Female Urinary Incontinence

An overview in clinical presentation and management

Dr. Salwan Al-SalihiUroGynaecologist and Pelvic floor surgeon

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Learning Objectives:

• Understand the clinical background and presentation of different types of urinary incontinence.

• Outline the different steps in diagnosing and managing such cases.

• To develop a clinical algorithm with channels for referral and future follow up.

• Outline different management options and there prospects.

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Urinary incontinence

v Prevalence in Australia: Incontinence in women varies from 16.5% in 20-40 year olds to 31% in over 80 year olds.

v The prevalence increases with age; among women, it is 2 fold higher in the over 80 age group compared to 20-40 age group. (The Australian Commonwealth Department of Health and Aged Care)

v Up to 65% of those women recall that their symptoms began either during or shortly after childbirth.

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In 2010, the total financial cost of incontinence in Australia was an estimated $42.9 billion1

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Statement: vEpidemiologic evidence

supports an association between PFDs and pregnancy and childbirth and suggest that the overall impact of parity is substantial.

v Among parous women, it has been estimated that 50% of incontinence and 75% of prolapse can be attributed to pregnancy and childbirth.

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Types of Urinary Incontinence: vUrodynamic stress incontinence.

vDetrusor over activity.

vMixed.

vOverflow incontinence.

vTemporary (UTI).

vFunctional disorder (mobility, cognitive).

vExtra urethral (ectopic ureter or Fistula).

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Clinical evaluation:vPresenting Symptoms:

type :SI, UI, insensible leakage

onset, frequency, duration, severity.

vAssociated Symptoms:

Urinary frequency, nocturia

Dysuria, bladder pain, haematuria

Voiding dysfunction

Bowel symptoms: constipation, AI

Effect on sexual function7

Urge Incontinence

InternationalContinenceSociety(ICS)definitionof

overactivebladder1

Urgencywithorwithouturgeincontinence,generallyusuallywithincreasedfrequencyandnocturia

Componentsofoveractivebladder

UrgencyThecomplaintofasudden compellingdesiretopassurinethatisdifficult

todefer

UrgencyUrinaryIncontinence

Thecomplaintofinvoluntary lossof

urinethatisaccompaniedbyor

immediatelyprecededbyurgency

UrinaryFrequencyTheneedtovoid

morethan8timesina24-hour period

NocturiaThecomplaintof

havingtovoidmorethanoncepernight

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Differentialdiagnosisofsymptomssuggestiveofoveractivebladderinwomen1

Adaptedfrom:1.RosenbergMTetal.CleveClinJMed2007;74Suppl3:S21–9.

§ Urinary tract infection

§ Prolapse

§ Urethral obstruction

§ Atrophic vaginitis

§ Bladder cancer

§ Interstitial cystitis

§ Postsurgical incontinence

§ Diabetes

§ Congestive heart failure

§ Multiple sclerosis

§ Medications/diuretics

§ Neurogenic bladder

§ Recent pelvic surgery

§ Stress urinary incontinence9

Management of DOA:vLifestyle changes therapy.

vPhysiotherapy.

vPharmacological therapy.

vAnti-continence devices.

vAbsorbent products catheters.

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Lifestyle changes: vDietary: some foods and beverages are

thought to contribute to bladder leak (not been proven it may be reasonable to see if eliminating one or all of them helps):

vAlcohol. vCarbonated (+/- Caffeine).vCoffee and tea (+/- Caffeine).vCitrus juice and fruits.

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Pharmacotherapy

5 broad classes:vDecrease detrusor contractility

vIncrease urethral resistance

vDual effects

vReduce fluid out put (Minirin)

vNeurotoxins

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Pharmacological therapy:Decrease detrusor contractility:vOxybutynin (Ditropan)/(Oxytrol)

v Tolterodine (Detrusitol)v Solafenacin (Vesicare)vDarifenacin (Enablex)

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When to refer? And “Who” do you refer to?

v Failed conservative Management.

v Pain, Haematuria or recurrent UTIs (>or=3 in 6/12)

v Voiding difficulty.v Suspected fistula.v Neuropathic bladder.v Significant pelvic organ

prolapse.v Uncertain diagnosis.

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Indications for Urodynamics:① Failed to respond to empirical treatment.② Previous continence surgery.③ Prior to definitive continence procedure.④ Prior to prolapse repair accompanying stress incontinence.⑤ Symptoms suggesting of voiding difficulty.⑥ Presence of neurological disease.

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Aim of Uds:

1. Identify / eliminate detrusor overactivity (it influence treatment options).

2. Identify / eliminate voiding difficulty (complicate treatment outcome)

3. Confirm the presence of SI.

4. Identify the presence of prolapse and relation to the bladder dysfunction (Boney’s test)

5. Assess severity ( help triage patients).

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Other treatment for OAB:Botulinum neurotoxin

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Sacral nerve Modulation (for refractory Bladder over activity)

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Surgery for UI

Augmentation cystoplasty

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Stress IncontinencevIncontinence of urine when the intra-vesical pressure

exceeds the maximum urethral pressure in the absence of detrusor activity.

vPresents as: involuntary leakage on effort or exertion, or on sneezing or coughing.

vDuring Urodynamics: the involuntary leakage of urine during increased abdominal pressure, in the absence of a detrusor contraction.

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Stress incontinence:

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Stress incontinence:

Female stress urinary incontinence (SUI) is a common condition, with prevalence rates ranging from 12.8% to 46.0%.

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NOT A SOLUTION

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Treatment : Conservative

} Lifestyle changes : correct exacerbating factors} Physiotherapy◦ Bladder re-training◦ PFE / Kegel exercises

� 30-50% improvement with supervised physio 3/12� Less 1/3 may be unable to do PFE correctly even with

physio} Vaginal cones

� Pelvic floor contraction required to keep cone in position� 70% improvement, need life-long use to maintain

improvement} Vaginal oestrogen

◦ ↑ subjective outcome in SI, no change in objective loss

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Surgical treatment SI

1. Retro pubic urethropexy (Burch)

2. Suburethrtal slings (TVT,TVT-O et al)

3. Retropubic Rectus sheath sling (Pubovaginal Sling).

4. Periurethral Injection

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Burch colposuspension}Gold standard for many years (not now) !

Laparoscopic colposuspension:Long learning curve: 35-50 cases

No standardized techniqueSuture type, placement and number identical to open

Expensive procedure RCT’s : LB to be as effective as OB for USI

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TVT

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TVT : technique

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TVT : complications

} General : anaesth, DVT} Bleeding (recorded case of EIA

perforation)} Infection

} Bladder perforation, injury to urethra} Bowel injury (uncommon)

} Voiding dysfunction (long-term catheter 1%, need to divide tape)

} Mesh erosion

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TVT

} The gold standard procedure of USI} Simple, safe and minimally invasive} Short learning curve: 5-10 cases

} Standardized technique} Appropriate in many clinical situations

} Most efficient} Over 1,000,000 cases

} 14.5 years data available now

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Refinements:

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Transobturator tapes

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Refinements:

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Mini Tapes (Single Incision Slings)

MiniArc Precise Sling (AMS)

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Periurethral bulking agents

}Cure rate (defined as dry) at 12/12 = 48% (RCOG 2003)

}Success rate (improvement) = 76%}Pros: fewer voiding problems,

repeatable procedure and its an out patient’s procedure.

}Cons: expensive and less effective with repeat

} 7+ years data available now

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Periurethral bulking agents

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Bulking Agents

•Macroplastique: Bulkamid:

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Pregnancy after continence surgeryvThere is no consensus on management

of pregnancy and delivery in women who have undergone a surgical procedure for treatment of SUI.

vWhile many patients and clinicians assume that cesarean delivery is the only delivery option in these cases, this has not been established.

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Case 1

v61y.o womanv2 yrs of mixed SI + UI

vDaily leakage, wearing padsvNo previous surgery

vExamination:vAtrophic vagina

vModerate rectocelevHypermobile BNvDemonstrable SI

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Management

üMSU

ü Bladder diary

üUrodynamics

Options:

vConservative treatment

vCorrect predisposing factors

vPhysiotherapy PFE & BRT

vVaginal oestrogen

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Urodynamics:

vDetrusor overactivity

vModerate UD SI

vMUCP 57cmH20

vNormal voiding

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Treat OAB first if large component of UI

Anti-cholinergics

Exclude C/I * glaucoma

Start Ditropan 5mg BD

Discuss anti-cholinergic s/e

If unable to tolerate s/e, try Tolterodine 2mg BD

Review 2/1242

Persistent SI despite conservative treatment

Offer surgery

TVT

85% success for SI

Warn risk of worsening UI

Vaginal repair only if prolapse symptomatic

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Case 2

v75 y.o womanvRecurrent SI

vPH: Burch colposuspension, VR x2vWet all the time

vSlow voiding since Burch

vExaminationvFixed BN

vMarked SI demonstratedvNo prolapse

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Management

Bladder diary

Physiotherapy

Urodynamics:

vStable detrusor

vMarked UD SI

vMUCP 15cmH20

vBorderline VD

vVoided 390ml, flow rate 12ml/sec, RV 100ml

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Assessment

Gross SI

Fixed BN

Low MUCP

Suggests intrinsic sphincter deficiency

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Management

Surgery:

Transurethral bulking agent

Macroplastique / Bulkamid

Under LA if necessary

Avoid slings/ tapes if VD

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Thank you..

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