Treatment of Stress Incontinence
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Transcript Treatment of Stress Incontinence
Evaluation and Treatment
of Urinary Incontinence
and Prolapse
Division of Urogynecology/
Reconstructive Pelvic Surgery
Department of Obstetrics and Gynecology
Rationale
●
Patients with conditions of pelvic
relaxation and urinary incontinence
present in a variety of ways.
● The physician should be familiar with the
types of pelvic relaxation and incontinence
and the approach to management of these
patients.
Objectives
The student will demonstrate knowledge of:
Predisposing factors for pelvic organ prolapse
and urinary incontinence
Anatomic changes, fascial defects and
neuromuscular pathophysiology
Signs and symptoms of pelvic organ prolapse
Physical exam
Treatment
International Continence Society
Definition of Urinary Incontinence
Involuntary
urine loss that is severe
enough to constitute a social or
hygiene problem and that is
objectively demonstrable
Questions for Patients
Do you leak urine when you cough,
sneeze, laugh, or exercise?
Do you leak on the way to the
bathroom?
Do you know the locations of bathrooms
when you are shopping or travelling?
Do you leak during intercourse?
Stress or Urge Incontinence?
EPIDEMIOLOGY
Estimates of prevalence vary
– Bias in sample surveys
– Patient under-reporting
– Differences in definitions, populations
studied and methods used
~ 13 million Americans are incontinent
– 10-35% of adults
ECONOMICS OF URINARY
INCONTINENCE
Direct health care costs
– > $15 billion/yr
Indirect health care costs
– Incontinence products
– Loss of work/productivity
Classifying Urinary
Incontinence
Stress
Urge
Mixed
Overflow
Other
– Functional
– Unconscious or Reflex
– Fistula
Tenets of Effective
Management
Assessment of
patient
Risk factors and
reversible causes
Treatment of
reversible conditions
Education
Treatment options
– QOL improvement
Management plan
RISK FACTORS
Gender
Immobility
Environmental Barriers
Altered Cognition &
Delirium
Medications
Smoking
Collagen Disorders
Neurologic Disease
Diabetes
Stroke
Menopause
Childbirth
Increased Abd Pressure
– Obesity
– Chronic Constipation
– Chronic Cough
– High Impact Physical Activity
PATIENT EVALUATION
History
Physical
Exam
Laboratory Tests
Urodynamic Testing
Voiding Diary
History
HPI
Mental Status Evaluation
Functional Assessment
Environmental Assessment
Social Factors
Voiding Diary
HPI
# Incontinent episodes
Triggers
– Stress +/- Urge
Volume of urine loss
Difficulty starting
stream (hesitancy)
Sensation of
incomplete emptying
Straining to empty
Number of pads/day
Frequency
Urgency
Nocturia
Enuresis
Dysuria
Hematuria
Post-void dribbling*
*Sign of what?
PMH
Parity
Birth trauma
Length of labor, especially 2nd stage
Previous gynecologic and/or
incontinence surgery
Back injury
Medical History
– MS, DM, CVA, Parkinsons
Medications
Cholinergic
– Retention
– Bladder irritability
Alpha-adrenergic
Anti-cholinergic
Alpha-blocking
– sphincter tone
– Retention
b b
b
a
TCA’s are both anticholinergic and alpha adrenergic
Diet
Caffeine
Citrus Foods &
– Cranberry Juice!
Spicy
Foods
Alcohol
Drinks
Functional and
Environmental Assessment
Manual Dexterity
Mobility
– Patient toilet unaided?
Access
– Distance to toilet or bedside commode (BSC)
Chair/bed transfers
Voiding Diary
Date
and Time
Fluid consumption w/ type and
volume
Voiding episodes w/ volume
Leaking episodes
Urgency
Physical Examination
General
GU
Neurologic
Direct Observation of Urine Loss
Post-Void Residual
Q-Tip Test
Physical Examination:
Gynecologic
External Genitalia: excoriation, erythema
Vaginal Introitus and Mucosa: caliber, atrophy
Anterior Vagina: urethral diverticulum
Lateral Vaginal Sidewalls
Posterior Vagina
Uterine or Vaginal Cuff: procidentia, prolapse
Urethra: caruncle
Anus and Rectum: rectal prolapse, sphincter integrity
Physical Examination :
Neurologic
S2 - S4
– Sharp and dull touch
Perineum and buttocks
– Reflexes
Bulbocavernosus
Anal Wink
Physical Examination:
Q-Tip Test
Assesses bladder neck mobility
Sterile technique
Anesthetic gel
+ 30o = UVJ hypermobility
SUI often has hypermobility
Hypermobility not necessarily SUI
- 20o
Urodynamics
Uroflowmetry
Cystometrogram
– Leak Testing
Electromyography
Micturition Study
Urethral Pressure
Profile
Videocystourethrography
Cystoscopy
Urodynamics
Male or Female?
LABORATORY TESTING
Urinalysis and Culture
– Bacterial mucosal irritation
– Unsuppresible detrusor activity
– Endotoxin inhibition of alpha-adrenergic
receptors in urethra
TREATMENT OPTIONS
Treating Reversible Conditions
Behavioral Therapy
Medications
Devices
Surgical
Reversible Conditions
UTI
Atrophic urethritis/vaginitis
Stool Impaction
Dietary
Medications
Inadequate/Excess fluid intake
– How many mL/day?
Reversible Conditions
Delirium
Psychological
Restricted
Mobility
Treatment of
Detrusor Overactivity
Dietary
Toileting Habits
– Scheduled Toileting +/- BSC
Urge Strategies
– Pelvic Muscle Exercises
Biofeedback
Electrical Stimulation
Treatment of
Detrusor Overactivity
Bladder has muscarinic receptors (M3)
Medications
– Ditropan
Side Effects
– Detrol
-Dry mouth
– Sanctura
-Dry eyes
– Vesicare
-Constipation
– Enablex
-Cognitive dysfunction
– Imipramine
Surgical Treatment of
Detrusor Overactivity
Refractory cases
– InterStim Device
– Percutaneous Tibial Nerve Stim (PTNS)
– Augmentation Cystoplasty
Many associated complications
Last resort procedure
Treatment of
Stress Incontinence
Burch Retropubic Urethropexy
Pubovaginal Sling
– Mesh or Fascial
Urethral Bulking
– Transurethral injection
Nonsurgical Treatment of
Stress Incontinence
PESSARIES
– Low morbidity
– Requires regular care
– Managed by patient
Fem-Soft
When to Refer?
Failed trial of conservative therapy
Pronounced anatomic defect
Persistent infection
Desire or need for surgery
Associated problems
SUMMARY
Investigation of the incontinent patient
– History
– Physical Exam
– Urinalysis and Culture
– +/- Urodynamic Testing
SUMMARY
Despite high prevalence and cost,
less than 50% of people with
urinary incontinence seek help!
So ASK your patients about it!
Definitions of Prolapse
ANTERIOR
– Anterior Wall Defect AKA Cystocele
POSTERIOR
– Posterior Wall Defect AKA Rectocele
– Small Bowel Herniation AKA Enterocele
LATERAL WALLS
– Paravaginal Defect
APICAL
– Uterine Prolapse
– Vaginal Vault Prolapse
ETIOLOGY
Childbirth
Increased Intra-abd
Pressure
Neurologic Injury
Genetic Predisposition
– Connective Tissue
Abnormalities
– Lifting
– Coughing
– Obesity
– Constipation/Straining
Estrogen Deficiency
Pelvic Organ Prolapse Repair
Symptoms of Prolapse
Pressure
Bulging
Vaginal irritation/Ulcers
PAIN IS NOT A PRESENTING
SYMPTOM
Compartment-Specific
Prolapse Symptoms
ANTERIOR
– Stress urinary incontinence
– Incomplete bladder emptying
– Possible increased frequency of UTIs
POSTERIOR
– Incomplete stool evacuation
– Splinting to assist defecation
Consequence of Prolapse
Diagnosis:
POP-Q
THERAPY
Conservative Therapy
– Pelvic Floor Muscle Exercises
– Pessary
Surgical Therapy
Pelvic Organ Prolapse Repair
Anterior
Compartment
– Vesico-vaginal
supportive tissue
Pelvic Organ Prolapse Repair
Anterior
Colporrhaphy
– Reinforcement and
repair of vesicovaginal supportive
tissue
– Non-permanent
plication sutures
Pelvic Organ Prolapse Repair
Posterior
Compartment
– Rectovaginal septum
– Denonvillier’s
“fascia”
Pelvic Organ Prolapse Repair
Posterior
Colporrhaphy
– Reinforcement
and repair of
rectovaginal
septum
– Non-permanent
plication sutures
Pelvic Organ Prolapse Repair
Lateral
Compartments
– Arcus Tendinius
Fascia Pelvis
(“White line”)
Pelvic Organ Prolapse Repair
Lateral Compartments
– Reattachment of vaginal supportive tissue to
white line
Pelvic Organ Prolapse Repair
Apical
Compartment
– Uterosacral
ligaments to
Uterus/cervix
Vaginal cuff
Cervical Os
Pelvic Organ Prolapse Repair
Apical
Compartment
– Attachment of
uterosacral
ligaments to
vaginal cuff
Pelvic Organ Prolapse Repair
Apical
Compartment
– Attachment of
vaginal cuff to
anterior longitudinal
sacral ligament
using a graft
Sacrum
Vagina
Robotic Sacrocolpopexy
Apical Compartment
– Robotically-Assisted
Laparoscopy
da Vinci® surgical system
– Approved in 2005
• Hysterectomy
• Myomectomy
• Sacrocolpopexy
SUMMARY
Prolapse is associated with pressure,
but not pain
Site-specific exam is aided by Q-tip
and half of speculum
Site-specific approach to repair
Treatment focused on symptom
improvement, not anatomical correction
Questions?