Obgyno Wino Podcast Episode 36 - Urinary Incontinence in Women
"Quality is not something you can do piecemeal. Either you believe in quality, or you don't. Either it surfaces everywhere and you commit to it everywhere, or you don't. There isn o gray area here." - Yvon Chouinard, founder of Patagonia
PB#155 - Published November 2015 (Reaffirmed 2018)
Urinary incontinence is extremely common, but it's not normal. Screening for incontinence is vital for all physicians with female patients.
A correct incontinence diagnosis is of utmost importance. Treatment will only work if you know what you're treating.
Minimum evaluation for a woman presenting with incontinence: history, urinalysis/= (and maybe culture), physical exam, demonstration of stress incontinence, evaluation of urethral mobility, and post-void residual.
Behavioral therapy and pelvic floor exercises improve symptoms of incontinence and may be recommended as first line therapy
Some background info on incontinence...
- super common: reported by 25% of young women, up to nearly 60% of middle-aged and postmenopausal women, and up to 75% of elderly women
- it's expensive: missed time at work, significant factor leading to nursing home admissions
- wide variety of etiologies:
- wide variety of types:
The office evaluation
- detailed history (PFDI is a 20 question inventory), review PMH (MS, diabetes, stroke, lumbar disc disease)
- 4 C's: caffeine, citrus, cigarettes, and carbonation (all bladder irritants)
- ask about bowel function! anal incontinence and constipation go hand in hand with urinary incontinence
- review meds: alpha and beta adrenergic meds, caffeine, alcohol, anticholinergics, and Ca-channel blockers can influence lower urinary tract function,
- external and internal exam (including rectal, as severe fecal impaction can influence incontinence!)
- evaluate for POP (see show notes for Episode 33) (reducing prolapse may unmask stress incontinence!)
- cough test
- urinalysis/culture (special cultures for atypical bugs like mycoplasma/ureaplasma?)
- urethral mobility
- urodynamic studies (UDS)
- cystourethroscopy ("cysto")
- neuro exam to test for motor or sensory deficits in LE (remember that S1-4 carry inputs that moderate micturition); testing typically also looks for anal wink and bulbocavernosus reflexes
Comments on the "cough test"
- if urine leaks WITH cough or valsalva: this is a positive test for stress urinary incontinence
- if no urine leaks with cough or valsalva but leaks immediately after: you may be looking at overactive bladder induced by. coughing
- if patient reports leaking at home but you aren't seeing leakage w/ cough in supine position, backfill bladder with 300 mL and repeat while standing
- still negative? recommend UDS
UDS: the gist
- cystometry: bladder and abdominal pressures are measured while bladder is backfilled; useful for gauging bladder compliance and detecting involuntary bladder spasms
- uroflowmetry (pressure-flow studies): measures rate of bladder emptying, which can be helpful in assessing voiding dysfunction
- urethral pressure profiling and Valsalva leak point pressures: in theory, poor urethral sphincter tone may indicate likelihood of incontinence post-hysterectomy, but outcomes studies have failed to show utility of these studies for this purpose
Cysto: the gist
- cysto is an endoscopic method of evaluating the urethra and bladder anatomy
- not always indicated in incontinence work-up, but may be useful in patients with urgency incontinence, hematuria, recurrent UTI, or suspicion of fistula/diverticulum
- with lubricated q-tip gently placed in the urethra, patient is asked to valsalva
- if angle is >30 angles off horizontal, this is considered "hyper-mobile"
- alternatively, pay close attention to Aa (review POPQ if you need to) with valsalva and you can gauge urethral mobility without jabbing around with a q-tip
- urethral hyper-mobility is a sign that incontinence surgery will be successful (twice as likely to fail if urethra isn't hyper-mobile prior to sling placement)
- have your patient void immediately prior to your evaluation
- drain the bladder by lubricated straight cath (before you do your cough test, duh)
- if <150 mL, this is considered adequate bladder voiding
- in the absence of POP, incomplete bladder emptying is rare; you may want to consider pressure-flow urodynamics prior to intervention
Treatment of incontinence: general
- corresponds w/ the type of incontinence after you complete thorough history, exam, and workup
- conservative measures shoulder be tried before surgery: pelvic floor exercises (+/- physical therapy), behavioral lifestyle modifications (less H2O consumption and bladder training), weight loss, pessaries (esp ring support), and pharmacotherapy
- surgical options may be more definitive but they come with risks: bleeding, infection, wound complications, injury to. nearby organs, urinary retention, and voiding dysfunction
How effective are incontinence pessaries?
- patient satisfaction has been the primary outcome in most studies
- effective alone but less effective than behavioral-physical therapy, but ~60% of patients will report improvements after 3 months of pessary use, though this number may decrease to about 50% after 12 months for patients relying on pessary or behavioral-physical therapy alone
- overall very reasonable option for poor surgical candidates, patients who wish to avoid surgery altogether, or patients who desire faster results than found through the behavioral-physical therapy route
How effective is weight loss in managing urinary incontinence?
- obese women have a 4-fold increased risk for developing stress urinary incontinence (SUI)
- even modest weight loss (8% of baseline weight) is effective at reducing incontinence episodes
- in a study of obese women w/ diabetes, each 1-kg of body weight lost, there was a 3% decreased risk of developing SUI
- one study found that 50% of patients who start with pelvic PT crossover to surgery, versus 10% in the opposite direction, but it's unclear the training, patience, and dedication of the physical therapists with whom the patients in this study were working
- Please refer to my interview with Julie Wiebe, PT, in Episode 35 of this very podcast for more on this juicy topic (KEY: KEGELS ARE NOT THE WHOLE STORY)
Meds for urgency and mixed urinary incontinence (no meds for SUI)
Anti-muscarinics - treat urge incontinence
- antagonizes M2 and M3 receptors to inhibitor detrusor activity
- examples: darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine, and trospium
- terrible side effects including dry mouth, dry eyes, blurred vision, constipation, urinary retention, dizziness, cardiac arrhythmias
Beta-agonists - treat urge incontinence
- mirabegron: agaonizes B3 receptors which inhibits detrusor activity
- may be better option for the elderly as it doesn't cross blood brain barrier
- side effects: tachycardia, headache, diarrhea
- use caution if your patient has severe HTN, end-stage renal disease, or severe liver impairment
Botox (aka OnabotulinumtoxinA)
- injected cystoscopically into detrusor muscle
- may lead to urinary retention or incomplete bladder emptying
- some studies suggest that more patients will report complete resolution of their urgency symptoms compared to patients using antimuscarinics
- even if it works, it'll likely need repeated in 6-12vmonths (but that ain't so bad, right?)
What is sacral neuromodulation and might it be helpful?
- stimulation of the nerves that innervate the bladder and pelvic floor
- procedure involves two stages: 1) electrode placement near the sacral roots to see it will even be helpful in managing urgency symptoms; 2) implantation of impulse generator if in fact it will be helpful
How could estrogen help w/ urinary incontinence?
- systemic estrogen therapy hasn't been found to be helpful for management of urinary incontinence in several large trials
- local estrogen, however, may be of some benefit
- injection of microbeads into the bladder neck and around the internal urethral sphincter trans- or peri-urethrally
- less effective than surgery for patients with intrinsic sphincter deficiency; however, may be a best option for poor surgical candidates, patients in whom surgery has failed, or in the case of clinical SUI without urethral hypermobility
Are we gonna talk about surgery or what?!
- generally not helpful for pure urge incontinence
- appropriate to recommend if it remains bothersome to patients after a good ol' college try with conservative approaches
- some women may simply decline conservative approaches, and you, as the surgeon, can offer surgery if you are comfortable with that plan
- after all, 1-year subjective and objective cure rates are higher after midurethral sling surgery than pelvic PT alone for SUI (again...there's a difference between pelvic PT and "good" pelvic PT)
- surgery also carries risks, including post-op urinary retention and iatrogenic urge incontinence (risks versus benefits)
Ins-and-outs of slings
- midurethral mesh slings just as effective as fascial slings and colposuspensions
- also fewer adverse events in the former such as lower risk of voiding dysfunction
- controversy still swirls around mesh for use in FPMRS, but sufficient safety data exists for the American Urogynecologic Society and the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction to now consider mesh slings as the standard of care
- two methods: transobturator and retropubic approach (similar SUI cure rates both objectively and subjectively - ~98%)
- transobturator approach: higher likelihood of groin pain
- retropubic approach: higher likelihood of voiding dysfunction, bladder perforation, major vascular or bowel injury, and intraoperative blood loss
- same risk of mesh erosion between the techniques (2%)
When should autologous fascial slings be recommended over mesh?
- severe SUI but a nonmobile, fixed urethra
- urethral diverticula or fistula
- complications with prior mesh procedure in the anterior compartment of the vagina
Should I place a sling concomitantly during pelvic organ prolapse (POP) surgery?
- 80% of women w/ POP have some degree of SUI, but not all women are bothered by both disorders equally (ask them)
- if they are bothered by the SUI, reasonable to place .a sling during POP surgery, as SUI can worsen with repair of POP
- 40% of women w/out SUI prior to POP surgery will develop "occult" SUI post-op
- reduce the prolapse during your pre-op evaluation w/ cough testing and UDS as appropriate to identify those patients who might benefit from prophylactic sling placement during their POP surgery
- prophylactic sling placement reducing risk of occult SUI from 50% to 25% (risk versus benefits)