Female Incontinence

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Female Incontinence

• Jeremy B. Myers, MD
• Clinical Instructor
• Department of Urology

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Overview

• The Problem
• Anatomy of the female urethra
• Incontinence stress and urge
• Diagnosis PCP and the urologist
• Non-surgical and surgical treatment

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Definition
Incontinence Stress incontinence leakage
associated with exertion, coughing sneezing or
laughing Urge incontinence leakage with
antecedent urgency Mixed incontinence leakage
associated with both symptoms
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Epidemiology
Incontinence in women 19 billion dollars / yr
Silent Epidemic
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Prevalence in women
Stress 49 Urge 22 Mixed 29
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Risk factors

• Age
• Female
• Obesity
• Vaginal delivery
• 10 versus 3 - 1 yr post delivery
• Menopause?
• HERS, WHI - systemic estrogen replacement doesnt
  help

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Epidemiology
Sandvik H, Hunskaar S, Seim A, Hermstad R, Vanvik
A, Bratt H. J Epidemiol Community Health 1993
47 497-9
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Anatomy
Urethral sphincter 2 components striated and
smooth muscle
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Anatomy
Striated sphincter is a horseshoe configuration
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Stress Incontinence

• Hammock theory
• Intrinsic sphincter deficiency

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Hammock Theory

• Urethral hypermobility structural loss of
  support for urethra leads to movement of the
  urethra during stress maneuvers and leak
• Q tip test gt 30 degrees of movement
• Problem little correlation many women had
  urethral hypermobility with no incontinence

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Hammock Theory
ATFP
The arcus tendinous fascia pelvis acts as 2
I-beams in the pelvis with the endopelvic fascia
serving as a hammock underneath the urethra
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Hammock Theory
Pressure
Hammock of endopelvic fascia acts as a backboard
for the urethra to be compressed against when
there are increases in abdominal pressure
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Urethral hypermobility
Valsalva
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Intrinsic Sphincter Deficiency (ISD)

• ISD certain number of women did not have
  hypermobility, but had a fixed incompetent
  sphincter
• Integrated theory Stress incontinence is a
  spectrum, all women have some degree of ISD the
  urethra should remain closed during any amount of
  descent and rotation during stress

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ISD
Open and pipe like urethra
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Urge Incontinence OAB

• Urge incontinence involuntary leakage with
  antecedent urgency
• Urgency the sudden compelling desire to void,
  which is difficult to defer
• Frequency the patient that complains of
  urinating to frequently
• Nocturia urinating at night 1 or more times

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Urge Incontinence OAB

• Overactive bladder (OAB) International
  continence society replaced terms
• Detrusor hyperreflexia
• Unstable bladder
• OAB
• Non-neurogenic OAB
• Neurogenic OAB MS, spinal cord injury, spina
  bifida, neurologic disease or injury

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Urge Incontinence OAB

• Prevalence 2 large crossectional survey studies
• 16 overall OAB (women 18-74)
• 6 with urge incontinence (2 lt 25 yrs, 20gt 65
  yrs)
• 10 with urgency episodes but not incontinence

-Campbell-Walsh Urology, 9th Ed., 2007.
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Urge Incontinence OAB

• Theories
• Neurogenic
• Myogenic
• Peripheral autonomic

Not well understood
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Diagnosis PCP

• Physical exam rule out pelvic organ prolapse or
  vaginal atrophy
• UA rule out infection or hematuria
• Direct observation demonstration of stress
  incontinence with valsalva or cough

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Diagnosis The Urologist

• Video Urodynamic studies (UDS)
• Cystoscopy

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Diagnosis

• Video Urodynamic studies (UDS)
• Allows the precise measurement of pressures
  exerted within the bladder
• Radiographically evaluates the bladder outlet
• Reliably differentiates between stress and urge
  incontinence prior to surgery or intervention
• Diagnosis of the decompensated bladder

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Diagnosis

• Video Urodynamic studies (UDS)
• Small catheter in rectum and bladder
• Rectal catheter pressure in abdomen (Pabd)
• Bladder catheter pressure in bladder (Pves)

Subtraction of 2 pressures gives the pressure
generated by the bladder wall Pdet
Pves Pabd Pdet
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flow
bladder catheter
rectal catheter
sphincter
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Leak
Pabd increases
Stress incontinence
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Leak
Pdet increases
Urge incontinence
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Treatment Stress Incontinence

• Nonsurgical
• Pelvic floor muscle training (Kegels)
• Biofeedback
• Electrical stimulation
• Pessaries
• Surgical recreating urethral support
• Abdominal
• Contemporary

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Treatment PFMT

• Kegel
• Increasing the muscle bulk of the levator ani and
  pelvic floor
• 50 of pts cant complete with simple
  instructions
• 25 of pts promote incontinence by improper
  performance

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Treatment PFMT
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Treatment PFMT
Dr. Kegels perineometer
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Treatment PFMT
Perform Kegel during vaginal exam
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Treatment Biofeedback

• Biofeedback training a patient to control their
  bodily function by providing them information
  about the function

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Treatment Biofeedback
Vaginal cones
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Treatment Electrical Stimulation

• Daily or every other day stimulation to the
  pelvic floor

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Treatment Pessaries

• A vaginal insert for pelvic organ prolapse that
  may also work for stress urinary incontinence

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Treatment Pessaries
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Outcomes Nonsurgical

• Modest improvements
• Pts with a small amount of leakage
• Pts who want a conservative trial
• Pts with significant comorbidities

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Treatments Surgical

• Surgical recreating urethral support allowing
  for coaptation of the urethra during increased
  abdominal pressures
• Abdominal approaches
• Open retropubic colposuspension
• Burch
• Marshall-Marchetti-Krantz (MMK)
• Contemporary
• Pubo-vaginal sling
• Tension free vaginal tape (TVT)

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Treatments Surgical

• Abdominal approaches Open retropubic
  colposuspension Burch or MMK

Coopers ligament
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Treatments Surgical

• Contemporary approaches pubovaginal sling

A strip of rectus fascia, or cadeveric fascia is
placed under the urethra and brought through the
abdominal fascia
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Treatments Surgical

• Contemporary approaches Tension free vaginal
  tape

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Outcomes surgical

• Outcomes long term continence (totally dry)
  exceed 80

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Treatment Urge Incontinence

• Nonsurgical
• Antimuscarinics
• Botox injection
• Surgical
• Cystoplasty
• Interstim

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Treatment Urge Incontinence

• Antimuscarinics tertiary amines that act to
  block the muscarinic receptors in response to
  acetocholine
• First line
• Oxybutinin (Ditropan)
• Tolteridine (Detrol)

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Treatment Urge Incontinence

• Oxybutinin N-desothyloxybutinin a metabolite
  responsible for the side effect profile
  Cytochrome P450 liver
• Efficacious 75 improvement in frequency and
  incontinence
• Up to 70 of patients have some adverse effect
• Dry mouth (10)
• Constipation
• Drowsiness
• Blurred vision
• depression

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Treatment Urge Incontinence

• Oxybutinin ER (Ditropan XL) metabolites are
  produced less with the extended release
• Drug is released over 24 hours primarily in the
  large bowel (no Cytochrome P450)
• Similar efficacy to Oxybutinin, pts may tolerate
  a larger dose

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Treatment Urge Incontinence

• Oxybutinin TDS (Oxytrol) metabolites are
  produced even less with transdermal
  administration
• Used commonly in neurogenics

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Treatment Urge Incontinence

• Tolteridine (Detrol) less lipophilic and does
  not cross the blood brain barrier as easily
• Comparable side effects
• Less CNS effects (elderly)
• Comparable efficacy

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Treatment Urge Incontinence

• Others
• Trospium (Sanctura)
• Darifenacin (Enablex)
• Solifenacin (Vesicare)

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Treatment Urge Incontinence
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Treatment Urge Incontinence
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Summary

• Urinary incontinence occurs in upwards of 30 of
  women, all women should be asked about bothersome
  incontinence
• Interview alone often indicates if the problem is
  from stress or urge incontinence and can suggest
  first line therapy
• Stress incontinence can be treated effectively
  with surgery, which for most cases is minimally
  morbid or invasive
• Overactive bladder is treated first line with
  antimuscarinic agents, which are much better
  tolerated in extended release formulations