1. Female Urinary Incontinence
Dr Ida Mah
Specialist in Urology
Hong Kong Urology Clinic
Pedder Street, Central
Hong Kong

2. Urinary Incontinence
The involuntary loss of urine per urethra

3. Prevalence Depends on diagnostic criteria and studied population
34% in Hong Kong women aged 18 and above reported urinary incontinence
Ma SS, Urogynecol J Pelvic Floor Dysfunct. 1997; 8 (6):
49% of female aged 18 and above have urinary incontinence
Ngan et al, the Hong Kong Practitioner 2006 vol 28
34% of female age experienced stress incontience
Pang MW et al, Hong Kong Med J 2005 Jun; 11(3):

4. Urinary Incontinence

5. Urinary Incontinence

6. Types of Urinary Incontinence
Stress Urinary Incontinence
Urge Urinary Incontinence
Mixed Urinary Incontinence
Overflow Urinary Incontinence

7. Stress Urinary Incontinence
Definition: the involuntary loss of urine per urethra caused by an increase in intra-abdominal pressure

8. Continence Mechanism Anatomical support Intrinsic urethral mechanisms:
Intact pelvic floor that hold the bladder neck and urethra in place
Intrinsic urethral mechanisms:
Coaptation
Mucosa
Submucosa
Compression
Internal sphincter
External sphincter
The precise anatomical and physiological mechanisms involved in the maintenance of urinary continence are poorly understood.
However from previous observations and experiments we found that basically two factors contributed to the continent mechanism
Firstly an intact pelvic floor that hold the bladder neck and proximal urethra in place even in case of increased intraabd pressure and secondly an intact urethral mechanisms which provide coaptation and compression of the urethra to prevent urine loss

9. Causes of SUI Pelvic floor laxity due to childbirth
Damage to the urethra due to
Radiation
Surgery (hx of urethral surgery)
Neurological
Trauma

10. History SUI is a clinical diagnosis Association activities
childbirth history
Hx of surgery or injury to the urethra
Effect on Quality of Life

11. Physical Examination Abdominal, rectal, vaginal examination
Look for presence of stress urinary incontinence
Look for coexisting pelvic organ prolapse
Assess pelvic floor muscle tone

12. Pad test Semi-qualitative assessment of the severity of leakage
1 hour, 2 hours or 24 hours
1 hour:
Patient is asked to drink 500cc of water
Then perform a series of standard exercise like climbing stairs and walking
Weight gain of pad is then measured
Significant if >2gm

13. Management of SUI
Conservative
Surgical

14. How to decide plan of treatment?
Severity of patients’ symptoms
Subjective and objective
Fitness for operation
Presence of other pathology
Complications or morbidity of treatment

15. Conservative Management
Behavioral Modification
Pharmacotherapy??
Pelvic floor exercise

16. Behavioral Modification
Diet and lifestyle changes: avoidance of caffeine, stop smoking etc
Fluid management
Timed voiding
Bowel habit: avoid constipation
Behavioural therapy are simple and effective ways for patient to regain their bladder control
Avoid excessive fluid intake Avoid cafffeine
Stop smoking

17. Pharmacotherapy Estrogen
Subjective but no objective improvement
Serotonin(5-HT) and noradrenaline reuptake inhibitor (Duloxetine)
Estrogen:many studies over the years No evidence it improves SUI, may have some subjective improvement
Ephedrine have been tried to augment the urethral sphincter function: high incidence of side effects with palpitation, headache, insomnia have limited their use

18. Duloxetine
Significantly reduces incontinence frequency and improve the patient’s QOL
Significant side effects of nausea,dry mouth, fatique, insomnia & constipation (11-23%)
Approved for use in patients with moderate to severe SUI in Europe
Not approved in the States for use in SUI by the FDA because of several suicidal deaths associated with withdrawal of the drug

19. Relax completely for at
Pelvic Floor Exercise
Locate pelvic floor muscles
Squeeze pelvic
floor muscles
as tightly as
possible for a
few seconds
(maximum of
10 seconds)
Repeat, as
recommended
by physician/
continence
advisor
Relax completely for at
least 10 seconds

20. Pelvic Floor Exercise
Make sure patients contract the appropriate muscle
Biofeedback
Vaginal cone
Perineometer

21. Pelvic Floor Exercise
Need a dedicated therapist to supervise the therapy and follow up the patients

22. Surgical Treatment for SUI
At least 150 surgery for GSI have been described in the literature
Over the past 15 years I have seen the rise and fall of many of them

23. Goal of Surgery for SUI Prevention of urethral descent
Retropubic Suspension
To provide a backboard against which the bladder neck and proximal urethra can be compressed during increases in intra-abdominal pressure
Sling Procedure

24. Surgical Rx of SUI Retropubic Suspensions Sling Procedures
Injection therapy

25. Burch Colposuspension
Described in 1961
Lateral fixation of urethrovaginal tissue to the Cooper’s ligament
Complications:
Enterocoele (5-10%)
Disadvantage: requirement of an abdominal incision

26. Surgical Rx of SUI Retropubic Suspensions Sling Procedures
Injection therapy

27. Sling Procedure Autologous Sling Synthetic Sling Rectus Fascia
Fascia Lata
Synthetic Sling
Polypropylene

28. Pubovaginal Sling(Autologous)

29. Tension Free Vaginal Tape
First described by Ulmsten in 1996
A polypropylene tape placed at mid-urethra
Tension free urethral support
Minimal invasive
Short hospital stay
Quick return to normal daily activities
> 1 million tapes have been implanted worldwide

30. Tension Free Vaginal Tape

31. Transobturator Tape

32. Results of Urethral Tape
85% cure rate at 1-3 year follow-up
Ulmsten U et al Br J Obstet Gynaecol 1999;106:
Olsson I et al Gynecol Obstet Invest 1999;48:
85% cure rate at 5 year follow-up
Nilson et al Inter Urogyne Journal 2001(suppl 2): S5-S8
TVT vs Colposuspension: similar success rate but TVT provides shorter hospital stay and less days off from work
Ward Hilton has in 2000 performed a RCT in UK comparing the result of TVT vs Colpo and they found that both are equally sucessful with a cure rate of 85 and 89% respectively
However TVT provide shorter hospital stay and less days off from work

33. Urge Incontinence
Urge incontinence is the involuntary loss of urine associated with or preceded by urgency
Caused by involuntary detrusor contraction (detrusor overactivity) during the filling phase

34. Definition
Detrusor overactivity is a urodynamic observation characterised by involuntary detrusor contractions during the filling phase which may be spontaneous or provoked
Neurogenic detrusor overactivity
Idiopathic detrusor overactivity
International Continence Society 2002

35. Symptom-based definition of Overactive Bladder
OAB is a syndrome referring to the symptoms of frequency, urgency, urge incontinence, either single or in any combination, when appearing in the absence of local pathologic or metabolic factors explaining these symptoms
Abrams P and Wein AJ: Urology 51(6):1062

36. Prevalence of OAB
8-35%, depends of studied population and methods of evaluation
13.7% in Hong Kong
More commonly in the elderly
Urge incontinence affects at least 13 million Americans at a cost to the economy of $16 billion annually

37. Bladder Filling & Emptying Cycle
1. Bladder fills
Detrusor muscle relaxes
2. First desire to
urinate (bladder
half full)
Urethral
sphincter
contracts
The cycle of
bladder filling
and emptying
Detrusor muscle
contracts
Urethral
sphincter
relaxes
3. Urination
voluntarily inhibited
until time and place
are right
Urination

38. Pathophysiology of OAB
Involuntary detrusor contractions occur during the filling phase which cause the sensation of urgency

39. Etiology of Detrusor Overactivity
Neurogenic
Spinal cord disorder, DM
Local bladder irritation
Stones, infection, tumour, foreign body
Bladder outlet obstruction
BPH
Aging
Idiopathic (OAB)

40. Etiology of Idiopathic OAB
Disorder of the micturition reflex
Loss of cortical or peripheral inhibition
Disorder of neurotransmission
Myogenic disorder
Structural changes cause increased sensitivity to stimulation
Behavioral / psychological

41. Etiology of OAB No single theory explains the pathophysiology of OAB
Significant advances have been made but still a long way to go to

42. Symptoms of OAB Frequency (85%) Urgency (54%) Urge incontinence (36%)
Nocturia
Milsom et al 1999

43. Goals of Evaluations Rule out local pathologic and metabolic factors
Identify other treatable / curable conditions
Identify other serious underlying conditions

44. Initial Evaluation
History
Physical Examination
Voiding diary

45. Evaluation: History Identify the symptoms of OAB
Frequency, urgency, urge incontinence, nocturia
Symptoms suggestive of underlying causes
Haematuria
Hx of urinary tract stones
Hx suggestive of outlet obstruction
Medical and neurological history

46. Evaluation: Physical Examiantion
General Examination (including bladder palpation)
Digital rectal examinatioin in males
Pelvic examination in females (observe for SUI and prolapse
Neurological examination

47. Evaluation: Voiding Diary

48. Evaluation: Lab tests Urinalysis Blood tests
MSU to rule out haematuria, pyuria, bacteruriaand glucosuria
Urine for cytology
Blood tests
Fasting blood glucose
Renal function

49. Evaluation: Radiology
KUB
To rule out underlying urinary tract especially bladder stones
USG kidneys and bladder
To detect bladder pathology
To detect upper tract damage in patients with neurogenic bladder

50. Urodynamic Study Filling cystometry Involuntary detrusor contraction
? >15cm water
Associated with symptoms
Spontaneous or provoked
Bladder capacity
Assess outlet obstruction

51. UD tracing : detrusor overactivity

52. Urodynamic Study False Positives False Negatives
60% of normal volunteers
False Negatives
10-40% with negative UDS have positive ambulatory UDS

53. Indications for UDS Treatment failure Suspect outlet obstruction
Association with stress incontinence
Suspect neurogenic bladder
Consideration of surgery

54. Indications for referral to urologists
Evidence of bladder outlet obstruction
Haematuria (? Underlying carcinoma)
Associated with neurological disease
Bladder stones
Associated with stress incontinence or pelvic prolapse
Failed medical treatment/consideration of surgical Rx

55. Management of OAB
Behavioral therapy
Pharmacologic therapy
Surgery

56. Behavioral Therapy Education Voiding diaries Fluid/dietary management
Bladder training/timed voiding/delayed voiding
Pelvic floor training/biofeedback

57. Education
Education on the normal bladder physiology and pathophysiology of OAB

58. Dietary advice Fluid management
Avoid stimulants like coffee, tea and alcohol

59. Behavioral Therapy Bladder training Timed voiding/delayed voiding
No standard protocol, teaching material or technique
Efficacy: low cure rates, improve efficacy if combined with drug Rx
Results better in urodynamically stable patients

60. Pelvic Floor Training
Competent pelvic floor muscles make the difference between wet and dry OAB
Indicated in patients with urge incontinence and weak pelvic floor muscle

61. Pharmacologic Therapy
Muscarinic cholinergic receptors located on detrusor muscle respond to parasympathetic mediated release of acetylcholine to stimulate detrusor contraction
5 muscarinic receptors have been described
M3 responsible for activating detrusor contraction
M3 receptors also mediate salivary secretions and bowel contraction (ie. Side effects)
4 types in human body

62. Side Effects of Drug Rx Mainly due to their anticholinergic action
Dry mouth
Blurred vision
Constipation
Tachycardia
Drowsiness

63. Contraindication and precaution
Contraindicated in patients with narrow angle glaucoma
Use with caution in patients with outlet obstruction as the drugs may precipitate retention

64. Oxybutynin (ditropan)
Binds to M2 and M3 receptors
Dosage: 2.5mg bd to 5mg tds
Significant side effects: dry mouth, decreased gastric motility
18% patients remain on Rx for over 6 months
Less side effects in children

65. Tolterodine (detrusitol)
Not receptor selective but selective for bladder tissue over salivary tissue
Efficacy similar to oxybutynin but less dry mouth and less withdrawals from drug Rx
Dosage: 2mg bd

66. Solifenacin (Vesicare)
Slow release
Plasma level rise over 4-6 hours , then steady over 24 hours
Demonstrated efficacy at a lower steady level to reduce side effects

67. Tricyclic Antideprssants
Imipramine most commonly used
Central and peripheral anticholinergic effects
Block norepinephrine and serotonin re-uptake thereby causing a direct inhibition of normal excitatory pathways
Sedative
Dosage: 10mg QD to 25mg QID
Side effects: anti-cholinergic side effects, weakness, fatigue

68. Acupuncture
Endorphinergic effects at the sacral spinal cord level or above
Inhibit somatovesical reflexes
Increase in peripheral circulation
Need randomised control studies

69. Surgical Treatment for OAB
Bladder overdistension
Supratrigonal transection of bladder
Bladder denervation
Neuromodulation: Interstim
BOTOX injection
Augmentation enterocystoplasty

70. Surgical Treatment for OAB
Bladder overdistension
Supratrigonal transection of bladder
Bladder denervation
Neuromodulation: Interstim
BOTOX injection
Augmentation enterocystoplasty

71. Sacral Neurmodulatioin
A tined lead is introduced to the S3 nerve foramen
Lead is then connected into a lead generator
Temporary vs permanent generator

72. Sacral Neuromodulation
Outcome
47% dry
29% improved
Side effects:
Pain (16%)
Implant infection (19%)
Lead migration (7%)
Cost

73. Surgical Treatment for OAB
Bladder overdistension
Supratrigonal transection of bladder
Bladder denervation
Neuromodulation: Interstim
BOTOX injection
Augmentation enterocystoplasty

74. Injection of BOTOX
BOTOX A blocks acetylcholine release at the neuromuscular junction
Injection of BOTOX at suburothelial space modulates the release of neurotransmitters from sensory nerve endings, thus inhibiting the occurrence of bladder overactivity

75. Injection Site Generally distributed around bladder Avoid dome
Potential for intraperitoneal injection
Difficulty of injection * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 75

76. Injection of BOTOX Advantage: Disadvantage Effective
Effect last for 6-8 months
Minimal invasive
Outpatient procedure
Disadvantage
Effect last for 6-8 months only
Risk of retention of urine (10%)
Limb weakness

77. Surgical Treatment Bladder overdistension
Supratrigonal transection of bladder
Bladder denervation
Neuromodulation: Interstim
Injection of BOTOX
Augmentation enterocystoplasty

78. Augmentation Enterocystoplasty
Clam cystoplasty
Up to 90% success rate in DI and neurogenic bladder
Increase the bladder capacity and abolish the unstable contraction

79. Side Effects of Cystoplasty
Retention of urine
Mucus plug retention
Stone formation
Electrolyte disturbance
Malignancy
Reserved for patients who have intractable symptoms and are willing to accept the possible side effects

80. Conclusions Urinary incontinence is a common problem
Treatment depends on the nature and severity of the condition
OAB: important to identify treatable underlying factors
Patients should be provided with information on various choices of Rx (conservative & operative)
With appropriate Rx patients could be cured of the incontinence and thus improving the quality of life