1. ABC Urinary Incontinence
Dr Tim Chang MBBS(SYD), FRANZCOG Gynaecologist, Endoscopic surgeon and IVF Fertility specialist
Dr. Christiane Mayer MD, FRANZCOG Obstetrician and Gynaecologist,
139 Dumaresq street
Campbelltown
----- Meeting Notes (30/03/ :09) -----
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all services previously provided
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2. ABC in Female Urinary Incontinence
Christiane Mayer
MD, FRANZCOG
Obstetrician & Gynaecologist

3. Overview Epidemiology Definition and Classification Etiology
Assessment and Evaluation
Treatment (non surgical)

5. Learning objectives
Feel more confidence in assessing female Pts with urinary incontinence +/- POP
Identify keyfactors in establishing a basic diagnosis
Understand the principles of management and treatmentoptions available for UI
Ability to select which patients are appropriate for non surgical Rx and when to refer to Specialist

6. Epidemiology of Urinary Incontinence
Prevalence
Community – 8 to 41%
Nursing Home – 40 to 70%
Incidence
20% over a one-year period
Source
Prevalence here is defined as any urine loss over the previous 12 months…
Incidence is defined as the probability of incontinence over a defined period of time with continence as a baseline…
These numbers may vary due to differences in study populations, variability in data collection and definitions applied.

7. Relationship to age
Risk of developing incontinence increases with age:
10% age 45 – 49 yrs
20% age 60 – 64 yrs
32% age 70 – 74 yrs

8. Impact on health
QOL : depression and anxiety, low self esteem, work impairment, social isolation
Morbidity: perineal infections, falls and fractures, admission to hospital/nursing homes
Sexual dysfunction: coital incontinence may affect up to one third of women with UI (Urgency UI)

9. Economic Impact Total Cost – 16.4 billion dollars
Community – 11.2 billion
Nursing Home – 5.2 billion
Greatest cost is for care and supplies such as laundry, pads and nappies
Less cost for diagnosis and treatment
Source

10. Underreported because of….
Embarrassment
A belief it is part of aging
Health care providers don’t ask!!
Fear of treatment/therapy

11. Urinary incontinence is NEVER normal!!

12. Definition of Urinary Incontinence
Any involuntary leakage of urine in sufficient amount or frequency to cause a social and/or healthproblem
Abrams P et al. Neurourol Urodyn 2002;21:
Source

13. Types of Urinary Incontinence
Stress Incontinence
Urgency Incontinence
Mixed Incontinence
Overflow Incontinence

14. Anatomy and Physiology of Micturition
1.Filling and storage
2.Expulsion of urine
Micturitionreflex
When bladder volume reaches ~ 400mls, stretch receptors of the bladder wall relay a message to the brain, which returns an impulse message for voiding back to the bladder. In response the detrusor muscle contracts and the urethral sphincter relaxes to allow micturition.

15. Continence requires Intact lower urinary tract
Intact neurological control
Cognitive ability
Functional ability/mobility
Motivation
Environmental factors

16. Stress Urinary Incontinence
The complaint of involuntary leakage with increased intraabdominal pressure:
exertion, sneezing, laughing or coughing
Highest incidence in women ages 45-49
Source

17. Riskfactors for Female SUI
Parity (Pregnancy + vaginal birth) Obesity Chron. constipation Chron. cough, COPD Aging (lower E2 levels) High impact physical activity

18. Etiology of Female SUI (Anatomic)

19. Urethral hypermobility and bladder neck funneling
Caused by insufficient support of urethra and bladder neck by pelvic floor muscles and vaginal connective tissue
 unability of urethra to close completely
 leakage (“like stepping on a hose in sand”)

20. Etiology of Female SUI (ISD)
Delancey JOL. World J Urol 2007;15:268.

21. Stress Incontinence Severity
Severe
Mild
Hypermobility
Intrinsic Sphincter
Deficiency

22. ISD Neuromuscular damage of urethral sphincter with loss of tone
Possibly after multiple surgeries
Severe leakage at rest or during minimal exertion
Challenging to treat and poor surgical outcome

23. Urge Urinary Incontinence
The complaint of involuntary leakage accompanied by or immediately preceded by sudden and strong urge to void
Detrusor overactivity DO : involuntary detrusor muscle contractions during bladder filling
Overactive Bladder Syndrome OAB : urgency, frequency, nocturia +/- incontinence( OAB wet and OAB dry)
Highest incidence in women > 65 yrs

24. Causes for UUI
Age ( decreased ability to inhibit contractions, decreased bladder capacity, urogenital atrophia….)
Neurologic disorders ( CNS inhibitory pathways interrupted)
Bladder abnormalities
idiopathic

25. Mixed Urinary Incontinence
The complaint of involuntary leakage associated with urgency AND also with exertion, effort, sneezing or coughing
Overlap of DO and impaired urethral sphincter function
Very common

26. Overflow Incontinence
Any involuntary loss of urine associated with overdistention of the bladder
Continuos leakage or “dribbling” on B/o incomplete bladder emptying

27. Overflow Incontinence
Detrusor underactivity:
- older women (5-10%)
- low estrogen state
- peripheral neuropathy (DM, Vit B12 def., ETOH)
- spinal cord damage (MS, spinal stenosis…)
Bladder outlet obstruction
- fibroids, advanced pelvic prolapse (beyond hymen), obstructing tumours….

28. Transient incontinence
Associated with reversible conditions (acute onset)
D I A P P E R S
Delirium
Infection
Atrophic vaginitis
Pharmaceuticals
Psychological
Excess urine output(endocrine)
Reduced mobility
Stool impaction

29. Evaluation of Urinary Incontinence
Patient History !!
Voiding Diary
Physical Examination
Cough Stress Test
Urinalysis
Post Void Residual Volume

30. Patient History Urinary Symptoms Stress Incontinence
1) Do you leak urine when you cough, sneeze or laugh?
2) Do you leak upon standing or walking?
3) How often do you experience leakage?
4) How much do you leak? Do you wear a pad?

31. Patient History Urinary Symptoms Urge Incontinence
1) How many times a day do you void? (frequency - > 8 voids in 24 hours)
2) Do you ever have a strong urge to void such that you feel you may leak? (urgency)
3) Do you ever leak before reaching the toilet? (urge incontinence)
4) How many times at night are you awakened by the need to urinate? (nocturia - > or = to 1 time per night)
5) Do you ever wet the bed? (nocturnal enuresis)
6) Do you wear a pad?

32. Patient History Urinary Symptoms Overflow Incontinence
1) Do you feel that your stream is adequate?
2) Do you feel that you fully empty your bladder?
3) Do you wear a pad?

33. Patient History Medications
Alpha-adrenergic agonists (urinary retention)
Alpha-adrenergic blockers (stress incontinence)
Anticholinergic agents (urinary retention)
Antidepressants (urinary retention)
Beta-adrenergic agonists (urinary retention)
Calcium-channel blockers (urinary retention)
Diuretics (frequency)

34. Patient History Impact on QOL incl. sexual activity Obstetric Hx
Medical Hx
DM, CVA, dementia, MS, parkinsonism
Past Surgical Hx
gynecologic, anti-incontinence
Social Hx
tobacco, caffeine, occupation
Impact on QOL incl. sexual activity

36. Physical Examination Weight/BMI Abdomen exclude mass
VE : atrophic changes
pelvic organ prolapse
pelvic mass
urethral caruncle
perineum
Rectal: tone of sphincter, faecal impaction
Neurological/Mental state

37. UI & POP Pelvic Organ Prolapse
POP may be seen in 50% of parous women
Common in women with UI
Symptomatic or asymptomatic
Similar RF as to Stress Incontinence:
parity
age/menopause
obesity ( chron. increased IAP)
genetics (tissue!)
previous Hysterectomy

38. Cough Stress Test
Performed with comfortable full bladder standing or in dorsal lithotomy
Observation of leakage with a strong cough
helps to confirm stress incontinence
Swift

39. Urinalysis Urine sampled to rule out the following: UTI haematuria
rule out stones
rule out tumor
confirm by microscopic analysis
send for cytology!

40. Post Void Residual Volume
Measurement of residual urine in bladder immediately after voiding through catheter placement or U/S
A volume of > 150 cc may be associated with voiding dysfunction and predisposes to overflow incontinence and UTI’s
Helpful for Pts with: severe POP/outlet obstruction
hx of retention (medication!)
neurology. diseases/neuropathy
recurrent UTIs

41. Urodynamics
Not part of initial evaluation and unnecessary to initiate Rx
Mixed incontinence
Recurrent incontinence
Voiding dysfunction
Overflow incontinence
Prior to intervention!

42. Initial Management
“ A journey of a thousand miles begins with one step ” ……(or one drop) Lao-tse
For ALL Pts with SUI/UUI/mixed UI:
Lifestyle modifications
Pelvic floor muscle exercises PFMT

43. General Management
Behavioral
Medical
Surgical (SUI)

44. Lifestyle Loose weight Reduce caffeine (tea!)
Normalise fluid intake ~ 1.5/2 l (incl. soups, watery fruits…)
Avoid constipation
Avoid evening fluids
Reduce /Stop smoking
Cranberry juice if h/o UTIs

45. PFMT/Kegel Contractions
Exercises of the pelvic floor musculature
10 deliberate, quick, hard contractions of 10 second duration (“ same muscles as you would stop the urine flow or gas ”)
3 times a day
At least 4 - 6/12

46. Additional support Supervision by Physiotherapist Cochrane 2012
Vaginal cones
Biofeedback
Useful if unable to isolate pelvic floor
Vaginal pressure sensor provides audible/visual feedback of strength of pelvic contractions
Can be done using electrical stimulation
1-2 times a week for 6 weeks

47. Overall Effectiveness of Conservative Therapy
Cochrane R/V 2014
Meta-analysis including 21 trials (n 1281)
PFMT better than placebo
Strong recommendation based on intermediate quality evidence
Questionable durability of effect

48. Non-surgical Treatment of SUI
Behavioural Rx :
Timed voiding to maintain an empty bladder (independent of urge)
Topical/vaginal estrogen : if atrophia in peri/postmenopausal women
Pharmacotherapy
Vaginal (Incontinence)Pessaries

49. Medical Therapy for SUI
Duloxetine Hydrochloride
Inhibits reuptake of serotonin and norepinephrine
Enhances urethral function in animal models
Systematic R/V 2012 similar to placebo
Alpha- agonists :
stimulate urethral muscle
not longer recommended

50. Treatment of Urgency Incontinence
Behavioural Rx = Bladder training
Topical estrogen : if atrophia in peri/postmenopausal women
Medical/Pharmacotherapy

51. Treatment of Urgency Incontinence
Bladder Retraining:
Aim to increase again bladder capacity
Timed voiding (voiding diary) by clock
Slowly increase intervals
“freeze and squeeze”
Stop going “just in case”
At least 3/12

52. Medical Treatment of OAB
Anticholinergica
Antimuscarinics:
Blocked release of Acetylcholin during bladder filling( inhibits detrusor & decreased urge) via muscarinic receptors
Compared to placebo >40 % rate improvement
Limited use due to S/E (dry mouth, constipation, cognitive impact)
Low dose slowly increase over few weeks
Check for urinary retention!

53. Medical Treatment of OAB
Antimuscarinics:
Oxybutynin IR (Ditropan) = non selective
Oxybutynin ER 5-10 mg daily
Oxytrol (transdermal patch) twice weekly – reduced S/E
Tolterodine(Detrol LA)= selective 2 mg daily
Solifenacin(Vesicare) 5 mg daily

54. Medical Treatment of OAB
Mirabegron (Betmiga)
Beta3 receptor- agonist
Used if bothersome S/E of Antimuscarinics
Or Contraindications (narrow angle glaucoma)
Similar effective in studies
Started 25 mg daily, up to 50 mg daily
Not to be used if severe or uncontrolled HT!

55. Treatment of Overflowincontinence
Treat underlying etiology
- POP pessaries/surgery
- change meds
- topical estrogen
- DM control…..
Challenging to treat
Double voiding
Intermittent self catheterisation

56. UI & Pelvic Organ Prolapse
POP-Q assessment  stage 0 – 4
Treatment
conservative : PFME
topical Estrogen
(Incontinence)Pessaries
surgical repair + incontinence surgery
Urodynamics prior to surgery!

57. When to refer to Specialist
Uncertain diagnosis
Haematuria in absence of UTI
Significant POP
Failed initial Rx
Pelvic pain
B/o complex neurological conditions
Recurrent UI after incontinence surgery
Post radiation, suspected fistula

58. Summary

60. Thank you !

61. Surgical Management of Urinary Incontinence
Tim Chang MBBS(SYD), FRANZCOG Gynaecologist, Endoscopic surgeon and IVF Fertility specialist
139 Dumaresq street
Campbelltown

62. Management of Incontinence
Cause
Severity
Patient expectations
Patient risk factors / co morbidities
Benefits and risks need to be aligned with patient expectations

63. Management of Incontinence
Womens perception of success of IC treatment based predominantly on reduction in IC episodes and other QoL measures rather than any special testing

64. Indications for referral
Failed conservative therapy and contemplating surgery
Haematuria without infection
Elevated PVR
Significant pain
Significant prolapse or pelvic masses
Suspected fistula
Suspected neurological condition
Uncertain diagnosis

65. Stress Incontinence

66. Conservative therapy Mild/moderate Incontinence Motivated patient
Desires future pregnancies
Unsuitable for surgery

67. Surgery Severe Urinary Stress Incontinece Failed conservative therapy
Patient preference

68. Surgery for Stress IC
Surgery offers high rates of cure for USI (80-90% vs 40-60% with conservative treatments)
Minimal invasive sling procedures have lead to increase surgical treatment for IC from 0.8/1000 women in 1979 to 1.0/1000 women
Ideally women should finished childbearing prior to anti-incontinence surgery

69. Choice of Surgery for Stress IC
Need for other procedures e.g hysterectomy
Coexisting prolapse
ISD
Medical status patient including age
Previous anti-incontinence surgery
Skill surgeon

70. Factors associated with failure of surgery
DI present (60% success for overall IC cure)
ISD (retropubic sling preferred)
Obesity
Chronic lung disease
Previous surgery
Hypoestrogenism/Poor nutrition/Advanced age

71. Types of surgery Mid Urethral Slings Colposuspension
Bladder neck slings

72. Midurethral Slings Revolutionised surgical treatment IC
Polypropylene tape
Vaginal procedure
Sling placed using trocars
Support the midurethra

73. Midurethral sling types
Retropubic
Transobturator
Minislings

74. Retropubic slings Introduced 1990s
Vagina up or Suprapubic down approach
Surgical time 30 minutes
Hospital stay day surgery -1 day
Return normal activities 2 weeks

75. Complications Retropubic tapes
Haemorrhage
Venous plexus 2%
Vascular 1/1000
Viscus injury
Bladder 4%
Bowel 1/1000
Retention 2%
Voiding dysfunction 5%
UTI %
DI %
Erosion %

76. Transobturator slings

77. Transobturator sling Introduced 2001 Similar efficacy
Inside out or outside in approaches
Reduced viscus + visceral injury
Decreased retention / voiding dysfunction
Groin pain

78. Minislings Microinvasive ( single incision) surgery
Aim to further reduced morbidity of surgery
Day surgery
Return to normal activities after 48 hours
90% efficacy (follow up data 18 months)

79. Intrinsic Urethral Sphincter deficiency (ISD)
Urodynamic diagnosis
MUCP <20cm H20 VLPP <60
Retropubic approach preferred to transobturator
Periurethral injections
Artifical Urinary Sphincter

80. Detrusor Instability Bladder retraining Estrogens Antimuscarinics
Selective β agonist
Botox
Sacral Modulation
Cystoplasty

81. Botox DI Failed drug therapy Improved urinary symptoms 70%
Continence rates 60%
Voiding dysfunction 40% (up to 10% symptomatic)
Lasts 6-9 months
On PBS urogynaecologist or urologist

82. Mixed Incontinece Behavioural therapy
Add drug therapy to maximally treat DI
Sling surgery
90% improves SI
50% improves DI
70% improves incontinence symptoms

83. Overflow Incontinece Bladder obstruction vs hypoactivebladder
Treat the aetiology if possible eg prolapse
SNM may be an option
Intermittent self catheterisation
Urine diversions

84. Summary Align patient expectations efficacy compared to morbidity
Midurethra slings treatment of choice
Botox management DI