#155 Urinary Incontinence in Women

Question 1

What percentage of young, middle-aged and postmenopausal women, and older women experience urinary incontinence?

Answer 1

Young = 25%
Middle-aged and postmenopausal = 44-57%
Older women = 75%

Question 2

What percentage of nursing home admissions of older women can be attributed to urinary incontinence?

Answer 2

Approximately 6%

Question 3

What percentage of women will seek care for their incontinence?

Answer 3

45%

Question 4

What is the differential diagnosis of urinary incontinence?

Answer 4

Stress incontinence, detrusor overactivity, fistula (vesical, ureteral, urethral), infectious (UTI, vaginitis), congenital (ectopic ureter, epispadias), functional, environmental, pharmacologic, metabolic

Question 5

What is chronic urinary retention?

Answer 5

Involuntary loss of urine when the bladder does not empty completely; associated with high residual urine volumes

Question 6

What is coital urinary incontinence?

Answer 6

Involuntary loss of urine with sexual intercourse

Question 7

What is continuous urinary incontinence?

Answer 7

Continuous involuntary loss of urine

Question 8

What is extraurethral urinary incontinence?

Answer 8

Urine leakage through channels other than the urethral meatus (eg, vesicovaginal, urethrovaginal, or ureterovaginal genitourinary fistulas; ectopic ureter)

Question 9

What is functional urinary incontinence?

Answer 9

Involuntary loss of urine that is due to cognitive, functional, or mobility impairments in the presence of an intact lower urinary tract system

Question 10

What is insensible urinary incontinence?

Answer 10

Involuntary loss of urine that occurs without awareness

Question 11

What is mixed urinary incontinence?

Answer 11

Involuntary loss of urine associated with urgency and with physical exertion, sneezing, or coughing

Question 12

What is nocturnal enuresis?

Answer 12

Involuntary loss of urine that occurs during sleep

Question 13

What is occult stress incontinence?

Answer 13

Stress urinary incontinence that is observed only after the reduction of coexistent pelvic organ prolapse

Question 14

What is overactive bladder?

Answer 14

Urinary urgency, typically accompanied by frequency and nocturia, with and without urge urinary incontinence in the absence of UTI or other obvious pathology

Question 15

What is postmicturition leakage?

Answer 15

Involuntary passage of urine after the completion of micturition

Question 16

What is postural urinary incontinence?

Answer 16

Involuntary loss of urine associated with change of body position

Question 17

What is stress urinary incontinence?

Answer 17

Involuntary loss of urine with effort or physical exertion or when sneezing or coughing

Question 18

What is urgency urinary incontinence?

Answer 18

Involuntary loss of urine associated with urgency or a sudden, compelling desire to void that is difficult to defer

Question 19

What is the goal of urodynamic testing?

Answer 19

Assess lower urinary tract function by measuring various aspects of urine storage and evacuation

Question 20

What components may be included in urodynamic testing?

Answer 20

Cystometry, uroflowmetry and pressure-flow studies, measures of urethral function including urethral pressure profiles and valsalva leak point pressures, electromyography

Question 21

What is cystometry?

Answer 21

Part of urodynamic testing that provides a graphic depiction of bladder (and abdominal) pressure relative to fluid volume during filling, storage, and voiding to assess bladder sensation, capacity, and compliance and to determine the presence and magnitude of voluntary and involuntary detrusor contractions

Question 22

What are uroflowmetry and pressure-flow studies?

Answer 22

Part of urodynamic testing that mesures the rate of urine flow and mechanism of bladder emptying (ie, presence or absence of coordinated detrusor contractions and urethral relaxation)

Question 23

What is the use of electromyography in urodynamic testing?

Answer 23

Study neuromuscular activity, especially that of pelvic muscles and urethral sphincter during voiding. Main role is detecting coordination between detrusor muscle contraction and urethral sphincter relaxation

Question 24

Is cystourethroscopy a routine part of incontinence work up?

Answer 24

No

Question 25

When would you use cystourethroscopy in an incontinence evaluation?

Answer 25

Microscopic hematuria, acute-onset or refractory urgency incontinence, recurrent UTIs, suspicion for fistula or foreign body after gyn surgery

Question 26

What conservative options are available to treat urinary incontinence?

Answer 26

Pelvic floor muscle exercises (w/ or w/o PT), behavioral and lifestyle modifications, continence-support pessaries, and pharmacotherapy

Question 27

What should be done intraop after retropubic or sling procedures?

Answer 27

Intraop cystourethroscopy to verify ureteral patency and absence of sutures or sling material in bladder

Question 28

What are most of the chronic complications after Burch colposuspension and sling procedures?

Answer 28

Voiding dysfunction and urge symptoms

Question 29

What is the minimum evaluation in women with urinary incontinence?

Answer 29

history, urinalysis, physical exam, demonstration of stress incontinence, assessment of urethral mobility, measurement of postvoid residual volume

Question 30

What are some validated urinary incontinence questionnaires?

Answer 30

Urogenital distress inventory, incontinence impact questionnaire, questionnaire for urinary incontinence diagnosis, incontinence quality of life questionnaire, incontinence severity index, international consultation on incontinence questionnaire

Question 31

What medical and neurological conditions may precipitate urinary incontinence?

Answer 31

Multiple sclerosis, diabetes, stroke, lumbar disk disease

Question 32

What agents/medications can affect lower urinary tract function?

Answer 32

diuretics, caffeine, alcohol, narcotic analgesics, anticholinergic drugs, antihistamines, psychotropic drugs, alpha-adrenergic blockers, alpha-adrenergic agonists, calcium channel blockers

Question 33

How long should patients keep a bladder diary for to provide sufficient clinical data?

Answer 33

Typically 3-5 days is sufficient

Question 34

What is the recommendation if microscopic hematuria is present on UA?

Answer 34

Further upper and lower urinary tract eval with cystoscopy and computed tomography

Question 35

What is the definition of microscopic hematuria?

Answer 35

Three or more RBCs per high-power field on microscopic examination of urinary sediment in the absence of obvious benign cause

Question 36

What nerve roots control micturition?

Answer 36

Sacral segments 2-4

Question 37

What reflexes are used to assess integrity of sacral reflex pathways?

Answer 37

Anal wink and bulbocavernosus reflexes

Question 38

How do you perform cough stress test?

Answer 38

Can be supine or standing. Should have full bladder of at least 300cc

Question 39

What is the definition of urethral mobility?

Answer 39

A resting angle or displacement angle of the uretra-bladder neck with maxiumum Valsalva of at least 30 degrees from the horizontal

Question 40

Is continence surgery more or less successful in women with urethral mobility before surgery?

Answer 40

More successful. Lack of urethral mobility associated with 1.9-fold increase in the failure rate of midurethral sling treatment

Question 41

For patient with stress urinary incontinence without urethral mobility what is best surgical approach?

Answer 41

Urethral bulking agents may better than sling or retropubic procedures

Question 42

What post void residual volume indicates adequate bladder emptying?

Answer 42

Less than 150mL by bladder ultrasound or catheter

Question 43

What is the next step if patient has elevated postvoid residual urine volume in absence of pelvic organ prolapse?

Answer 43

Evaluation of the bladder-emptying mechanism, usually with a pressure-flow urodynamic study

Question 44

When is lower urinary tract evaluation with mulitchannel urodynamic testing indicated?

Answer 44

Unclear diagnosis after basic office evaluation, symptoms that do not correlate with objective findings, failure to improve with treatment, prior incontinence or pelvic floor surgery

Question 45

Is pre op multichannel urodynamic testing necessary prior to primary anti-incontinence in women with uncomplicated stress urinary incontinence?

Answer 45

Not necessary (PVR <150cL, negative eUS, pos cough stress test, no POP beyond hymen)

Question 46

How does use of incontinence pessaries compare to behavioral therapy with pelvic floor muscle trianing?

Answer 46

Behavior therapy slightly higher satisfaction at three months (75%), but both groups rates to 50% by 1 year. Pessaries useful for women who want to avoid surgery and are not likely to adhere to behavior therapy, want more immediate results

Question 47

How effective is lifestyle modifications (bladder training, weight loss, fluid management, muscle exercises, etc) at improving incontinence?

Answer 47

50% reduction in mean incontinence episodes. Same effectiveness for stress, urgency, mixed incontinence

Question 48

What is bladder training?

Answer 48

Timed voiding, bladder drills. Aims to increase the time interval between voiding

Question 49

What type of incontinence is bladder training useful for?

Answer 49

All types, urge, stress, and mixed. Typically thought of for urge incontinence

Question 50

What is the risk for stress incontinence among obese women vs normal BMI women (fold change)?

Answer 50

4.2-fold greater risk in obese

Question 51

Weight loss, in obese women, improves the episodes of which type(s) of incontinence?

Answer 51

Stress

Question 52

What dietary fluid management techniques can women with incontinence be counseled about?

Answer 52

Decrease fluid intake several hours before bedtime, reduction in excessive fluid intake (no more than 2L per day), frequent bladder emptying. Limit caffeine intake to as little as 1 cup of coffee per day

Question 53

What is the subjective and objective 1 year cure rate after midurethral sling for stress urinary incontinence?

Answer 53

85% (subjective) and 76.5% (objective)

Question 54

What is the subjective and objective 1 year cure rate after physical therapy?

Answer 54

53% (subjective) and 58.8% (objective)

Question 55

Pharmacotherapy is best for which type of urinary inconteincen?

Answer 55

Urgency urinary incontinence. Medical treatments of stress urinary incontinence are less effective and are generally not recommended

Question 56

What categories of medications are used to treat urge urinary incontinence?

Answer 56

Antimuscarinic, beta-agonist, onabotulinumtoxinA

Question 57

What is the mechanism of action of antimuscarinic agents used to treat urge urinary incontinence?

Answer 57

Block parasympathetic muscarinic receptors and act on bladder M2 and M3 receptors to inhibit involuntary detrusor contractions

Question 58

What antimuscarinic medications are available for the treatment of urge urinary incontinence?

Answer 58

Darifenacin, solifenacin, fesoterodine, tolterodine, oxybutynin, trospium

Question 59

What is mechanism of action of mirabegron?

Answer 59

Beta-agonist that activates the beta-3 adrenergic receptor in detrusor muscle

Question 60

What are the most common adverse events with mirabegron use?

Answer 60

Tachycardia, headache, and diarrhea (rates similar to placebo)

Question 61

What are contraindications to Mirabegron use?

Answer 61

Severe uncontrolled hypertension, end-stage renal disease, or significant liver impairment

Question 62

What beta-agonist is approved for use in urge urinary incontinence?

Answer 62

Mirabegron

Question 63

What is onabotulinumtoxinA mechanism of action?

Answer 63

Muscle paralytic by inhibiting the presynaptic release of acetylcholine from motor neurons at the neuromuscular junction.

Question 64

How is onabotulinumtoxinA administered for urge urinary incontinence?

Answer 64

Cystoscopic injection

Question 65

Are antimuscarinics or onabotulinumtoxinA injections associated with greater reduction in daily incontinence episodes?

Answer 65

Similar reductions

Question 66

What are adverse events associated with onabotulinumtoxinA injections for overactive bladder?

Answer 66

Higher risk of UTI (33%) and voiding dysfunction (urinary retention, incomplete bladder emptying) that required catheterization (5%).

Question 67

What is mechanism of action for sacral neuromodulation for overactive bladder?

Answer 67

Unknown, may modulate reflex pathways affecting bladder storage and emptying

Question 68

How successful is sacral neuromodulation at treating overactive bladder?

Answer 68

62% success rate for treating refractory urinary urgency incontinence. 26% completely dry, 36% with more than 50% reduction of incontinence episodes

Question 69

Is there a role for estrogen in treatment of urinary incontinence?

Answer 69

Systemic estrogen therapy may increase occurence of stress incontinence. However, vaginal estrogen may be of some benefit

Question 70

Are urethral bulking agents for stress urinary incontinence more or less effective than sling procedure?

Answer 70

Less effective

Question 71

What agents are used for urethral bulking?

Answer 71

Collagen, pyrolytic carbon-coated beads, calcium hydroxylapatite

Question 72

What is the primary surgical treatment for stress urinary incontinence?

Answer 72

Midurethral synthetic mesh slings

Question 73

What are the surgical options for stress urinary incontinence?

Answer 73

Midurethral synthetic mesh slings, autologous fascial bladder neck slings, Burch colposuspension (LSC or open), urethral bulking

Question 74

What are the two main approaches for placement of midurethral slings?

Answer 74

Retropubic and transobturator

Question 75

Is retropubic or transobturator midurethral sling placement associated with higher cure rates?

Answer 75

Similar short-term and long-term cure rates.

Question 76

Which complications are more common with retropubic midurethral sling placement? Transobturator?

Answer 76

Retropubic: voiding dysfunction, bladder perforation, major vascular or visceral injury, and higher operative blood loss Transobturator: Groin pain

Question 77

What is the rate of mesh complications (exposures, erosions) after midurethral sling placement?

Answer 77

2%. No difference between route of placement.

Question 78

How do outcomes of single-incision mini-slings compare to standard length retropubic and transobturator slings?

Answer 78

Significantly lower subjective and objective cure rates, higher rates of reoperation

Question 79

When should you consider autologous fascial bladder neck slings for patients with stress urinary incontinence?

Answer 79

Decline or not candidates for synthetic mesh slings; women with severe stress urinary incontinence and a nonmobile, fixed urethra; urethral diverticula or fistula; or complications from mesh previously placed in anterior vagina

Question 80

True or false: autologous bladder neck slings can be placed under more tension than synthetic slings?

Answer 80

True, decreased risk of urethral erosion compared to synthetic material

Question 81

What percentage of women without stress urinary incontinence develop symptoms of stress urinary incontinence after surgical correction of pelvic organ prolapse?

Answer 81

Approximately 40%

Question 82

Is voiding dysfunction more common with open colposuspension or synthetic midurethral slings?

Answer 82

Open colposuspension

Question 83

In women without preoperative stress urinary stress incontinence, does Burch colposuspension or retropubic sling placement at the time of pelvic organ prolapse surgery decrease risk of post op stress urinary incontinence?

Answer 83

Yes. Rates decreased from 44-49% to 24%. But need to counsel patients about risk of additional surgical procedure

Question 84

How do pessaries affect urinary incontinence?

Answer 84

Incontinence pessaries may improve the symptoms of stress and mixed urinary incontinence, but objective evidence regarding effectiveness has not been reported