Urinary Incontinence in Women

Educational Objectives

The goal of this program is to improve the management of women with urinary incontinence. After hearing and assimilating this program, the clinician will be better able to:

1. Recognize the causes of different types of urinary incontinence.
2. Choose an appropriate urodynamic study or other tool in the assessment of a patient with urinary incontinence.
3. Counsel patients on techniques for effective conservative management of urinary incontinence.
4. Advise patients about the efficacy and adverse effects associated with medical treatment of overactive bladder.
5. Identify patients for whom surgical management of incontinence is appropriate.

Summary

Urinary incontinence: is among the primary reasons families and patients seek assisted living and institutionalized care; care is sought by only ≈40% of women affected; taking a history can be problematic, as stress incontinence (SI) can resemble overactive bladder (OAB); patients may report a family member who did not receive relief from a “bladder tack,” which contributes to reluctance to seek care; patients may consider incontinence to be a natural part of life; the hallmarks are leaking unintentionally, leaking frequently, and a volume of leakage that causes distress (eg, embarrassment, significant limitation of lifestyle and activities); extremely common; frequency increases with age; care is expensive, including the cost of institutionalized care; women limit activities that cause them to leak, including healthy physical activity

Urine storage and elimination: the micturition center in the pons controls contraction of the bladder; only the sphincter is under voluntary control; when voiding is socially inappropriate, the sphincter contracts and the bladder relaxes; different types of bladder dysfunction are caused by injury or disease affecting the brain, spinal cord dysfunction disrupting communication, and sacral or lower spinal injury; the bladder can fill almost to terminal capacity with no change in pressure (compliance); at a socially appropriate time for voiding, the sphincter and pelvic floor relax

Categories of incontinence:primary — SI is the most common (50%-70%); OAB accounts for ≈33%; some individuals have mixed incontinence (SI and OAB); nonprimary — includes overflow, neurogenic bladder, fistulas, and functional incontinence; disruption — OAB causes the most stress and disruption to life; women with SI learn the triggers for leaking, but OAB is unpredictable and the volume of urine loss is greater (the bladder is emptied inappropriately)

Stress incontinence: some individuals have a normally functioning but hypermobile urethra and some have a urethra that does not function well; typically consists of leakage with any increase in abdominal pressure (eg, coughing, sneezing, laughing, exercising); urine loss is typically of a small volume (“a squirt”); the activity that causes leakage is typically predictable; women change their activities and limit the things that cause leaking; birth trauma — normal anatomic relationships of pelvic structures are altered by childbirth; tissues are pulled and nerves (eg, the pudendal nerve) are stretched; the “pubocervical fascia” around the vagina is not true fascia but a thickened confluence of connective tissue that provides support; when stretched by childbirth, it does not easily return to normal; tears in the pubocervical fascia can cause, eg, prolapse, hernia, and cystocele; genuine SI (type 2) — the urethra is hypermobile but typically closes normally; intrinsic sphincter deficiency (ISD) — causes the same symptoms (leaking with cough or Valsalva maneuver) as genuine SI, but the urethra does not close well; can be associated with neurologic injury, radiation, or radical surgery; the urethra may be mobile or fixed

Mechanism of SI: as the bladder fills, Valsalva maneuver causes increased pressure against a closed urethra; intact support and a normally functioning urethra can overcome the added pressure and the patient remains continent; if the urethra lacks support or tone, the added pressure overcomes the urethral closure pressure and leaking occurs; in type 2 SI, the pelvic floor is weakened and the paravaginal connective tissue is stretched; the pelvic floor should contract with every cough and sneeze; a weakened, stretched, and unsupported pelvic floor drops with increased pressure, and the angle of the urethra changes; physical therapy aims to tighten the pelvic floor; with ISD, the urethra does not close well; because a different physiologic process is involved, therapy is different

Overactive bladder: also called urge incontinence; formerly called detrusor instability; causes involuntary loss of urine owing to an uncontrolled bladder contraction; some women have triggers (eg, pulling into the driveway, noise of running water); worsened by consumption of caffeine; urinary tract infection (UTI) is common; characterized by the triad of urinary urgency, frequency, and incontinence

Mixed incontinence: determine whether SI or OAB is most problematic when deciding on management; first-line therapy for both conditions is the same; treat the predominant symptom and reassess in 6 to 8 wk

Overflow incontinence and neurogenic bladder: many etiologies are similar or shared (eg, stroke, severe diabetes, neurologic disorders, neural tube defects, pelvic surgery); patients with overflow incontinence have trouble contracting and emptying the bladder; neurogenic bladder causes uncontrollable contractions; contraction against the sphincter can cause urinary reflux into the kidneys

Functional incontinence: some patients have difficulty reaching the bathroom for physical reasons (eg, use of a walker); a bedside commode can improve the sense of self-control

History: always ask about incontinence; give women permission to register a complaint; patients with true OAB likely have issues during the day and at night; if patients need to plan stops when driving >90 min, urgency and frequency is significant; always ask about caffeine consumption; ask how the issue affects quality of life; voiding diary — patients record the amount of every void, all drinks consumed, the activity in progress when leaking occurs, and any sense of urgency; 3 days is sufficient; Sandvik Incontinence Severity Index — validated tool; asks about the frequency (eg, daily, weekly, monthly) and amount (eg, drop, squirt, gush) of leaking; the score can help to educate patients and set expectations for therapy

Physical examination: patients with prolapse outside the hymen require evaluation; kinking of the urethra with bladder prolapse may prevent leaking or make voiding difficult; contraction of the bladder can then overcome ureteral pressure and cause reflux into the kidneys, resulting in hydronephrosis and irreparable kidney damage; relieving the kink with a pessary or surgery may cause leaking to start; before prescribing antispasmodic medication, ensure that patients can empty the bladder well (perform catheterization for measurement of postvoid residual [PVR] 30 min after voiding); use of antispasmodic medication by patients who do not empty well can lead to severe urinary retention (1 L in a bladder with a normal capacity of 300-600 mL); send a sterile urine collection for culture to assess for chronic UTI

Prolapse: may occur in the anterior wall, posterior wall, at the apex of the vagina, or in ≥1 compartment; pelvic organ prolapse quantification system (POP-Q) — uses anatomic points to provide a picture of the patient’s prolapse; the American Urogynecologic Society (AUGS) provides an online tool to illustrate the results (useful for clinicians and patients); Q-tip test — painful, even with topical anesthetic agent; currently used only for preoperative urodynamics, 20 min after a catheter coated with xylocaine jelly has been placed; helps to quantify the degree of urethral rotation with Valsalva maneuver (patients with mobile urethras are treated differently); PVR — ultrasonography is expensive; for office assessment, use a small catheter; <100 mL is excellent; 100 to 200 mL is acceptable; >200 mL requires reevaluation; send urine culture before prescribing antispasmodic agents

Urodynamics:simple — a graduated cylinder is filled with saline and attached to a catheter; the rise and fall of fluid is assessed; useful for patients with leakage and significant prolapse; place ≈300 mL in the bladder, remove the catheter, and reduce prolapse with a cotton swab; if the patient leaks with coughing, she will be unsatisfied with a pessary or prolapse repair (85% chance of leaking); complex — a computer is attached to a urethral and a vaginal or rectal catheter; the pressure line shows uncontrolled bladder contractions, and the flow line indicates leakage; helps to assess urine storage and bladder emptying; results can help predict whether surgery will be helpful

Nonsurgical therapy:conservative management — first-line therapy for SI or OAB; consists of behavioral or lifestyle modifications and pelvic floor exercises (ie, Kegels); documentation is important (quality measure); patient handouts are available at voicesforpfd.org (from AUGS); 3 daily sets of 10 pelvic floor squeezes (10-sec squeeze, 10-sec rest) provides statistically significant improvement in urgency and SI; voiding training involves progressive small increases in the time between voids; achieving an interval of ≈3 hr provides significant lifestyle improvement; handouts also list bladder irritants (eg, caffeine, artificial sweeteners) and ways to manage the amount of urine produced (eg, limit alcohol [inhibits antidiuretic hormone]); complete resolution occurs in 25%, and 85% see clinically significant improvement (use the data to encourage patients); biofeedback — physical therapists provide training; visual and auditory displays help patients improve their pelvic-floor exercise technique

Pessary: more effective for prolapse than for incontinence; space-filling types are better for patients with severe prolapse (harder to place and remove but stay in place better than support pessaries); the speaker uses ring pessaries in ≈95% of patients who require support; have patients return ≈1 wk after placement to assess comfort, to see whether the pessary stayed in place, and to see whether resolving prolapse has caused leaking; unlike tampons (used by some patients to support the urethra during exercise; constant use risks infection), pessaries are nonabsorbent

Treatment of OAB when conservative management fails: AUGS provides an algorithm; most medications are antimuscarinic anticholinergic agents (extremely effective but adverse effects include constipation, blurred vision, headache, and dizziness); the M3 muscarinic receptor is almost exclusive to the bladder; β receptors cause direct relaxation of the detrusor, whereas muscarinic receptors prevent contraction (passive relaxation); antimuscarinic agents are antagonists of acetylcholine; newer agents that are more selective for the M3 receptor have fewer adverse effects; oxybutynin is an older agent; long-acting agents improve compliance and reduce adverse effects; use caution in patients with narrow-angle glaucoma; trospium likely crosses the blood-brain barrier and may be more useful for patients with cognitive or balance issues; solifenacin was recently approved for use in combination with β-3 receptor agonists (eg, mirabegron); β-3 agonists have few adverse effects but can cause significant exacerbation of hypertension; speaker’s practice — start with oxybutynin 3 times daily (inexpensive and covered by insurance); reassess at 2 wk; if the patient is not seeing adequate benefit, double the dose to 10 mg; adverse effects prevent use in ≈30%, justifying a switch to a different agent; compare 3-day voiding diaries with and without medication; if patients do not tolerate oxybutynin, switch to a long-acting antimuscarinic or a β-3 agonist (the latter is more effective but covered by few insurances)

Treatment of OAB when medication fails:nerve stimulation — the nerves that supply the bladder exit the spinal cord at S2 through S4; external sacral neuromodulators provide pulsatile stimulation to S3; the precise mechanism of efficacy is unknown, but the resultant “confusion” of the reflex arc improves OAB; a nerve from S3 descends behind the medial malleolus, lending itself to office-based stimulation; spinal stimulation requires anesthesia and an implanted device (risk for infection); office-based therapy is equally effective and much less expensive; 30 min of therapy is performed weekly for 12 wk, followed by monthly maintenance (covered by Medicare); referred to as percutaneous tibial nerve stimulation (PTNS); bladder augmentation — rarely performed; onabotulinumtoxinA — presynaptic inhibitor of acetylcholine release; paralyzes the detrusor; causes obstruction in ≈10% (patients must be willing and able to self-catheterize) and UTI in ≈30%; treatment requires ≈30 min in the office; every surface of the bladder is injected, except the trigone; extremely effective; cost-effective over 2 yr compared with medication (related to compliance); repeat every 5 to 9 mo

Treatment of SI when conservative management fails: most therapy is surgical; in patients with ISD, with or without urethral mobility, the urethra does not close properly and must be “pinched” using a sling; periurethral bulking involves injection of nonabsorbable material (eg, collagen, carbon beads) around the urethra until it closes (very effective); bulking is likely required in patients with a fixed urethra owing to radical pelvic surgery and radiation therapy; historically, ≤20 procedures were labelled “bladder tacks”; over the last 25 yr, urologists and urogynecologists have performed randomized controlled trials to determine which procedures are effective; it is now known that vaginal hysterectomy with anterior colporrhaphy and Kelly plication is not effective for incontinence; a specific procedure must be done to support the urethra; patients who had a continence procedure ≈20 yr ago may begin to leak again

Types of slings: tension-free vaginal tape (TVT) — sling is placed beneath the urethra through a vaginal incision; the sling material exits the mons pubis through 2 small incisions, passing beside the bladder (small risk for cystotomy); the large vessels to the lower extremity are 2 to 3 cm away; the immovable sling provides a fulcrum that stabilizes the urethra when the patient bears down; the rate of bladder and vascular injury is slightly higher than with other methods; transobturator sling — the approach is more horizontal, with lateral passage of the sling; avoids the vascular structures and the bladder; equally effective as TVT; the rate of bladder injury and iatrogenic bladder spasm is far lower; other slings — some perforate the perineum; single-incision vaginal slings avoid causing perineal pain and are extremely effective

Counseling patients: advise that today’s procedures differ from those used in the past and are now 85% effective; however, not all patients require surgery

Follow-up: reassess 3 to 4 wk after diagnosis (with voiding diaries); the effect of conservative management is apparent after 6 to 8 wk, but it is important to check in to encourage continuation of efforts and to make adjustments to medications; refer patients who need surgery for SI; if the clinical picture is clearly OAB and patients can empty their bladder, try multiple medications

Reasons for referral: prolapse outside the vagina; significantly elevated PVR; uncertain diagnosis; lack of success with conservative management and other therapies; recurrent UTI (may be due to incomplete emptying, urethral diverticulum); pain or blood with urination (infection is the most common cause of hematuria, followed by unknown reasons, then stone or malformation; tumor is far less likely); neurologic disorders (eg, multiple sclerosis, Parkinson disease, neural tube defect, spinal surgery, stroke)

Final points: the keys to diagnosis are physical examination, PVR, and urine culture; use daily estrogen creams or tablets in patients using pessaries (see patients every 6-8 wk [4 wk for space-occupying pessaries])

Readings

Al-Shaikh G et al. Pessary use in stress urinary incontinence: a review of advantages, complications, patient satisfaction, and quality of life. Int J Womens Health. 2018 Apr 17;10:195-201; Arnouk A et al. Physical, complementary, and alternative medicine in the treatment of pelvic floor disorders. Curr Urol Rep. 2017 Jun;18(6):47. doi: 10.1007/s11934-017-0694-7; Clothier JC and Wright AJ. Dysfunctional voiding: the importance of non-invasive urodynamics in diagnosis and treatment. Pediatr Nephrol. 2018 Mar;33(3):381-94; Dumoulin C et al. Conservative management for female urinary incontinence and pelvic organ prolapse review 2013: summary of the 5th International Consultation on Incontinence. Neurourol Urodyn. 2016 Jan;35(1):15-20; Hu JS and Pierre EF. Urinary incontinence in women: evaluation and management. Am Fam Physician. 2019 Sep 15;100(6):339-48; Irwin GM. Urinary incontinence. Prim Care. 2019 Jun;46(2):233-42; Jelovsek JE. Predicting urinary incontinence after surgery for pelvic organ prolapse. Curr Opin Obstet Gynecol. 2016 Oct;28(5):399-406; Lavelle ES and Zyczynski HM. Stress urinary incontinence: comparative efficacy trials. Obstet Gynecol Clin North Am. 2016 Mar;43(1):45-57; Lukacz ES et al. Urinary incontinence in women: a review. JAMA. 2017 Oct 24;318(16):1592-1604; Madhu C et al. How to use the pelvic organ prolapse quantification (POP-Q) system? Neurourol Urodyn. 2018 Aug;37(S6):S39-43; Nie X et al. A meta-analysis of pelvic floor muscle training for the treatment of urinary incontinence. Int J Gynaecol Obstet. 2017 Sep;138(3):250-5; Noblett KL and Buono K. Sacral nerve stimulation as a therapy for patients with refractory voiding and bowel dysfunction. Obstet Gynecol. 2018 Dec;132(6):1337-45; Sandvik H et al. Validation of the incontinence severity index: comparison with pad-weighting tests. Int Urogynecol J Pelvic Floor Dysfunct. 2006 Sep;17(5):520-4; Song P et al. The efficacy and safety comparison of surgical treatments for stress urinary incontinence: a network meta-analysis. Neurourol Urodyn. 2018 Apr;37(4):1119-1211; Tutulo M et al. What is new in neuromodulation for overactive bladder? Eur Urol Focus. 2018 Jan;4(1):49-53; Wallace KM and Drake MJ. Overactive bladder. F1000 Res. 2015 Dec 7;4:F1000 Faculty Rev-1406. doi: 10.12688/f1000research.7131.1; White N and Iglesia CB. Overactive bladder. Obstet Gynecol Clin North Am. 2016 Mar;43(1):59-68; Zhao Y et al. Bulking agents – an analysis of 500 cases and review of the literature. Clin Exp Obstet Gynecol. 2016;43(5):666-72.

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Stephenson was recorded at Women’s Health Conference, presented by the Brody School of Medicine at East Carolina University and UNC Eshelman School of Pharmacy, in association with Eastern Area Health Education Center, and held February 22, 2019, in Greenville, NC. For information about upcoming CME conferences from Eastern Area Health Education Center, please visit www.Easternahec.net. Audio Digest thanks Dr. Stephenson, the Brody School of Medicine at East Carolina University, UNC Eshelman School of Pharmacy, and Eastern Area Health Education Center for their cooperation in the production of this program.

CME/CE INFO

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