Urinary Incontinence

1
Urinary Incontinence

• Elia Fanous M.D.
• Department of Obstetrics and Gynecology
• University of Tennessee Memphis

2
Case Presentation

• 59 yo G2 P2 presents wearing a pessary for
  bladder descent and urinary incontinence.
• Patient doing well with pessary but now desires
  surgical treatment.

3
Review of Systems

• Denies frequency urgency or nocturia
• Denies fecal incontinence constipation or
  difficulty evacuating stool
• Leaks urine with coughing laughing etc
• ROS otherwise negative

4
Past Medical History

• Hypertension
• Hypercholesterolemia

5
Past Surgical History

• Total Abdominal Hysterectomy and Retropubic
  Bladder Suspension
• Thyroid surgery for benign tumor

6
Obstetrical History

• Spontaneous Vaginal Delivery x 2

7
Gynecological History

• TAH/Burch for fibroids/stress incontinence
  respectively
• Otherwise negative GYN history

8
Medications

• Lipitor
• Lisinopril

9
Physical Exam

• 56 158 AFVSS
• Vulva normal
• Grade 2 anterior vaginal wall defect with mobile
  urethra
• Urethra and bladder are nontender without any
  evidence of mass
• Perineum revealed normal reflex and sensation
• Lower extremity and neurological exam intact
• Post Void Residual was 80cc

10
Lab

• Urinalysis and Urine Culture were negative

11
Urodynamics

• Uroflow 517cc total void 24cc/sec max rate
  13cc/sec average rate flow time of 39 seconds
  and a normal voiding pattern.
• Cystometrogram 1st sensation at 223cc strong
  desire at 232cc urgency at 380cc and no
  involuntary detrusor contractions.
• Leak Point Pressure positive stress test with
  an average vesical valsalva leak point pressure
  of 100cm H2O
• Urethral Pressure Profile max urethral closing
  pressure was 34cm H2O
• Pressure Flow Study 415 cc void 18cc/s max
  11cc/s average

12
Cystourethroscopy

• Patient prepped in lithotomy position
• 2 Urojet instilled
• 70 Cystoscope inserted
• Bladder normal without lesions
• Ureteral Orifices normal with efflux

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Assessment

• Grade 2 anterior vaginal wall defect
• Recurrent genuine stress urinary incontinence
• Urethral mobility

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Plan

• Pubovaginal sling
• Anterior repair
• Cystoscopy

15
Urinary Incontinece

• Any Loss of Urine during a 12-month period
• Classification
• Stress
• Urge
• Mixed
• Overflow
• Others

16
Prevalence/Incidence

• Aging Population postmenopausal females 23 of
  pop in 1995 will increase to 33 in 2050
• Estimates from literature are only close
  approximations
• Prevalence 8-41 for any incont 3-14 daily
  incont 40-70 of nursing home women
• Incidence - but one study showed a one-year
  incidence of approx 20

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Risk Factors

• Childbirth/Parity
• assoc with stress incont but not with urge
• biggest increase in risk is between women with
  one SVD and women with none
• prevalence increases in smaller increments for
  each SVD after the first

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Risk Factors

• Menopause/Aging
• Estrogen plays a role in maintaining normal
  urinary function
• With increasing age uninhibited bladder
  contractions and post void residual increase
  while max urethral closing pressure and urethral
  length decrease
• 30 increase risk with each 5yr increase in age

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Risk Factors

• Smoking all forms of incont
• Obesity assoc with stress incont
• Functional/Cognitive Impairments
• Hysterectomy
• Race
• White women gt risk for incontinence and pelvic
  support disorders

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Evaluation

• History
• Urinary Diary
• GYN Exam
• Neurological Exam
• Measuring Urethral Mobility
• Office Diagnostic Tests
• Urodynamics

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History

• Do you leak urine when you cough sneeze or
  laugh
• Do you ever have such a strong need to urinate
  that if you dont reach the toilet you may leak
• If yes to 2 do you leak before you reach the
  toilet
• How many times during the day do you urinate
• How many times do you void at night after youve
  gone to bed
• Have you wet the bed in the last year

22
History

• Do you develop an urgent need to urinate when you
  are under stress in a hurry or are nervous
• Do you leak during or after sex
• How often do you leak
• Do you have to wear a pad
• Have you had bladder urine or kidney infections
• Any pain or discomfort with urination

23
History

• Any blood in your urine
• Do you find it hard to begin urinating
• Do you have a slow stream or have to strain to
  pass your urine
• After you urinate do you have dribbling or feel
  that your bladder is still full

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History

• After the urologic history take a medical
  surgical ob/gyn neuro and surgical history.
• DM CVA Lumbar disk dz
• COPD/chronic cough
• Constipation
• Hysterectomy Vaginal repair retropubic surgery
  or radiation
• Medicines diuretics caffeine
  anti-cholinergics alcohol narcotics psyche
  meds a-blockers a- or ß- agonists and Calcium
  channel blockers

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Urinary Diary

• Record volume and frequency of fluid intake and
  voiding for 1-7 days
• Record episodes of incontinence
• Record Nocturia/Enuresis
• Record max volume voided (approximates bladder
  capacity)

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Gyn Exam

• R/O Vaginal dischargin
• Look for atrophy
• R/O Urethral diverticulum carcinoma etc...
• Assess anterior support/urethral mobility
  posterior support and apical support
• BME for other Gyn pathology
• Rectal to r/o fecal impaction

27
Neurological Exam

• Look for common diseases associated with
  urological disturbances Parkinsons MS CVA
  Infection and tumors
• S2-S4
• Extend/Flex hips knees and ankles and
  invert/evert feets
• DTRs patellar ankle and plantar
• Determine strength of anal sphincter and
  bulbocavernosus muscle
• Assess sensory function along sacral dermatomes
• Assess sacral reflexes anal and bulbocavernosus
  reflexes

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Urethral Mobility

• Radiologic Assessment
• -Lateral Cystourethrography
• -Videocystourethrography
• Ultrasonography
• Q-Tip Test

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Office Diagnostic Tests

• Laboratory
• UA CS
• Blood work to r/o compromised renal function
• Simple Cystometrics
• Urodynamic Testing
• Cystoscopy and cytology
• For PT with hematuria or acute onset of
  irritative voiding symptoms in the absence of UTI

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Urodynamics

• Indications
• complicated incontinence
• Pre-op
• After failure of an anti-incontinence procedure

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Urodynamics

• Components (a combo of any listed below)
• Cystometry study of bladder fxn
• Pressure-flow study bladder fxn during void
• Videourodynamics
• Uroflowmetry (study of flow rates) PVR
• Electromyography (EMG)
• Urethral Pressure Profilometry
• Ambulatory Urodynamics

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Stable Bladder
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Detrusor Instability
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Genuine Stress Incontinence
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Treatment

• Who to treat and by Whom
• Non-surgical treatment
• Lifestyle changes
• Physical Therapy
• Bladder retraining
• Anti-incontinence devices
• Pharmacological treatment
• Surgery for GSI

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Surgical Procedures

• Six basic surgical themes
• Bladder buttress operations (anterior repair
  etc)
• Retropubic operations (Burch MMK etc)
• Bladder neck suspensions (Raz Stamey Pereyra
  etc)
• Sling procedures (TVT PV Sling etc)
• Periurethral Injections
• Artificial urinary sphincter

37
Bladder Buttress

• Post-op continence rates are lower when compared
  to other procedures
• Still in use for correction of cystocele and can
  be performed in conjunction with other
  incontinence procedures

38
Retropubic Operations

• Marshall Marchetti Krantz (MMK) cystourethropexy
  1949
• Para-urethral vaginal wall suspended to symphisis
  pubis
• Burch colposuspension 1961
• Para-urethral vaginal wall suspended to Coopers
  ligament
• Paravaginal fascial repair
• Para-urethral vaginal wall suspended to the
  tendinous arc on the pelvic sidewall

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Bladder Neck Suspensions

• Pereyra
• Stamey
• Raz

40
Sling Procedures

• Suburethral sling is a strip of material that is
  tunneled underneath the bladder neck and/or
  proximal or midurethra and then attached to above
  structures such as rectus fascia or pelvic
  sidewall to create a posterior support or
  hammock effect to the bladder neck and proximal
  urethra
• Initially used for ISD (intrinsic sphincter
  deficiency) but now used for all kinds GSI

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Slings

• Materials
• Autologous fascia lata or rectus abdominis
• Homologous materials (cadaveric fascia lata)
• Synthetic

42
Slings

• Types of slings
• Traditional suburethral (rectus abdominis) sling
• Minimally invasive suburethral slings
• Transvaginal bone-anchored sling (In-Fast
  Vesica)
• Tension free vaginal tape (TVT) only sling
  placed at the midurethra
• Initial results are encouraging but long-term
  results are lacking

43
TVT Operative Technique

• Abdominal incisions made
• Vaginal wall incision made
• Paraurethral dissection performed
• Trocar with tape advanced through vaginal
  incision urogenital diaphragm and retropubic
  space until its tip is brought out to the
  abdominal incision
• Cystoscopy
• Trocar and tape pulled through tension is
  adjusted and plastic sheath is removed
• Abdominal and vaginal incisions are closed

44
Periurethral Bulking Injection

• Indicated for patients with stress incontinence
  who have
• Medical conditions that make them unfit for
  surgery
• A history of partially successful treatment and
  wish to avoid more invasive procedures
• Particularly indicated in patients with ISD

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Periurethral Bulking Injections

• Purpose is to bulk up the tissue at the bladder
  neck in order to increase urethral closure
  pressure
• Bulking agents
• Collagen
• Silicone
• Teflon
• Fat
• Durasphere (carbon beads in a carrier gel)
• FDA approved bulking agents

46
Artificial Urinary Sphincter

• Indicated mainly in patients who have undergone
  recurrent previous surgery for GSI and have ISD
• Few reports on this as first-line treatment so
  results are difficult to interpret.
• As high as 92 continence rate but also a high
  revision rate of 17

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Comparative Outcomes
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