URINARY INCONTINENCE

Overview & Management

Dr. Hussam Hassan

H M 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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ANATOMY

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Urethra is stabilized during stress by three interrelated mechanisms

One 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 mechanism involves 2 bundles of striated muscle, the

urethrovaginal sphincter and

the compressor urethrae

These muscles may aid in compressing the urethra shut during stress maneuvers

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H M Hassan

Hypermobility doesn’t always mean

Incontinence

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Urinary incontinenceEpidemiology

Although the prevalence of UI increases with age, UI should not be considered a normal part of the aging process.

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

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:

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 Overflow incontinence is not a symptom or

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

Stress incontinence on prolapse reduction is a term used to describe stress incontinence observed only after reduction of pelvic prolapse

kinking of the urethra caused by the prolapse itself provides for at least part of the continence mechanism

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

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 Uncertain diagnosis and inability to develop

a reasonable treatment plan

Failure to respond to the patient's satisfaction to an adequate therapeutic trial.

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 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 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

Lifestyle issues, such as SMOKING, ALCOHOL OR CAFFEINE abuse, and occupational and recreational factors causing severe or repetitive increases in intra-abdominal pressure

MEDICATIONS

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Relevant complicating

Medical problems may include the following: Chronic cough

Chronic obstructive pulmonary disease (COPD)

Congestive heart failure

DIABETES MELLITUS OBESITY Connective tissue disorders

Postmenopausal HYPOESTROGENISM CNS OR SPINAL CORD DISORDERS

Chronic UTIS

Urinary tract stones Benign prostatic hyperplasia Cancer of pelvic organs

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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 >30 degrees) Pad Test(Intravesical methylene blue, oral

phenazopyridine:1g\hour-4g\24hour)

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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

(UDS) is the most accurate tool available for the assessment of LUT function

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 Stress incontinence: Pelvic floor physiotherapy, anti-

incontinence devices, Medical treatment and surgery

Urge incontinence: Changes in diet, behavioral modification, pelvic-floor exercises, and/or medications and new forms of surgical intervention

Mixed incontinence: Pelvic floor physical therapy, anticholinergic drugs, and surgery

Overflow incontinence: Catheterization regimen or diversion

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 treatmentSUI

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 qidExtended 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 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, placebo-

controlled 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

BurchMarshall-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):

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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H M Hassan

Transobturator Sling (TOT) The transobturator sling (tot sling) is subfascial, ie

the needle or the sling NEVER enters the retropubic space.

Monarc Needle Design TOT

Helical Needles

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H M Hassan

Transobturator Landmarks

Obturator canal

Urethra

SAFE ENTRY ZONE of MONARC

NEEDLE

Adductor longus

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Monarc Needle Passage

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Monarc Mesh PositionSPARC/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

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

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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H M Hassan

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 Surgery does not restore the same mechanism

of continence. BUT a compensatory approach

The surgeon’s preference, coexisting problems, and anatomic features and general health condition

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

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

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.

Most studies have not demonstrated a significant difference between (Burch) and pubovaginal slings.

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 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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H M Hassan

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)

Artificial Urinary Sphincter

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H M Hassan

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 4-10%,

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: Oct 7, 2013 CAMPBELL-WALSH UROLOGY, TENTH EDITION 2012

THANKS FOR LESTINING

H M Hassan