Transcript Urinary Incontinence

Overview & Management
Dr. Hussam
Hassan
Definition of Urinary Incontinence
 Involuntary
loss of urine that is
objectively demonstrable and that is
severe enough to constitute a social
or hygienic problem.
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Urethra is stabilized during stress by three
interrelated mechanisms
 One
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mechanism :is reflex, or voluntary,
closure of the pelvic floor
Contraction of the levator ani complex
elevates the proximal urethra and bladder
neck,
tightens intact connective tissue supports,
and elevates the perineal body, which may
serve as a urethral backstop.
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The second mechanism
involves intact connective tissue support to
the bladder neck and urethra
 The pubocervicovesical or anterior endopelvic
connective tissue in the area of the bladder
neck is attached to the back of the pubic
bone,
 the arcus tendineus fascia pelvis, and the
perineal membrane.
 The pubourethral ligaments also suspend the
middle portion of the urethra to the back of the
pubic bone.
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The third mechanism
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mechanism involves 2 bundles of striated
muscle, the urethrovaginal sphincter and
the compressor urethrae
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These muscles may aid in compressing the
urethra shut during stress maneuvers
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Urinary incontinence
Epidemiology
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Although the prevalence of UI increases with age, UI
should not be considered a normal part of the aging
process.
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For non institutionalized persons older than 60 years
of age, the prevalence of UI ranges from 15 to 35
percent, with women having twice the prevalence of
men
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Approximately 53% of the homebound elderly are
incontinent
(Urinary incontinence affects up to 7% of children
older than 5 years, 10-35% of adults, and 50-84% of
the elderly )
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CLASSIFICATION OF UI:
1. Urgency Urinary Incontinence (UUI)`~22%
= involuntary leakage occurs with a strong,
sudden, and uncontrollable desire to urinate
as result of involuntary detrusor
contraction.
2. Stress Urinary Incontinence (SUI): (49%)
= involuntary leakage on effort or exertion or
on sneezing or coughing, as a result of
insufficient urethral closure pressure.
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3. Mixed Urinary Incontinence  29%
= UUI + SUI marked by involuntary
leakage associated with urgency and also
with exertion, effort, sneezing, or
coughing
4. Functional: due to reasons other than
neuro-urologic and lower urinary tract
dysfunction (eg, delirium, psychiatric
disorders, urinary infection, reduced
mobility)
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Transient: (Functional incontinence)Causes:
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D: Delirium or acute confusion
I: Infection (symptomatic UTI)
A: Atrophic vaginitis or urethritis
P: Pharmaceutical agents Psychological
disorders (depression,
Excess urine production
Restricted mobility
Stool impaction
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Other types of UI
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Overflow incontinence is not a symptom or
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condition but rather a term used to describe
leakage of urine associated with urinary
retention.
Extraurethral incontinence is the observation
of urine leakage through channels other than
the urethra (e.g : fistula or ectopic ureter)
immediately after passing urine
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OCCULT STRESS INCONTINENCE
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Stress incontinence on prolapse reduction is a
term used to describe stress incontinence
observed only after reduction of pelvic prolapse
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kinking of the urethra caused by the prolapse itself
provides for at least part of the continence
mechanism
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These patients may have a history of stress
incontinence that improved and finally resolved as
their prolapse worsened
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The diagnosis can be made by stress
testing with the prolapse reduced or by
pessary placement and pad testing
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BUT incontinence procedures are not
without their own morbidities and should
not be performed unless necessary.
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Diagnosis
 ALL Patients
history, physical examination, and
urinalysis. measurement of postvoid residual volume.
 In selected patients:
Voiding diary
 Cotton swab test
 Cough stress test
 Cystoscopy
 Urodynamic studies
 Radiologic evaluation (as indicated)
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Q-tip (cotton swab) Test
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Criteria for further evaluation
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Uncertain diagnosis and inability to develop
a reasonable treatment plan
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Failure to respond to the patient's
satisfaction to an adequate therapeutic trial.
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Consideration of surgical intervention,
particularly if previous surgery failed or the
patient is a high surgical risk.
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The presence of comorbid conditions:
 incontinence associated with recurrent
symptomatic UTI
 persistent symptoms of difficult bladder
emptying
 history of previous anti-incontinence surgery
or radical pelvic surgery
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The presence of comorbid conditions:
 prostate nodule, asymmetry, or other
suspicion of prostate cancer
 abnormal PVR urine
 neurologic condition, such as multiple
sclerosis and spinal cord lesions or injury
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Hematuria without infection.
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History
Severity and quantity of urine lost and frequency
of incontinence episodes
 Duration of the complaint and whether problems
have been worsening
 Triggering Factors or events (eg, cough,
sneeze, lifting, bending, feeling of urgency,
sound of running water, sexual activity/orgasm)
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History (cont…)
Constant Versus Intermittent urine loss
 Associated Frequency, urgency, dysuria,
pain with a full bladder
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History of urinary tract infections (UTIS)
 Concomitant Fecal Incontinence or
pelvic organ prolapse
 Coexistent complicating or exacerbating
medical problems
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History (cont…)
 Obstetrical
history, including difficult
deliveries, grand multiparity, forceps use,
obstetrical lacerations, and large babies
History of PELVIC SURGERY, especially prior
incontinence procedures, hysterectomy, or
pelvic floor reconstructive procedures
 Other urologic procedures
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Spinal and central NERVOUS SYSTEM SURGERY
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Lifestyle issues, such as SMOKING,
ALCOHOL OR CAFFEINE abuse, and
occupational and recreational factors
causing severe or repetitive increases in
intra-abdominal pressure
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MEDICATIONS
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Relevant complicating
Medical problems may include the following:
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Chronic cough
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Chronic obstructive pulmonary disease
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Congestive heart failure
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DIABETES MELLITUS
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OBESITY
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Connective tissue disorders
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Postmenopausal HYPOESTROGENISM
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CNS OR SPINAL CORD DISORDERS
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Chronic
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Urinary tract stones
Benign prostatic hyperplasia
Cancer of pelvic organs
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(COPD)
UTIS
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Medications that may be associated with UI
 Alpha-adrenergic agonists (urinary retention)
 Alpha-adrenergic blockers (stress incontinence)
 Anticholinergic agents (urinary retention)
 Antidepressants (urinary retention)
 Beta-adrenergic agonists (urinary retention)
 Calcium-channel blockers (urinary retention)
 Diuretics (frequency)
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Physical Examination
A focused physical examination should be
performed
 Vulvae/Vagina/Urethral Meatus
(hypoestrogenemia/caruncle)
 Urethra
(hypermobility/tenderness/diverticulum)
 Pelvic Organ Prolapse
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Pelvic Exam
 Neurologic Assessment (perineal
sensation, anal sphincter tone) pulbo
cavernous reflex
Cotton Swab Test(the Q-tip will rotate
 Pad Test(Intravesical methylene blue, oral
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phenazopyridine:1g\hour-4g\24hour)
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>30 degrees
)
Specialized diagnostic tests
 Urodynamic
tests.
 Endoscopic tests.
 Imaging tests.
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Urodynamic studies
Parameters measured during
urodynamic evaluation
1. Post void residual volume (PVR)
2. Uroflow
3. Pressure flow study
4. Cystometrogram (CMG)
5. Abdominal Leak-Point Pressure (ALPP)
6. Video urodynamics
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Urodynamics
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(UDS) is the most accurate tool available for
the assessment of LUT function
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UDS should be strongly considered before
intervention in:
 failed previous treatment or surgery
 mixed incontinence
 obstructive symptoms
 neurologic disease
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Cystoscopy
It should be performed in patients who
present with:
 urinary urgency
 findings suggestive of a diverticulum or
fistula
 Hematuria
 other irritative symptoms Particularly :
 if they have previously undergone a
previous anti-incontinence procedure
 pelvic radiation
 pelvic prolapse repair
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Treatment Overview
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Stress incontinence: Pelvic floor physiotherapy, anti-
incontinence devices, Medical treatment and surgery
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Urge incontinence: Changes in diet, behavioral
modification, pelvic-floor exercises, and/or medications
and new forms of surgical intervention
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Mixed incontinence: Pelvic floor physical therapy,
anticholinergic drugs, and surgery
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Overflow incontinence: Catheterization regimen or
diversion
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Functional incontinence: Treatment of the underlying
cause
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Kegel Contractions
Exercises of the pelvic floor musculature
 15 deliberate, quick, hard contractions of 10
second duration with 15 second intervals of
muscle relaxation
 3 times a day for a total of 45 contractions
 Approximately 6-12 weeks of exercises are
required before improvement is noted,
 and 3-6 months are needed before maximal
benefit is reached
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Medical treatment
SUI
 Alpha-adrenergic Agonists:
Pseudoephedrine
 Norepinephrine
 Ephedrine
 Hormone
 Duloxetine
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alpha-adrenergic agonists
Pseudoephedrine hydrochloride is
found in cough and cold preparations
and antihistamines.
 Sudafed
 . Adult
- Nonextended release: 60 mg PO qid
Extended release: 120 mg PO bid
 Pediatric
- Not established
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Hormone
Hormone replacement therapy (HRT)
maintain and restore the health of
urethral tissues in women
 vaginal estrogen is given at 0.5-2.0g
per day.
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Duloxetine
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not approved by
FDA
Balanced inhibitor of serotonin and norepinephrine
reuptake
increases serotonin and norepinephrine levels in the
sacral spinal cord, thereby enhancing pudendal
nerve activity, which leads to increased contraction
of the urethral sphincters
Duloxetine(cymbalta®) 60mg bid re-evaluated after
2-4 W
A multicenter, double-blind, randomized, placebocontrolled study in 2,758 women
Reduction in IEF in 51% (drug) vs. 31% (placebo)
at 6 weeks
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SURGERY
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Approaches for Stress
Incontinence
 Abdominal approaches
○ Retropubic colpo-suspension
 Burch
 Marshall-Marchetti-Krantz (MMK)
 Contemporary
○ Pubo-vaginal sling
○ Tension free vaginal tape (TVT)
○ Trans-obturator tape (TOT)
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Retropubic Colpo-suspension
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MMK
BURCH
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Tension Free vaginal Taping (TVT):
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Through a small vaginal incision, permanent
mesh-like material is placed underneath the
urethra and anchored to the abdominal muscles
above the pubic bone.
General anesthesia or local anesthesia is
required.
Advantages
Less invasive, Small incisions- Local anesthesia
Same day or overnight surgery stay
Return to work in 2 - 3 weeks
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Transobturator Sling (TOT)
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The transobturator sling (tot sling) is subfascial, ie
the needle or the sling NEVER enters the retropubic
space.
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Monarc Needle Design TOT
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Helical Needles
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Transobturator Landmarks
Adductor longus
Urethra
Obturator canal
SAFE ENTRY ZONE
of MONARC
NEEDLE
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Monarc Needle Passage
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Monarc Mesh Position
SPARC/TVT
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TVT-O
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Mini Arc
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TVT-S
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MiniArc(TVT-s) Data
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Kennelly M et al. J Urol (In Press)
Multi-center study with 188 patients and 12 month
follow-up
Mean operative time – 11 minutes
Mean length of stay – 9.5 hours
Mean pain score (0-10) at discharge – 1.3
Cough-stress Test negative in 90.6 %
One-hour PWT < 1 g in 84.5 %
Adverse events included UTI (4.3%), temporary
retention (3.2%), dyspareunia (2.1%) and vaginal
extrusion (2.1%)
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The meta-analysis by Jarvis which reviewed over
20 000 patients who had undergone the
procedures
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Procedure
First procedure (%) Recurrent incontinence (%)
Bladder buttress
67.8
ND
MMK
89.5
ND
Burch colposuspension
89.8
82.5
Bladder neck suspension
86.7
86.4
Slings
93.9
86.1
Injectables
45.5
57.8
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Retropubic vs Transobturator
•2010 multi-center trial with 12-month follow-up
Equivalent objective success
 Transobturator
approach has more leg
weakness/ groin numbness
 Retropubic approach has more bladder injuries
and de novo voiding dysfunction
 TVT exhibited higher incidence of bladder
perforation (7% vs. 0%) and more postoperative
voiding dysfunction (Barber et al 2008)
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Complications:
Difficulty urinating and incomplete emptying of the bladder
(urinary retention), although this is usually temporary
 Urinary tract infection
 Difficult or painful intercourse
 Bladder injury in the two national registries ranges from
2.7% to 3.8%.
 Hemorrhage is relatively rare
 vaginal, urethral, and intravesical erosion
 The erosion rate reported in the literature for
polypropylene mesh is 0.5% to 1.3%
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Surgery Keypoints
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Surgery does not restore the same mechanism
of continence. BUT a compensatory approach
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The surgeon’s preference, coexisting problems,
and anatomic features and general health
condition
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There is lack of a clear consensus as to which
procedure is most effective but contemporary
practice is shifting to the “loose” urethral sling
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MMK, placement of sutures through the pubic
symphysis incurs the risk of osteitis pubis in 0.9% to
3.2% of patients
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The Burch should be regarded as the standard open
retropubic procedure for incontinence in primary or
secondary surgery with proven long-term success
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The risk of temporary urinary retention lasting
more than 4 weeks postoperatively is 5% for
all retropubic suspensions
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All patients should be counseled before
surgery about the potential need for
intermittent self-catheterization
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Burch may aggravate posterior vaginal wall
weakness, predisposing to enterocele.
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Most studies have not demonstrated a significant
difference between (Burch) and pubovaginal
slings.
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At this time, the TVT procedure appears to be at
least equivalent to the Burch and in general is
probably better.
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Bulking Agents
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For the treatment of low-threshold stress
incontinence
Collagen (bovine) and Durasphere
(carbon-coated beads) typically employed
in past
Coaptite (Calcium hydroxyl petite)
Introduced via intra-urethral or peri-urethral
injection
Improvement seen in approximately 70% of
patients
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Artificial Urinary Sphincter
 Indicated when surgery fails to correct stress
incontinence.
 Post radical Prostatectomy
 The device consists of a cuff which is placed around the
bladder neck.
 A balloon reservoir, containing fluid is placed in the
peritoneal cavity or under the anterior rectus sheath, and
a small pump is situated in one labium major (scrotum)
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 Under
normal conditions the cuff is full with fluid
thus closing the bladder neck.
 When
voiding is desired the pump is pressed to
force the fluid in the cuff to go back into the balloon
reservoir so that voiding can occur.
 The
cuff then gradually refills over the next few
minutes.
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AUS
Much longer mean follow-up 3 to 7.7
years
 •Continent (0-1 pads) –59-91%
 •Complications –Urethral atrophy 410%, erosion 4-10%, infection 1-14%,
mechanical failure 0-29%
 •Most revisions are within first 36-48
months
 •Long-term mechanical failure rate: 36%
at 10 years
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Medscape
Updated:
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CAMPBELL-WALSH UROLOGY, TENTH EDITION 2012
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Oct 7, 2013
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