Innovations in the Treatment of Female Urinary Incontinence

1. Innovations in the Treatment of Female Urinary Incontinence James Chivian Lukban DO, FACOG, FACS Director, Division of Urogynecology Associate Professor of Obstetrics and Gynecology Eastern Virginia Medical School Norfolk, Virginia

2. Disclosures • Novasys – Consultant, Speaker, Grant Recipient • AMS – Consultant, Speaker, Grant Recipient, Facilitator • Pfizer - Speaker

3. Epidemiology of Urinary Incontinence • Prevalence • Community – 8 to 41% • Nursing Home – 40 to 70% • Incidence • 20% over a one-year period

4. Epidemiology (United States) 28M Women With Urinary Incontinence 15M Women With Stress Urinary Incontinence Health Research International, 2005

5. Economic Impact • Total Cost – 16.4 billion dollars (1994) • Community – 11.2 billion • Nursing Home – 5.2 billion • Greatest cost is for care and supplies such as laundry, pads and diapers • Less cost for diagnosis and treatment

6. Definition of Urinary Incontinence • The complaint of any involuntary leakage of urine Abrams P et al. Neurourol Urodyn 2002;21:167-78.

7. Types of Urinary Incontinence • Transurethral • Stress Urinary Incontinence • Urge Urinary Incontinence • Mixed Incontinence • Overflow Incontinence

8. Stress Urinary Incontinence • The complaint of involuntary leakage on effort or exertion, or sneezing or coughing Abrams P et al. Neurourol Urodyn 2002;21:167-78.

9. Urge Urinary Incontinence • The complaint of involuntary leakage accompanied by or immediately preceded by urgency Abrams P et al. Neurourol Urodyn 2002;21:167-78.

10. Mixed Urinary Incontinence • The complaint of involuntary leakage associated with urgency and also with exertion, effort, sneezing or coughing Abrams P et al. Neurourol Urodyn 2002;21:167-78.

11. Overflow Incontinence • Any involuntary loss of urine associated with overdistention of the bladder Abrams P et al. Scand J Urol Nephrol 1988;114(suppl):5.

12. Risk Factors for Female SUI • Age and Parity • Pelvic floor muscle denervation and endopelvic fascial disruption • Physical activity level • Individual impact is variable A QOL Problem!

13. Etiology of Female SUI (Anatomic)

14. Etiology of Female SUI (ISD) Delancey JOL. World J Urol 2007;15:268.

15. Stress Incontinence Severity Severe Mild Intrinsic Sphincter Deficiency (Type III) Hypermobility (Type II)

16. Evaluation of Urinary Incontinence • Patient History • Voiding Diary • Physical Examination • Bedside Cystometry • Cough Stress Test • Post Void Residual Volume • Urinalysis

17. Patient History • Urinary Symptoms • Stress Incontinence • 1) Do you leak urine when you cough, sneeze or laugh ? • 2) Do you leak upon standing or walking? • 3) What percentage of time do you leak with provocation? • 4) Do you wear a pad?

18. Patient History • Urinary Symptoms • Urge Incontinence • 1) How many times a day do you urinate? (frequency - > 8 voids in 24 hours) • 2) Do you ever have a strong urge to void such that you feel you may leak? (urgency) • 3) Do you ever leak before reaching the toilet? (urge incontinence)

19. Patient History • Urinary Symptoms (continued) • Urge Incontinence • 4) How many times at night are you awakened by the need to urinate? (nocturia - > or = to 1 time per night) • 5) Do you ever wet the bed? (nocturnalenuresis) • 6) Do you wear a pad? • Overflow Incontinence • 1) Do you feel that your stream is adequate? • 2) Do you feel that you fully evacuate your bladder? • 3) Do you wear a pad?

20. Patient History • Medications • 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)

21. Patient History • GU History • Past Medical History • CVA, dementia, MS, parkinsonism, SCI • Past Surgical History • gynecologic, anti-incontinence • Social History • tobacco, caffeine, occupation

23. Physical Examination • Vulvae/Vagina/Urethral Meatus (hypoestrogenemia/caruncle) • Urethra (hypermobility/tenderness/diverticulum) • Pelvic Organ Prolapse • Pelvic Exam • Neurologic Assessment (perineal sensation, anal sphincter tone)

24. Urinalysis • Urine sampled to rule out the following: • UTI • hematuria • rule out stones • rule out tumor • confirm by microscopic analysis • send for cytology

26. Bedside Cystometry • Requires transurethral catheter attached to a 50 cc syringe • Aliquots of 50 cc of sterile water are introduced • Normal desire and maximum cystometric capacity are determined • Meniscus is observed for rises in level during filling

28. Post Void Residual Volume • Measurement of residual volume of urine in bladder immediately after voiding • Determined through transurethral catheter placement or ultrasound • A volume of > 75 cc may be associated with voiding dysfunction and predispose one to overflow incontinence and UTI’s

29. Cough Stress Test • Performed at maximum cystometric capacity • Observation of leakage with a strong cough • High sensitivity in detecting stress incontinence

30. Multichannel Urodynamics • Mixed incontinence • Recurrent incontinence • Voiding dysfunction

33. Treatment of Stress Incontinence • Timed voiding • Kegel contractions • Biofeedback • Functional electrical stimulation • Medical treatment • Anti-incontinence surgery • Bulking agents

34. Timed Voiding • Regular bladder evacuation independent of urge to maintain an empty bladder

35. 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

36. Biofeedback • Vaginal cones • Vaginal manometry or electromyography • Concomitant measurement of abdominal muscle activity • 1-2 times a week for 6 weeks

37. Functional Electrical Stimulation • Introduced by Caldwell in 1963 • Utility in treating musculature in patients unable to isolate the pelvic floor • Often used in conjunction with biofeedback • Symptom improvement in approximately 60% of patients Payne CK. Electrostimulation. In: Urinary Incontinence, O’Donnell PD, ed. 1997, 287-94.

38. Overall Effectiveness of Conservative Therapy • Latthe PM et al. Nonsurgical Treatment of SUI: Grading of Evidence in Systematic Reviews. BJOG 2008;115:435-444. • Meta-analysis of 6 reviews • PFMT better than placebo • Strong recommendation based on intermediate quality evidence • Questionable durability of effect

39. Medical Therapy for SUI • Duloxetine Hydrochloride • Inhibits reuptake of serotonin and norepinephrine • Enhances urethral function in animal models through Onuf’s nucleus • Reduction in IEF in 51% (drug) vs. 31% (placebo) at 6 weeks • Not currently available in US for SUI Cardozo L et al. Curr Med Res Opin 2010;26:253-61.

41. Anti-incontinence Surgery • Anterior colporrhaphy with Kelly plication • Retropubic urethropexy • Burch • Marsahll-Marchetti-Krantz (MMK) • Suburethral sling procedure • Traditional • Mid-urethral Tape

49. TVT Nillson CG et al. In J Pelvic Floor Dysfunct 2009;6:72-3.

50. Monarc Needle Design • Helical Needles