Upright exam underused: preop office evaluation for stress urinary incontinence.(Gynecology)

BIG SKY, MONT. -- Examination of the patient in an upright position is a key component of a good office evaluation for stress urinary incontinence, and it's one most gynecologists overlook, Dr. Steven D. McCarus said at a meeting on ob.gyn., gynecologic oncology, and reproductive endocrinology.

"I'm amazed at how many patients say, 'Dr. Steve, I've never had anybody do that.' If you're doing pelvic floor corrective surgery, that's an extremely important part of the evaluation because you're going to pick up a high rectocele, an enterocele, a vaginal cuff prolapse, or an anterior enterocele. It takes 2 minutes. You've really got to do it," declared Dr. McCarus, chief of the division of gynecologic endoscopy at Florida Hospital Celebration Health in Orlando, Fla.

Perhaps even more important, he continued, a brief upright exam sends a message to the patient that she's getting state-of-the-art care. "You've shown the patient something that probably, in the last 15 years of going to gynecologists, nobody has ever done," he said.

The preoperative office evaluation of a patient with stress urinary incontinence is aimed at determining which type of incontinence she has so the right operation can be selected. If, for example, she has a mixed mechanism involving a hypermobile urethra and intrinsic sphincteric deficiency, a transvaginal tape (TVT) procedure is really the way to go. It addresses both mechanisms by achieving coaptation of the proximal urethra and repositioning of the sphincteric unit.

In this setting, the Burch retropubic bladder neck procedure familiar to most gynecologists is simply the wrong operation. Intrinsic sphincteric deficiency is the number-one reason for failed Burch procedures. Indeed, the operation has a 54% failure rate in women whose urinary incontinence is due wholly or in part to intrinsic sphincteric deficiency.

On the other hand, if office urodynamic testing shows the ...