URINARY INCONTINENCE

Marsha K. Guess, MD, MS Assistant professor and Fellowship Director Section of Urogynecology & Reconstructive Pelvic Surgery The Departments of Obstetrics, Gynecology & Reproductive Sciences & Urology

Urinary Incontinence

The involuntary loss of urine

STATISTICS:

10-60% of women report urinary incontinence

Only 10-20% seek medical care Billions of dollars spent annually on incontinence products (in North America)

Nygaard, I. et al. JAMA 2008;300:1311-1316.

PSYCHOSOCIAL IMPACT

Higher prevalence of depression, embarrassment, loss of self esteem, anxiety Decrease in excursions outside home, social interactions, sexual activity
Major factor in the decision to place a relative in a nursing home

TYPES OF URINARY INCONTINENCE

Genuine Stress Urinary Incontinence
Detrusor Instability

Intrinsic Sphincter Deficiency

Overflow Incontinence Functional/Transient incontinence

PATHOPHYSIOLOGY OF SUI

SYMPTOMS ASSOCIATED WITH URGENCY INCONTINENCE

Complaint
Daytime frequency
Nocturia Nocturnal enuresis Urgency Urinary incontinence urgency

Definition
voids too often/day
voids too often/night loss of urine during sleep sudden desire to void involuntary loss of urine with or immediately preceded by
Abrams P et al. Am J Obstet Gynecol. 2002;287(1):116-126.

INTRINSIC SPHINCTER DEFICIENCY

Problem with ability of urethra to close

Drain pipe urethra

ISD RISK FACTORS

Age Trauma/childbirth Previous Incontinence Surgery

PATIENT EVALUATION

Explore symptoms: duration frequency precipitants most bothersome

Focus on medical, surgical, neurological & genitourinary history

diabetes mellitus multiple sclerosis mental status

hx of previous incontinence surgery failure of previous pharmacotherapy symptoms of prolapse

Review voiding patterns/fluid intake

Obtain voiding diary

PHYSICAL EXAMINATION

Problem with support of urethra Goal: stabilize urethra

Normal

Abnormal

EVALUATION OF URINARY INCONTINENCE

Post-void residual

Urinalysis
Urine culture

Urine cytology
HbA1C Voiding diary Urodynamics Cystoscopy

VOIDING DIARY
Voiding Diary 11/18/05
Time Amount 100cc 50cc 25 cc 150cc 100cc 150cc 50cc 75cc 90cc 120cc 100cc 100cc 50cc 25 cc 160cc 100cc 150cc 50cc 75cc 90cc 120cc 2130 Leaks 0 1 2 1 0 0 0 1 0 0 0 0 1 0 1 0 1 0 0 0 1 9 7:00am 7:45am 8:15am 9:00am 9:30am 11:00am 1:15am 3:00pm 5:00pm 6:30pm 7:30pm 8:00pm 8:45pm 9:15pm 10:00pm 10:30pm 11:00pm 1:15am 3:00am 5:00am 6:15am Total Drinks cup with meds 8oz water 12oz coffee 8oz water 12 oz coffee

cup with meds 8oz water

8oz water

2160

URODYNAMICS

CYSTOSCOPY

INDICATIONS FOR URODYNAMIC TESTING

Previous failed surgery When surgery is planned Uncertain etiology to incontinence Concomitant prolapse (Potential incontinence) Failed medical treatment

CONSERVATIVE MANAGEMENT OF SUI

Behavior modification

Bladder Training
Physiotherapy Mechanical devices Pharmacological Therapy

BIOFEEDBACK

GSUI PELVIC FLOOR EXERCISES

Kegels alone vs. Vaginal cones vs. Pressure biofeedback

All improved symptoms and QOL No significant difference between groups

Laycock et al. 2001

GSUI

WEIGHT LOSS

13 morbidly obese women

Results:
9/12 with resolution of urinary symptoms post-op Objective and subjective improvement of stress and urge incontinence
Bump et al. 1992 10 moderately obese women (mean BMI 38.3) 4 or more episodes of incontinence /day

Results:
50% in incontinence episode with > 5% weight loss
Subak et al. 2002

GSUI PESSARY

SURGICAL MANAGEMENT OF SUI

SLINGS FOR SUI

CONSERVATIVE MANAGEMENT OF UUI

Behavior modification
Bladder Training

Pharmacological
Therapy

Electrical Stimulation

ANTICHOLINERGIC SIDE EFFECTS

Dry mouth Blurred vision Drowsiness Tachycardia

Constipation

ANTICHOLINERGIC CONTRAINDICATIONS
Narrow angle glaucoma
Intestinal obstruction Cardiac arrhythmia Myasthenia gravis

ELECTRICAL STIMULATION FOR UUI

BULKING AGENTS FOR ISD

BULKING AGENTS FOR ISD

BULKING AGENTS FOR ISD

BOTOX

CONCLUSION
Urogynecology includes a wide variety of lower urinary tract and pelvic floor disorders Patient satisfaction is optimized when meticulous care is taken to adequately evaluate patients and individualize therapy Patience is a virtue!!!!