Female Urinary Incontinence

Dr Ida MahSpecialist in UrologyHong Kong Urology ClinicPedder Street, CentralHong Kong

Urinary Incontinence

The involuntary loss of urine per urethra

Prevalence

Depends on diagnostic criteria and studied population

34% in Hong Kong women aged 18 and above reported urinary incontinence– Ma SS, Urogynecol J Pelvic Floor Dysfunct. 1997; 8 (6): 327-31

49% of female aged 18 and above have urinary incontinence– Ngan et al, the Hong Kong Practitioner 2006 vol 28

34% of female age 10-90 experienced stress incontience– Pang MW et al, Hong Kong Med J 2005 Jun; 11(3): 158-63

Urinary Incontinence

Urinary Incontinence

Types of Urinary Incontinence

Stress Urinary Incontinence Urge Urinary Incontinence Mixed Urinary Incontinence Overflow Urinary Incontinence

Stress Urinary Incontinence

Definition: the involuntary loss of urine per urethra caused by an increase in intra-abdominal pressure

Continence Mechanism

Anatomical support– Intact pelvic floor that hold the bladder

neck and urethra in place Intrinsic urethral mechanisms:

– Coaptation Mucosa Submucosa

– Compression Submucosa Internal sphincter External sphincter

Causes of SUI

Pelvic floor laxity due to childbirth Damage to the urethra due to

– Radiation– Surgery (hx of urethral surgery)– Neurological– Trauma

History

SUI is a clinical diagnosis Association activities childbirth history Hx of surgery or injury to the

urethra Effect on Quality of Life

Physical Examination

Abdominal, rectal, vaginal examination– Look for presence of stress urinary

incontinence– Look for coexisting pelvic organ

prolapse– Assess pelvic floor muscle tone

Pad test

Semi-qualitative assessment of the severity of leakage

1 hour, 2 hours or 24 hours 1 hour:

– Patient is asked to drink 500cc of water– Then perform a series of standard exercise

like climbing stairs and walking– Weight gain of pad is then measured– Significant if >2gm

Management of SUI

Conservative

Surgical

How to decide plan of treatment?

Severity of patients’ symptoms– Subjective and objective

Fitness for operation Presence of other pathology Complications or morbidity of

treatment

Conservative Management

Behavioral Modification

Pharmacotherapy??

Pelvic floor exercise

Behavioral Modification

Diet and lifestyle changes: avoidance of caffeine, stop smoking etc

Fluid management

Timed voiding Bowel habit:

avoid constipation

Pharmacotherapy

Estrogen– Subjective but no objective

improvement Serotonin(5-HT) and

noradrenaline reuptake inhibitor (Duloxetine)

Duloxetine

Significantly reduces incontinence frequency and improve the patient’s QOL

Significant side effects of nausea,dry mouth, fatique, insomnia & constipation (11-23%)

Approved for use in patients with moderate to severe SUI in Europe

Not approved in the States for use in SUI by the FDA because of several suicidal deaths associated with withdrawal of the drug

Locate pelvic floor muscles

Squeeze pelvicfloor musclesas tightly aspossible for afew seconds(maximum of10 seconds)

Relax completely for atleast 10 seconds

Repeat, asrecommendedby physician/

continenceadvisor

Pelvic Floor Exercise

Pelvic Floor Exercise Make sure

patients contract the appropriate muscle

Biofeedback– Vaginal cone– Perineometer

Pelvic Floor Exercise

Need a dedicated therapist to supervise the therapy and follow up the patients

Surgical Treatment for SUI

Goal of Surgery for SUI

Prevention of urethral descent– Retropubic Suspension

To provide a backboard against which the bladder neck and proximal urethra can be compressed during increases in intra-abdominal pressure– Sling Procedure

Surgical Rx of SUI

Retropubic Suspensions Sling Procedures Injection therapy

Burch Colposuspension

Described in 1961 Lateral fixation of

urethrovaginal tissue to the Cooper’s ligament

Complications:– Enterocoele (5-10%)

Disadvantage: requirement of an abdominal incision

Surgical Rx of SUI

Retropubic Suspensions Sling Procedures Injection therapy

Sling Procedure

Autologous Sling– Rectus Fascia– Fascia Lata

Synthetic Sling– Polypropylene

Pubovaginal Sling(Autologous)

Tension Free Vaginal Tape First described by

Ulmsten in 1996 A polypropylene

tape placed at mid-urethra

Tension free urethral support

Minimal invasive Short hospital stay Quick return to

normal daily activities

> 1 million tapes have been implanted worldwide

Tension Free Vaginal Tape

Transobturator Tape

Results of Urethral Tape 85% cure rate at 1-3 year follow-

up– Ulmsten U et al Br J Obstet Gynaecol 1999;106:345-350– Olsson I et al Gynecol Obstet Invest 1999;48:267-269

85% cure rate at 5 year follow-up– Nilson et al Inter Urogyne Journal 2001(suppl 2): S5-S8

TVT vs Colposuspension: similar success rate but TVT provides shorter hospital stay and less days off from work

Urge Incontinence

Urge incontinence is the involuntary loss of urine associated with or preceded by urgency

Caused by involuntary detrusor contraction (detrusor overactivity) during the filling phase

Definition

Detrusor overactivity is a urodynamic observation characterised by involuntary detrusor contractions during the filling phase which may be spontaneous or provoked– Neurogenic detrusor overactivity– Idiopathic detrusor overactivity

International Continence Society 2002

Symptom-based definition of Overactive Bladder OAB is a syndrome referring to

the symptoms of frequency, urgency, urge incontinence, either single or in any combination, when appearing in the absence of local pathologic or metabolic factors explaining these symptoms

Abrams P and Wein AJ: Urology 51(6):1062

Prevalence of OAB

8-35%, depends of studied population and methods of evaluation

13.7% in Hong Kong More commonly in the elderly Urge incontinence affects at least

13 million Americans at a cost to the economy of $16 billion annually

Bladder Filling & Emptying Cycle

The cycle ofbladder fillingand emptying

1. Bladder fills

2. First desire tourinate (bladder

half full)

Urination 3. Urinationvoluntarily inhibiteduntil time and place

are right

Detrusor musclecontracts

Detrusor muscle relaxes

Urethralsphinctercontracts

Urethralsphincterrelaxes

Pathophysiology of OAB Involuntary

detrusor contractions occur during the filling phase which cause the sensation of urgency

Etiology of Detrusor Overactivity Neurogenic

– Spinal cord disorder, DM Local bladder irritation

– Stones, infection, tumour, foreign body

Bladder outlet obstruction– BPH

Aging Idiopathic (OAB)

Etiology of Idiopathic OAB Disorder of the micturition reflex

– Loss of cortical or peripheral inhibition

Disorder of neurotransmission Myogenic disorder

– Structural changes cause increased sensitivity to stimulation

Behavioral / psychological

Etiology of OAB

No single theory explains the pathophysiology of OAB

Significant advances have been made but still a long way to go to

Symptoms of OAB

Frequency (85%) Urgency (54%) Urge incontinence (36%) Nocturia

• Milsom et al 1999

Goals of Evaluations

Rule out local pathologic and metabolic factors

Identify other treatable / curable conditions

Identify other serious underlying conditions

Initial Evaluation

History Physical Examination Voiding diary

Evaluation: History

Identify the symptoms of OAB– Frequency, urgency, urge incontinence,

nocturia Symptoms suggestive of underlying

causes– Haematuria– Hx of urinary tract stones

Hx suggestive of outlet obstruction Medical and neurological history

Evaluation: Physical Examiantion General Examination (including

bladder palpation) Digital rectal examinatioin in

males Pelvic examination in females

(observe for SUI and prolapse Neurological examination

Evaluation: Voiding Diary

Evaluation: Lab tests

Urinalysis– MSU to rule out haematuria, pyuria,

bacteruriaand glucosuria– Urine for cytology

Blood tests– Fasting blood glucose– Renal function

Evaluation: Radiology

KUB– To rule out underlying urinary tract

especially bladder stones USG kidneys and bladder

– To detect bladder pathology– To detect upper tract damage in

patients with neurogenic bladder

Urodynamic Study

Filling cystometry

Involuntary detrusor contraction

? >15cm water Associated

with symptoms Spontaneous

or provoked Bladder

capacity Assess outlet

obstruction

UD tracing : detrusor overactivity

Urodynamic Study

False Positives– 60% of normal volunteers

False Negatives– 10-40% with negative UDS have

positive ambulatory UDS

Indications for UDS

Treatment failure Suspect outlet obstruction Association with stress

incontinence Suspect neurogenic bladder Consideration of surgery

Indications for referral to urologists Evidence of bladder outlet

obstruction Haematuria (? Underlying

carcinoma) Associated with neurological

disease Bladder stones Associated with stress

incontinence or pelvic prolapse Failed medical

treatment/consideration of surgical Rx

Management of OAB

Behavioral therapy Pharmacologic therapy Surgery

Behavioral Therapy

Education Voiding diaries Fluid/dietary management Bladder training/timed

voiding/delayed voiding Pelvic floor training/biofeedback

Education

Education on the normal bladder physiology and pathophysiology of OAB

Dietary advice

Fluid management

Avoid stimulants like coffee, tea and alcohol

Behavioral Therapy

Bladder training Timed voiding/delayed voiding No standard protocol, teaching

material or technique Efficacy: low cure rates, improve

efficacy if combined with drug Rx Results better in urodynamically

stable patients

Pelvic Floor Training

Competent pelvic floor muscles make the difference between wet and dry OAB

Indicated in patients with urge incontinence and weak pelvic floor muscle

Pharmacologic Therapy Muscarinic cholinergic receptors

located on detrusor muscle respond to parasympathetic mediated release of acetylcholine to stimulate detrusor contraction

5 muscarinic receptors have been described

M3 responsible for activating detrusor contraction

M3 receptors also mediate salivary secretions and bowel contraction (ie. Side effects)

Side Effects of Drug Rx

Mainly due to their anticholinergic action

Dry mouth Blurred vision Constipation Tachycardia Drowsiness

Contraindication and precaution

Contraindicated in patients with narrow angle glaucoma

Use with caution in patients with outlet obstruction as the drugs may precipitate retention

Oxybutynin (ditropan)

Binds to M2 and M3 receptors Dosage: 2.5mg bd to 5mg tds Significant side effects: dry

mouth, decreased gastric motility 18% patients remain on Rx for

over 6 months Less side effects in children

Tolterodine (detrusitol)

Not receptor selective but selective for bladder tissue over salivary tissue

Efficacy similar to oxybutynin but less dry mouth and less withdrawals from drug Rx

Dosage: 2mg bd

Solifenacin (Vesicare)

Slow release Plasma level rise over 4-6 hours ,

then steady over 24 hours Demonstrated efficacy at a lower

steady level to reduce side effects

Tricyclic Antideprssants Imipramine most commonly used Central and peripheral anticholinergic

effects Block norepinephrine and serotonin re-

uptake thereby causing a direct inhibition of normal excitatory pathways

Sedative Dosage: 10mg QD to 25mg QID Side effects: anti-cholinergic side

effects, weakness, fatigue

Acupuncture

Endorphinergic effects at the sacral spinal cord level or above

Inhibit somatovesical reflexes Increase in peripheral circulation Need randomised control studies

Surgical Treatment for OAB Bladder overdistension Supratrigonal transection of

bladder Bladder denervation Neuromodulation: Interstim BOTOX injection Augmentation enterocystoplasty

Surgical Treatment for OAB Bladder overdistension Supratrigonal transection of

bladder Bladder denervation Neuromodulation: Interstim BOTOX injection Augmentation enterocystoplasty

Sacral Neurmodulatioin

A tined lead is introduced to the S3 nerve foramen

Lead is then connected into a lead generator

Temporary vs permanent generator

Sacral Neuromodulation Outcome

– 47% dry– 29% improved

Side effects:– Pain (16%)– Implant infection (19%)– Lead migration (7%)

Cost

Surgical Treatment for OAB Bladder overdistension Supratrigonal transection of

bladder Bladder denervation Neuromodulation: Interstim BOTOX injection Augmentation enterocystoplasty

Injection of BOTOX BOTOX A blocks

acetylcholine release at the neuromuscular junction

Injection of BOTOX at suburothelial space modulates the release of neurotransmitters from sensory nerve endings, thus inhibiting the occurrence of bladder overactivity

Injection Site

Generally distributed around bladder–Avoid dome

Potential for intraperitoneal injection

Difficulty of injection

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Injection of BOTOX

Advantage:– Effective– Effect last for 6-8

months– Minimal invasive– Outpatient

procedure

Disadvantage– Effect last for 6-8

months only– Risk of retention

of urine (10%)– Limb weakness

Surgical Treatment

Bladder overdistension Supratrigonal transection of

bladder Bladder denervation Neuromodulation: Interstim Injection of BOTOX Augmentation enterocystoplasty

Augmentation Enterocystoplasty

Clam cystoplasty Up to 90%

success rate in DI and neurogenic bladder

Increase the bladder capacity and abolish the unstable contraction

Side Effects of Cystoplasty Retention of urine Mucus plug retention Stone formation Electrolyte disturbance Malignancy

Reserved for patients who have intractable symptoms and are willing to accept the possible side effects

Conclusions

Urinary incontinence is a common problem Treatment depends on the nature and

severity of the condition OAB: important to identify treatable

underlying factors Patients should be provided with information

on various choices of Rx (conservative & operative)

With appropriate Rx patients could be cured of the incontinence and thus improving the quality of life