SUI

Stress Urinary Incontinence James Balmforth Subspeciality Trainee in Urogynaecology Department of Urogynaecology Kings College Hospital, London, UK Linda Cardozo Professor of Urogynaecology Department of Urogynaecology Kings College Hospital, London, UK Correspondence: James Balmforth, MRCOG Department of Urogynaecology Suite 8, Golden Jubilee Wing, Telephone: 0207 346 3568 Fax: 0207 346 3449 E-mail: jrbalmforth@hotmail.com Kings College Hospital, Denmark Hill London SE5 9RS © 2005 Prous Science Stress Urinary Incontinence Contents • • • • • Definition Epidemiology Aetiology Assessment Treatment © 2005 Prous Science Stress Urinary Incontinence Definition • Stress Urinary Incontinence (SUI) is the involuntary leakage of urine per urethram during periods of increased intra-abdominal pressure in the absence of a detrusor contraction1 Stress Urinary Incontinence Epidemiology 40 35 30 25 20 15 10 5 0 Total 25-29 35-39 45-49 55-59 65-69 75-79 85-89 n = 27,936 women • Urinary incontinence is commoner with increasing age2 % Age (years) Stress Urinary Incontinence Epidemiology • Urinary incontinence is more prevalent than many other chronic diseases in women Prevalence in Women 40% 30% 20% 10% 0% 35% 25% 20% 8% Incontinence Hypertension Depression Diabetes Stress Urinary Incontinence Aetiology Multifactorial Consisting of intrinsic and acquired elements Constitutional quality of connective tissue Pregnancy / childbirth Age Oestrogen status Previous pelvic surgery Abdominal mass Co-existing gynaecological conditions • • • • • • • Stress Urinary Incontinence Aetiology Predispose Gender Race Neurologic Muscular Anatomic Collagen Family Promote Childbirth Obesity Pelvic surgery Lung disease Smoking Menopause Constipation Recreation Occupation Medications Infection Decompensate Aging Dementia Debility Disease Medications + + - + Stress Urinary Incontinence Prevention / Treatment Behavioral modification Pelvic floor muscle training Incontinence surgery Pharmacological treatment Stress Urinary Incontinence Aetiology Stress Incontinence occurs when: Intra-abdominal pressure exceeds urethral pressure, resulting in leakage Intra-abdominal pressure is increased by Exercise Cough Sneeze Obesity Urethral closure pressure is increased by Pelvic floor muscle training Surgery Pharmacological agents Stress Urinary Incontinence Aetiology Both pregnancy itself and mode of delivery are risk factors for SUI. Caesarean section may confer some protection, but after 1 or 2 children any advantage is lost Urinary Incontinence Postpartum3 • 1 normal delivery • 1 Caesarean section • 3 Caesarean sections 24.6% 5-11% 35% Stress Urinary Incontinence Assessment: Medical History • • • • • Urinary function Sexual difficulties Bowel function Quality of Life (QoL) – patient perspective Relevant general medical history Stress Urinary Incontinence Assessment: Clinical Examination • General physical examination mobility, mental state, fitness for surgery, neurological, oestrogenisation of tissues • Abdominal examination • Pelvic examination consider other gynaecological pathology • Prolapse grading position ? supine, left lateral, standing Stress Urinary Incontinence Assessment Pelvic Examination • • • • • • • • Degree of prolapse ? Pelvic Mass Pelvic floor muscle tone Voluntary pelvic floor contraction Perineal skin condition Palpation of anterior vaginal wall and urethra Determine degree of oestrogenization May observe leakage on coughing Stress Urinary Incontinence Coexistent pelvic organ prolapse Stress Urinary Incontinence Investigations Simple (Office tests) Urinalysis Urine culture Urinary diary Pad test Complex (Urodynamics) Uroflowmetry Cystometry Urethral function tests Ultrasound Videocystometry Ambulatory urodynamics Stress Urinary Incontinence Investigations: Simple office tests • Urinary diary Will detect compulsive fluid drinker Excess caffeine / alcohol • Urinalysis Screen for urinary tract infection Diabetes mellitus • Urine culture Confirm urinary tract infection + sensitivities Consider culture of ‘fastidious organisms’ Stress Urinary Incontinence Investigations Urinalysis Urinary Diary • • • • • Bacteriuria Hematuria Pyuria Glycosuria Proteinuria Stress Urinary Incontinence Investigations Urinary diary • Simple objective assessment of fluid balance • Records input and output and timing of leakage • Chart kept for one week or less Useful for • Improving fluid management • Shows frequency of incontinence episodes • Monitoring treatment Stress Urinary Incontinence Investigations What are ‘urodynamics’? • Measurements to quantify the ability of the bladder to store and expel urine • Allow objective assessment of bladder function and are more accurate than history alone in reaching a diagnosis Aims of urodynamic investigations • • • • • Make accurate diagnosis Verify / quantify incontinence Identify underlying pathology Monitor treatment Education / Research / Audit Stress Urinary Incontinence Investigations - Uroflowmetry Flowmeter Normal flow trace Stress Urinary Incontinence Treatment: Primary Prevention Lifestyle interventions • • • • Weight loss Cessation of smoking Avoidance of heavy exercise / straining Effective management of constipation Pregnancy and childbirth • Antenatal pelvic floor exercises • Active management of labour • Role of elective caesarean section? Stress Urinary Incontinence Treatment: Conservative Management When is a conservative approach justified? • • • • • • • • Extremes of age Pregnancy Family incomplete Medically unfit Awaiting / unwilling to undergo surgery Occasional incontinence Complicating factors Voiding difficulties / mixed incontinence Stress Urinary Incontinence Pelvic Floor Physiotherapy 1) Reinforcement of cortical awareness of muscle groups 2) Hypertrophy of existing muscle fibres 3) General increase in muscle tone and strength RCT Evidence4 • More effective than no treatment • More effective than electrical stimulation • More effective than vaginal cones Stress Urinary Incontinence Treatment: Surgical Treatments Traditional Traditional Surgical Approach 1. Elevate bladder neck and proximal urethra 2. Support bladder neck and prevent funnelling 3. Increase outflow resistance vs Modern Modern Surgical Approach 1. ‘Integral Theory’ of urinary incontinence5 2. Proposes that stress incontinence results from the failure of the pubourethral ligaments in the mid-urethra Stress Urinary Incontinence Surgical Treatment: Cure Rates Objective cure rates for first procedure and recurrent incontinence6 Procedure Mean (%) 95% CI Mean (%) 95% CI First Procedure Slings Burch colposuspension Needle suspension Anterior vaginal repair Injectables 93.9 89.8 86.7 67.8 45.5 89.2 - 98.6 87.6 - 92.1 75.5 - 97.9 62.9 - 72.8 28.5 - 62.5 Recurrent Incontinence 86.1 82.5 86.4 N/A 57.8 82.4 - 89.8 76.3 - 88.7 72.4 - 100 N/A 43.2 - 72.4 Randomised control trial evidence suggests that Tension-free Vaginal Tape (TVT) has a similar cure rate to colposuspension.7 Many of the other less invasive, mid-urethral ‘slings’ have not yet been adequately tested Stress Urinary Incontinence Treatment: Surgical Treatments Historically colposuspension has been regarded as most likely to produce a lasting cure and correct cystocele Long-term results of colposuspension • 85–90% cure at 10 years • 10% rectocoele • 10% ‘de novo’ detrusor overactivity (DO) • • • • So why develop new treatments? Surgical cure rates <100% Complications - voiding difficulties and DO Recovery time can be slow Expense Stress Urinary Incontinence Less Invasive Surgery: Mid-urethral Tapes meatus mid-urethra bladder neck Cadaveric dissection showing position of mid-urethral ‘hammock’ Stress Urinary Incontinence Less Invasive Surgery: Trans-obturator Tapes Anatomical landmarks Tape passes through medial edge of obturator foramen just below the insertion of the adductor longus tendon Stress Urinary Incontinence Drug Treatment - Duloxetine hydrochloride The first drug to be developed specifically for stress incontinence • Serotonin and noradrenaline balanced reuptake inhibitor • Stimulates output from the pudendal motor nucleus • Improved urethral function in women Stress Urinary Incontinence Non-Medical Management Don’t forget adjuvant non-medical treatment, which can greatly improve patient’s quality of life • • • • • What is available? Pads and pants Devices (and appliances) Aides Indwelling catheters Intermittent catheterisation Stress Urinary Incontinence - Management HISTORY Incontinence on physical activity • General assessment • Physical examination: abdominal, pelvic, neurological • ? Oestrogen status - if atrophic, treat as necessary • Assess quality of life and desire for treatment • Frequency volume chart • Urinalysis ± urine culture – if infected, treat and reassess • Assess post-void residual volume (by catheter or ultrasound) • Assess for pelvic organ mobility / prolapse • Consider imaging of the UT • Urodynamics • Lifestyle interventions ± Pelvic floor muscle training If initial therapy fails, consider • Stress incontinence surgery / correct prolapse surgically CLINICAL ASSESSMENT TREATMENT Stress Urinary Incontinence Conclusions • • • Stress urinary incontinence is a common and distressing condition Thorough investigation and diagnosis is essential prior to treatment Treatment should be individualised Stress Urinary Incontinence Conclusions • • • Trends towards less invasive surgery have reduced hospital stay, morbidity and mortality Effective nonsurgical management is available as adjunct or following surgical failure Incontinence should not be viewed as a normal part of aging or shameful; incontinence should be viewed as treatable References 1. Abrams, P., Cardozo, L., Fall, M. et al. The standardisaton of terminology in lower urinary tract function. Neurourol Urodyn 2002, 21: 167-78. 2. Hannestad, Y.S., Rortveit, G., Sandvik, H., Hunskar, S. A community-based epidemiological survey of female urinary incontinence: The Norwegian EPINCONT Study. J Clin Epidemiol 2000, 53: 1150-7. 3. Wilson, P.D., Herbison, R.M., Herbison, G.P. Obstetric practice and the prevalence of urinary incontinence three months after delivery. Br J Obstet Gynaecol 1996; 103: 154-61. 4. Bo, K., Talseth, T., Holme, I. Single blind, randomised controlled trial of pelvic floor exercises, electrical stimulation, vaginal cones, and no treatment in management of genuine stress incontinence in women. Br Med J 1999, 318: 48793. 5. Petros, P.E., Ulmsten, U.I. An integral theory of female urinary incontinence. Experimental and clinical considerations. Acta Obstet Gynecol Scand Supp 1990, 153: 7-31. 6. Jarvis, G.J. Surgery for stress incontinence. Br J Obstet Gynaecol 1994, 101: 371-4. 7. Ward, K.L., Hilton, P. A randomised trial of colposuspension and tensionfree vaginal tape (TVT) for primary genuine stress incontinence - 2 year follow-up. Int Urogynecol J Pelvic Floor Dysfunct 2001, 12 : S7-S8.