Urinary Incontinence in Women

Urinary Incontinence in Women

ETIOLOGY

 10~70% of women 

 Increase gradually during young adult life,

    broad peak around middle age,

    steadily increase in the elderly

 Most women do not seek medical help

 Cost: $12.43 billion in USA

 Among ambulatory women

   : urodynamic stress incontinence (29~75%)

   : detrusor overactivity (7~33%)

   : mixed forms

 Among older

   : stress incontinence ↓

   : detrusor abnormalities & mixed forms↑

 Increase age (>70 years)

   : more severe and troublesome incontinence

DIAGNOSIS

 History and voiding diary

   : voiding daily (3- to 7-day)

     -diurnal voiding frequency

       nocturnal voiding frequency

       number if incontinence episodes

   : medical– pulmonary(coughing)bowel(constipation)

     neurologic- diabetes, stroke, lumbar disk disease

     gynecologic- pelvic organ prolapse

     obstetric

     surgical- hysterectomy, vaginal repair, RTx ...

 Physical examination

   : palpation of the ant. vaginal wall & urethra

     - urethral discharge or tenderness

       → diverticulum, inflammation, neoplasm

   : pelvic examination

     - vulvar, vaginal atrophy in menopausal state

  ant. vaginal relaxation, prox. urethral detachment,

     ant. vaginal scarring, prolapse, cystocele, recto-

     cele 

   : bimanual & rectal examination

     - anal sphincter tone, laceration

        anorectal pathology

        fecal impaction

   : neurologic examination

    - S2~S4 (controlling micturition) 

       bulbocavernosus m. levators, ext. anal sphincter

       lower extremity motor (along sacral dermatomes)

 Measuring urethral mobility

   : aids in the diagnosis of incontinence &

     in planning treatment      

   : predicting mobility by examination- inaccurate

   : Q-tip test

     - placement of a cotton swab in the urethra to

        the level of the vesical neck and measurement

        of the axis change with straining

   : stress incontinence- urethral hypermobility

   

   : but, when abnormality of voiding or detrusor

     → require the measurement of detrusor pressure

         during filling and emptying

   

   : other test (perineal USG, MRI)

     - be used for assessment of bladder neck

        mobility 

 Laboratory tests

   : urinalysis- bacteriuria

   : blood test (BUN, Cr, glucose, Ca)

     - renal function

   : urine cytology- not recommended in incontinence

     - but, hematuria or acute onset of irritative voiding

        cistoscopy & cytology to exclude neoplasm

 Office evaluation of bladder filling and voiding

   : office setting

     - the amount of urine

        the time of normal voiding

        residual urine volume (catheter, ultrasound)

        

     - bladder capacity (syringe, bulb)

        cough stress test

 Urodynamic test

   : cystometry

     - test of detrusor function

     - assess bladder sensation, capacity, compliance

     - determine the presence of both voluntary and

        involuntary detrusor contractions

   

   : uroflowmetry

     - electronic measure of urine flow rate and pattern

   : electromyography

     - striated urethral sphincter

     - assess neurogenic voiding dysfunction

   : postvoid residual urine volume

     - < 50 mL  adequate voiding

        > 200 mL  inadequate voiding

     - 50~200 mL

       → repeat test

 Cystourethroscopy

   : bladder lesion (diverticula, fistula, stricture …)

     foreign bodies

   : evaluation of postop. Incontinence and

     other intraop. or postop. lower urinary tract

     complication

MANAGEMENT OPTIONS

   : absorbent products are most common method

   : but, with mild symptoms

     cannot be cured depend on barrier management

 Behavioral approaches

   : lifestyle intervention

     - weight loss, caffeine reduction, fluid manage,

        reduction of physical force (work, exercise),

        cessation smoking, relief of constipation

   : bladder training

     - bladder drills or timed voiding

     - increase the interval between voiding

     - patient education, scheduled voiding 

   : pelvic muscle exercise

     - ‘Kegel’ exercise

     - strengthen the voluntary peritrethral and peri-

        vaginal muscles (urethral sphincter, levator ani)

     - with bladder training, bio feedback, electrical

        stimulation 

 케겔운동의 방법  

   ▶1단계 : 소변을 참을 때를 연상하며 질을 1초 동안 수축했다가

                 긴장을 푸는 것을 반복합니다. 

   ▶2단계 : 1단계가 익숙해지면 질을 5∼10초 동안 수축했다가 

                 긴장을 푸는 것을 반복합니다. 

   ▶3단계 : 질의 근육을 마치 질이 물을 빨아올리듯이 뒤에서 앞

                 으로 수축하고 다시 물을 내뱉듯이 풀어버립니다. 한

                 번에 10회씩 하루 다섯 번 반복합니다. 

   :케겔운동은 쉽게 말해 소변을 참을 때를 연상하며 질을 조였다 풀기를 반복하는 것입니다. 이 때, 질근육만을 수축하고 다리 엉덩이 근육은 움직이지 않는 것이 요령입니다. 하루에 20회 정도로 시작해서 점차 400회 정도까지 늘려나갑니다

 Medical management

   : urethra and bladder contain a rich supply to

     estrogens receptors

     - estrogen affects postmenopausal urogenic

       symptoms

      →however, increase in urinary incontinence

   : other agents for frequency, urgency, incontinence

     - unpredictable response, side effect ↑

   : drugs improve detrusor overactivity by inhibiting

     the contractile activity of bladder

     - anticholinergic agents

        tricyclic antidepressants

        musculotropic drugs

 Surgical treatments

   I. retropubic colposuspension

     - suspend and stabilize the ant. vaginal wall, 

        bladder neck and prox. urethra

      → prevent their descents and allows for urethral

          compression against a stable urethral layer

     - technique

        two or three nonabsorbable sutures on each 

        side of the mid urethra and bladder neck

  II. tension-free vaginal tape

     - impairment of the pubourethral ligaments

     - polypropylene mesh is placed at the mid urethra

     - other material and modified methods

  III. bulking agents(collagen, carbon beads, fat) inject

     - around bladder neck and prox. urethra 

     - transurethrally, periurethrally

     - usually, second line therapy, nonmobile bladder

        neck and high risk of operation

   : complications

     - lower urinary tract injury, hemorrhage, bowel

        injury, wound complications, retention, UTI

     - perform cystoscopy 

        to verify urethral patency and the absence of

        sutures or sling material in the bladder 

   

   : incontinence with pelvic organ prolapse

     - uterine prolapse, cystocele

     - reduced or repaired (potential incontinence)

CLINICAL CONSIDERATIONS AND RECOMMENDATIONS

 When is office evaluation of bladder filling, voiding,

    or cystometry useful for evaluation of incontinence?

   : whenever objective clinical findings do not

      correlate with symptoms, bladder filling and

      cough stress tests are useful

   : monitored periodically to evaluate response

   : patient fails to improve to her satisfaction

   : retrograde bladder filling

     - bladder sensation and capacity

     - normal range : 300~700 mL

        but, large capacity are not always pathologic

        (33% of >800mL capacity:urodynamically normal)

        (13% : true bladder atony)   

   : loss of urine with coughing and absence of urge

     - suggests urodynamic stress incontinence

   : prolonged loss of urine(5~10 seconds after cough)

     no urine loss with provocation

     - other cause (detrusor ovaractivity) 

   : artifact introduced by increases in intraabdominal

     pressure caused by straining or movement

     - so, tests should be repeated

   : cystometric test

     - more complex disorder (ex. neurogenic)

     - measurements of detrusor pressure

 When are urethral pressure profilometry and leak

   point pressure measurements useful for evaluation

   of incontinence?

   : urethral pressure profilometry

     - not standardized

        able to contribute to the DDx. 

   : leak point pressure measurement

     - amount of increase in intraabdominal pressure

        that cause stress incontinence

 When is cystoscopy useful for evaluation of

    incontinence?

   : sterile hematuria, pyuria, irritative voiding, pain,

     recurrent cystitis, in the absence of any reversible

     causes, suburethral mass, when urodynamic 

     testing fails to duplicate symptoms

   : bladder lesion - < 2%

   : not routinely

 Are pessaries and medical devices effective for

   the treatment of urinary incontinence?

   : support bladder neck

     - may be effective for some cases

   : replacement of the prolapsed ant. vaginal wall

     with a pessary

     - responsible for either continence or some

        degree of urinary retention

 Are behavior modifications (eg, bladder retraining,

   biofeedback, weight loss) effective for the

   treatment of urinary incontinence?

   : individualized scheduled voiding, diary keeping,

     pelvic muscle exercise

     - 50 % reduction of incontinence episodes

        (15% in controls)

     - this was maintained for 6 months

     - no differences in treatment efficacy by type of

        incontinence (stress, urge, mixed)  

   : behavior training with biofeedback

     -63% mean reduction

   : with pelvic floor electrical stimulation

     -did not result in significantly greater improvement

  

    behavior therapy can be recommended as a

       noninvasive treatment in many women

    

      

   : combining drugs therapy- not enough evidence

   : obesity

     - 4.2-fold greater risk of stress incontinence

 Are pelvic muscle exercises effective for the

   treatment of urinary incontinence?

   : better than no treatment or placebo

   : reduces incontinence 

                       and increases vaginal pressure

 Is pharmacotherapy (eg, estrogen, tolterodine,

   oxybutynin, imipramine) effective for the treatment

   of urinary incontinence?

   : post menopausal women with at least one episode

     if incontinence weekly

     - exacerbation incontinence

        hormone therapy :39%

        placebo: 27%

   : another study

     - both combination HT or unopposed estrogen

       → increase the incidence of incontinence

    oral estrogen regimen cannot be recommended 

       as treatment or prevention for incontinence

   : anticholinergics (oxybutin chloride, tolteridine)

     - therapy for bladder overactivity

      → small benefit

          but, side effect (dry mouth, blurred vision,

           constipation, nausea, dizziness, headache) 

 Is ther a role for bulking agents in the treatment

   of urinary incontinence?

   : gultaraldehyde cross-linked collagen

     - cure rate : 7~83% over 10-year period

     - limitation : durability and long-term results

     - two or three injections are likely to be required

        to achieve a satisfactory result

 When is surgery indicated for 

                                          urinary incontinenece?

   : conservative treatments have failed

     patient wishes further treatment

   

   : not all patients need urodynamic testing before

     surgery

   : if detrusor overactivity patient

     - appropriate behavioral and medical therapy

   

 Which type of surgery is indicated in  the treatment

    of urinary incontinence?

   : retropubic colposuspension

     - urodynamic stress incontinence

        hypermobile prox. urethra and bladder neck

     - depend on many factor

        need for laparotomy for other pelvic desease

        pelvic organ prolapse, age and health

     - but long term result (sling op. is better) 

     - add hysterectomy

        → little to the efficacy in curing incontinence

   : retropubic suspension and sling procedure

     more efficacious than transvaginal needle susp-

     ension or anterior colporrhaphy with slightly higher

     complication rates

    : Burch colposuspension vs. tension-free tape

      - cure rate (57% vs. 66%)

      - Burch : delayed voiding, op. time↑, return time 

                    to normal activity ↑

         tension-free tape : bladder injury ↑

   : paravaginal defect repair 

                                   vs. Burch colposuspension

     - after 3 years continent rate (62% vs. 100%)

   : laparocopic Burch op. is better?

     - inconclusive

   : tension-free tape

     - cured 85% , improved 10.6%, failure 4.7%

        similar cure rate with Burch colposuspension

 for the patients with both prolapse and urinary incontinence, what surgical procedures are

   appropriate?

   : have a number of treatment options

   : abdominally, sacral colpopexy or retropubic

                       clposuspension

     transvaginally, sling placed operation

SUMMARY

 Behavioral therapy (bladder training and prompt

    voiding) improved incontinence and can be

    recommended in many women

 Pelvic floor training 

   : to be an effective treatment for stress and mixed   

     incontinenece

 Pharmacologic agents(oxybutynin, tolterodine)

   : small benefit in detrusor overactivity women

 Cytometric test 

   : nor routinely

 Bulking agent

   : relatively noninvasive

   : when operation is contraindication

 Burch colposuspension and sling  procedure

   : long-term data is similar

   : depend on patient characteristics and surgeon’s

     exrerience 

 Combination of hysterectomy and Burch op.

   : not result in higher continence rates than Burch

     procedure alone

 Tension-free vaginal tape and open Burch 

    colposuspension have similar success rate

 Ant. colporrhaphy, needle urethropexy, paravaginal 

   defect repair

   : lower cure rates than Burch procedure