Urinary Incontinence in Women

Which treatments hold water?

Lieschen H. Quiroz, M.D.Associate Professor & Section Chief

Fellowship Director

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Objective• To review current epidemiology and

clinical presentation of urinary

incontinence

• To review the basic evaluation for

patients

• To learn of surgical and nonsurgical

options for management

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• Pelvic floor disorders (PFDs):

– Urinary incontinence (UI)

– Fecal incontinence (FI)

– Pelvic organ prolapse (POP)

• OB/GYN Subspecialty:

– Urogynecology

– Female Pelvic Medicine & Reconstructive Surgery (FPMRS)

Pelvic Floor Disorders

Incontinence: a common problem

Common and undertreated

Nearly 50% of adult women

experience incontinence

and 25-61% seek care

Reluctance may be from

embarrassment, lack of

knowledge of treatment and

fear of surgery

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Impact on Health Quality of life- depression, work impairment, social

isolation

Sexual dysfunction-

Morbidity- increase mortality and healthcare costs

Increase caregiver burden- not able to perform other

ADLs

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Shaw, C et al.. Fam prac 2001; 18:48-52.

Cumulative Lifetime Risk

0%

5%

10%

15%

20%

20 30 40 50 60 70 80

Cum

ula

tive incid

ence (

%)

Age (years)

Either SUI POP Either: 20.2%

(95%CI: 19.2, 21.2)

SUI: 14.5%

(95%CI: 13.4, 15.5)

POP: 13.7%

(95%CI: 12.6, 14.8)

Wu et al. Obstet Gynecol, 2014. PMID: 24807341.

Lifetime Risk of Surgery (SUI or POP)

Wu et al. Obstet Gynecol, 2014. PMID: 24807341.

0%

5%

10%

15%

20%

20 30 40 50 60 70 80

Cum

ula

tive incid

ence (

%)

Age (years)

80 yrs: 20.2%

1 in 5 women will undergo

surgery for stress incontinence

or prolapse by the age of 80

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Urinary Incontinence

A symptom

A sign

A condition

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Definition: Urinary incontinence

- Stress Urinary Incontinence (SUI)- the complaint of

involuntary leakage on effort on exertion, or on sneezing or coughing

- Urge Incontinence (UUI) - the complaint of involuntary

leakage accompanied by or immediately preceded by urgency

- Mixed Incontinence- the complaint of involuntary leakage

associate with urgency an also with exertion, effort, sneezing or

coughing.

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Abrams et al,. Am J Obstet Gynecol. 2002 Jul;187(1):116-26.

Screening

First step is screening patients for symptoms

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Brown J.S. et al: The sensitivity and specificity of a simple test to distinguish between urge

and stress urinary incontinence. Ann Intern Med 144. (10): 715-723.2006

Differential Diagnosis

GU etiology Non GU etiology

Filling/storage Functional

-SUI

-Overactive bladder

-Mixed incontinence

-Overflow incontinence

Neurologic

Cognitive

Environmental

Pharmacologic

Fistula Metabolic

-Vesical/ureteral/urethral

Congenital

-Ectopic ureter

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From: Walters, MD. Description and classification of LUT Dysfunction and POP. En:

Walters MD Karram MM: Urogynecology and Reconstructive Surgery

Medical History

DIAPPERS: Reversible Causes of Incontinence

D elirium or confusion

I nfection, UTI

A trophic genital tract changes (vaginitis, urethritis)

P sychologic

P harmaceutical agents

E xcess urine production

R estricted mobility

S tool impaction

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Conditions Causing Acute Urinary Incontinence

Delirium or confusion

Restricted mobility

Drugs

Urinary retention

Urinary Infection

Urethritis

Fecal impaction

Spinal cord compression

Polyuria

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Office Evaluation of Female UI

History Gynecologic

Urologic

Neurologic

General Medical

Drugs

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Office Evaluation of Female UI

History

Urologic symptoms SUI

UUI

Urgency/frequency

Number of voids in the day/ or after going to bed

Bedwetting

Dysuria

Difficulty voiding

Post-void fullness

Post-void dribbling

Hematuria

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Drugs that May Affect Lower Urinary Tract

Class of Drugs Side Effect Impact on LUT

Psychotropic agents

Antidepressants

Antipsychotics

Sedatives/hypnotics

Alcohol

Caffeine

Diuretics

Narcotics

Ace Inhibitors

Calcium channel blockers

Anticholinergic

Alpha-adrenergic agonists

Alpha-adrenergic blockers

Beta-adrenergic agonists

Anticholinergic, sedation

Anticholinergic, sedation

Sedation, muscle relaxation

Sedation, impaired mobility

Sedation, confusion

Cough

Increase Urethral Tone

Decrease Urethral Tone

Increase Urethral Tone

Urinary retention

Urinary retention

Urinary retention

Diuresis, frequency

Urgency, frequency

Polyuria, urgency, frequency

Urinary retention, fecal impaction

Aggravate preexisting SUI

Urinary retention, overflow

incontinence

Urinary retention, overflow

incontinence

Urinary retention

Stress incontinence

Urinary retention

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Bladder Diary

18http://www.augs.org/Portals/0/Voiding_Diary.pdf

Diagnostic Evaluation

Neurologic Sensation S2-S4 Pelvic reflexes

Pelvic Support (POP-Q) Muscle strength Q-tip PVR or US for residual urine Cough Stress Test

Postvoid residual testing h/o pelvic surgery, DM, other neurologic conditions. Elevated if >150cc on 2 occasions

Evaluate for UTI- can mimic either SUI or UUI

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Physical Examinaton for POP

Evaluate all anatomic sites for possible defects

Urethra

Bladder

Cervix or apex

Cul-de-sac

Rectum

Perineal body

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Pelvic Muscle Strength Testing Physical Exam

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Grade Examination

0 No visualized or palpable contraction

1 Flicker

2 Weak pelvic contraction

3 Moderate Contraction with an element of lift

4 Good contraction with lift and holding power

5 Strong squeeze with good lift gripping examining

hand

Vasavada, S., Apelle, R. ( 2005) Female Urology, Urogynecology and Voiding Dysfunction. Marcel Dekker, p.134.

Urethrovesicle Junction Mobility

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▪Q-tip test

Office Evaluation of Female Urinary

Laboratory Tests

Urinalysis

Urine Culture

Other: BUN/Cr, Cytology

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Simple CMG

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Clinic Note for a simple CMG Timed, measured void

Urinalysis

PVR volume with catheter or US

First sensation to bladder filling

Bladder capacity

Provocation during filling to elicit OAB

Full bladder cough stress test

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Physical Exam: Cough Stress Test

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Acute Condition?

Urinary Incontinence in WomenHistory and physical examination

Post-void residual urine measurement

YesTreat

Complex Condition?Consult w/ Urogynecologist

or Urologist

No

No

Yes

Sx of SUI? Yes

Urgency,

Frequency, Enuresis?Presume Mixed UIPresume DO

Stress Test? +

No

Urgency,

Frequency, Enuresis?No

Presume SUI

Yes

YesProminent

SUI Sx TX

Nonsurgical Treatment: SUI

Behavioral Management of fluid intake

Weight reduction

Pelvic floor exercises for SUI http://kidney.niddk.nih.gov/Kudiseases/pubs/pdf/exercise_ez.pdf

Recommended regimen includes 3 sets of 8-12 slow velocity, maximum intensity PFE sustained for 8-10 sec

3-4 times/week for 15-20 weeks.

Patients who fail to improve with this approach should be referred to a specialist

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Physiotherapy for Stress Incontinence Trained physical therapist

Biofeedback

Electrical stimulation

Goal

Rehabilitate and strengthen pelvic floor muscles

Outcomes

Improvement: 50-75%

May take 2-3 months to see improvement

Risks: none!

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Nonsurgical Treatment: SUI Pessary

Silicone devices that can provide support to pelvic organs and treat SUI by increasing urethral resistance

~50% of women who use a pessary for SUI continue to use it at 2 years

Discontinue if: irritation, discharge, odor, ulceration, bleeding

Low cost, easy to use, rare side effects

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Nguyen J.N., et al. Pessary treatment of pelvic relaxation: factors affecting successful

fitting and continued use. J Wound Ostomy Continence Nurs 32. (4): 255-261.2005

Modern Pessaries

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Surgical Management

Several conditions must be met

Correct diagnosis

Trial of conservative therapy

Acceptable surgical candidate

Does not desire fertility (+/-)

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Surgical Management Patients who fail pelvic floor exercises and devices

should be referred to a specialist to consider further

options

Mainstay surgeries include:

Minimally invasive midurethral sling-retropubic or

transobturator approach

Retropubic urethropexy (Burch procedure)

Transurethral bulking agents

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NEW Developments OTC Option for SUI

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Urge Incontinence (UUI) - the complaint of

involuntary leakage accompanied by or immediately

preceded by urgency

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Treatment UUI

Behavioral

Fluid management

Timed voiding

Pelvic floor exercises

Biofeedback

Shown to be as effective as anticholinergic medication in treatment of UUI in older women

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Burgio K.L., et al: Behavioral vs drug treatment for urge urinary incontinence in older women: a randomized

controlled trial. JAMA 280. (23): 1995-2000.1998

Physiotherapy for Urge Incontinence

Behavioral

modification

Retraining drills

Fluid management

Decrease bladder

irritants

“Freeze and squeeze”

Biofeedback

Electrical stimulation

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Anticholinergic agents Belladona first introduced in 1936

Atropine: first anticholinergic introduced. Prominent

sdx profile

Severe side effects led

to development

synthetic analogs

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Oxybutinin Tertiary amine, Nonselective Antagonist

“Mixed” action:

anticholinergic

antispasmodic

local anesthetic

antihistaminic effects

PO (IR and CR), intravesical, PR, and

transdermal

2.5- 5 mg tid or qid

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Oxybutynin – transdermal(Oxytrol)

Bypasses the first-pass GI and hepatic metabolism Patch applied 2x/wk Applied to dry, intact skin on the abdomen, hip or

buttock New application site with each new system Avoid re-application to the same site within 7 daysIn vivo delivery rate of 3.9 mg per day After removal, plasma concentrations of oxybutynin

and N-desethyloxybytynin decline with a half-life of 7 – 8 hours

Plasma concentration declines within 1 – 2 hrs after removal

Adhesion: 0.4% completely detached; 0.7% partially detached

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Oxybutynin – TD (Oxytrol) Severe application site reactions 5 %

10% resulting in discontinuation – most secondary to

application site reaction

None d/c’ed due to dry mouth

Several studies comparing to placebo and other

anticholinergics (eg. Long acting Tolterodine) prove it

effective in treatment UI sx.

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Dmochowski RR, et al; Transdermal Oxybutynin Study Group. Comparative efficacy and safety of

transdermal oxybutynin and oral tolterodine versus placebo in previously treated patients with urge

and mixed urinary incontinence.

Urology. 2003 Aug;62(2):237-42.

Dmochowski RR, et al. Transdermal oxybutynin in the treatment of adults with overactive bladder:

combined results of two randomized clinical trials.World J Urol. 2005 Sep;23(4):263-70. Epub 2005

Nov 8.

Oxybutynin – TD (Gelnique)

Transdermal delivery system (Gel 10%)

Average daily dose of 1 gram

(concentration 100mg/mg)

serum concentration 5 ng/ml

Skin reaction 5.4% (PI)

3.9% trial discontinuation

Tolteridine (Detrol) Nonselective Antimuscarinic

Fast absorption

IR half-life 2-3 hrs

ER –Detrol LA- 2 mg, 4 mg

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Solifenacin (Vesicare) Potent M3 Receptor antagonist, selective M3>M2

Half life ~50 hours (range 45-68)

5 mg, 10 mg; once a day dosing

Metabolized (primarily by CYP3A4) in the liver

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Darifenacin (Enablex) Potent muscarinic M3 selective receptor antagonist

7.5 mg, 15 mg once daily

Metabolized CYP450 3A4 and 2D6: caution with

TCA, flucanide, thioridazine & any CYP inhibitor

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Trospium Quaternary amine compound

Higher specificity to M2 M3

Half life 12-18 hrs; 20 mg bid

Excreted unchanged; no CYP450 interaction;

renal excretion careful w/ digoxin, procainamide, morphine, metformin

Low (5%) biological activity

Does not cross blood brain barrier (less lipophilic) -> no negative cognitive effects

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Fesoteradine (Toviaz) Approved by FDA in October 2008

Nonhepatically metabolized to 5-HMT, which is the

active metabolite of tolterodine.

Phase III trial demonstrated clinical improvement in

OAB sx for patients treated with 4 mg and 8 mg.

Most common Sdx: Dry mouth

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Nitti et al. J Urol 2007; 178; 2488.

Mirabegron (Mybetriq) β3-Adrenoceptor Agonist

Once daily dosing (25mg-50mg)

Cui et al

Compared with placebo, ↓ # incontinent episodes

/24hrs by -0.44 (95% CI -0.59, -0.29)

Less dry mouth than anti-cholinergics

treatment-emergent HTN developed in 8.4 % on placebo,

13.6 % on mirabegron 25 mg, and 10 % on mirabegron

50 mg

Cui Y, Zong H, Yang C, et al. The efficacy and safety of mirabegron in treating OAB: a systematic review and meta-

analysis of phase III trials. Int Urol Nephrol 2014; 46:275.

Wagg A, Cardozo L, Nitti VW, et al. The efficacy and tolerability of the β3-adrenoceptor agonist mirabegron for the

treatment of symptoms of overactive bladder in older patients. Age Ageing 2014; 43:666.

What if they fail medications, what do you do in your practice?What are the options?

Normal bladder capacity:

▪ Botox

▪ PTNS (Peripheral tibial nerve stimulation)

▪ Interstim (Sacral nerve stimulation)

BotulinumToxin About 70%

improvement

in symptoms

Risk UTI, retention

Repeated q4-6 mo’s

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Sacral Neuromodulation InterStim®

Successful treatment of:

Urgency-frequency 64%

Urge incontinence 76%

Urinary retention 61%

Complications

Pain at implant/electrode site

Infection

Lead migration

InterStimInterStim®® TherapyTherapySacral Nerve Stimulation for Urinary Sacral Nerve Stimulation for Urinary

ControlControl

InterStimInterStim®® Test Stimulation Test Stimulation

ProcedureProcedure

◼◼ Simple outpatient procedure Simple outpatient procedure

◼◼ Done under local anestheticDone under local anesthetic

Implantation of Interstim® System

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Summary PFD are common and costly in terms of health care

dollars and patient quality of life

Effective nonsurgical interventions exist for urinary incontinence

Primary care providers are ideal for screening for these disorders

Better understanding of prevention methods of PFD in women of all ages

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Thank YouLieschen-quiroz@ouhsc.edu

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