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Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Urethrocele with Stress Incontinence


Text Only Home | Graphic-Rich Site | Overview | Risk and Causation | Diagnosis | Treatment | Prognosis | Differential Diagnosis | Specialists | Comorbid Conditions | Complications | Factors Influencing Duration | Length of Disability | Duration Trends | Ability to Work | Failure to Recover | Medical Codes | References

Medical Codes

ICD-9-CM:
618.03 - Prolapse of Vaginal Walls without Mention of Uterine Prolapse, Urethrocele
625.6 - Stress Incontinence, Female
788.33 - Symptoms Involving Urinary System, Mixed Incontinence (Female) (Male); Urge and Stress

Related Terms

  • Herniation of Female Urethra with Stress Incontinence
  • Prolapse of Female Urethra with Stress Incontinence

Overview

Image Description:
Urethrocele with Stress Incontinence - A view of the lower abdomen of a female figure reveals the abdominal cavity with the bladder and urethra, the tube that leads from the bladder. The urethra is depicted as collapsed against the front wall of the vaginal area.
Click to see Image

Urethrocele is the protrusion (herniation or prolapse) of the female urethra into the front wall of the vagina. The urethra is a small, muscular tube that carries urine from the bladder and normally lies just in front of the vagina. The herniation may be slight and high in the vagina, or large and low with visible bulging at the vaginal entrance. Urethrocele usually coexists with cystocele (cystourethrocele), the protrusion of the bladder through a weak spot in the wall of the vagina.

Stress incontinence is the involuntary discharge of urine due to increased intra-abdominal pressure such as during physical exertion, coughing, sneezing, laughing or lifting. It often is associated with urethrocele. An incompetent bladder outlet (poor urethral sphincter function) may also contribute to stress incontinence.

Incidence and Prevalence: Urinary stress incontinence affects up 60% of women over their lifetime (Vasavada).

White women have a higher incidence of urethrocele than blacks or Asian women (Callahan). Prevalence of female stress incontinence in whites is 41%, blacks 31%, and Hispanics 30% (Vasavada).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Risk factors for stress incontinence and for urethrocele include female sex, pregnancy, menopause, advanced age, and obesity. Repetitive activities that increase intra-abdominal pressure (e.g., lifting, chronic cough, constipation), traumatic labor and delivery that damages pelvic floor muscles, and removal of the uterus (hysterectomy) also can result in urinary stress incontinence and urethrocele (Callahan).

Source: Medical Disability Advisor



Diagnosis

History: The woman may report involuntary leakage of urine with coughing, laughing, sneezing, straining, quick movements, changes in position, physical activity, or athletics. A large urethrocele may result in increased urinary frequency, urgency in urination, difficulty emptying the bladder, painful sexual intercourse (dyspareunia), and frequent urinary tract infections. The woman may report a feeling of pressure or heaviness in the lower abdomen.

To gather more information for an accurate diagnosis, the woman may be asked to keep a diary to record the times and amount of urine leakage over a 24 to 72 hour period, fluid intake, and any activity that causes leakage.

Physical exam: A pelvic exam is done to detect any physical conditions that may be linked to incontinence. When the woman is asked to strain, a sliding downward and forward of the urethra and its external opening may be observed. A neurologic exam focusing on the nerves in this area tests reflexes and sensation.

Tests: Tests may include urinalysis and urine culture to rule out infection as the cause of incontinence. A urinary stress test, in which, with a partially filled bladder, the woman is asked to cough while straining to demonstrate leakage of urine. A small percentage of women with stress incontinence do not exhibit incontinence during this test.

The "cotton swab test" involves placing a sterile, lubricated applicator into the urethra to determine if the bladder neck and urethra are hypermobile. The angle of the applicator stick at rest is compared to the angle while the woman is straining. A change of more than 30° while straining indicates poor muscle support.

A "pad test" also may be performed, in which the woman wears a pre-weighed sanitary pad during exercise or other activity that usually results in incontinence. The pad is then reweighed to determine the amount of urine leaked, if any. Another test involves use of a nontoxic dye in the bladder. A pad stained with dye at the end of the physical activity indicates urine leakage.

X-ray studies with contrast dye (voiding cystourethrogram, intravenous pyelogram [IVP]) are performed to detect structural abnormalities of the urethra, bladder, and kidneys. Urodynamic studies (filling and emptying of the bladder) should be performed before any surgical urological corrective procedure.

A urethral pressure profile (UPP) indicates whether an individual would be helped by the standard surgical procedures for stress incontinence. The success rate of surgery is poor in individuals with very low resting urethral closure pressure.

Source: Medical Disability Advisor



Treatment

Weight loss is recommended for obese individuals to reduce abdominal pressure. Medications may be prescribed that help tighten the muscles of the urethra and block bladder contractions in mild to moderate cases. Hormones (especially estrogen) may improve the tone, quality, and circulation (vascularity) of the muscles and surrounding tissue. This treatment uses either an estrogen cream inserted into the vagina, pills taken orally, or skin patches. Women may be instructed to avoid caffeinated beverages and alcohol, and stop smoking.

Isometric (Kegel) exercises can strengthen pelvic floor muscles and reduce or cure stress leakage. Kegel exercises may provide only partial relief for older women, those with severe stress incontinence, and those with a large urethrocele.

Weighted cones can be used to strengthen the muscles that keep the urethra closed. The cones are inserted into the woman's vagina twice a day for about 15 minutes. She then periodically substitutes cones of increasing weight to strengthen the muscles.

A stiff ring (pessary) is a device that helps to reposition the urethra and leads to less stress leakage. The devise is fitted by a doctor and inserted into the vagina by a doctor or nurse. The individual can insert the device once she has learned how to do it and how to take care of it with periodic follow-up office visits. Another nonsurgical method for reducing stress incontinence is electrical stimulation of pelvic floor muscles. This improves continence by stimulating contraction of the urethral muscles. Biofeedback also may be used to enhance muscular control. Teflon or collagen can be injected into the area around the urethra (collagen periurethral injection). It helps to close the urethra and reduce leakage.

Various surgical procedures involve pulling the bladder up to a more normal position by making an incision in the vagina or abdomen and securing it with a suture attached to muscle, ligament, or bone. For severe cases of stress incontinence, the bladder may be secured with a wide sling (pubovaginal sling) or with transvaginal tape. In rare cases, a doughnut-shaped sac (an artificial urinary sphincter) that circles the urethra is implanted. By pressing a valve under the skin, the sac is deflated and removes pressure from the urethra, allowing passage of urine; this procedure is more commonly performed in men. Plastic surgery of the urethra (urethroplasty) is performed to correct the prolapsed urethra.

Source: Medical Disability Advisor



Prognosis

Any of the various methods of surgical repair (i.e., using a suture, sling, or implant to raise the prolapsed bladder and/or urethra) are considered standard treatments for stress incontinence in women. The success rate is high when performed on appropriate candidates (Chen). Women with a poorer prognosis are those who have had previous surgical failures, have poor urethral closing pressure at rest, certain underlying conditions (e.g., obesity, diabetes), or mixed urinary incontinence (urge and stress incontinence). Urge incompetence, also called overactive bladder syndrome, is caused by abnormal contractions of the bladder muscle (detrusor muscle).

Surgery to suspend the bladder neck (pubovaginal sling) has a failure rate of 18% (Katz).

Source: Medical Disability Advisor



Differential Diagnosis

  • Cystocele
  • Diverticulum
  • Mixed incontinence
  • Psychogenic (functional) incontinence
  • Psychological conditions
  • Severe constipation
  • Urethral tumor
  • Urge incontinence
  • Urinary tract infection (UTI)

Source: Medical Disability Advisor



Specialists

  • General Surgeon
  • Gynecologist
  • Urologist

Source: Medical Disability Advisor



Comorbid Conditions

  • Diabetes
  • Obesity
  • Urinary tract infection

Source: Medical Disability Advisor



Complications

Although urethrocele with stress incontinence has minor physical complications, it can have major social and psychological effects. Complications from medical therapy include side effects from prescribed medications and local irritation from use of mechanical devices. If surgery is performed, standard postoperative complications (i.e., bleeding, infection) may occur.

Urinary tract infections may coexist with urinary incontinence and increase recovery time. Obesity can affect recovery as excess weight increases pressure on the bladder.

Source: Medical Disability Advisor



Factors Influencing Duration

The particular treatment or surgical procedure, any complications, and the individual's job requirements may influence the length of disability.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Following surgical repair, the woman may need temporary reassigned to largely sedentary work duties. Extended restrictions may include no lifting heavy weights or any work classified as heavy duty. If surgery is performed, the individual will need to avoid heavy lifting, straining, and prolonged standing for up to 3 months (Katz).

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Was diagnosis of stress incontinence confirmed?
  • Was the presence of urethrocele confirmed with a pelvic exam?
  • Were other causes of incontinence (e.g., medications, urinary tract infections) ruled out?

Regarding treatment:

  • Has weight loss or medication been effective in relieving symptoms?
  • Has length of medication trial been adequate to gauge effectiveness?
  • Has individual been encouraged to perform Kegel exercises to strengthen pelvic floor muscles? Have other strengthening tools been tried?
  • Have other nonsurgical treatments such as electrical stimulation, biofeedback, or collagen injections been tried?
  • Have exercises or other nonsurgical methods been effective in reducing incontinence?
  • If nonsurgical methods have failed to reduce symptoms, is surgical intervention now warranted?

Regarding prognosis:

  • Is individual an appropriate candidate for surgical intervention?
  • Is obesity a factor affecting the outcome of the treatment? If so, how is this being addressed?
  • Has individual experienced any complications such as urinary tract infection or bleeding that may affect recovery?

Source: Medical Disability Advisor



References

Cited

Callahan, Tamara L., A. B. Caughey, and L. Heffner. "Chapter 18: Pelvic Relaxation." Blueprints Obstetrics and Gynecology. 3rd ed. Blackwell Publishing, 2004. 162-179.

Chen, Peter. "Stress Incontinence." MedlinePlus. 24 Apr. 2008. National Library of Medicine. 13 Aug. 2009 <http://www.nlm.nih.gov/medlineplus/ency/article/000891.htm>.

Katz, V. L., et al., eds. "Chapter 20: Anatomic Defects of the Abdominal Wall and Pelvic Floor." Comprehensive Gynecology. 5th ed. Mosby Elsevier, 2007. MD Consult. Elsevier, Inc. <http://mdconsult.com>.

Vasavada, Sandip P., and Raymond Rackley. "Pubovaginal Sling." eMedicine. Eds. Edward David Kim, et al. 26 Sep. 2013. Medscape. 3 Jul. 2014 <http://emedicine.medscape.com/article/447951-overview>.

Vasavada, Sandip P., Maude E. Carmel, and Raymond Rackley. "Urinary Incontinence." eMedicine. 2 May. 2014. Medscape. 3 Jul. 2014 <http://emedicine.medscape.com/article/452289-overview>.

Source: Medical Disability Advisor