixed Incontinence (n = 12) n
YO
7 3 4 3 10 8 2 0 4 2 2 0
58.3* 25.0" 33.3 25.0 83.3 66.7 16.7 0 33.3 16.7 16.7 0
3.57 f 2.1 8 3.09 f 1.91
3.08 f 2.61 2.67 f 2.27
328.5 f 87.0 41.2 11.6 30.8 f 16.3
*
286.3 f 94.0 41 .O f 19.7 30.6 14.6
1.9 f 1.6 3.2 k 3.4
2.6 f 2.0 4.6 k 4.8
*
aData presented as means and standard deviations. bData presented in milliliters. CData presented in centimeters. dMeasured in microvolts. *X' = 3.86; p < .05. '*Fisher's Exact Test p < .07
compared to the MI group (25%) (Fisher's one-tailed test p < .07). There were no differences in the rates of urethral suspension surgeries or hysterectomies, although a higher incidence of hysterectomies was found in the GSI subjects. Although it is a general consensus that cystoceles, rectoceles, or uterine prolapse is not a causative factor of incontinence (Green, 1968; Weigel, 1988), researchers have found a significant correlation between the presence of cystoceles and a diagnosis of anatomic Stress Incontinence (Fine, Mauldin, & Harte, 1988; Stanton, 1987).In the authors' clinical trial sample the presence of first, second, or third degree cystoceles or rectoceles was not statistically different between women with a diagnosis of either GSI (74%)or MI (83.3%).Although the majority of the sample had some type of pelvic relaxation, the largest percentage presented with first degree cystoceles. The occurrence of stress incontinence has also been attributed to mu1tiple vaginal deliveries or pelvic surgery (Ouslander et al., 1985). In this study's sample there were no significant differences between the two groups in either number of pregnancies (GSI X = 3.37 f 2.18; MI X = 3.08 f 2.61) or vaginal deliveries (GSI X = 3.09 f 1.91; MI X = 2.67 f 2.27). These similar
VOLUME 4, NUMBER 1, JANUARY-MARCH, 1992
findings could be attributed to the fact that the MI women have a component of their problem that is the same as those with GSI, but also have additional urge symptoms. URODYNAMIC FINDINGS Table 2 presents the measurements obtained during the urodynamic assessment of bladder capacity, functional urethral length, and urethral closure pressures. As shown, there were no statistically significant differences between subgroups for functional urethral lengths and urethral closure pressures ( t < 1.0). However, the bladder capacity of the MI group tended to be lower than the GSI group ( t = 1.6). This trend toward reduced bladder capacity in the subjects with MI may be attributed to their detrusor hyperactivity. ELECTROMYOGRAPH RECORDINGS Electromyograph readings were reflective of the two groups' ability to contract their pelvic muscles during quick and sustained contractions. Both the GSI group and the MI group showed similar pelvic muscle activity during their performance on electromyography with nonsignificant changes in measurements (Table 2).
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TABLE 3. QUANTIFICATION OF URINE LOSS WITH DIFFERENTIAL MANEUVERS BY DIAGNOSTIC GROUP
Differential Maneuvers Stress maneuvers (Step up and down, cough, heel, bounce, sit-up and down, walk 50 yd) Hand wash (wash hands for 1 minute)
Genuine Stress Incontinence ( n = 123)
Mixed Incontinence ( n = 12)
i*SD
i f S D
+ 23.0
26.1 f 28.5"
6.3 f 22.7
37.2 i 41.3"
12.3
Note. SD = standard deviation. ' p < . l ." p
< ,001.
T h e obstetric and gynecologic findings in both groups Tablr 3 presents the results for the analyses on both found cystoceles present in 74% of GSI individuals and sections of the perineal pad tests. T h e MI group lost 83% of MI individuals. Although the incidence of foux times more urine on the hand wash maneuver of rectoceles was less, it still was comparable across groups the perineal pad test than the GSI group ( F [1,12] = (42% GSI and 33% MI). T h e most significant finding 6.51, p < .03). In contrast, there were no significant on pelvic examination was the increased incidence of differences between diagnostic groups on the stress poor muscle tone and presence of atrophic vaginitis maneuvers portion of the perineal pad test. Reflecting in women with GSI. In this study those subjects with these differences, the 95% confidence intervals for the a diagnosis of MI had fewer lower urinary tract changes hand wash maneuver were mutually exclusive (MI = (i.e., atrophic vaginitis or poor vaginal muscle tone). 10.89 to 63.41; GSI = 2.23 to 10.32), whereas the 95% This finding might be expected because the primary confidence intervals for stress maneuvers were mutually etiology of MI is attributed to detrusor instability. This inclusive (MI = 7.98 to 44.21; GSI = 8.18 to 16.38). is further supported by the decreased bladder capacity This further supports the fact that the GSI and MI and increased nocturnal and diurnal voidings found subjects had similar loss of sphincter tone as shown in MI individuals. T h e perineal pad test for quantification of urine loss by comparable urine losses on stress maneuvers. discriminated significantly between diagnoses, as the However, those subjects with MI and evidence of hand wash maneuver produced a four times greater detrusor instability lost a significantly greater amount amount of urine loss in clients with a urodynamic of urine on the hand wash maneuver. diagnosis of MI as compared to those with GSI. This finding supports the theory that r u n n i n g water stimulates the urge to void in subjects with an unstable bladder component to their incontinent problem. An DISCUSSION additional discriminating factor between diagnoses was Comparisons of the GSI and MI subjects showed that the statistically significant increased incidence of poor women with MI were more likely to state that their vaginal muscle tone and atrophic vaginitis in the GSI problem had been worsening for a longer length of women. Examination of the electromyograph activity timr. When their types of losses were compared, there of the pelvic muscle revealed no significant differences were no significant differences even though the GSI between groups. Similarly, no differences were found group had more losses with stress maneuvers such as on either urethral pressures o r bladder capacity, coughing and rising from bed. T h e only significant although those clients with MI had lower bladder difference in type of loss that discriminated between capacities. the groups was found in MI individuals. There was a greater incidence of urine loss after the urge to void. A difference in voiding patterns between diagnostic CONCLUSIONS groups continued with the MI group having a greater In this clinical trial the subjects' urodynamic frequency of diurnal and nocturnal voids. This finding is substantiated by the fact that the GSI group used diagnoses of GSI and MI were strongly correlated with one-quarter fewer nighttime protective pads than did their performance o n the quantification pad test. T h e hand wash maneuver clearly identified those clients with those with an urge component to their problem.
QUANTIFICATION OF URINE LOSS
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JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS
an urge component to their urine loss problem. Similar 10 this objective finding was the subjective reporting of urine loss immediately after the voiding urge in pedicting a urodynamic diagnosis of MI. Although the sample size of subjects with MI was small, these results showed that symptoms, pelvic muscle tone, and a noninvasive procedure such as the pel ineal pad weighing test can be employed in assisting the N P to differentiate between a stress and urge etiology of inrontinence. T h e ability to accurately assess the etiology of incontinence without resorting to an invasive procedure gives the primary health care provider an exprdient, cost-effective mechanism for initiating appropriate therapy. These objective and subjective findings that differentiate between urologic diagnoses
can substantiate data-based practice for NPs. Interventions for clients with urine loss symptoms can be based on vaginal changes, provocative perineal pad test, and an in-depth assessment of the type of activity associated with the urine loss. This study's findings could be further validated by re-examining whether the significantly different changes in vaginal mucosa, vaginal muscle tone, and urine loss activity during provocative testing could also identify persons diagnosed as pure urge incontinence. Therefore, further research should reexamine the conclusions of this study to determine its applicability and replicability with a cohort of subjects diagnosed as having detrusor instability without a stress component.
References Abrams, P., Blaivas, J. G., Stanton, S. L., & Andersen, J. T. (1988). The standardisation of terminology of lower urinary tract function. Scandinavian Journal of Urology and Nephrology, 22(Suppl. 114), 5-1 9. Burns, P. A , Marecki, M., Dittmar, S., & Bullough, 6. (1985). Kegel's exercises with biofeedback therapy for treatment of stress incontinence. Nurse Practitioner, 7 0(2), p. 28. Burns, P. A.. Nochajski, T., Clesse-Desotelle, P. M., & Pranikoff. K. (1990). Recruitment experiences in the stress incontinence clinical trial. Neurology and Urodynamics, 9, 53-62. Cantor, T. J., & Bates, C P. (1980). A comparative study of symptoms and objective urodynamic findings in 214 incontinent women. British Journal of Obstetrics and Gynecology, 87, 889-892. Diokno. A. C., Brock, B. M., Brown, M. B., & Herzog, R. A. (1986). Prevalenceof urinary incontinence and other urological symptoms in the non-institutionalizedelderly.Journalof Urology, 5,136,10221025 Fantl, A,, Harkins, S. W., Wyman. J. F., Choi, S. C., & Taylor, J. R. (1987). Fluid loss quantitation test in women with urinary incontinence: A test-retest analysis. Obstetrics and Gynecology, 70(5),739-743. Fine, P. M., Mauldin, J. E., Harte, E. H. (1988). Stress incontinence in women; a practical method of evaluation. Journal of Reproductive Medicine, 33(9), 749-756. Green, T H., Jr. (1968). The problem of urinary stress incontinence in the female; an appraisal of its current status. Obstetrical and Gynecological Survey, 23, 603-634.
Jarvis. G. J., Hall, S., Stamp, S., Millar, D. R., & Johnson, A. (1980, October). An assessment of urodynamic examination in incontinent women. British Journal of Obstetrics and Gynaecology, 87, 893-896. Kaufrnan. J. M. (1 979). Urodynamics in stress urinary incontinence. Journal of Urology, 122,(6), 778-782. Milne. J. (1976). Prevalence of incontinence in the elderly. In F. L. Willington (Ed.), Incontinence in the elderly (pp. 9-21). New York: Academic Press. Neeson, J. D., & Stockdale, C. R. (1 981 ). The practitioners handbook of ambulatory oblgyn. New York: Wiley. Ouslander,J., Kane, R., Vollmer, S., & Menezes, M. (1985). Technologies formanaging urinary incontinence (Health Technology Case Study 33),(Report No. OTA-HCS-33). Washington, DC: U.S. Congress, Office of Technology Assessment.This case study was performed as part of OTA's assessments of Federal Policies and the Medical Devices lndustry and Technology and Aging in America. Stanton, S. (1 987). Urinary incontinence in females. Practitioner, 237, 52-59. Sutherst, J., Brown, M., & Shawer, M. (1981). Assessing the severity of urinary incontinence in women by weighing perineal pads. Lancet, I,p. 1 128. Weigel. J. W. (1988). Urinary incontinence. Journal of Enterostomal Therapy, 15(1), 24-29. Willington, F. L. (1 975). Significance of incompetence of personal sanitary habits. Nursing Times, 71, 340-341.
1 In the July/September 1991 issue, Jean O'Farrell Ussher, MS, RN, C, GNP, was incorrectly identified. She was a former nursing faculty member of the University of Lowell, Lowell, Massachusetts. We are sorry.
VOLUME 4, NUMBER I , JANUARY-MARCH, 1992
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PhD, RN, FAAN
Associate Professor and Director Nurse Practitioner Program, School of Nursing, State University of New York. Buffalo
Thomas H. Nochajski
PhD
Research Scientist, Research Institute on Alcoholism Buffalo, New York
Kevin Pranikoff
MD
Associate Professor, Department of Urology, State University of New York, Buffalo
Nurse practitioners (NP) are often confronted with female clients who describe various types of urine loss symptoms. To establish an accurate diagnosis and therapeutic intervention, it is important for the NP to identify the etiology of the urine loss complaint. The purpose of the study is to compare symptoms and physical findings that differentiate between the urodynamic diagnoses of genuine stress incontinence (GSI) and mixed incontinence (MI) in 135 clinical trial subjects: 123 diagnosed as GSI and 12 as MI. These subjects participated in a randomized controlled clinical trial to investigate the efficacy of biofeedback and pelvic floor exercises for incontinence treatment. Data were analyzed for significant differences between these two groups on urologic and gynecologic symptoms, pelvic muscle relaxation, vaginal mucosa, vaginal electromyograph readings, urodynamic parameters, and quantified measure of urine loss. One-way analysis of variance (ANOVA) showed significant difference in nocturnal and diurnal voidings and urine loss immediately after sensing the urge to void in the MI and GSI subjects. Chi-square analyses found a significantly decreased incidence of poor vaginal tone and atrophic vaginal mucosa in the MI group as compared to the GSI group. The MI group also lost significantly more urine than did the GSI group on the hand wash maneuver of the perineal pad test. Although the sample size of MI subjects was small, these results show that a noninvasive history and physical examination can differentiate between urologic diagnoses. This approach provides a cost-effective expedient protocol to aid the NP in establishing a differential diagnosis between genuine stress and mixed incontinence.
T h e International Continence Society defines urinary incontinence as a condition where involuntary loss of urine becomes a social or hygienic problem (Abrams, Blaivas, Stanton, & Andersen, 1988). For those afflicted it can be frustrating, embarrassing, and socially stigmatizing. Few acknowledge serious disruption of their domestic or social lives and consequently neglect to seek medical attention. Furthermore, if attention is sought they are often ignored or told i t is a consequence of aging (Willington, 1975). ~
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Address correspondence and reprint requests to Patricia A. Burns, PhD, RN, FAAN, 806 Kimball Tower School of Nursing, SUNY at Buffalo, Buffalo, NY 14214. Funded by a cooperative agreement (UOI AG0526001) from the National Institute of Aging and the Center for Nursing Research.
VOLUME 4, NUMBER 1, JANUARY-MARCH, 1992
Gender differences have been found in the prevalence of incontinence with rates of 37.7%in females compared to 18.9%in males (Diokno, Brock, Brown, & Herzog, 1986; Milne, 1976). Almost 38% of the female sample ( n = 1, 145)in the Medical, Epidemiological, and Social Aspects of Aging (MESA) study reported urine loss symptoms, with the greatest percentage (55.3%) reporting mixed stress and urge incontinence (Diokno et al., 1986). Stress incontinence is defined as an involuntary loss of urine during increased intra-abdominal pressure without evidence of detrusor contraction. This leakage can result from pelvic relaxation secondary to vaginal childbirth, decreased estrogen during menopause, increased abdominal pressure with conditions such as obesity, or physiologic functions such as straining with 15
bowel movements, coughing, sneezing, laughing, and running (Ouslander, Kane, Vollmer, & Menezes, 1985). Urge incontinence, or detrusor instability, is a condition characterized by involuntary bladder contractions during bladder filling. This will usually cause symptoms of frequency, urgency, and nocturia; often the person feels the urge to pass urine, but cannot control micturition (Neeson & Stockdale, 1981). The diagnoses of mixed incontinence (MI) is given when the client has symptoms of stress and urge incontinence. Differential diagnostic procedures of incontinence (i.e., physiologic monitoring of the lower urinary tract [urodynamic evaluation]) have been considered by some to be essential in determining an accurate urologic diagnosis (Jarvis, Hall, Stamp, Millar, & Johnson, 1980). Other investigators consider a urodynamic procedure as invasive and unnecessary (Kaufman, 1979). Cantor and Bates (1980) found that a careful history of stress incontinent individuals was sufficient to establish a urologic diagnosis, and further invasive investigation should be reserved for clients having symptoms of nocturia, nocturnal enuresis, and/or urge incontinence. The purpose of this paper is to identify factors-either subjective reports or objective measures-that differentiate between subjects diagnosed as having genuine stress incontinence (GSI) or MI. These differential factors could provide a database for nurse practitioners (NP) to establish an incontinence diagnosis based on history and physical findings. Comparisons are presented between GSI and MI subjects across a variety of characteristics, including demographics, history of urine loss, nocturia, prior surgical procedures, and physiologic findings.
METHODS Subjects were recruited for a clinical trial to test the efficacy of a behavioral treatment for stress incontinence in ambulatory females. Of 1,042 volunteers who responded to various newspaper advertisements and other recruitment methods, 135 met study criteria (Burns, Nochajski, Clesse-Desotelle, & Pranikoff, 1990). The major reasons for exclusion were urine loss attributed to urgency (n = 202), information seekers (n = 195), canceled appointments (n = 72), less than three urine losses per week (n = 47), and refusal of random assignment (n = 23). Subjects between the ages of 55 and 78 were processed into the clinical trial through three screening procedwes. Female volunteers were initially screened in a telephone interview to assure that clients were (a) experiencing urine loss symptoms, (b) agreeable to
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randomization, and (c) available for the entire trial and 6-month follow-up visits. Eligibility was again assessed at a second screening by an NP who performed a physical and pelvic examination. Subjects were required to meet the following criteria: (a) able to produce a urine loss with stress maneuvers (i.e., cough, bear down, heel bounce), (b) record a minimum of three losses on a 7-day urinary diary, and (c) achieve a mini-mental score of 23 or greater. At the third and final screening a urodynamic evaluation was performed using a DANTEC 2 100 Urodynamic System recorder (DANTEC Electronics, Allendale, New Jersey). This included cystometries, urethral pressures, and profilometries that were obtained in supine and standingpositions. Subjects with obstructive uropathy or with a urinary residual greater than 50 cc were excluded. Urodynamic diagnoses of the included study subjects identified 123 women as stress incontinent and 12 as having MI. All study subjects were then randomized in blocks of 12 into a biofeedback group, pelvic floor exercise group, or control group. HISTORY AND PHYSICAL EXAMINATION The history and physical examination performed by an NP evaluated the urine loss problem and determined if the subjects met study criteria. The nature of the incontinence was obtained by study subjects logging their urine loss episodes on a 24-hour diary. Records were kept of the following urinary activities: (a) time of normal voids, (b) time of urine loss episodes, and (c) type of activity associated with urine loss (i.e., coughing, sneezing, laughing, etc.) throughout the 8 weeks of treatment and again 2 weeks before the 3- and 6-month follow-up visits. Physical examinations were performed on all subjects to determine (a) the presence and degree of pelvic relaxation (cystoceles and rectoceles), (b) atrophic vaginitis, (c) vaginal muscle tone, and (d) presence of urine loss with stress maneuvers. The following grading criteria were used to determine the degree of pelvic relaxation: (a) first degree-the appearance of slight deviation, (b) second degree-protrusion at the introitus, and (c) third degree-protrusion beyond the introitus (Neeson 8c Stockdale, 1981). Atrophic vaginitis was diagnosed as pale vaginal mucosa with decreased rugae and/or localized areas of vaginitis in the posterior fornix and around the urethral orifice (Neeson & Stockdale, 19811. Vaginal muscle tone was assessed during pelvic examination by instructing the subject to squeeze around the examiner’s finger as tightly as possible. The strength of the muscle was measured on a 4-point subjective scale with zero equaling an absence of muscle contraction and 4 being full pressure anteriorly and posteriorly around the examining finger. Stress
JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS
incontinenre was induced by having the subjects drink 400 cc of water approximately 45 minutes before being asked to cough or bear down in either a supine and/or standing position.
ELECTROMYOGRAPH READINGS Elrctromyograph recordings were obtained using a J & J M53 Electromyograph machine and a D-200 Digital Integrator (Bio-Medical Instruments, Warren, Michigan) to record the vaginal muscle activity as measured in microvolts by a vaginal probe o r perineometer (Burns, Marecki, Dittmar, & Bullough, 1985). A computer recorded the 1-second readings of the subjects’ pelvic muscle contraction as the subjects performed quick and sustained pelvic floor exercises. These were displayed as a line graph on the computer monitor, and then the numerical scores were printed. Electromyograph measures for the quick contractions were obtained at 1-second intervals during a 3-second time span. Subjects relaxed between contractions for 10 seconds or until they resumed a baseline relaxation reading. This procedure was repeated five times with an average of the five, peak, quick contractions comprising the quick electromyograph measure. Pearson correlations of the five, peak measures had a mean of .90 with a range of .83 to .93. The sustained electromyograph score was derived by taking the average of the peak and four subsequent contraction readings. As with the quick contraction readings, an average of 5 scores comprised the final measure. Pearson correlations o f the five sustained measures again showed statistical consistency with a mean of .89 and a range of .78 to .95.
URODYNAM IC EVALUAT10N T h e urodynamic methods, definitions, and units conformed to the standards recommended by the International Continence Society (Abrams et al., 1988). The procedure began with uroflometry and measurement of residual urine. Subjects with obstructive uropathy defined as uroflow less than 15 cc per second ( n = 5) or a residual greater than 50 cc ( n = 5) were eliminated from the study and referred for appropriate treatment. Maximal urethral pressure (MUP) was measured during a pelvic muscle contraction in the lithotomy position. Static urethral closure pressure profilometry (UCPP), which is the pressure differential between urethra and bladder, was performed with the bladder empty and full in the lithotomy position and again full in the standing position. Dynamic UCPP was also accomplished in the latter two positions. Cystometry was performed in the lithotomy position with room temperature water delivered at 50 cc per minute via peristaltic pump. An additional standing
VOLUME 4, NUMBER 1, JANUARY-MARCH, 1992
position with heel bouncing and running water provocation was employed if detrusor instability was not identified i n the supine position. A diagnosis of GSI was made if the subjects lost urine with coughing and/or straining on physical examination in either the supine or erect position, or demonstrated detrusor stability on cystometrogram with or without a loss of urethral closure pressure on dynamic UCPP. Mixed urinary incontinence was diagnosed when subjects (a) lost urine while performing stress maneuvers on physical examination; (b) evidenced detrusor instability o n cystometrogram, defined as uninhibited contractions of greater than 10 cm H20; and (c) lost urethral closure pressure on dynamic UCPP. Even though the study attempted to recruit mainly GSI individuals, 12 of the 135 subjects were found on urodynamic evaluation to have MI.
QUANTIFICATION OF URINE LOSS An objective quantification of urine loss was obtained using a modification developed by Fantl, Harkins, Wyman, Choi, & Taylor, (1987) of the technique described by (Sutherst, Brown, & Shawer, 1981). Patients were filled to bladder capacity with sterile normal saline at room temperature using a 16F catheter. Filling ceased when subjects reported a full bladder and the filling volume recorded. T w o preweighed absorbent pads were secured against the perineum and held in place with the patients’ undergarments. T h e subject was then asked to walk a 50-yard distance at her own pace, stair climb, produce a series of coughs, heel-bounce, and assume sitting and standing positions. Each maneuver was performed five consecutive times. On completion of this portion of the test, the pads were replaced with a second set of preweighed pads. Finally, the subjects were requested to perform a hand wash under running water for 1 minute. T h e perineal pads were again removed and weighed using a Port-0-Gram Ohaus Electronic Scale (minimal unit: 0.1 gm) (Ohaus Scale, Florham, New Jersey).
RESULTS T h e following measures, vaginal muscle tone, presince or absence of atrophic vaginitis, previous pelvic surgeries, degree of pelvic relaxation (cystoceles, rectoceles), history and type of urine loss, urodynamic parameters, electromyograph readings, and urine losses as measured by the perineal pad test, were analyzed using Chi-square and one-tailed Fisher’s exact tests for the categorical variables and one-way ANOVA for the continuous variables. T h e authors recognize that the discrepancy i n size of subgroups is large, a n d
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TABLE 1. HISTORY OF SELF-REPORTS OF URINE LOSS AND NORMAL VOIDS BY DIAGNOSTIC GROUP Incontinent and Urinary History
History of Urine Loss Number of years with urine loss Years condition has worsened Number of weekly losses Self-Reports of Urine Loss Cough Bowel movement Rising up from sitting Rising from bed Sneeze Bending down Lifting objects Exercising Sitting Laughing Sleeping Voids Normal Voiding Nocturnal voids Diurnal voids
Genuine Stress Incontinence ( n = 123)
Mixed Incontinence ( n = 12)
i f S D
%fSD
12.3 f 11.7 1.9 f 2.6 16.9 f 16.1
1 3 . 0 f 11.3 3.9 f 6.8 21.4 It 13.1
3.0 f 2.1 f 2.0 f 1.7 f 1.5 f 0.6 f 0.6 f 0.6 f 0.4 f 0.3 f 0.3 f 0.9 f
6.5 3.2 4.2 3.2 2.8 1.3 1.5 1.6 1.8 1.0 1.5
1.0
2.0 f 1.0 5.1 f 2.0
1.9 f 2.7 f 2.6 f 1.0f 1.6 f 1.3f 1.6 f 0.8 f 0.2 f 0.3 f 0.3 f 1.7f
2.9 5.6 3.1 1.3 2.8 1.7 2.6 1.4 0.6 0.7 0.9 1.1**
2 . 9 f 1.1' 6.6 f 1.9*
Note. SD = standard deviation. ' p < .05. **p < .01.
generalizability of these findings is limited. However, the Fisher's test was employed as a more stringent analysis of a 2-X-2 table. When the ANOVA homogeneity of variance tests were nonsignificant, the pooled variance tests were used. Separate variance contrasts were used when variances differed significantly. The sociodemographic characteristics for the two subgroups, GSI and MI, showed that subjects were predominately white and married. Also, the ages of the two subgroups did not differ significantly between the GSI group (62.31 f 5.89) and MI group (64.17 f 6.77). INCONTINENCE HISTORY The comparative figures for symptoms associated with urine loss are shown in Table 1. The number of years the two groups suffered from the problem were relatively equivalent. Also, although not significant (t's Il.O), i t is interesting to note that the GSI group indicated fewer years for length of time the condition worsened and also indicated fewer weekly losses. When considering the types of urine losses experienced, of ,greatest interest is the relative patterns of losses that occurred for the two groups in the week before the urodynamic evaluation. It can be seen that the GSI group experienced more losses for coughing and rising from bed, whereas the MI group frequently reported greater losses when having a bowel movement, bending down, lifting objects, and rising from sitting positions. 18
Subjects were also asked if they lost urine with symptoms previously described as attributable to detrusor instability or urge incontinence. In validating the diagnosis these results revealed that the loss of urine after sensing the urge to void was reported significantly more often in those subjects with MI than those with GSI ( F (1,133)= 7.06, p < .01). Diurnal (6 a.m. to 10 p.m.) and nocturnal (10 p.m. to 6 a.m.) voids were analyzed to determine if women with an urge component to their urine loss problem (MI group) differed in their nocturnal voiding patterns. The results yielded significant differences for nocturnal ( F (1,132) = 5.13, p < .03) and diurnal ( F (1,132) = 6.40, p < .02) voids. The diurnal and nocturnal voids were greater in the MI group. GYNECOLOGIC FACTORS Table 2 presents the gynecologic findings of female subjects and the differentiation between diagnostic groups. Comparisons were made between the presence of cystoceles and rectoceles, atrophic vaginitis, and vaginal muscle tone for both diagnostic categories. There was a significant difference for vaginal muscle tone (X* [df = 1, n = 1351 = 3.86, p < .05), with the GSI group demonstrating a larger percentage of poor muscle tone (Table 2) than the MI group (82.1% vs. 58.3%,respectively). Similarly, the presence of atrophic vaginitis was increased in the GSI group (52%) as
JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS
TABLE 2. OBSTETRlCAL/GYNECOLOGlCAL/URODY NAMIC/ELECTROMYOGRAPHFINDINGS BY DIAGNOSTIC GROUP Variables
Pelvic Changes Poor vaginal muscle tone Presence of atrophic vaginitis Urethral suspension Hysterectomy Cystocele Grade 1 Grade 2 Grade 3 Rectocele Grade 1 Grade 2 Grade 3 Obstetrical Historya Pregnancies Vaginal deliveries Urodynamic Parameters Bladder capacityb Functional urethral lengthc Urethral closure pressurec Electromyographd Sustained contraction Ouick contraction
Genuine Stress Incontinence ( n = 123) n
%
101 64 31 52 91 66 24 1 52 44 7 1
82.1 52.0 25.2 42.3 74.0 53.7 19.5 0.8 42.3 35.8 5.7 0.8
Mixed Incontinence (n = 12) n
YO
7 3 4 3 10 8 2 0 4 2 2 0
58.3* 25.0" 33.3 25.0 83.3 66.7 16.7 0 33.3 16.7 16.7 0
3.57 f 2.1 8 3.09 f 1.91
3.08 f 2.61 2.67 f 2.27
328.5 f 87.0 41.2 11.6 30.8 f 16.3
*
286.3 f 94.0 41 .O f 19.7 30.6 14.6
1.9 f 1.6 3.2 k 3.4
2.6 f 2.0 4.6 k 4.8
*
aData presented as means and standard deviations. bData presented in milliliters. CData presented in centimeters. dMeasured in microvolts. *X' = 3.86; p < .05. '*Fisher's Exact Test p < .07
compared to the MI group (25%) (Fisher's one-tailed test p < .07). There were no differences in the rates of urethral suspension surgeries or hysterectomies, although a higher incidence of hysterectomies was found in the GSI subjects. Although it is a general consensus that cystoceles, rectoceles, or uterine prolapse is not a causative factor of incontinence (Green, 1968; Weigel, 1988), researchers have found a significant correlation between the presence of cystoceles and a diagnosis of anatomic Stress Incontinence (Fine, Mauldin, & Harte, 1988; Stanton, 1987).In the authors' clinical trial sample the presence of first, second, or third degree cystoceles or rectoceles was not statistically different between women with a diagnosis of either GSI (74%)or MI (83.3%).Although the majority of the sample had some type of pelvic relaxation, the largest percentage presented with first degree cystoceles. The occurrence of stress incontinence has also been attributed to mu1tiple vaginal deliveries or pelvic surgery (Ouslander et al., 1985). In this study's sample there were no significant differences between the two groups in either number of pregnancies (GSI X = 3.37 f 2.18; MI X = 3.08 f 2.61) or vaginal deliveries (GSI X = 3.09 f 1.91; MI X = 2.67 f 2.27). These similar
VOLUME 4, NUMBER 1, JANUARY-MARCH, 1992
findings could be attributed to the fact that the MI women have a component of their problem that is the same as those with GSI, but also have additional urge symptoms. URODYNAMIC FINDINGS Table 2 presents the measurements obtained during the urodynamic assessment of bladder capacity, functional urethral length, and urethral closure pressures. As shown, there were no statistically significant differences between subgroups for functional urethral lengths and urethral closure pressures ( t < 1.0). However, the bladder capacity of the MI group tended to be lower than the GSI group ( t = 1.6). This trend toward reduced bladder capacity in the subjects with MI may be attributed to their detrusor hyperactivity. ELECTROMYOGRAPH RECORDINGS Electromyograph readings were reflective of the two groups' ability to contract their pelvic muscles during quick and sustained contractions. Both the GSI group and the MI group showed similar pelvic muscle activity during their performance on electromyography with nonsignificant changes in measurements (Table 2).
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TABLE 3. QUANTIFICATION OF URINE LOSS WITH DIFFERENTIAL MANEUVERS BY DIAGNOSTIC GROUP
Differential Maneuvers Stress maneuvers (Step up and down, cough, heel, bounce, sit-up and down, walk 50 yd) Hand wash (wash hands for 1 minute)
Genuine Stress Incontinence ( n = 123)
Mixed Incontinence ( n = 12)
i*SD
i f S D
+ 23.0
26.1 f 28.5"
6.3 f 22.7
37.2 i 41.3"
12.3
Note. SD = standard deviation. ' p < . l ." p
< ,001.
T h e obstetric and gynecologic findings in both groups Tablr 3 presents the results for the analyses on both found cystoceles present in 74% of GSI individuals and sections of the perineal pad tests. T h e MI group lost 83% of MI individuals. Although the incidence of foux times more urine on the hand wash maneuver of rectoceles was less, it still was comparable across groups the perineal pad test than the GSI group ( F [1,12] = (42% GSI and 33% MI). T h e most significant finding 6.51, p < .03). In contrast, there were no significant on pelvic examination was the increased incidence of differences between diagnostic groups on the stress poor muscle tone and presence of atrophic vaginitis maneuvers portion of the perineal pad test. Reflecting in women with GSI. In this study those subjects with these differences, the 95% confidence intervals for the a diagnosis of MI had fewer lower urinary tract changes hand wash maneuver were mutually exclusive (MI = (i.e., atrophic vaginitis or poor vaginal muscle tone). 10.89 to 63.41; GSI = 2.23 to 10.32), whereas the 95% This finding might be expected because the primary confidence intervals for stress maneuvers were mutually etiology of MI is attributed to detrusor instability. This inclusive (MI = 7.98 to 44.21; GSI = 8.18 to 16.38). is further supported by the decreased bladder capacity This further supports the fact that the GSI and MI and increased nocturnal and diurnal voidings found subjects had similar loss of sphincter tone as shown in MI individuals. T h e perineal pad test for quantification of urine loss by comparable urine losses on stress maneuvers. discriminated significantly between diagnoses, as the However, those subjects with MI and evidence of hand wash maneuver produced a four times greater detrusor instability lost a significantly greater amount amount of urine loss in clients with a urodynamic of urine on the hand wash maneuver. diagnosis of MI as compared to those with GSI. This finding supports the theory that r u n n i n g water stimulates the urge to void in subjects with an unstable bladder component to their incontinent problem. An DISCUSSION additional discriminating factor between diagnoses was Comparisons of the GSI and MI subjects showed that the statistically significant increased incidence of poor women with MI were more likely to state that their vaginal muscle tone and atrophic vaginitis in the GSI problem had been worsening for a longer length of women. Examination of the electromyograph activity timr. When their types of losses were compared, there of the pelvic muscle revealed no significant differences were no significant differences even though the GSI between groups. Similarly, no differences were found group had more losses with stress maneuvers such as on either urethral pressures o r bladder capacity, coughing and rising from bed. T h e only significant although those clients with MI had lower bladder difference in type of loss that discriminated between capacities. the groups was found in MI individuals. There was a greater incidence of urine loss after the urge to void. A difference in voiding patterns between diagnostic CONCLUSIONS groups continued with the MI group having a greater In this clinical trial the subjects' urodynamic frequency of diurnal and nocturnal voids. This finding is substantiated by the fact that the GSI group used diagnoses of GSI and MI were strongly correlated with one-quarter fewer nighttime protective pads than did their performance o n the quantification pad test. T h e hand wash maneuver clearly identified those clients with those with an urge component to their problem.
QUANTIFICATION OF URINE LOSS
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JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS
an urge component to their urine loss problem. Similar 10 this objective finding was the subjective reporting of urine loss immediately after the voiding urge in pedicting a urodynamic diagnosis of MI. Although the sample size of subjects with MI was small, these results showed that symptoms, pelvic muscle tone, and a noninvasive procedure such as the pel ineal pad weighing test can be employed in assisting the N P to differentiate between a stress and urge etiology of inrontinence. T h e ability to accurately assess the etiology of incontinence without resorting to an invasive procedure gives the primary health care provider an exprdient, cost-effective mechanism for initiating appropriate therapy. These objective and subjective findings that differentiate between urologic diagnoses
can substantiate data-based practice for NPs. Interventions for clients with urine loss symptoms can be based on vaginal changes, provocative perineal pad test, and an in-depth assessment of the type of activity associated with the urine loss. This study's findings could be further validated by re-examining whether the significantly different changes in vaginal mucosa, vaginal muscle tone, and urine loss activity during provocative testing could also identify persons diagnosed as pure urge incontinence. Therefore, further research should reexamine the conclusions of this study to determine its applicability and replicability with a cohort of subjects diagnosed as having detrusor instability without a stress component.
References Abrams, P., Blaivas, J. G., Stanton, S. L., & Andersen, J. T. (1988). The standardisation of terminology of lower urinary tract function. Scandinavian Journal of Urology and Nephrology, 22(Suppl. 114), 5-1 9. Burns, P. A , Marecki, M., Dittmar, S., & Bullough, 6. (1985). Kegel's exercises with biofeedback therapy for treatment of stress incontinence. Nurse Practitioner, 7 0(2), p. 28. Burns, P. A.. Nochajski, T., Clesse-Desotelle, P. M., & Pranikoff. K. (1990). Recruitment experiences in the stress incontinence clinical trial. Neurology and Urodynamics, 9, 53-62. Cantor, T. J., & Bates, C P. (1980). A comparative study of symptoms and objective urodynamic findings in 214 incontinent women. British Journal of Obstetrics and Gynecology, 87, 889-892. Diokno. A. C., Brock, B. M., Brown, M. B., & Herzog, R. A. (1986). Prevalenceof urinary incontinence and other urological symptoms in the non-institutionalizedelderly.Journalof Urology, 5,136,10221025 Fantl, A,, Harkins, S. W., Wyman. J. F., Choi, S. C., & Taylor, J. R. (1987). Fluid loss quantitation test in women with urinary incontinence: A test-retest analysis. Obstetrics and Gynecology, 70(5),739-743. Fine, P. M., Mauldin, J. E., Harte, E. H. (1988). Stress incontinence in women; a practical method of evaluation. Journal of Reproductive Medicine, 33(9), 749-756. Green, T H., Jr. (1968). The problem of urinary stress incontinence in the female; an appraisal of its current status. Obstetrical and Gynecological Survey, 23, 603-634.
Jarvis. G. J., Hall, S., Stamp, S., Millar, D. R., & Johnson, A. (1980, October). An assessment of urodynamic examination in incontinent women. British Journal of Obstetrics and Gynaecology, 87, 893-896. Kaufrnan. J. M. (1 979). Urodynamics in stress urinary incontinence. Journal of Urology, 122,(6), 778-782. Milne. J. (1976). Prevalence of incontinence in the elderly. In F. L. Willington (Ed.), Incontinence in the elderly (pp. 9-21). New York: Academic Press. Neeson, J. D., & Stockdale, C. R. (1 981 ). The practitioners handbook of ambulatory oblgyn. New York: Wiley. Ouslander,J., Kane, R., Vollmer, S., & Menezes, M. (1985). Technologies formanaging urinary incontinence (Health Technology Case Study 33),(Report No. OTA-HCS-33). Washington, DC: U.S. Congress, Office of Technology Assessment.This case study was performed as part of OTA's assessments of Federal Policies and the Medical Devices lndustry and Technology and Aging in America. Stanton, S. (1 987). Urinary incontinence in females. Practitioner, 237, 52-59. Sutherst, J., Brown, M., & Shawer, M. (1981). Assessing the severity of urinary incontinence in women by weighing perineal pads. Lancet, I,p. 1 128. Weigel. J. W. (1988). Urinary incontinence. Journal of Enterostomal Therapy, 15(1), 24-29. Willington, F. L. (1 975). Significance of incompetence of personal sanitary habits. Nursing Times, 71, 340-341.
1 In the July/September 1991 issue, Jean O'Farrell Ussher, MS, RN, C, GNP, was incorrectly identified. She was a former nursing faculty member of the University of Lowell, Lowell, Massachusetts. We are sorry.
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