Incontinência urinária e fecal: Como avaliar

Convidad Sex Jun 21, 2013 10:47 am

Como avaliar a incontinencia fecal em idosos (ou pacientes em geral)?

EVALUATION — Evaluation of patients with fecal incontinence begins with a careful medical history followed by a thorough physical examination, and specific testing. As mentioned above, the subject is difficult for many patients to discuss; as a result specific questioning is often required (table 2).
History — The history should initially focus on determining whether fecal incontinence is truly present, and its severity. True incontinence must be differentiated from frequency and urgency without loss of bowel contents, which can occur in the setting of inflammatory disease, irritable bowel syndrome, and pelvic irradiation [41]. Questioning should then focus on determining the onset, duration, frequency, and severity of symptoms, precipitating events, and obtaining history of prior vaginal delivery, anorectal surgery, pelvic irradiation, diabetes, neurologic disease, and whether symptoms occur in a background of diarrhea.
Physical examination — The physical examination should include inspection of the perianal area and an internal digital examination. External examination may reveal chemical dermatitis, suggesting chronic incontinence, a fistula, prolapsing hemorrhoids, or rectal prolapse. Perianal sensation should be tested by evoking the anocutaneous reflex (anal wink sign). This is done by gently stroking the skin immediately surrounding the anus and observing a reflexive contraction of the external anal sphincter. An anal wink should be elicited bilaterally. The absence of this reflex suggests nerve damage and interruption of the spinal arc.
Digital examination should be performed to detect obvious anal pathology (such as a mass or fecal impaction) and provide a crude assessment of the anal resting tone (which is mostly due to tonic contraction of the IAS). Patients should be instructed to bear down and then to squeeze against the finger, which permits appreciation of the movement and angle of the puborectalis muscle, pelvic floor descent, and squeeze pressure [42]. However, the accuracy of these components of the physical examination are highly dependent upon experience and, as a general rule, correlate poorly with objective measures of anorectal function [42], though one study did find a correlation of squeeze pressure on a scale of 1 to 5 (with 0 = no discernible pressure and 5= extremely tight) with findings on manometry [43].
Diagnostic procedures — The history and physical examination often provide insight into the etiology of fecal incontinence, thereby permitting focused diagnostic testing. However, we recommend that most patients have inspection of distal colon and the anus with flexible sigmoidoscopy and anoscopy (if the anal canal is not well-visualized during sigmoidoscopy) to exclude mucosal inflammation, masses, or other such pathology. In addition, appropriate testing should be obtained for patients with diarrhea, which often includes stool studies, and a full colonoscopy. Substitution of medications that are known to cause diarrhea should also be considered.
A variety of other tests are available that measure specific components of anorectal function. Some of the more common will be reviewed below. The American Gastroenterological Association (AGA) guideline for anorectal testing techniques [44], as well as other AGA guidelines, can be accessed through the AGA web site at www.gastro.org/practice/medical-position-statements.
Anorectal manometry — Anorectal manometry can measure parameters such as maximal resting anal pressure, amplitude and duration of squeeze pressure, the rectoanal inhibitory reflex, threshold of conscious rectal sensation, rectal compliance, and rectal and anal pressures during straining [45]. High resolution anorectal manometry provides greater anatomic detail compared to standard water perfused manometry [46]. The AGA technical review for anorectal testing techniques [47], as well as other AGA guidelines, can be accessed through the AGA web site at www.gastro.org/practice/medical-position-statements.
It is most useful when it reveals an abnormally low sphincter pressure demonstrating that a sphincter defect is present. Decreased resting pressure suggests isolated IAS sphincter dysfunction, while decreased squeeze pressure suggests isolated EAS dysfunction. Patients with severe weakness of the external anal sphincter may have prolapsed rectum [48].
Rectal sensation can be assessed by inflating a rectal balloon to detect the threshold (smallest volume of rectal distension) for three common sensations: the first detectable sensation (rectal sensory threshold), the sensation of urgency to defecate, and the sensation of pain (maximum tolerable volume). However, the clinical significance of the last two thresholds is less well-established than the first since the rectal sensory threshold is valuable for determining whether biofeedback will be helpful [44]. Biofeedback is unlikely to be helpful in patients in whom the rectal sensory threshold is poor.
The anorectal inhibitory reflex can be demonstrated by measuring the amount of distension required to induce relaxation of the IAS (typically 20 mL). However, as mentioned above, the anorectal inhibitory reflex is not essential for continence.
Pudendal nerve terminal latency — Pudendal nerve terminal latency (PNTL) is determined by measuring the time required after stimulating the pudendal nerves with an electrode as it crosses the ischial spine to induce a contraction of the EAS. Normal delay is approximately 2.0 msec; prolongation of the PNTL suggests damage to the nerve. However, this technique is operator dependent and has poor correlation with clinical symptoms and histologic findings [44]. The AGA technical review for anorectal testing techniques [47], as well as other AGA guidelines, can be accessed through the AGA web site at www.gastro.org/practice/medical-position-statements.
Endorectal ultrasound and magnetic resonance imaging — Structural abnormalities of the anal sphincters, the rectal wall, and the puborectalis muscle can be understood in detail with endorectal ultrasound (picture 1A-B) or magnetic resonance imaging (MRI). Both techniques are comparable in the diagnosis of EAS, although endorectal ultrasound is more economical [49]. Disruptions of the sphincters detected by ultrasound correlate well with manometric findings. A defect in the IAS is accompanied by lower resting pressures while EAS defects are associated with lower anal squeeze pressure [50]. Furthermore, the size of the EAS defect inversely correlates with the maximum squeeze pressure [51].
Thus, endorectal ultrasound is most useful for establishing the diagnosis in patients in whom the medical history or manometric findings suggest occult sphincter injury, and is currently the simplest, most reliable, and least invasive test for defining anatomic defects in the external and internal anal sphincters. (See "Endorectal endoscopic ultrasound in the evaluation of fecal incontinence".)
Defecography — Defecography is performed by instilling a barium paste into the rectum while, with the patient seated on a radiolucent commode, films are taken of the anorectal anatomy at rest and during straining and defecation. Defecography can measure the anorectal angle, evaluate pelvic descent, and detect occult or overt rectal prolapse. However, its benefit in the evaluation of patients with fecal incontinence is limited [44]. The AGA technical review for anorectal testing techniques [47], as well as other AGA guidelines, can be accessed through the AGA web site at www.gastro.org/practice/medical-position-statements.
An alternative to traditional defecography is MRI defecography (also known as dynamic MRI imaging), which contributes added information regarding the pelvic floor anatomy [52,53].
Electromyography — Electromyography (EMG) activity of the anal sphincter can be performed using a surface electrode or a concentric needle. EMG is sometimes helpful in evaluating neurogenic or myopathic damage in patients with fecal incontinence. However, endorectal ultrasound may have rendered the EMG obsolete in sphincter mapping because of the discomfort associated with EMG.
Benefit of anorectal functional testing — The benefit of obtaining anorectal testing in patients with fecal incontinence was illustrated in a study in which anorectal testing led to an alteration in diagnosis in 19 percent and of treatment in 16 percent of 50 patients who had been assessed by history and physical examination alone [54]. Another study that included 56 patients with fecal incontinence demonstrated that manometry, sensitivity testing, PNTL, and saline continence tests provided a better understanding of the underlying pathophysiology that directed specific interventions.

Fonte: Kristen Robson, MD; Anthony J Lembo, MD; Section Editor; Nicholas J Talley, MD, PhD; Deputy Editor; Shilpa Grover, MD, MPH. Uptodate. May 14, 2012

Como avaliar a incontinência Urinária

The history, physical examination, and urinalysis are sufficient to guide initial therapy based on a working diagnosis of the type and etiology of urinary incontinence [6]. Not all components of the evaluation have to be done in a single visit. The initial visit can be used to classify the type of incontinence, evaluate for potentially reversible conditions, and obtain a urinalysis. These evaluations can be used to initiate treatment/investigation of comorbid conditions and initiate lifestyle and behavioral treatments as appropriate. In the subsequent visit (within one to two months) outcome from initial management can be assessed and more detailed examination completed.
Patients may have had prior negative experiences with clinicians who provided either perfunctory or nihilistic urinary incontinence care. An empathic approach with a commitment to devote effort to the problem is an important aspect of care. Specialized testing and referral are not necessary for initial evaluation and treatment for most patients [6]. (See 'Specialist referral' below.)
History — Providers must initiate the discussion of voiding symptoms with their patients because less than one-half of incontinent individuals report the problem to healthcare personnel [4].
Key components of the history include:

The onset and course of incontinence and associated lower urinary tract symptoms. Lower urinary tract symptoms which occur suddenly, in the absence of symptoms of an acute urinary tract infection, may indicate neurological or neoplastic causes, and should prompt further investigation (evaluation of neurological symptoms, neurological examination, urine cytology, specialist referral).
Leakage frequency, volume, timing, and associated symptoms (eg, urgency, effort maneuvers, urinary frequency, nocturia, hesitancy, interrupted voiding, incomplete emptying, straining to empty, sense of warning). The severity of incontinence can be determined using standardized questionnaires, such as the Sandvik Severity Index, that determines a score based on the frequency of episodes and amount of urine leaked (figure 2) [28,29].
Precipitants (eg, caffeinated beverages, alcohol, physical activity, cough, laughing, sound of water, placing hands in water).
Bowel and sexual function (impaction can cause impaired bladder emptying; bowel control and sexual function share the same sacral cord innervation as the bladder; fecal incontinence is more common in people with urinary incontinence).
Status of other medical conditions and symptoms, parity, and prescribed and over-the-counter medications, along with their temporal relationship to urinary incontinence onset or worsening (eg, a stroke of several years' duration is unlikely to be responsible for new onset urinary incontinence).
Previous types of continence treatment and its outcome should be reviewed.

Classifying type of incontinence from symptoms — Little is known about how factors such as age, race/ethnicity, and comorbidity affect the reliability and validity of specific urinary symptoms in predicting the type of incontinence. However, several generalization can be made:

Urgency symptoms (eg "Do you experience such a strong and sudden urge to void that you leak before reaching the toilet?") are sensitive and specific for the diagnosis of urge incontinence (positive likelihood ratio (LR) 4.2, 95% CI 2.3-7.6; negative LR 0.48, 0.36-0.62) [30]. A report of such symptoms is also a reliable diagnostic tool, with approximately a 90 percent agreement between two interviews [31].
Leakage with stress maneuvers (coughing, laughing, bending over, running, changing position) has the same reliability as urgency symptoms and is highly sensitive but has lower specificity [30]. "Stress" leakage can occur with detrusor overactivity, DHIC, and incomplete bladder emptying.
Frequency, nocturia, slow urine stream, hesitancy, interrupted voiding, straining, and terminal dribbling are commonly associated with urinary incontinence. These symptoms lack diagnostic specificity and may occur with detrusor overactivity, DHIC, outlet obstruction, detrusor underactivity, fluid intake, medications, and many medical conditions.
Nocturia may be related to nocturnal polyuria (eg, from late evening beverages, pedal edema, congestive heart failure, or sleep apnea), sleep disturbance (eg, from depression, pain, or medication), or from the lower urinary tract (detrusor overactivity, eg, benign prostatic enlargement). (See "Nocturia: Clinical presentation, diagnosis, and treatment".)

Symptom diagnostic tool — A brief questionnaire, the 3IQ, has been developed to categorize incontinence (urge, stress, other, or mixed urinary incontinence) and guide the primary care clinician toward an initial treatment plan [32]. A multicenter study of 300 middle aged women with moderate incontinence evaluated the performance of the 3IQ tool, using the results of a specialist urogynecologic workup as the "gold standard". For urge incontinence, the tool had a sensitivity of 0.75 and specificity of 0.77; sensitivity was greater for stress incontinence (0.86) but specificity was lower (0.60). Performance of this tool in older women, those with coexistent pelvic organ prolapse, and in other racial and ethnic groups needs to be established (figure 3) [32].
Bother and impact on quality of life — Urinary incontinence has a profound effect on many domains of quality of life, and is associated with depression, work impairment, and sexual dysfunction [33]. Incontinence in frail older persons is also associated with increased caregiver burdens.
Patients and clinicians often diverge in their assessment of the impact of urinary incontinence [34] and interpatient variability is common [33]. Therefore, it is important to explore the extent of bother and degree to which incontinence impacts the life of the patient (and/or caregiver).
Patients should be questioned about impact on work, activities of daily living, sleep, sexual activity, recreational activity, social interactions, interpersonal relationship, self-concept and perceptions, emotional coping, and general perception of health. Patients who report no bother should be questioned further as some patients, especially older patients, may assume that incontinence symptoms are normal or that treatment would be ineffective.
A number of well-validated instruments are available for evaluating incontinence-specific quality of life (table 3).
Determining the most bothersome aspect may help target management. As an example, treatment that only relieves daytime incontinence might be considered a failure if the patient is mainly concerned about nocturia.
Bladder diary — Bladder diaries (also called frequency-volume charts) are patient recordings of the time and volume of all continent and incontinent voids. Diaries provide a reproducible and reliable measure of incontinence frequency before and after treatment [7,35]. Reliability is greatest with seven-day diaries [36]. However, these are burdensome and two- or three-day diaries are commonly used in both clinical and research settings.
Diaries provide information on the usual timing and circumstances of urinary incontinence, modal voided volume (amount of urine per void, a proxy for functional bladder volume), voiding and urinary incontinence frequency, and total daytime and nocturnal urine output (figure 4). However, basic diary parameters such as frequency and volume are neither sensitive nor specific for determining the urodynamic cause of incontinence [30,37].
Most specialists have all patients complete a diary. However, this approach is often impractical in primary care, and its utility is unproven. Specific situations in which bladder diaries can be clinically helpful and should be considered include the following:

Nocturia — A bladder diary can help determine whether nocturia is due to an intrinsic problem (such as detrusor overactivity) or nocturnal polyuria. (See "Nocturia: Clinical presentation, diagnosis, and treatment".)
High urinary frequency and/or incontinence frequency — Diaries can help confirm patient reports of very frequent urination or leakage, and assess whether frequency is associated with high urine output (eg, high fluid intake or the rare case of diabetes insipidus).
Unclear history — Diaries can help determine incontinence severity by quantifying incontinence frequency and volume when patients or caretaker have difficulty giving a consistent description of leakage episodes.

To complete a diary, patients (or caretakers) are instructed to record the time and volume of every continent and incontinent void over at least 48 to 72 hours (figure 4). Toilet inserts with volume markings (commonly called "hats") are helpful. Other information that should be recorded in the bladder diary includes pertinent associated activities (eg, coffee drinking, exercise) and hours of sleep. Urinary incontinence volumes can be estimated as drops, small, medium, and soaking. In institutional settings, the staff should check the continence status (eg, dry, damp, or soaked) every two hours if they cannot monitor urine output.
Physical examination — All women presenting with incontinence should have a pelvic examination. However, a comprehensive examination extending "above the waistline" is often necessary to detect contributory factors and underlying serious conditions, especially in older persons. Urinary incontinence may be the only presenting symptom of morbid and sometimes life-threatening disease in both young and older persons. Thus, the evaluation should consider neurologic conditions (eg, multiple sclerosis, cord lesions), bladder and prostate neoplasms (especially if risk factors are present), and sleep apnea in persons with nocturia. (See "Nocturia: Clinical presentation, diagnosis, and treatment".)
The key points in the detailed physical examination are:

The cardiovascular examination should look for evidence of volume overload (eg, rales, pedal edema).
The abdomen should be palpated for masses and tenderness, although the abdominal exam is an insensitive test for bladder distention.
The extremities should be examined for joint mobility, function, and peripheral edema.
The genital examination in women should include inspection of the vaginal mucosa for atrophy (thinning, pallor, loss of rugae), narrowing of the introitus by a posterior synechia, vault stenosis, and inflammation (erythema, petechiae, telangiectasia, friability). A bimanual examination should be done to evaluate for masses or tenderness. The adequacy of pelvic support may be assessed by a split-speculum exam, removing the top blade of the speculum and holding the bottom blade firmly against the posterior vaginal wall for support. Ask the woman to cough, looking for whether the urethra remains firmly fixed or swings quickly forward (urethral hypermobility) and for bulging of the anterior vaginal wall either to or through the level of the hymenal ring (anterior wall support defect, or cystocoele). Check for a posterior wall support defect (rectocele) by turning the single blade of the speculum to support the anterior vaginal wall and having the patient cough again.
In men, the digital rectal exam should be performed to estimate prostate size and detect any abnormalities suggestive of prostate cancer.
A detailed neurologic examination is not necessary in the initial evaluation of incontinence, but should be considered for patients with sudden onset of incontinence (especially urge), known neurological disease, or new onset of neurological symptoms [6]. The testing should include an evaluation of sacral root integrity, including perineal sensation, resting and volitional tone of the anal sphincter, anal wink (visual or palpated anal contraction in response to a light scratch of the perineal skin lateral to the anus), and the bulbocavernosus reflex (similar anal contraction in response to a light squeeze of the clitoris or glans penis). In addition, vibration and peripheral sensation should be evaluated in testing for peripheral neuropathy. (See "The detailed neurologic examination in adults".)
Evaluation in older persons should include screening for depression, assessment of functional status, and (for treatment planning) evaluation of cognitive function [38]. Specific comorbidities may also indicate need for targeted evaluation. For patients with extensive osteoarthritis, the examination should include assessment of neck movement (lateral rotation and flexion) and evaluation for interosseous muscle wasting of the hands. These changes, especially if a Babinski reflex is also present, suggest cervical spondylosis or stenosis causing interruption of inhibitory tracts to the detrusor and thus detrusor overactivity.

Laboratory tests — A urinalysis should be performed in all patients, with urine culture if infection is suspected. In older women, the interpretation of the urinalysis must take into account the high prevalence of asymptomatic bacteriuria, which is not a cause of incontinence. (See "Approach to the adult with asymptomatic bacteriuria".)
Current guidelines do not recommend routine testing of renal function [22]. Serum calcium and glucose testing may be considered in patients with frequency and/or an increased urine volume as recorded in a bladder diary. Vitamin B12 level may be considered in older persons with an elevated PVR. (See "Etiology and clinical manifestations of vitamin B12 and folic acid deficiency".)
Urine cytology is indicated only if there is hematuria or pelvic pain.
Clinical testing
Stress test — Expert opinion recommends a clinical bladder stress test for persons with stress incontinence symptoms who are being evaluated in specialist care settings. The utility of stress testing in primary care is less certain [22]. Testing in primary care to confirm stress leakage may be helpful before recommending intensive pelvic muscle exercise programs, or when patients fail to respond to empiric therapy based on incontinence symptoms.
In women, a positive bladder stress test is helpful in confirming stress leakage in patients with stress or mixed incontinence symptoms, although a negative test is less useful because it may result from a small urine volume in the bladder or patient inhibition [30]. However, a positive bladder stress test does not necessitate treatment unless the patient indicates sufficient bother related to stress leakage.
The test is performed by asking the patient, with a full bladder, to stand, relax, and give a single vigorous cough (determining whether leakage is instantaneous or delayed is difficult with multiple coughs). A chux or pad is held underneath the perineum or on the floor and the clinician observes directly whether there is leakage from the urethra.
Leakage instantaneous with cough suggests stress incontinence, while delayed leakage suggests cough-induced detrusor overactivity, especially if there is large volume leakage that is difficult to stop.
Postvoid residual volume — Postvoid residual (PVR) testing, by catheterization or ultrasound, is recommended in current guidelines for evaluation of incontinence. However, high quality evidence from randomized trials is not available to support this recommendation, which is based on expert opinion [39,40]. The 4^th International Consultation on Incontinence recommends against PVR testing as part of the initial evaluation [22].
Parameters for interpreting the results of PVR testing are neither standardized nor well evaluated. The prevalence of elevated PVR is generally low even in symptomatic populations, and results might not change overall management. Additionally, it may not be practical to perform PVR measurement by catheterization or ultrasound in the primary care setting. The inability to perform PVR testing in primary care settings should not preclude the evaluation and management of the majority of patients with incontinence.
Expert opinion suggests that a PVR should be performed in patients with incontinence who have higher risk for an elevated PVR [41,42]. Indications include the following:

Women who develop recurrent or a new type of incontinence after anti-incontinence surgery or who have significant pelvic organ prolapse
Persons with specific neurological disease (eg, spinal cord injury, Parkinson disease)
Persons who have failed empiric antimuscarinic drug therapy
Persons with recurrent urinary tract infections
Persons with detrusor underactivity or bladder outlet obstruction determined by previous urodynamic testing
Persons with prior episodes of urinary retention
Persons with severe constipation
Persons on high doses or multiple agents that can suppress detrusor contractility or increase sphincter tone (table 1A-B)
Persons with diabetes mellitus with peripheral neuropathy

In general, a PVR of less than 50 mL is considered adequate emptying, and a PVR greater than 200 mL is considered inadequate and suggestive of either detrusor weakness or obstruction [17]. However, a PVR greater than 200 to 300 mL in women does not in itself require treatment in the absence of symptoms or recurrent infection. Treatment of coexisting conditions (eg, treatment of constipation, stopping medications with antimuscarinic action) may reduce PVR.
Urine flow rate — Routine measurement of the peak urine flow rate with a flowmeter is not recommended, especially in women.
Urodynamic testing — Routine urodynamic testing in the evaluation of urinary incontinence is not recommended [43]. Urodynamics are the physiological diagnostic "gold standard", but are invasive, expensive, require special equipment and training, are not usually necessary to make the diagnosis, and have not been found to affect outcome.
Urodynamics can correlate poorly with symptoms. Lower urinary tract pathology is rarely the only etiologic factor due to the multifactorial nature of urinary incontinence; misplaced focus upon a urodynamic diagnosis may detract from more relevant precipitants. Adverse effects of urodynamics primarily involve minor patient discomfort and a 2 percent rate of urinary tract infection. The precise diagnosis offered by urodynamic testing is most important when invasive therapy is planned [44]. (See "Treatment of urinary incontinence".)
Options for using specialized diagnostic tests are demonstrated in the table (table 4).
Clinicians should be aware of what diagnostic information urodynamic tests can and cannot provide [1].

Fluid cystometry provides information on bladder proprioception (sensation), capacity, the presence of detrusor overactivity (uninhibited contractions), contractility, and voiding efficacy. Carbon dioxide cystometry is unreliable because the gas is compressible and can irritate the bladder.
Simultaneous measurement of abdominal pressure during cystometry is necessary to exclude the effects of abdominal straining and detect DHIC.
Fluoroscopy, abdominal leak-point pressure, or profilometry is required for the urodynamic diagnosis of stress urinary incontinence. Abdominal leak-point pressure is the intravesical pressure at which urine leakage occurs in the absence of a detrusor contraction [1], determined by measurement of detrusor pressure while the patient strains and noting (visually or fluoroscopically) the pressure at which urine passes into the urethra in the absence of a phasic detrusor contraction. Profilometry is the measurement of urethral pressure, generally along the length of the urethra.
Pressure-flow studies (analysis of the relation between detrusor pressure and urethral flow during voiding) has been the gold standard for the urodynamic diagnosis of outlet obstruction; reliability has been questioned by more recent studies.

Bedside cystometric testing was popularized to detect detrusor overactivity and measure bladder capacity and postvoid residual in frail older persons. This study should no longer be used because of lack of sensitivity and specificity.
Specialist referral — Indications for specialist referral are:
Immediate specialist referral

Incontinence with abdominal and/or pelvic pain
Hematuria in the absence of a urinary tract infection
Suspected fistula
Complex neurological conditions (eg Parkinson disease, spinal cord injury, possible normal pressure hydrocephalus [cognitive impairment, wide-based gait, urinary incontinence])
Abnormal findings (pelvic mass or symptomatic organ prolapse beyond the hymen in women)

Fonte: Catherine E DuBeau, MD; Section Editors; Linda Brubaker, MD, FACS, FACOG; Kenneth E Schmader, MD; Deputy Editor; Fenny H Lin, MD. Uptodate, Oct 28, 2011.