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.