Urethral Examination

Assessment of urethral function should be included as part of the initial examination. The anterior vagina and urethra should be palpated to evaluate for tenderness, masses, or a urethral discharge that might suggest a diverticulum or other urethral pathology.

An empty supine stress test (ESST) should be performed. This is done with the patient in the lithotomy position after a recent void. The labia are separated and the woman is asked to cough or Valsalva, and any urine leakage is noted. Lobel and Sand6 conducted a 1996 study and reported that the ESST had a 98% positive predictive value for diagnosing SUI documented on urodynamic testing. We use this test to screen for the presence of intrinsic sphincteric deficiency.

Another examination technique that is useful for evaluation of urethral support is the Q-tip test. This test is performed by placing a sterile, lubricated cotton swab into the urethra to the level of the bladder neck with the patient in the flat dorsal lithotomy position. She performs a Valsalva maneuver and the maximum angle of deflection is recorded with a protractor. An angle of deflection of positive 30 degrees or more from the horizontal is considered indicative of urethral hypermobility. Although a high strain angle is associated with the presence of SUI, there is a large overlap between incontinent and continent women. Because of this, the Q-tip test should never be used as a single factor in making a diagnosis, but rather as an adjunct to the physical examination. It is often useful in choosing a treatment regimen. We use the Q-tip test along with testing of urethral sphincteric function to make therapeutic recommendations in women with SUI (Table 3-1.2).

Other techniques have been described to assess bladder neck support. Cystourethrography using contrast material or a bead-chain has been used. Sagittal images are taken at rest and with maximum straining. Rotational descent of the urethra can thus be calculated. The contrast technique also allows visualization of the proximal urethra. This can help determine whether there is funneling of the bladder neck and may diagnose a urethral diverticulum.

Perineal and vaginal ultrasound techniques have also been described to obtain similar information. In the hands of experienced operators, sonography seems to produce

Table 3-1.2. Treatment of stress urinary incontinence algorithm based on urethral evaluation

Function (UPP,VLPP)

Normal

Low

Mobility >30 (Q-tip test)

Kegels, physio, pessary,TVT, BurchJOS

Sling (traditional),

<30

Kegels, physio

Bulking agents

UPP, urethral pressure profilometry; VLPP,Valsalva leak point pressure;TVT, tensionfree vaginal tape;TOS,transobturator sling; physio, pelvic floor rehabilitation.

similar results without the risk and complication of fluoroscopy and contrast materials.

Herbal Remedies For Acid Reflux

Herbal Remedies For Acid Reflux

Gastroesophageal reflux disease is the medical term for what we know as acid reflux. Acid reflux occurs when the stomach releases its liquid back into the esophagus, causing inflammation and damage to the esophageal lining. The regurgitated acid most often consists of a few compoundsbr acid, bile, and pepsin.

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