#155 Urinary Incontinence in Women Flashcards
What percentage of young, middle-aged and postmenopausal women, and older women experience urinary incontinence?
Young = 25%
Middle-aged and postmenopausal = 44-57%
Older women = 75%
What percentage of nursing home admissions of older women can be attributed to urinary incontinence?
Approximately 6%
What percentage of women will seek care for their incontinence?
45%
What is the differential diagnosis of urinary incontinence?
Stress incontinence, detrusor overactivity, fistula (vesical, ureteral, urethral), infectious (UTI, vaginitis), congenital (ectopic ureter, epispadias), functional, environmental, pharmacologic, metabolic
What is chronic urinary retention?
Involuntary loss of urine when the bladder does not empty completely; associated with high residual urine volumes
What is coital urinary incontinence?
Involuntary loss of urine with sexual intercourse
What is continuous urinary incontinence?
Continuous involuntary loss of urine
What is extraurethral urinary incontinence?
Urine leakage through channels other than the urethral meatus (eg, vesicovaginal, urethrovaginal, or ureterovaginal genitourinary fistulas; ectopic ureter)
What is functional urinary incontinence?
Involuntary loss of urine that is due to cognitive, functional, or mobility impairments in the presence of an intact lower urinary tract system
What is insensible urinary incontinence?
Involuntary loss of urine that occurs without awareness
What is mixed urinary incontinence?
Involuntary loss of urine associated with urgency and with physical exertion, sneezing, or coughing
What is nocturnal enuresis?
Involuntary loss of urine that occurs during sleep
What is occult stress incontinence?
Stress urinary incontinence that is observed only after the reduction of coexistent pelvic organ prolapse
What is overactive bladder?
Urinary urgency, typically accompanied by frequency and nocturia, with and without urge urinary incontinence in the absence of UTI or other obvious pathology
What is postmicturition leakage?
Involuntary passage of urine after the completion of micturition
What is postural urinary incontinence?
Involuntary loss of urine associated with change of body position
What is stress urinary incontinence?
Involuntary loss of urine with effort or physical exertion or when sneezing or coughing
What is urgency urinary incontinence?
Involuntary loss of urine associated with urgency or a sudden, compelling desire to void that is difficult to defer
What is the goal of urodynamic testing?
Assess lower urinary tract function by measuring various aspects of urine storage and evacuation
What components may be included in urodynamic testing?
Cystometry, uroflowmetry and pressure-flow studies, measures of urethral function including urethral pressure profiles and valsalva leak point pressures, electromyography
What is cystometry?
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
What are uroflowmetry and pressure-flow studies?
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)
What is the use of electromyography in urodynamic testing?
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
Is cystourethroscopy a routine part of incontinence work up?
No
When would you use cystourethroscopy in an incontinence evaluation?
Microscopic hematuria, acute-onset or refractory urgency incontinence, recurrent UTIs, suspicion for fistula or foreign body after gyn surgery
What conservative options are available to treat urinary incontinence?
Pelvic floor muscle exercises (w/ or w/o PT), behavioral and lifestyle modifications, continence-support pessaries, and pharmacotherapy
What should be done intraop after retropubic or sling procedures?
Intraop cystourethroscopy to verify ureteral patency and absence of sutures or sling material in bladder
What are most of the chronic complications after Burch colposuspension and sling procedures?
Voiding dysfunction and urge symptoms
What is the minimum evaluation in women with urinary incontinence?
history, urinalysis, physical exam, demonstration of stress incontinence, assessment of urethral mobility, measurement of postvoid residual volume
What are some validated urinary incontinence questionnaires?
Urogenital distress inventory, incontinence impact questionnaire, questionnaire for urinary incontinence diagnosis, incontinence quality of life questionnaire, incontinence severity index, international consultation on incontinence questionnaire
What medical and neurological conditions may precipitate urinary incontinence?
Multiple sclerosis, diabetes, stroke, lumbar disk disease
What agents/medications can affect lower urinary tract function?
diuretics, caffeine, alcohol, narcotic analgesics, anticholinergic drugs, antihistamines, psychotropic drugs, alpha-adrenergic blockers, alpha-adrenergic agonists, calcium channel blockers
How long should patients keep a bladder diary for to provide sufficient clinical data?
Typically 3-5 days is sufficient
What is the recommendation if microscopic hematuria is present on UA?
Further upper and lower urinary tract eval with cystoscopy and computed tomography
What is the definition of microscopic hematuria?
Three or more RBCs per high-power field on microscopic examination of urinary sediment in the absence of obvious benign cause
What nerve roots control micturition?
Sacral segments 2-4
What reflexes are used to assess integrity of sacral reflex pathways?
Anal wink and bulbocavernosus reflexes
How do you perform cough stress test?
Can be supine or standing. Should have full bladder of at least 300cc
What is the definition of urethral mobility?
A resting angle or displacement angle of the uretra-bladder neck with maxiumum Valsalva of at least 30 degrees from the horizontal
Is continence surgery more or less successful in women with urethral mobility before surgery?
More successful. Lack of urethral mobility associated with 1.9-fold increase in the failure rate of midurethral sling treatment
For patient with stress urinary incontinence without urethral mobility what is best surgical approach?
Urethral bulking agents may better than sling or retropubic procedures
What post void residual volume indicates adequate bladder emptying?
Less than 150mL by bladder ultrasound or catheter
What is the next step if patient has elevated postvoid residual urine volume in absence of pelvic organ prolapse?
Evaluation of the bladder-emptying mechanism, usually with a pressure-flow urodynamic study
When is lower urinary tract evaluation with mulitchannel urodynamic testing indicated?
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
Is pre op multichannel urodynamic testing necessary prior to primary anti-incontinence in women with uncomplicated stress urinary incontinence?
Not necessary (PVR <150cL, negative eUS, pos cough stress test, no POP beyond hymen)
How does use of incontinence pessaries compare to behavioral therapy with pelvic floor muscle trianing?
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
How effective is lifestyle modifications (bladder training, weight loss, fluid management, muscle exercises, etc) at improving incontinence?
50% reduction in mean incontinence episodes. Same effectiveness for stress, urgency, mixed incontinence
What is bladder training?
Timed voiding, bladder drills. Aims to increase the time interval between voiding
What type of incontinence is bladder training useful for?
All types, urge, stress, and mixed. Typically thought of for urge incontinence
What is the risk for stress incontinence among obese women vs normal BMI women (fold change)?
4.2-fold greater risk in obese
Weight loss, in obese women, improves the episodes of which type(s) of incontinence?
Stress
What dietary fluid management techniques can women with incontinence be counseled about?
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
What is the subjective and objective 1 year cure rate after midurethral sling for stress urinary incontinence?
85% (subjective) and 76.5% (objective)
What is the subjective and objective 1 year cure rate after physical therapy?
53% (subjective) and 58.8% (objective)
Pharmacotherapy is best for which type of urinary inconteincen?
Urgency urinary incontinence. Medical treatments of stress urinary incontinence are less effective and are generally not recommended
What categories of medications are used to treat urge urinary incontinence?
Antimuscarinic, beta-agonist, onabotulinumtoxinA
What is the mechanism of action of antimuscarinic agents used to treat urge urinary incontinence?
Block parasympathetic muscarinic receptors and act on bladder M2 and M3 receptors to inhibit involuntary detrusor contractions
What antimuscarinic medications are available for the treatment of urge urinary incontinence?
Darifenacin, solifenacin, fesoterodine, tolterodine, oxybutynin, trospium
What is mechanism of action of mirabegron?
Beta-agonist that activates the beta-3 adrenergic receptor in detrusor muscle
What are the most common adverse events with mirabegron use?
Tachycardia, headache, and diarrhea (rates similar to placebo)
What are contraindications to Mirabegron use?
Severe uncontrolled hypertension, end-stage renal disease, or significant liver impairment
What beta-agonist is approved for use in urge urinary incontinence?
Mirabegron
What is onabotulinumtoxinA mechanism of action?
Muscle paralytic by inhibiting the presynaptic release of acetylcholine from motor neurons at the neuromuscular junction.
How is onabotulinumtoxinA administered for urge urinary incontinence?
Cystoscopic injection
Are antimuscarinics or onabotulinumtoxinA injections associated with greater reduction in daily incontinence episodes?
Similar reductions
What are adverse events associated with onabotulinumtoxinA injections for overactive bladder?
Higher risk of UTI (33%) and voiding dysfunction (urinary retention, incomplete bladder emptying) that required catheterization (5%).
What is mechanism of action for sacral neuromodulation for overactive bladder?
Unknown, may modulate reflex pathways affecting bladder storage and emptying
How successful is sacral neuromodulation at treating overactive bladder?
62% success rate for treating refractory urinary urgency incontinence. 26% completely dry, 36% with more than 50% reduction of incontinence episodes
Is there a role for estrogen in treatment of urinary incontinence?
Systemic estrogen therapy may increase occurence of stress incontinence. However, vaginal estrogen may be of some benefit
Are urethral bulking agents for stress urinary incontinence more or less effective than sling procedure?
Less effective
What agents are used for urethral bulking?
Collagen, pyrolytic carbon-coated beads, calcium hydroxylapatite
What is the primary surgical treatment for stress urinary incontinence?
Midurethral synthetic mesh slings
What are the surgical options for stress urinary incontinence?
Midurethral synthetic mesh slings, autologous fascial bladder neck slings, Burch colposuspension (LSC or open), urethral bulking
What are the two main approaches for placement of midurethral slings?
Retropubic and transobturator
Is retropubic or transobturator midurethral sling placement associated with higher cure rates?
Similar short-term and long-term cure rates.
Which complications are more common with retropubic midurethral sling placement? Transobturator?
Retropubic: voiding dysfunction, bladder perforation, major vascular or visceral injury, and higher operative blood loss
Transobturator: Groin pain
What is the rate of mesh complications (exposures, erosions) after midurethral sling placement?
2%. No difference between route of placement.
How do outcomes of single-incision mini-slings compare to standard length retropubic and transobturator slings?
Significantly lower subjective and objective cure rates, higher rates of reoperation
When should you consider autologous fascial bladder neck slings for patients with stress urinary incontinence?
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
True or false: autologous bladder neck slings can be placed under more tension than synthetic slings?
True, decreased risk of urethral erosion compared to synthetic material
What percentage of women without stress urinary incontinence develop symptoms of stress urinary incontinence after surgical correction of pelvic organ prolapse?
Approximately 40%
Is voiding dysfunction more common with open colposuspension or synthetic midurethral slings?
Open colposuspension
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?
Yes. Rates decreased from 44-49% to 24%. But need to counsel patients about risk of additional surgical procedure
How do pessaries affect urinary incontinence?
Incontinence pessaries may improve the symptoms of stress and mixed urinary incontinence, but objective evidence regarding effectiveness has not been reported
