Incontinence in Women

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Incontinence in Women

• Neena Agarwala, M.D.

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Prevalence

• 8-51 in community
• Atleast 50 in nursing homes
• 25 suffer from severe incontinence
• Greatest in older women and increases with age
• Incontinence 6-10x greater in women than in men
• By 2040 22 of female population will begt65

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Impact on quality of life

• Significant worldwide health problem
• Affects 16 million women in US
• Cost of diagnosing and managing UI exceed 26
  billion annually in US
• Adult diaper sales 5-6 billion/yr
• Great social impact as well
• Leaking depression stop exercise gain
  weight and so on --- ----

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Approach

• Every woman is different
• Consider quality of life from the patients point
  of view
• History
• Voiding diary
• Quality of life assessment

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Normal Bladder Function

• Functional urethra is intra-abdominal
• Increased abdominal pressure transmitted equally
  to bladder and urethra
• With increased stress urethro-vescial junction
  responds to stress by closing tight
• Bladder is a voluntary smooth muscle
• Inherent ability to maintain low pressure with
  filling-increase in volume- compliance

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History

• Diabetis mellitus
• Thyroid disease
• Multiple sclerosis
• Stroke
• Back pain or injuries
• Surgery
• Medications
• Alpha methyldopa
• Prazosin
• Phenothiazines
• Diazepam
• Diuretics
• Antihistamines
• Anticholinergics
• Dosage increases
• Closed angle glaucoma

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Physical Examination

• Age
• Estrogen status menopause - hormones
• Weight Obesity
• Neurologic status
• Mobility and gait
• Thoracic, lumbar and sacral nerves
• Motor strength
• Sensory status and anal wink
• Pelvic muscle strength Kegel squeeze
• Vulva atrophy
• Vagina infection
• Urethra diverticula, urethritis
• Urethral mobility
• Urine in vagina
• Prolapse cystocele, rectocele, uterine or vault
  prolapse
• Stress test with bladder 1/2 full
• Post void residual
• Urinalysis and culture
• Simple or complex cystometric evaluation

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Classification

• Genuine (true) Stress incontinence 50
• Urge incontinence 30
• Mixed incontinence 20
• Overflow incontinence
• Total incontinence
• Unclassified incontinence

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Stress Incontinence

• Continent at rest or minimal activity
• Incontinent with stress
• Exercise
• Coughing
• Sneezing
• Heavy lifting
• UV junction is no longer above the urogenital
  diaphragm and doesnt see the increased stress

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Signs and symptoms

• History of loss of urine with stress
• Absence of frequency, urgency, dysuria
• Nl U/A and negative culture
• PE shows loss of anterior support, possible
  cystocele
• Q-tip test shows greater than 30 deg deviation
• May have other prolapses
• Demonstrated loss of urine with cough
• Neurological exam sensory motor- nl

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Cystometric Evaluation

• Simple- After void, insert foley, measure PVR,
  lt50cc. Attach syringe to foley, instill sterile
  saline. Normal first desire 200cc.
• Observe column of saline, unusual waves suggest
  detrusor dyssynergia.
• Maximum bladder capacity 500 cc.
• Remove 250 cc, remove foley, ask to cough, loss
  of urine suggests GSI.

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Definition

• Genuine Stress Urinary Incontinence
• (GSUI)
• involuntary loss of urine with a rise in
  intra-abdominal pressure in the absence of any
  rise in detrusor pressure
• Urethral hypermobility

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Helpful hints

• Stress induced detrusor instability
• May be confused with GSI
• See loss of urine after cough, but delayed
• Bladder overactive after stress
• Incontinence may only be seen in standing
  position
• Correction of the cystocele may produce
  incontinence since UVJ slightly kinked

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Non surgical therapy

• Occlusive devices
• Pessaries
• Incontinence dishes
• Strengthening pelvic floor musculature
• Kegel exercises
• Physical therapy for pelvic floor rehabilitation
• Biofeedback
• Electrical stimulation
• Local Estrogen therapy

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Surgery?

• Bonney test Gentle support of bladder neck
  during exam and asking patient to cough again
• If continent, surgical repair is likely to be
  successful
• Surgical repairs aim at elevation of bladder neck
  and correction of the pubovesical fascia tears
• Burch Urethropexy, Marshall-Marchetti-krantz
  procedure
• Sling procedures
• Anterior colporrhaphy
• Paravaginal repair

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Intrinsic sphinteric deficiency

• Incontinence type III, a variant of GSUI
• Unhealthy urethra
• Advanced age
• Inadequate estrogen
• Neurologic lesions
• Vaginal surgery
• Severe incontinence
• Leaks with each step
• Supporting the UVJ will not help
• Need to bulk up the urethra almost obstruct it

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Urge Incontinence

• Loss of urine associated with uncontrollable urge
  to void
• Uninhibited, involuntary detrusor contractions
• Pressure-volume relation out of balance
• Also called unstable bladder
• Frequency
• Urgency
• nocturia
• Chronic irritation due to infection, irritation
  or tumors

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Treatment

• Primarily medical
• Most commonly anticholinergics
• Ditropan oxybutynin chloride
• Detrol
• Imipramine
• Levbid, cytospaz hyoscyamine sulphate
• Side effects- dry mouth, constipation etc.
• Behavioral
• Bladder retraining
• Pelvic-floor rehabilitation

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Mixed Incontinence

• Some degree of both stress and urge
• More difficult to treat
• Need to do complex urodynamic studies to
  determine major component
• Precisely predict success with surgery
• Surgery may worsen the urge component
• Properly counsel patient

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Overflow Incontinence

• Neurogenic bladder
• Multiple sclerosis, spinal cord lesions, stroke
• Diabetis
• Trauma
• Radical hysterectomy
• Normal innervation absent or damaged
• Loss of vesical reflexes and emptying sensation
• Overdistended bladder with overflow

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• Complaints of fullness, pressure
• Large bladder capacity
• Absence of uninhibited bladder contractions
• Treatment medical
• Cholinergics to increase tone and contractility
• Urecholine- bethanechol

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Complex Urodynamic Evaluation

• Needed in special circumstances
• Need for surgery
• Failed surgical procedure
• Mixed incontinence
• anticipate voiding dysfunction post surgery
• Advanced prolapse
• Large residual capacity
• Very small bladder capacity
• Urge incontinence not characteristic,
  discrepancy b/w history and exam
• Complex history and symptoms

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Studies

• Cystometry
• Compliance, fd 90-150ml, nd 200-300ml, sd 400-550
  ml, true subtracted detrusor pressures
• Valsalva leak point pressure
• Amount of intraabdominal pressure needed to leak
• lt60 cm H2O is ISD
• Urethral pressure profile
• Full bladder, catheter pulled along urethra
• Urethral closure pressure gt30 cm H20 nl, lt20 is
  ISD
• Uroflow
• Rate and pattern of urine flow
• Peak flow 20-30 ml/sec
• Pressure flow test
• Details voiding mechanism, obstructive
  dysfunction, poor contractility
• Voiding detrusor pressure 10-30 cm H20 is nl
• Electromyography
• Electrical activity of pelvic floor musculature
• Timing and degree of muscle relaxation impacts
  voiding mechanism

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Urodynamic evaluation answers

• 1. Does the patient have stress incontinence ?
• Stress test
• Valsalva leak point pressure
• 2. Does she have ISD ?
• Urethral pressure profile
• Valsalva leak point pressure
• 3. Does she have overactive bladder?
• Multichannel urodynamics
• 4. What is the voiding mechanism?
• Uroflow
• Pressure flow study
• Electromyography

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Examination of bladder and urethra

• Cystoscopy
• Urethroscopy

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Non surgical therapy

• Occlusive mechanical devices
• Pessaries
• Incontinence dishes
• Have no serious side effects
• can be done at home
• Do not limit future treatment options
• Often successful in treating mild to moderate
  incontinence.

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Goal of incontinence surgeryNow

• 1. Restore and/or reinforce the pubourethral
  ligaments at the mid-urethra.
• 2. Restore and/or reinforce the suburethral
  vaginal hammock at the mid-urethra.
• 3. Reinforce the paraurethral connective tissue.

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Support materials

• Autologous
• Patients own tissue
• Thigh, hip or abdomen
• Second incision
• No rejection
• Allograft
• Donor tissue from cadavers
• Have risk of disease transmission
• Fascia seems to disappear
• Synthetic
• Synthetic materials
• Foreign body reaction
• Prone to erosion
• No risk of disease transmission
• Xenograft
• Non-human donor tissue
• May have risk of disease transmission
• Tissue remodeling

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Tension free vaginal tape procedure
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Sling placement
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Guide the Needle Tip to the Abdominal Incision
Tension Free
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Risks Bladder perforation
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Intrinsic sphinteric deficiency

• Unhealthy urethra
• Advanced age
• Inadequate estrogen
• Neurologic lesions
• Previous vaginal surgery
• Radiation
• Severe incontinence with spontaneous relaxation
  of urethra without bladder contractions
• Leaks with each step
• Need to bulk up the urethra

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DurasphereTM

• A sterile, nonpyrogenic injectable bulking
  material composed of pyrolytic carbon coated
  beads suspended in a water based carrier gel
  containing beta glucan. The water based carrier
  gel is approximately ninety seven percent water
  by volume and three percent beta glucan.
• Injected sub-mucosally at the bladder neck.
• Creates increased tissue bulk and subsequent
  coaptation of the bladder neck and/or urethra.

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DurasphereTM

• Helps the weak muscles of the bladder neck by
  adding bulk to the area. The added bulk allows
  the bladder neck to close enough to help stop
  urine from leaking.

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InterStim Therapy -- Sacral Nerve Stimulation
(SNS) for Urinary Control

• A revolutionary approach to managing urinary
  retention and the symptoms of overactive bladder,
  including urinary urge incontinence and
  significant symptoms of urgency-frequency alone
  or in combination in patients who have failed or
  could not tolerate more conservative treatments.
• Electrical stimulation of the sacral nerves that
  control voiding function

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Sacral Nerve Stimulation

• Used for refractory urgency, frequency and
  non-obstructive retention
• Needs a minimally invasive surgery for
  implantation
• Simplified implant procedure, now performed
  percutaneously with only local anesthesia.
• The tined lead holds itself