Evaluation and Treatment of

Incontinence
Stress Urinary Incontinence

• SUI
– Involuntary leakage of urine on effort, exertion, sneezing or coughing
• ISD
– Maximal urethral closure pressure <20
– Leak point pressure <60
URODYNAMICS
• Not required for most SUI cases
• SUI evaluation
– + cough stress test
– Neg UA
– PVR < 150 cc
– Urethral hypermobility
• Consider UDS if
– Prior pelvic surgery
– Failed treatment
– Prolapse beyond the hymen
– Unable to demonstrate SUI
– Unclear history
 First Line
Treatment
Lifestyle Alterations

• Timed bladder emptying

• Reduce fluid intake or caffeine
• Protective pads
• Optimize pulmonary diseases
• Smoking Cessation
• Weight loss
• Obesity: 4.2 x higher risk SUI
• -8% reduction in weight sig. improvement
Behavioral Intervention

• Pelvic floor muscle training

– Kegel, gynecologist, popularized in 1940’s
– Combine behavioral and physical therapy
– Effective in reducing SUI, UUI, MUI
– At least 12 weeks therapy
• 50% vs 12% improvement
Mechanical Devices

• Pessaries
Can be used in patients with hypermobile bladder neck
 Incontinence dishes
 Incontinence knobs

• Urethral Devices
– Occlusive plugs
• Reliance Insert, FemSoft
Second Line
Treatment
Estrogen
• Local estrogen: Cochrane Review 2012 9
• 34 trials (19,676 total, 9599 received estrogen with 1464 local estrogen)
• Local estrogen
– Improved incontinence (RR 0.74, CI 0.64-0.86)
– 1-2 fewer voids/ day
– Less frequency and urgency
• Systemic estrogen
– CCE+MPA and CEE only
– Increased SUI and UUI in those with no baseline complaint
– Increased frequency, limited daily activities, and bothered them more in baseline UI group
Tricyclic Antidepressants

• Imipramine 10mg qhs in elderly, 25mg TID, 75mg BID

– Decrease bladder contractility and increase urethral resistance
– Central and peripheral anticholinergic
– Block active transport of norepi and serotonin
– Lin et al small study (n=40)
• 35% cure rate by negative pad test and 50% improvement

• SE: dry mouth, blurred vision, urinary retention, constipation, orthostatic hypotension,
sedation, tremors, sexual, jaundice
Third Line
Treatment
Burch Colposuspension
Burch’s

Success rate
• 39 trials, 3,301 women
• 1st year 85 – 90%
• 5 year 70%
• No significant difference between open and laparoscopic approach

Lapitan et al, Cochrane Database Systematic Reviews 2008

Burch’s Colposuspension

Complications

• Detrusor overactivity 5 – 10%

• Voiding difficulty 10 – 15%

• Apical / posterior 5 – 17%

compartment prolapse
Rectus Fascial Sling
 Burch vs Fascial Sling
• Albo et al 2007
• Multi-center RCT (n=655)
• 24 months, success for SUI
– 66% for sling
– 49% for Burch, p<0.001
• Sling: higher UTIs, voiding difficulty, post-op UUI
• Adverse events similar
• Treatment satisfaction at 24 months
– 86% sling
– 78% burch, p=0.02
Midurethral-slings

• Three major slings available

- Tension-free vaginal tape (retropubic approach)
- Tension-free vaginal tape (transobturator approach)
- Mini-sling
lower cure then TVT or TOT
Peri-urethral Injection
Artificial Sphincter
OAB
OAB
• Overactive bladder(OAB) syndrome
– Urgency, with or without urge incontinence, usually with frequency and nocturia
without evidence of UTI or other pathology. (International Continence Society)
• The pathophysiology of overactive bladder syndrome is complex, and
involves both peripheral and CNS factors.

Haylen et al. An international urogynecological association

(IUGA)/international continence society (ISC) joint report on the
terminology for female pelvic floor dysfunction. Neuro and
Urodyn 2010;29:4-20
Additional Symptoms

 Urgency
 A sudden, compelling desire to pass urine, which is difficult to defer

 Frequency
 >7 voids daytime

 Nocturia
 Interruption of sleep 1 or more times to void

 Urge incontinence
 Involuntary leakage associated with sudden compelling desire to void

Haylen et al. An international urogynecological association

(IUGA)/international continence society (ISC) joint report on the
terminology for female pelvic floor dysfunction. Neuro and
Urodyn 2010;29:4-20
Treatment Options
1. Conservative:
 Bladder retraining, Biofeedback
 Behavior modification, fluid management
 Pelvic floor exercises

2. Pharmacology:
 Anti-muscarinics
 B3 agonists
 Contraindicated uncontrolled HTN, end stage renal disease, live disease

3. Procedures:
 Percutaneous tibial nerve stimulation
 Interstim neuromodulator
 Botox: inhibits presynaptic release Ach
Pharmacology
 Non-selective Muscarinic receptor antagonists:
 Tolterodine-IR, ER
 Oxybutynin-IR, ER, transdermal, topical gel
 Trospium Chloride-IR, ER
 Solifenacin succinate
 Fesoterodine

 Selective: M3
 Darifenacin

 Beta 3 agonists

 mirabegron
Muscarinic Receptor
Receptor subtype Distribution Potential impact
M1 Brain Cognitive
dysfunction,impaired
learning

M2 Heart tachycardia
M3 Salivary glands Dry mouth
M3 GI tract Decreased bowel
motility
M3 Bladder Bladder SM control

M4 Brain unclear
M5 Ciliary eye muscle Loss of visual
accommodation
Multichannel
urodynamics
Who needs testing?

• Women with a confusing or unclear history

• Women unable to give a good history
• Patients who have failed prior therapies or have recurrent problems
• Any other concerns
 Who doesn’t need testing?
VALUE trial
Basic parts

• Simple Uroflowmetry – no catheters

• Filling and voiding cystometrogram (CMG)
• Urethral pressure profile (MUCP)
• Complex uroflowmetry- catheters in place
• Video option – same test but with fluoro
 Uroflowmetry
• Ideally done at start of test before any instrumentation
• Info we get:
– Flow rate is the volume of fluid expelled via the urethra per unit time and is expressed in ml per second
– Q max is the maximum measured value of the flow rate
– Voided volume is the total volume expelled per the urethra
– Flow time is the time over which measurable flow occurs. Voiding time is the total duration of micturition,
including interruptions. If flow is continuous, flow time = voiding time.
– Q average is the average flow rate = voided volume divided by flow time
– Time to max flow is the elapsed time from onset of flow to maximum flow
Uroflow
Uroflow
• If we see an abnormal uroflow,
ask the patient if she feels like
today’s void is normal
• If it’s a low volume void (<200),
consider repeating it at the end of
the test
• If it’s interrupted, does she still
empty at the end of the day?
• Is prolapse keeping her from
emptying? Consider repeating
the test with a pessary in place.
Cystometry

• Used to study both the storage and voiding phase of micturition

• Simple cystometry is what you can do in any office with a catheter, tumi syringe and saline or
sterile water
• During filling phase, we are going to slowly retrograde fill the bladder (50-70 mL/min)
• Watch for DO and do provocative testing
Cystometry
First sensation <100
Normal desire – 150-200
Strong desire – 200-250
Capacity – 300-500

Stress test throughout, I

do 150, 300 and capacity.
Standing and removal of
catheter only if I don’t get
a response sitting. With
and without prolapse
reduced.
Cystometry
Leak point pressures

• Leak point pressure (LPP) is a measurement of the amount abdominal pressure or detrusor
pressure required to overcome outlet resistance and produce incontinence.
• VLPP is the precise pressure at which leakage occurs.
– Less than 60 is c/w ISD.
– Calculated measurement (Pves with valsalva at leak – Pves at rest)
VLPP
 Urethral pressure profile
• Urethral pressure profilometry is a graphic representation of pressure within the urethra at successive
points along its length. There is no general consensus on how best to evaluate urethral function in
women with lower urinary tract dysfunction.
• Maximum urethral closure pressure (MUCP) -- is the difference between the maximum urethral
pressure and the intravesical pressure.
– Values less than 20 are c/w ISD
UPP
Urethral pressure profile
UPP
UPP

Pclo
Voiding cystometry or Pressure-flow
studies
• Looks at the 2nd half of cystometry – the voiding phase
• How should the coordinated efforts of the bladder work?
• Lots of room for artifact here but at least get a sense of detrusor function (y/n), straining to
void, and whether they empty.
Pressure flow study
Pressure flow study
Pressure flow study
Pressure flow study
Questions?