Urinary Incontinence in Women

1. Urinary Incontinence in Women Clinical management guideline for Obstetrician-Gynecologist Number 63, June 2005 부산백병원 산부인과 R3 서 영 진

2. 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

4. 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

5. 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 ...

7. 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

8. : 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)

9. 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

11. : 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

12. 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

13. 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

14. 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

15. : 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

16. Cystourethroscopy : bladder lesion (diverticula, fistula, stricture …) foreign bodies : evaluation of postop. Incontinence and other intraop. or postop. lower urinary tract complication

17. MANAGEMENT OPTIONS : absorbent products are most common method : but, with mild symptoms  cannot be cured depend on barrier management

18. 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

19. : pelvic muscle exercise - ‘Kegel’ exercise - strengthen the voluntary peritrethral and peri- vaginal muscles (urethral sphincter, levator ani) - with bladder training, bio feedback, electrical stimulation

20. 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

21. 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 ↑

22. : drugs improve detrusor overactivity by inhibiting the contractile activity of bladder - anticholinergic agents tricyclic antidepressants musculotropic drugs

23. 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

24. 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

25. : 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)

27. 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

28. : 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)

29. : 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

30. 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

31. 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

32. 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

33. 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)

34. : 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

35. : combining drugs therapy- not enough evidence : obesity - 4.2-fold greater risk of stress incontinence

36. Are pelvic muscle exercises effective for the treatment of urinary incontinence? : better than no treatment or placebo : reduces incontinence and increases vaginal pressure

37. 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

38.  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)

39. 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

40. 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

41. 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

42. : 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 ↑

43. : 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

44. 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

45. 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

46. 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

47. 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