Urinary Incontinence:a Review

Stress Urinary Incontinence

1. An involuntary loss of urine during coughing, or physical exertion
2. Evident as leakage of urine on increased abdominal pressure without change in detrusor pressure (VLPP) during filling phase on UDS(SPECIALISED PRESSURE MANOMETRY)


It is a common and distressing problem, which may have a profound impact on quality of life. Urinary incontinence almost always results from an underlying treatable medical condition but is under-reported to medical practitioners.




Usual cause of stress urinary incontinence
1. Vaginal delivery--multiple vaginal births(unattended deliveries common in ESPECIALLY in villages)
2. Aging
3. Estrogen deficiency(Some woman leak one week before menstrual period.The lowered estrogen levels that particular time may lead to lower muscular pressure around the urethra, increasing chances of leakage. The incidence of stress incontinence increases following menopause, similarly because of lowered estrogen levels)
4. Neurological disease(especially diabetes)
5. In female high-level athletes, effort incontinence occurs in all sports involving abrupt repeated increases in intra-abdominal pressure that may exceed perineal floor resistance


As In India; multiple vaginal births are a common scenario and there is cultural taboo so incontinence is very high in prevalence but majority of household women suffer from it silently.Many of them avoid mingling in social occasions for fear of leakage preferring to remain aloof.The urine leakage is equally annoying to their sex partners which may severely affect sex life and adversely affect married life.There are certain myths in society about stress urinary leakage:
1. Urinary incontinence/prolapse is a natural part of aging
2. Nothing can be done about it
3. Surgery is the only solution(phobia for doctors;thinking that they will invariably suggest surgery for the disease)


Prevalence:
Reported prevalence rates range from 4.5% to 53%
Our Hopsital Statistics shows:
1. 50 Patients of stress/mixed incontinence / 6 months
2. 10 Undergo UDS/ 6months
3. 3-4 Undergo surgical intervention




Can we do something to remove doctor phobia especially in Indian society?
Can Nurse led continence service of any use?

A study was conducted by Matharu et al in 2004 where women aged ≥40 yrs with LUTS (n= 2421) were randomly allocated to a nurse-led continence service.Out of them , 450 underwent urodynamic study.The results showed women with OAB, 79.1% were correctly allocated anticholinergics & 64.8% were allocated pelvic floor training protocol(PFT).Of all women with urodynamic SUI, 88.8% were allocated PFT.This shows that nurse led continence service fairly treat women and this type of service can be initiated by Government of India to avoid urine leakage misery.

Management of tress urinary incontinence:
Continence and micturition involve a balance between urethral closure and detrusor muscle activity. Urethral pressure normally exceeds bladder pressure, resulting in urine remaining in the bladder. The proximal urethra and bladder are both within the pelvis. Intraabdominal pressure increases (from coughing and sneezing) are transmitted to both urethra and bladder equally, leaving the pressure differential unchanged, resulting in continence. Normal voiding is the result of changes in both of these pressure factors:urethral pressure falls and bladder pressure rises. SUI is due essentially to insufficient strength of the pelvic floor muscles. It is the loss of small amounts of urine associated with coughing, laughing, sneezing, exercising or other movements that increase intra-abdominal pressure and thus increase pressure on the bladder. The urethra is supported by fascia of the pelvic floor. If this support is insufficient, the urethra can move downward at times of increased abdominal pressure, allowing urine to pass.
So the basic aim of the treatment is Aim: To improve urethral resistance.These are the conservative measures:

1.Weight loss
A study published in The New England Journal of Medicine on January 29, 2009, demonstrated that weight loss in overweight women reduced stress incontinence. The study included women with a Body Mass Index (BMI) over 25 and at least 10 episodes of urinary incontinence per week. The results demonstrated that with exercise and restricted diet they had a 70% or greater reduction in overall incontinence episodes.So weigth loss should be the first thing a woman ahould follow for reduction in incontinence.
2. Absorbent products
Absorbent products include, undergarments, protective underwear, briefs, diapers and underpads.There are some assist devices used like vaginal pessaries,femsoft catheter as physical barrier for prevention of urinary leakage.
4. Exercises
One of the most common treatment recommendations includes exercising the muscles of the pelvis. Kegel exercises to strengthen or retrain pelvic floor muscles and sphincter muscles can reduce stress leakage.

Role of pelvic floor training:
The Cochrane Incontinence Group Specialized Trials Register included One arm comprised PFT, the other either no treatment, placebo, sham treatment. A total 13 trials involving 714 women were included.They concluded that PFT be included in first-line conservative management programs.Basically suffering woman should Identify the pubococcygeus muscle first with the help of urologist and then Exercise the muscle (10 s contraction followed by 10 s relaxation) 30 to 80 times /day.This Increases muscle support of the pelvic viscera &increased closing force on the urethra and the benefits may be seen in 2 to 6 weeks.
An alternative or adjunct to PME is exercises the pelvic muscles by holding small weights inside the vagina for up to 15 minutes bid.Successiely the weights can be increased I ncreasing the capacity of the pubococcygeus muscle contraction.Success rate up to 70% to 80%. A recent Cochrane Review shows no advantage to combining PFT with biofeedback over the use of well-done PFT alone.Atleast 3 months of pelvic floor exercises are necessary.
Biofeedback:
Biofeedback uses measuring devices to help the patient become aware of his or her body's functioning. By using electronic devices or diaries to track when the bladder and urethral muscles contract, the patient can gain control over these muscles. Biofeedback can be used with pelvic muscle exercises


RESULTS OF PELVIC FLOOR TRAINING:
There was a trial
1. 76 women underwent a 3-month exercise program & followed for 1 year.
2. 30% of subjects were cured &17% were improved.
3. Subjects with severe incontinence did not benefit from the therapy

Medications
Medications can reduce many types of leakage. Drugs with a-adrenergic activity to increase bladder outlet resistance.For Example ..phenylpropanolamine 25-75 mg bid &imipramine10-25 mg qd-tid.These medicines have been taken off from the U.S. market because of concerns about hemorrhagic strokes in young women.A new nedicine has been tried in SUI:duloxetene :called drug which kills three birds in one stone. It is Combined serotonin and nor-epinephrine re-uptake inhibitor.Its actions are :
o Increases tone of external urethral sphincter
o In an integrated analysis of 4 randomised controlled trials, it significantly decreased incontinence episode frequency by 51.5%
A study by Drutz et al revealed In a subgroup of women with severe SUI awaiting surgery, duloxetine was found to be effective.Incontinence decreased by 46% or their Incontinence Quality of Life (I-QOL) score improved by 6.3 points.



Vaginal oestrogens:
Vaginal oestrogens are used in SUI especially in aging population.The basis behind is
• Common embryonic origin of bladder urethra & vagina
• High concentration of estrogen receptors in pelvic tissues
• General collagen deficiency state (falconer et al., 1994)
• Urethral coaptation affected by loss of estrogen

The oestrogen cream can improve the mucosal integrity and suppleness of the urethra and the vagina thereby take care of the urethral coaptation.These medicines can produce harmful side effects if used for long periods. There is an increased risk of cancers of the breast and endometrium (lining of the uterus). A patient should talk to a doctor about the risks and benefits of long-term use of medications.
When should doctor send the patient for surgery?(Vague indicators)
1. Severe SUI(≥ 2 PADS /DAY)
2. Duration of symptoms> 5 years
3. VLPP≤80 cm H2O-Urdynamic parameters
Apart from that:
1. Pt with significant associated prolapse that may be corrected at the same time
2. High levels of physical stress owing to lifestyle or occupation-models,athletes,stage performers
Summary:
a) SUI needs to be treated with conservative measures initially: simple, inexpensive and without complications
b) No need of UDS prior to conservative measures
c) Duloxetine helpful in noncompliant pt.

Surgical Management of Stress Urinary Incontinence
Marshall Marchetti Krantz (MMK)
This procedure requires an abdominal incision. The bladder neck and urethra are separated from the back surface of the pubic bone. Sutures are placed on either side of the urethra and bladder neck, which are elevated to a higher position. The free ends of the stitches are anchored to surrounding cartilage and pubic bone.
Burch Colposuspension
This vaginal suspension procedure often is performed when the abdomen is open for another purpose, such as abdominal hysterectomy. The bladder neck and urethra are separated from the back surface of the pubic bone. The bladder neck then is elevated by lateral sutures that pass through the vagina and pubic ligaments.

Needle Suspension
Several needle suspension procedures have been developed, each named after its creator (e.g., Stamey, Raz, Gittes); however, the basic technique is the same. Essentially, sutures are placed through the pubic skin or a vaginal incision into the anchoring tissues on each side of the bladder neck and tied to the fibrous tissue or pubic bone.
Sling Procedures
Patients with severe stress incontinence and intrinsic sphincter deficiency may be candidates for a sling procedure. The goal of this treatment is to create sufficient urethral compression to achieve bladder control.
There are two techniques:
percutaneous, which requires a small abdominal incision, and
transvaginal, which is performed through the vagina.
Percutaneous slings
The pubovaginal sling is made of a strip of tissue from the patient's abdominal fascia (fibrous tissue). A synthetic sling may be used, but urethral tissue erosion commonly occurs.
An incision is made above the pubic bone, and a strip of abdominal fascia (the sling) is removed. Another incision is made in the vaginal wall, through which the sling is grasped and adjusted around the bladder neck. The sling is secured by two sutures loosely tied to each other above the pubic bone incision, providing a hammock to support the bladder neck.
Possible complications include accidental bladder injury, infection, and prolonged urinary retention, which may require chronic intermittent self-catheterization.
Transvaginal slings

No abdominal incision is required and a small incision is made in the vaginal wall. The permanenet tape is introduced via the vagina .The trocars are used to introduce the tape are removed through small incisions at both the sides of the inner thighs.


Overactive bladder:
• Overactive bladder (OAB) is a syndrome characterized by
 Urgency
 With or without urge incontinence
 Usually accompanied by frequency and nocturia
Prevalence:
• Worldwide it is known to affect 50-100 million people
• OAB affects approximately 16%-22% of adult population.

• The Prevalence increases with advancing age.







National Overactive Bladder Evaluation (NOBLE) Study: Similar Prevalence Among Men and Women
Effects of overactive bladder:
1)Physical Problems:
 Limitation of physical activities
 Discomfort due to dampness
 Unpleasant odour
 Skin rashes/ ulcers
 Confinement in nursing homes
 Insomnia
 Falls


2)Psychological problems:
 Loss of independence — feels tied to home
 Fear of embarrassment
 Loss of dignity & self esteem
 Affects career
 Depression
 Suicide


3)Social problems:
 Reduction in social interaction/ increased social isolation
 Alteration of travel plans (e.g. plan around availability of toilets)
 Cessation of some hobbies
4) sexual problems:
 Avoidance of sexual contact
Basic evaluation for patient of urgency
To be done in all patients
 History & micturition diary
 Physical examination
 Laboratory tests
Supplementary assessments.
 BUN, Serum creatinine.
 Serum Glucose.
 Urine cytology and AFB.
• Specialized tests must be tailored according to the questions that need to be answered:
 Urodynamic Tests: in medication failure,prior to invasive therapy
 Endoscopic tests:hematuria,sterile pyuria
Management of overactive bladder:
• Non-pharmacologic methods:
Bladder training/PFT: Pelvic Floor Muscle Training:
• Drawing in” or “lifting up” of peri-anal musculature with minimal contractions of abdomen, thigh and buttocks
• Contractions to be sustained for at least 10 seconds and done for 30-80 times/day for at least 8 weeks (Ferguson et al;1990)
• Standards for assessment of change in pelvic function not yet established

• Pharmacotherapy


Various drugs used in overactive bladder

• Botox:
Botox :A toxin –dose:300 U,
Injected intravesically(over 25-30 sites)
Causes afferent nerve denervation
Injection repeated every 6 monthly








• Neuromodulation:
 S3 afferent nerve stimulation inhibits detrusor activity at the level of the sacral spinal cord
 Sacral nerve stimulation therapy consists of two parts
 An initial percutaneous nerve evaluation (PNE)
 Followed by surgical implantation of a permanent electrode lead and pulse generator.

• Surgery:Augmentation cystoplasty:
 Patch of detubularized intestine used to augment bladder
 Complications (30-50%)
o Intestinal obstruction
o Need of CIC
o Calculus
o Metabolic complications
o Malignancy