URINARY INCONTINENCE IN WOMEN

STRESS URINARY INCONTINENCE IN WOMEN The Definition, Prevalence, and Risk Factors for Stress Urinary Incontinence WWW.SMSO.NET The Definition, Prevalence  clinical definition of SUI has been established by the International Continence Society,  the epidemiologic definition has not been established,  broad disparity in reported prevalence rates.  observed prevalence of between 4% and 35%. WWW.SMSO.NET Prevalence WWW.SMSO.NET Clinical Definitions  “the complaint of involuntary leakage on effort or exertion, or on sneezing or coughing.”  “the observation of involuntary leakage from urethra,synchronous with exertion/effort, or on sneezing or coughing.”  the involuntary leakage of urine during increased abdominal pressure in the absence of detrosal contraction WWW.SMSO.NET   Both Weidner and colleagues and FitzGerald and Brubaker independently demonstrated that an evaluation based on symptoms alone can be misleading. The investigators showed that, although only 30% of the women reported pure SUI by symptoms, 62% had pure SUI established by urodynamics. WWW.SMSO.NET Risk Factors Aging  Obesity   Smoking WWW.SMSO.NET Risk Factors Pregnancy Childbirth    Rortveit and colleagues reported the attributable risk of vaginal delivery to be approximately 35% In contrast, MacLennan and colleagues analyzed a population of 1546 women in South Australia and concluded that there was no increased risk of SUI among women who had undergone vaginal delivery compared with those who had delivered by cesarean section. Data presented by Brown and colleagues indicate no statistically significant increase in risk of SUI in women of increasing parity. WWW.SMSO.NET Vaginal Delivery and Subsequent Risk for SUI  Overall, 30% of women will develop SUI within 5 years after first vaginal delivery  Almost 5% of women have had SUI prior to first pregnancy  Risk for future SUI is 4-times higher for women who were incontinent during pregnancy and/or puerperium WWW.SMSO.NET Incontinence Impacts Quality of Life (QoL) QoL Indicator Social Impact of SUI Isolation Physical Sexual Psychological Limits activities Avoidance Depression,loss of self esteem Occupational Domestic Decreased productivity Personal hygiene WWW.SMSO.NET Incontinence Quality of Life (I-QoL) Instrument WWW.SMSO.NET Stress Urinary Incontinence Neurophysiology WWW.SMSO.NET Neurophysiology novel concepts have emerged regarding possible neurologic dysfunctions that might underlie the development of SUI, as well as potential novel strategies for pharmacologic therapy. WWW.SMSO.NET Efferent Pathways: spinal Components  Parasympathetic.  Sympathetic.  Somatic. WWW.SMSO.NET Parasympathetic Nerves  Preganglionic axons emerge, as the pelvic nerve, from the sacral parasympathetic nucleus in the intermediolateral column of sacral spinal segments S2 to S4 and synapse in the pelvic ganglia,  Postganglionic axons continue for a short distance in the pelvic nerve and terminate in the detrusor layer, WWW.SMSO.NET Parasympathetic Nerves Ach.  Released from pregangelionic nerve endings-acts on nicotinic receptors  Released from postgangelionic nerve ending-acts on M2, M3 receptors ATP.  appears to be mediated by stimulation of one or more members of the P2X family of purinoceptors.  In an analysis conducted by O’Reilly and colleagues, the concentration of P2X1 receptors was significantly higher in abnormal bladders WWW.SMSO.NET compared with control bladders, Sympathetic Nerves    Preganglionic sympathetic neurons are located in the intermediolateral column of thoracolumbar cord segments T10 to L2. Postganglionic axons travel in the hypogastric nerve and transmit norepinephrine (NE) at their terminals. The major terminals are in the urethra and bladder neck,as well as in the bladder body. Some preganglionic sympatheticfibers pass through (but do not terminate in) the inferior mesenteric ganglia and ultimately synapse with postganglionic neurons in the paravertebral ganglia. WWW.SMSO.NET Somatic Nerves  The efferent motoneurons are located in Onuf’s nucleus, along the lateral border of the ventral horn in sacral spinal cord segments S2 to S4. carried in the pudendal nerve and release ACh at their terminals.  The ACh acts on nicotinic receptors in the striated muscle,inducing muscle contraction to maintain closure of the EUS. WWW.SMSO.NET WWW.SMSO.NET WWW.SMSO.NET Efferent Pathways: Supraspinal Components  The PMC and PSC are the final integrative centers.  Neurons in the PSC project directly to the motoneurons in Onuf’s nucleus,and stimulation of PSC neurons causes EUS contractions.  Neurons in the PMC project to the sacral parasympathetic nucleus, and stimulation of PMC neurons results in bladder contractionsas well as relaxation of the internal urethral sphincter and EUS. WWW.SMSO.NET Supraspinal Components neurotransmitters WWW.SMSO.NET Afferent Pathways WWW.SMSO.NET WWW.SMSO.NET Potential Targets for Therapy  No therapy currently in use has has widespread success for patients with SUI.  Drugs traditionally used to treat SUI tend to target the smooth muscle or postjunctional muscarinic or adrenergic receptors.  Lepor and colleagues compared neuroreceptor densities in biopsies of normal and hyperreflexic human bladders and reported a lower-thannormal density of muscarinic receptors and a high density of -adrenoceptors in the abnormal WWW.SMSO.NET bladders. Potential Targets for Therapy    Another suggested approach to ameliorating overactivity of the bladder is to activate the detrusor-relaxing ß3-adrenoceptor Two potential targets for SUI therapy that have recently drawn considerable attention are serotonin and NE, which are transmitted to Onuf’snucleus from the raphe nucleus and locus coeruleus, respectively. Duloxetine, a drug that inhibits reuptake of both serotonin and NE and thereby enhances their potency at the site of action, is currently undergoing clinical trials for the treatment of SUI. WWW.SMSO.NET Stress Urinary Incontinence The Pathophysiology WWW.SMSO.NET SUI Pathophysiology  In the early 1900s, Bonney hypothesized that (SUI) was a result of sagging of the pubocervical muscle sheet, not intravesical pressure on the sphincter.  The functional theories of Barnes; he posited that incontinence could result from an increase in intravesical pressure, a lowering of the powers of resistance or urethral sphincter action, or a combination of both. WWW.SMSO.NET SUI Pathophysiology The transmitted intra abdominal pressure maintained continence by augmenting the pressure resulting from sphincteric function. In cases of stress incontinence there is poor transmission of intra-abdominal WWW.SMSO.NET pressure to the lower Magnitude of Stress on the Bladder PTD =  Pves - Pura.  STRESS  PTD > URETHRAL CLOSURE P.  STRESS  PTD < URETHRAL CLOSURE P.  WWW.SMSO.NET SUI Pathophysiology sphincteric dysfunction. In women with “intrinsic sphincteric deficiency,” the urethral sphincter cannot generate enough resistance to retain urine in the bladder, especially during stress maneuvers.  Current theories integrate anatomic and functional factors, as well as the effects of neuromuscular injury, aging, and  WWW.SMSO.NET Urinary Incontinence Evaluation WWW.SMSO.NET Reasons for Underreporting Embarrassment  Considered a normal part of aging  Availability of absorbent products  Poor knowledge of management options  Low expectations for treatment  Fear of surgery  WWW.SMSO.NET Initial Assessment For Urinary Incontinence History  Urinalysis and other basic tests  Physical/pelvic exam  Urodynamic testing  WWW.SMSO.NET Asking the Patient About Stress and Urge Incontinence  During the last week, how many times did you accidentally leak urine with: 1. A physical activity like coughing, sneezing, lifting, or exercising? 2. A feeling of strong, sudden need to pass your urine that did not allow you to get to the toilet fast enough? WWW.SMSO.NET Urinalysis Bacteriuria  Hematuria  Pyuria  Glycosuria  Proteinuria  WWW.SMSO.NET Other Basic Tests Postvoid residual  Pad Test • Quantitates urine loss  Stress Test or Cough Test • Identifies urine leakage  Cotton Swab Test • Demonstrates urethral hypermobility  WWW.SMSO.NET Physical Examination Concerns  Abdominal • Mass  Pelvic • Prolapse, mass, atrophy, voluntary pelvic floor contraction  Rectal • Mass, tone, voluntary contraction  Sacral neurological • Sensation, reflex, foot movements WWW.SMSO.NET Urodynamic study  Urodynamic studies are likely not required if nonsurgical,completely reversible, inexpensive therapy is planned.  (ICI) recommended urodynamic study in the following cases only: 1) voiding difficulty or neuropathy is suspected, 2) the patient has failed nonsurgical or surgical therapy, or 3) invasive or surgical treatments are being WWW.SMSO.NET considered. Urodynamic study Urodynamic studies • Confirm SUI • Assess urethral function • Assess for occult urge urinary incontinence • Evaluate compliance  WWW.SMSO.NET Stress Urinary Incontinence Treatment Options WWW.SMSO.NET Characteristics of the “Perfect” Therapy for Stress Urinary Incontinence        100% Effective Durable/permanent Simple, quick, and easy to perform or implement Minimally invasive and completely reversible Applicable and effective for all types of stress urinary incontinence Low morbidity and/or complications WWW.SMSO.NET Inexpensive for the patient, health care Nonsurgical Interventions        Behavioral Therapy Pelvic Floor Muscle Training(PFMT) Pelvic floor electrical stimulation Vaginal Cones Continence Devices Intravaginal Supportive Devices (Pessaries) Pharmacologic Therapy WWW.SMSO.NET Behavioral Therapy       Aim: is to help regain bladder control by increasing the effective capacity of the bladder A behavioral modification program for SUI consists of the following: 1) fluid and dietary management, 2) timed voiding,or bladder training, and 3) a voiding log or diary, usually combined with WWW.SMSO.NET 4) PFEs or Kegel exercises. Behavioral Therapy Outcomes with behavioral therapy are quite good.  Fantl and colleagues recorded a 57% reduction in incontinence episodes and a 54% reduction in the quantity of urine loss  WWW.SMSO.NET Pelvic Floor Muscle Training (PFMT)  Patients in the PFE are received weekly training with a physiotherapist and were instructed to perform the exercises 3 times daily with 8 to 12 repetitions per session.  A recent study by Diokno and colleagues was the first to demonstrate that a structured behavioral modification and PFMT program may actually prevent the subsequent development of urinary incontinence WWW.SMSO.NET Electrical Stimulation  There is no universally agreed upon method of pelvic floor electrical stimulation application (anal probe,vaginal probe), duration of therapy(weeks, months, permanent), amplitude or frequency of impulse required to optimally treat SUI, or timing of therapy (number of sessions per day,number of days per week).  Goode and colleagues there was no significant difference between the PFMT groups with or without pelvic floor electrical WWW.SMSO.NET stimulation. Vaginal Cones  The vaginal cone is a tampon-like device that is inserted into the vagina and kept in place by active muscle contraction of the pelvic floor.  The 2nd ICI concluded that vaginal cones do not have any additional benefit for patients already practicing PFMT program. WWW.SMSO.NET . Continence Devices  Occlusive Devices Extraurethral. Intraurethral. Intravaginal Supportive Devices(Pessaries)  WWW.SMSO.NET Pharmacologic Therapy   -Adrenergic Agonists Investigators have reported good to excellent results in patients receiving ephedrine for relatively mild symptoms of sphincter incontinence.  It rarely brings about total dryness in cases of severe or even moderate SUI. WWW.SMSO.NET Tricyclic antidepressants  Tricyclic antidepressants (particularly imipramine hydrochloride)  3 major pharmacologic actions:  1) central and peripheral anticholinergic effects  2) block the active transport system in the presynaptic nerve ending, which is responsible for the reuptake of the released amin neurotransmitters norepinephrine and serotonin; and  3) they act as sedatives,  In an open-label study by Lin and colleagues,40 women with SUI received imipramine, 25 mg, 3 times daily for 3 months. Results demonstrated a WWW.SMSO.NET 35% cure rate by pad test Duloxetine  In a study by Norton and colleagues, patients with SUI were randomized to receive duloxetine, 20 mg/d, 40 mg/d, or 80 mg/d, or placebo. With the highest dosage of duloxetine, 50% of patients had a reduction in incontinence episode WWW.SMSO.NET Other drugs ß-Adrenergic Antagonists  ß-Adrenergic Agonists  Hormonal Therapy  WWW.SMSO.NET Surgical options  There are close to 200 different operations that are used to treat SUI in women  In general, surgical correction of female SUI is directed toward one of the 2 following goals: 1) repositioning procedures 2) coaptation and/or compression or otherwise augmenting the urethral resistance provided by the intrinsic sphincter unit.  the best SUI operation is the first procedure.  The best operation is also the one with which the surgeon is the most familiar. WWW.SMSO.NET WWW.SMSO.NET WWW.SMSO.NET WWW.SMSO.NET WWW.SMSO.NET WWW.SMSO.NET Main Points Various pharmacologic therapies have been used, with widely varying success rates, for the treatment of SUI in women. These include -adrenergic agonists, imipramine, duloxetine, and estrogen.  Tension-free vaginal tape is associated with an excellent 5-year subjective and objective cure rate (84.7%).  WWW.SMSO.NET