Incontinence in Women
Neena Agarwala, M.D.
Prevalence
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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 be>65
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 --- ----
Approach
• Every woman is different
• Consider quality of life from the
patient’s point of view
• History
• Voiding diary
• Quality of life assessment
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 volumecompliance
History
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Diabetis mellitus
Thyroid disease
Multiple sclerosis
Stroke
Back pain or injuries
Surgery
Medications
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Alpha methyldopa
Prazosin
Phenothiazines
Diazepam
Diuretics
Antihistamines
Anticholinergics
Dosage increases
• Closed angle glaucoma
Physical Examination
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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
Classification
• Genuine (true) Stress incontinence
~50%
• Urge incontinence
~30%
• Mixed incontinence
~20%
• Overflow incontinence
• Total incontinence
• Unclassified incontinence
Stress Incontinence
• Continent at rest or minimal activity
• Incontinent with stress
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Exercise
Coughing
Sneezing
Heavy lifting
• UV junction is no longer above the
urogenital diaphragm and doesn’t see the
increased stress
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
Cystometric Evaluation
• Simple- After void, insert foley,
measure PVR, <50cc. 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.
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
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
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
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-Marchettikrantz procedure
– Sling procedures
– Anterior colporrhaphy
– Paravaginal repair
Intrinsic sphinteric
deficiency
• Incontinence type III, a variant of GSUI
• Unhealthy urethra
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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
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
Treatment
• Primarily medical
• Most commonly anticholinergics
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Ditropan – oxybutynin chloride
Detrol
Imipramine
Levbid, cytospaz – hyoscyamine sulphate
• Side effects- dry mouth, constipation etc.
• Behavioral
– Bladder retraining
– Pelvic-floor rehabilitation
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
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
• Complaints of fullness, pressure
• Large bladder capacity
• Absence of uninhibited bladder
contractions
• Treatment – medical
– Cholinergics to increase tone and
contractility
• Urecholine- bethanechol
Complex Urodynamic
Evaluation
• Needed in special circumstances
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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
• Cystometry
Studies
• 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
• <60 cm H2O is ISD
• Urethral pressure profile
• Full bladder, catheter pulled along urethra
• Urethral closure pressure >30 cm H20 nl, <20 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
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
Examination of bladder
and urethra
• Cystoscopy
• Urethroscopy
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.
Goal of incontinence
surgery
Now……
• 1. Restore and/or reinforce the
pubourethral ligaments at the midurethra.
• 2. Restore and/or reinforce the
suburethral vaginal hammock at the
mid-urethra.
• 3. Reinforce the paraurethral
connective tissue.
Support materials
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Autologous
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Allograft
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Synthetic
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Xenograft
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Patient’s own tissue
Thigh, hip or abdomen
Second incision
No rejection
• Donor tissue from cadavers
• Have risk of disease transmission
• Fascia seems to disappear
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Synthetic materials
Foreign body reaction
Prone to erosion
No risk of disease transmission
• Non-human donor tissue
• May have risk of disease
transmission
• Tissue remodeling
Tension free vaginal tape
procedure
Sling placement
Guide the Needle Tip to the
Abdominal Incision
Tension Free……
Risks: Bladder
perforation
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
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
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.
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.
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.