UROGYNECOLOGY ISSUES
| URINARY INCONTINENCE: THE BASICS— Sean L. Francis, MD, Assistant Professor and Chief, Section of Urogynecology
and Pelvic Surgery, Medical College of Georgia, Augusta
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| General considerations: prevalence—estimated 10% to 35% of adults; 50% of institutionalized patients; 33 million
Americans; societal impact—1994 direct cost $11.2 billion annually in community and $5.2 billion annually
in nursing homes (60% greater than 1990 estimate); 1995 total societal costs $26.3 billion annually for people ≥65
yr of age; pads and protection account for 50% to 75% of cost; nursing home admissions, 15%; treatment, 10%; diagnosis
and evaluations, 1%; estimated cost of incontinence increased by 250% over past 10 yr; patient’s quality of
life (QOL) also suffers; data show direct correlation with hip fracture and depression
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| Definitions (International Incontinence Society): stress urinary incontinence (SUI)—involuntary leakage
from urethra with laughing, coughing, or sneezing; urge incontinence (UI)—involuntary leakage accompanied by
or immediately preceded by urgency; intrinsic sphincter deficiency (ISD)—type III stress incontinence, ie, inability
to maintain effective urethral closure pressure at rest and during periods of physical activity; seen commonly after
Burch procedure; overactive bladder (OAB)—detrusor muscle overactivity most common cause (urodynamics finding;
>15 cm of water); may be neurogenic or idiopathic; subset of patients complain of urge and urinary incontinence
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| Diagnostic approach: determine type of incontinence, ie, SUI, OAB, overflow; look for contributing factors, eg,
medications, medical problems, prolapse; determine severity of problem by asking patient how incontinence affects
QOL (incontinence questionnaire recommended); spectrum of disease possible; evaluation—history (can diagnose
90% of patient’s problem) and physical examination; urodynamic or office cystometry; postvoid residual
(strongly recommended to differentiate OAB from overflow incontinence); voiding diary can uncover possible
causes, eg, excessive fluid intake
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| Overflow incontinence: typically seen in patient with neurogenic problem; bladder does not empty; history—
patient presents with random dribbling, occasional loss of majority of urine, history of severe prolapse, previous
incontinence surgery; physical findings—overcorrected urethra (angle of cotton-tip applicator placed in urethra
should be close to zero), prolapse, other obvious obstruction; urodynamic evaluation helpful in diagnosing obstruction
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| Potential incontinence: “foggy” diagnosis; no or little history of SUI; evidence of vaginal prolapse seen on physical
examination; significant leakage after prolapse surgery; office cystometrography recommended before prolapse
surgery (reduce prolapse and look for typical signs of SUI, eg, nonsustained leakage with stress in supine
position; speaker uses Texas swab [large cotton swab] or pessary)
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| Urge incontinence (UI): leakage caused by running water, frequency, tobacco, caffeine, or diuretics; generally no
physical findings on examination; urodynamic findings—detrusor contractions >15 cm of water during bladder filling
(most patients with UI have no findings on urodynamics); antimuscarinic agents recommended only for patients
with UI, not appropriate for patients with SUI
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| Stress urinary incontinence: leakage with laugh, cough, sneeze, or exercise; urethral hypermobility (>40°) seen on
physical examination; urodynamics helpful in determining urethral pressure profile, whether patient has ISD, and course
of treatment (transobturator sling, tension free transvaginal tape (TVT) sling, periuretheral injection)
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| Intrinsic sphincter deficiency: same presentation as patient with SUI; may have subtle indications in history
(leakage upon rising in morning, less movement required to cause leakage, more frequent leakage); may or may not
have urethral hypermobility; urodynamic findings include low urethral pressures (<20 cm of water) or low Valsalva
leak point pressure (<60 cm of water); cystoscopy recommended for evaluation; consider ISD as possible diagnosis
before performing surgery; some health care providers doubt diagnosis of ISD; evidence of failures of
transobturator slings in low pressure urethra
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| Office urodynamics: not essential in all cases of urinary incontinence; essential for urogynecologist because patient
profile more complicated; recommended (medicolegally) if patient under consideration for sling or for diagnosing
ISD; price of urodynamics systems considerably less than in past; allows for billing under many current
procedural terminology (CPT) codes
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| Management considerations: kegel exercises—studies show most effective when taught by physical therapist
with biofeedback training; medications and stimulants—speaker believes estrogen plays role in treatment of incontinence;
review patient’s use of medications (eg, diuretics) and stimulants (eg, caffeine, alcohol); look for causes of
incontinence—altered mental status, infection in lower urinary tract, atrophic urethritis and/or vaginitis, over-the-
counter or prescription pharmacologic agents, and psychogenic causes; medications—oxybutynin (eg, Ditropan);
darifenacin (Enablex); trospium (Sanctura); solifenacin (Vesicare); tolterodine (Detrol); investigational agents, eg,
beta-3 adrenoreceptor agonists, potassium channel openers, serotonin receptor agonists, botulinum toxin, gene
therapy, and stem cell-based agents
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| Surgery: considerations—type of incontinence, coexisting problems, surgical risk, and effects on QOL; types of
surgery—systematic review of studies evaluating surgery for SUI shows colposuspension (Burch procedure) may
be most effective, with effects longest lasting (compared to transvaginal and anterior repair needle procedures); retropubic
suspensions and slings currently considered gold standard surgical procedures for urinary incontinence;
Burch colposuspension procedure and traditional sling (previously considered gold standard) associated with complications,
urinary retention, and required hospitalization and incision
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| Sling systems: premarket notification 510(k)—new device essentially equivalent to device approved by Food and
Drug Administration (FDA); definition of equivalence—new device has same intended use as predicate device and
has same technologic characteristics, or has different technologic characteristics, but is as safe and effective as
predicate device; if approved, can be used without human clinical trial; medical device development $78 billion industry
annually; 9000 devices introduced in 1995, and 13,000 introduced in 2000; FDA inspections decreased
from 1995 (3602) to 2000 (1800); Manufacturer and User Facility Device Experience Database—voluntary reports
of adverse events involving medical devices (www.fda.gov/cdrh/maude.html); transobturator sling—introduced
by Delorme in 2001; perforation of bladder reduced; important that patient undergoes thorough evaluation for appropriateness
of sling; speaker emphasizes importance of doing cystoscopy before doing surgery (despite what
manufacturer publicizes)
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| Other options: Interstim—“pacemaker” for bladder; approved in 1997; >30 publications reporting success; associated
with adverse events; bulking agents —usually not first-line therapy (not effective long term); indicated for patient
with ISD who is poor surgical risk and who has sling
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| NONSURGICAL MANAGEMENT OF URINARY INCONTINENCE AND PELVIC ORGAN PROLAPSE —
Steven Swift, MD, Associate Professor, Department of Obstetrics and Gynecology, Medical University of South
Carolina, Charleston
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| General considerations: pessary—excellent modality for management of pelvic organ prolapse; Medicare reimburses
only for procedure of fitting pessary, not for physician’s cost of pessary; specific CPT code for fitting and insertion;
new treatment for SUI—duloxetine (Cymbalta) approved in United States for treatment of depression and
pain, but also shown effective for treating SUI (approved in Europe for this use)
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| Physiology of bladder function: parasympathetic system releases acetylcholine, causing detrusor muscle to contract;
adrenergic system releases norepinephrine, causing detrusor muscle to relax; beta receptors in bladder cause
relaxation; alpha receptors in bladder neck cause partial contraction of smooth muscle in bladder neck;
duloxetine—does not cause retention; targets Onuf’s nucleus in spinal cord; increases tone of smooth muscle component
of urethral sphincter; mechanism unclear; clinical trials show ≈50% improvement in incontinence with duloxetine
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| Pharmacologic management: no commercially available β-agonist specific to bladder (associated with significant
cardiovascular side effects); limited data on alpha-adrenergic stimulators to increase muscle tone of bladder neck
(studies done using phenylpropanolamine; pulled from market because of adverse events when used for other reasons)
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 | Antimuscarinic (anticholinergic) agents: mainstay for treatment of OAB; with newer agents, side effects (dry mouth
and dry eye most common) significant in only ≈2% to 5% of patients; Overactive Bladder: Performance of Extended
Release Agents (OPERA) study—financed by manufacturer of Ditropan XL (oxybutynin); compared Ditropan
XL to tolterodine (Detrol LA); showed similar reduction in incontinence episodes, urinary frequency, and
urgency; similar rates of side effects; no statistically significant differences; trial—compared 5 or 10 mg solifenacin
(Vesicare) to 4 mg Detrol LA; showed solifenacin slightly more effective, but both are reliable medications;
speaker provides patient with 2-wk supply (length of time needed to see improvement in dryness) of free samples
available in office; oxybutynin—slightly more potent (20 mg qd prescribed; significant side effects); same dosage
of solifenacin and tolterodine requires 2 to 3 pills/day (significantly more expensive); trospium (Sanctura) and
darifenacin (Enablex)—safe medications, with potentially fewer central nervous system effects; oxybutynin transdermal
(Oxytrol)—fewest anticholergic effects (no first pass in liver); 5% of patients allergic to adhesive; slightly
less effective than other medications
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| Behavior therapy: considered “potty training” for adults; difficult if patient has transportation issues (requires office
visit every 2-3 wk), is unreliable, or in profession that does not allow scheduled breaks (eg, teacher); success
depends on intensity of program and motivation of patient and health care provider; requires patient keep voiding
diary to determine longest possible voiding interval; high cost in terms of health care provider’s time; studies report
80% reduction in incontinence episodes (75%-80% with medication); Kegel exercises—extremely effective if done
properly; recommend patient work with physical therapist specializing in biofeedback training to ensure exercises
done properly (no way to visualize whether patient performing correctly); duloxetine—cure rate ≈50% (similar to
α-andrenergic agents); effective within 2 wk (2 mo before efficacy seen with Kegel exercises); nausea most common
side effect
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| Pelvic organ prolapse: affects 3% to 5% of population; 10% of women have surgery to correct prolapse, of whom
30% require second operation; reports in literature of ureteral obstruction leading to renal failure; patient not desiring
surgery should undergo renal ultrasonography annually; surgical correction required if evidence of hydronephrosis
present; pessaries—variety of shapes and sizes; literature shows higher success rates with ring and Gellhorn
pessaries; pessary sits at introitus and must be bigger than introitus; instruct patient to sit on toilet and bear down to
ensure pessary does not fall out; ≈50% to 75% of patients can be fitted with pessary; speaker suggests patient try
pessary before undergoing prolapse surgery because pessary may not be option if patient fails surgery (failure rate
for prolapse surgery ≈30%); 50% of patients require refitting; start patient on vaginal estrogen cream after initial
fitting; large introitus and short vaginal vault barriers to proper fit of pessary; older women more accepting of pessaries;
study shows more acceptance of Gellhorn pessary than ring pessary; instruct patient to remove and wash
pessary and leave out one night per week; sexual intercourse can occur with pessary in place; if patient cannot tolerate,
refit with another size or shape and follow up in 1 wk; if tolerating well, follow up again in ≈3 mo, then annually;
if tolerating, but cannot place and remove, have patient come into office monthly to remove, clean, and
replace
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| Summary: overactive bladder (urge incontinence) treated equally well with anticholinergics and behavior modification;
speaker recommends solifenacin and tolterodine; stress incontinence treated equally well with pelvic floor
muscle reeducation and duloxetine
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Suggested Reading
Armstrong RB et al: Safety and tolerability of extended-release oxybutynin once daily in urinary incontinence:
combined results from two phase 4 controlled clinical trials. Int Urol Nephrol [Epub ahead of print], 2007; Chapple
CR: A Comparison of the Efficacy and Tolerability of Solifenacin Succinate and Extended Release Tolterodine at
Treating Overactive Bladder Syndrome: Results of the STAR trial. Eur Urol 48:464, 2005; Dallenbach P et al:
Risk factors for pelvic organ prolapse repair after hysterectomy. Obstet Gynecol 110:625, 2007; Diokno AC et al:
Prospective, randomized, double-blind study of the efficacy and tolerability of the extended-release formulations of
oxybutynin and tolterodine for overactive bladder: results of the OPERA trial. Mayo Clin Proc 78:687, 2003;
Fernando RJ et al: Effect of vaginal pessaries on symptoms associated with pelvic organ prolapse. Obstet Gynecol
108:93, 2006; Francis SL, Stager R: Surgery for vaginal prolapse: a review. J Reprod Med 51:75, 2006; Moore
RD et al: Tension-free vaginal tape sling for recurrent stress incontinence after transobturator tape sling failure. Int
Urogynecol J Pelvic Floor Dysfunct 18:309, 2007; Steers WD et al: Duloxetine compared with placebo for treating
women with symptoms of overactive bladder. BJU Int 100:337, 2007.
Educational Objectives
| The goal of this program is to improve the diagnosis and management of urinary incontinence. After hearing and assimilating
this program, the clinician will be better able to:
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| 1. Identify the type of urinary incontinence a patient has.
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| 2. Evaluate the patient complaining of urinary incontinence.
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| 3. Research the safety and effectiveness of sling systems.
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| 4. Prescribe medical treatment for women experiencing urinary incontinence.
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| 5. Counsel patients about the use of pessaries for pelvic organ prolapse.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose
relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any
identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary
business or commercial interest. For this program, the following has been disclosed: Dr. Francis is on the
Speakers’ Bureau of Pfizer and Coloplast. Dr. Swift is on the Speakers’ Bureau of Astellas Pharma Inc and Bard.
Editor’s Note
Medical College of Georgia, Continuing Education: www.mcg.edu/ce/med.html
Medical University of South Carolina, Continuing Education: www.cme.musc.edu
Acknowledgments
Dr. Francis was recorded at Clinical Approaches to Obstetrics and Gynecology, sponsored by the Medical College of
Georgia, held on June 29 to July 1, 2007, in Savannah, GA. Dr. Swift was recorded at How to Treat a Lady, sponsored
by the Medical University of South Carolina, held on October 20-22, 2006, in Charleston, SC.
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