URINARY INCONTINENCE IN WOMEN
| OFFICE EVALUATION —Rosanne Marie Kho, MD, Senior Associate Consultant, Mayo Clinic College of Medicine, Scottsdale,
AZ
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| Differential diagnosis: genitourinary (GU) conditions, ie, stress, urge, and mixed incontinence; fistulas of vesical, ureteral,
or urethral origin; ectopic ureter; non-GU factors—functional status (eg, ability to reach bathroom in time); pharmacologic
agents; medical conditions
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| Factors causing leakage of urine: failure of sphincteric function (includes intrinsic and extrinsic factors; can be related
to estrogenic effects on lower urogenital tract, or previous urethral disease and manipulation); extrinsic factors (eg,
problems that weaken support of pubourethral ligament); urge incontinence (bladder leakage caused by detrusor overactivity
or detrusor and urothelial hypersensitivity); points—physician must assess coordination between detrusor muscles and
sphincter; any lesions of central nervous system occurring at or above thoracic spine can adversely affect bladder function
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| Patient history: medications—affecting urethral pressure, bladder pressure, and urine volume (diuretics); increasing
bladder pressure and impairing voiding function (eg, β-blockers for Parkinson’s disease); producing cough (angiotensin-
converting enzyme [ACE] inhibitors); exacerbating constipation and urine leakage; altering mentation (ie, psychotropics);
factors that alter pelvic organ function—parity, number of vaginal births, and whether patient had previous traumatic delivery
that could affect continence; pelvic surgery or radiation therapy; diabetes; neurologic disorders; problems that can
increase stressors and exacerbate incontinence (eg, increased coughing, chronic obstructive pulmonary disease [COPD],
asthma, reactive airway disease); other factors associated with leakage—dementia; psychiatric disease; bladder infections
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| Physical examination: begins before physician meets patient, eg, wheelchair parked outside door of examination room
provides information on individual’s physical status; determine viability—assess patient’s position while sitting; cognition;
mentation; dexterity; ambulation; with patient on examination table, evaluate—vulva (look for excoriations or other
problems caused by wet anti-incontinence pads); vagina (look for estrogenic effects or signs of atrophy that can be targeted
by therapy); pelvic relaxation—study before inserting speculum; to evaluate mobility of bladder neck, have patient cough
or perform Valsalva maneuver; limit use of Q-tip test to women with persistent leakage after failed surgery; use maximum
straining or large cough to elicit objective evidence of urine leakage; determining status of nerves—for sympathetic
nerves from T11 to L2, test leg sensation, strength, and reflexes; for parasympathetic nerves, evaluate bulbocavernosal and
clitoral reflexes during pelvic examination, eg, to elicit contraction of anal sphincter (ie, anal wink), stroke tissue lateral to
labia minora or gently tap on clitoris; while performing speculum examination—evaluate top of vagina; look for signs of
uterine descensus (if uterus in place); assess apical support of vagina (remove anterior portion of speculum before evaluation;
look for evidence of central or lateral defects that can affect treatment strategy); assess posterior segment; during bimanual
examination—palpate under urethra and check for masses, tenderness, or drainage; look for signs of diverticula;
check tone of rectal and levator ani muscles; evaluate bladder emptying—assess detrusor function; ask patient to empty
bladder and use bladder scan to determine postvoid residual (note, catheter evaluation can be used when imaging equipment
unavailable); office evaluation of bladder filling—requires 60-mL syringe with Foley catheter; to determine maximum
capacity, fill bladder and look for detrusor instability, ie, contraction with detrusor activity and sudden rise in fluid
level in syringe
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| Urodynamic evaluation: not indicated in women who—have not had previous surgery; present with straightforward
stress urinary incontinence and hypermobile bladder neck; indicated in women—who present with complex symptoms;
who have urge incontinence (look for concomitant stress urinary incontinence in these individuals); in whom multiple
medical and surgical interventions have failed
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| CONSERVATIVE THERAPY FOR STRESS AND URGE INCONTINENCE —G. Willy Davila, MD, Chair, Department
of Gynecology, and Head, Section of Urogynecology and Reconstructive Pelvic Surgery, Cleveland Clinic Florida, Weston
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| Candidates for nonsurgical therapy: women with mild to moderate stress incontinence, exteriorized genital prolapse,
or significant sphincteric deficiency; patients who cannot contract pelvic floor muscles
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| Stress incontinence: sphincteric problem; continence requires coordination between intrinsic and extrinsic muscle activity;
intrinsic vs extrinsic function—women with weak intrinsic sphincteric function leak easily; women with good intrinsic
sphincteric function and poor extrinsic sphincteric function leak more readily with coughing, sneezing, or physical
activity; pelvic floor exercises—most effective for strengthening weakened voluntary (extrinsic) sphincteric muscles;
less effective for strengthening involuntary (intrinsic) muscles
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| Pelvic floor muscles: key component of bladder outlet function in women (assuming individual has normal innervation,
good urethral tone permits reflex inhibition of uninhibited bladder contractions); constitute complex structure that supports
entire pelvic floor; palpation of pelvic floor muscles—essential when examining woman with prolapse or pelvic floor
symptoms; identifies muscle tears and defects; helps select candidates for Kegel exercises; trigger points—identified with
palpation; include areas of contracted muscle tissue and scarring that produce neuritis; women with interstitial cystitis (IC)
and vulvodynia may have tender trigger points in levator muscles that can be treated with local anesthetic or steroid injections
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| Behavioral modifications: regulated voiding—options include timed voiding (eg, elderly benefit from voiding by
clock rather than desire) and prompted voiding (patient must be told when to void); approach benefits woman with neurogenic
bladder, impaired sensation, and inability to sense urgency or judge urine content of bladder; bladder drills for patients
with overactive bladders—important; scheduled approach lengthens voiding intervals until reasonable interval of
2 to 3 hr achieved; bladder diary—key management tool; contributes to successful conservative therapy among women
with overactive bladders; helps patient appreciate improvements achieved by conservative therapy; includes documenting
urinations, sensations of urgency, incontinence episodes, fluid intake, and timing and type of fluid consumed; regular review
of diary helps physician counsel patient and document therapeutic efficacy; bladder retraining with voiding—
helpful in managing patients who void every 30 to 60 min; takes time for patient to learn; increases voiding interval by 30
min/wk; goal to achieve voiding interval of 2.5 to 3 hr; associated with ≈50% objective reduction in urine loss and incontinence
episodes
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| Kegel exercises: simple oral or written instructions often not adequate; points—physician must take time during pelvic
examination to help patient identify pelvic floor muscles; if patient cannot feel or identify muscles, recruit physical therapist
to provide proper exercise training; visual aid (eg, illustration showing that tightening pelvic muscles lengthens urethra
and increases pressure within urethra) useful training tool
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| Options to enhance efficacy of Kegel exercises: biofeedback—educational tool; helps patient visualize contraction
of pelvic floor muscles; without biofeedback, patient may be performing poor Kegel exercises or abdominal contractions
that hinder pelvic floor function; physical therapist—key to successful use of biofeedback; helps patient isolate
levator and pelvic floor muscles and perform more efficient Kegel exercises; vaginal cones—available in various
weights; strong pelvic floor muscles will contract and hold cone within vagina while woman ambulates; if cone falls out,
Kegel exercises must be performed to strengthen muscles; Colpexin Sphere—space-occupying device worn within vagina;
reduces prolapse and enables patient to perform proper Kegel exercises (once muscles become strong enough,
woman with advanced prolapse can undergo conservative management); less logistically demanding than pessary; contraindicated
in patients who cannot contract pelvic floor muscles; data suggest approach augments bladder neck support
in women with stress incontinence; functional electrical stimulation (FES)—works better for managing detrusor overactivity
or instability than for stress incontinence; voluntary Kegel exercises more effective than FES-stimulated exercises
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| Bottom line: based on data—pelvic floor exercises remain most effective treatment option; role of Kegel exercises
should be emphasized; in women who are atrophic 6 wk after reconstructive surgery—continue using estrogen cream;
recommend performing Kegel exercises on regular basis to maintain integrity of repair; combination conservative
therapy—enhances therapeutic efficacy; in most cases, symptoms reduced by ≈90% in most patients
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| Mechanical devices for exercise-associated urinary incontinence: tampon viable option—for patients who
do not want to wear Smith-Hodge pessary or Colpexin Sphere and women with mild prolapse; contraceptive
diaphragms—can obstruct urethra (excessive obstruction may lead to recurrent urinary tract infections and irritative
voiding after removal of diaphragm); replaced by better devices; other options—intraurethral and external devices
generally unsatisfactory; urethral plug may provide occasional benefit; valved catheter used in select patients with
marked stress incontinence
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 | Pessaries: achieve effect similar to that provided by Burch colposuspension; efficacy measured by Q-tip angle test; regular
use contraindicated in patients with bleeding or markedly atrophic mucosa; estrogen cream—important in postmenopausal
women; 0.5- to 1.0-g dose can be inserted with pessary in place; limiting use to 2 nights/wk prevents
systemic absorption; pessary can be removed nightly or for ≥2 nights/wk; fine tuning—for advanced prolapse, Gellhorn
pessary used most often (Cube pessary associated with excessive suction adhesion to vaginal walls); for stress incontinence,
Smith-Hodge pessary probably best option; caveat—maintain adequate selection of pessaries in office to
provide patient with properly fitting device
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| Individualizing therapy: for mild to moderate stress incontinence—Kegel exercises excellent option; prolapse may
be exteriorized with pessary or Colpexin Sphere; patients with intrinsic sphincteric deficiency—probably not good candidates
for Kegel exercises; may benefit from use of pessary; usually require sling procedure to manage problem; when
patients cannot contract pelvic floor muscles appropriately—electrical stimulation may help muscles contract; surgery
recommended for those experiencing stress incontinence
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| MEDICAL THERAPY FOR URINARY STRESS INCONTINENCE —Peter K. Sand, MD, Professor of Obstetrics and
Gynecology, Northwestern University, Feinberg School of Medicine; Director, Evanston Continence Center; and Director,
Division of Urogynecology and Pelvic Reconstructive Surgery, Evanston Northwestern Healthcare, Chicago, IL
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| Drugs used to treat stress incontinence: α-adrenergic agents—options include phenylpropanolamine (withdrawn
from market; associated with risk for stroke) and pseudoephedrine; imipramine (Tofranil)—serotonin and norepinephrine
inhibitor; increases urethral sphincteric tone; study evaluating management of overactive bladders and urge urinary
incontinence shows imipramine works as well as oxybutynin (eg, Ditropan; Ditropan XL); duloxetine (Cymbalta)—used
off-label for managing urinary incontinence in United States; use hampered by nausea rate of 23% during first month of
therapy (problem resolves within 1-4 wk)
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| Bladder activity: with normal bladder function—urine can be stored at low bladder pressure without urgency; bladder
should remain closed until individual decides to void; with voiding, bladder and urethral activity occur in coordination; in
overactive bladder, patient experiences—decrease in warning time; urgency; eventual decrease in functional bladder capacity;
combination of behavioral therapy and drug therapy—more effective than using either approach independently;
adding antimuscarinic therapy to preexisting behavioral therapy enhances therapeutic results
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| Tricyclic antidepressants: for bladder overactivity—imipramine; doxepin (eg, Sinequan) more effective than placebo;
amitriptyline—nociceptive blocker often used to treat IC; no more effective than placebo for treating detrusor overactivity; effective
for managing sensory symptoms of urgency and frequency
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| Nocturnal enuresis with marked nocturia: caused by reverse diuresis associated with age-related decline in secretion
of antidiuretic hormone; synthetic antidiuretic hormone, ie, 1-deamino-8-D-arginine vasopressin (DDAVP)—available as
nasal spray or pill; corrects reverse diuresis; concentrates urine to treat nocturia; risk for hyponatremia and water intoxication
mandates electrolyte monitoring in middle-aged and older patients
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| Reducing urge incontinence: tolterodine, extended-release (Detrol LA)—no more effective than immediate-release
formulation; produces 28% less dry mouth; less potent than oxybutynin in reducing incontinence episodes; oxybutynin,
extended-release (Ditropan XL) and transdermal system (Oxytrol)—reduce dry mouth and constipation; forced-dose titrations
decrease incontinence episodes by 83% to 90%
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Drug Comparisons
| Ditropan XL vs Detrol LA: Overactive Bladder: Judging Effective Control and Treatment (OBJECT) trial—Ditropan
XL 10 mg more effective than bid Detrol LA in reducing incontinence and urinary frequency; Overactive bladder: Performance
of Extended-Release Agents (OPERA) trial—compared Ditropan XL (10 mg) to Detrol LA (4 mg); both drugs
similarly effective in reducing episodes of urge incontinence; Ditropan XL proved superior to Detrol LA in reducing urinary
frequency and rendering patients completely dry
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| Oxytrol transdermal system: associated with lower incidence of dry mouth and constipation than other oxybutynin
formulations; activity may be related to significant reduction in n-desethyloxybutynin exposure achieved with transdermal
administration; superior to placebo in reducing incontinence episodes and increasing voided volume; caveat—
pruritus or erythema after patch removal may be associated with removal techniques
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| Trospium chloride: quaternary amine; less likely to cross blood-brain barrier; safe; episodes of urge incontinence reduced
by ≈66%; after 12 wk of treatment, episodes of incontinence eliminated in 30% of subjects, and urinary frequency
reduced by ≈20%; produced greater increase in voided volume than any other medication in worldwide literature;
points—nocturia most often associated with nocturnal polyuria; increased voided volume reduces urgency and improves
nocturia by reducing number of trips to bathroom
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| Solifenacin (Vesicare): safe and effective; 5-mg dose—reduces urinary frequency and incontinence; increases voided
volume by 19%; 10-mg dose—increases voided volume by 25%; can affect nocturia; data show—5-mg dose made 51% of
women (14 leakage episodes per week) completely dry, according to 3-day diary; solifenacin more effective in reducing incontinence
and urgency than Detrol LA; Vesicare Efficacy and safety iN patients with Urgency Study (VENUS)—
solifenacin better than placebo for treating urgency (5-mg and 10-mg doses increased median warning time by ≈30 sec and
mean warning time by ≈3 min); less dry mouth and constipation seen with 5-mg dose than with other oral medications
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| Darifenacin (Enablex): 7.5- and 15-mg doses markedly reduce urgency, incontinence, and number of voids; 15-mg
dose significantly increases voided volume (7.5-mg dose less effective); effectively manages nocturia; provides good cognitive
and cardiac safety; produces less dry mouth
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| Future developments: new antimuscarinics; potassium channel openers; calcium channel blockers; prostaglandin inhibitors;
neurokinin receptor antagonists; β-adenoreceptor antagonists; botulinum toxin (Botox)
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Suggested Reading
Anderson RU et al: Effectiveness and tolerability of extended-release oxybutynin vs extended-release tolterodine in
women with or without prior anticholinergic treatment for overactive bladder. Int Urogynecol J Pelvic Floor Dysfunct
17:502, 2006; 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 39:1069, 2007; Chapple CR et
al: Treatment outcomes in the STAR study: a subanalysis of solifenacin 5 mg and tolterodine ER 4 mg. Eur Urol 52:1195,
2007; Davila GW: Transdermal oxybutynin in the treatment of overactive bladder. Clin Interv Aging 1:99, 2006; Neumann
PB et al: Pelvic floor muscle training and adjunctive therapies for the treatment of stress urinary incontinence in
women: a systematic review. BMC Women’s Health 6:11, 2006; Roe B et al: systematic reviews of bladder training and
voiding programmes in adults: a synopsis of findings from data analysis and outcomes using metastudy techniques. J Adv
Nurs 57:15, 2007; Sasso KM: The Colpexin Sphere: a new conservative management option for pelvic organ prolapse.
Urol Nurs 26:433, 2006; Smith PP et al: Current trends in the evaluation and management of female urinary incontinence.
CMAJ 175:1233, 2006; Trowbridge ER, Fenner DE: Practicalities and pitfalls of pessaries in older women.
Clin Obstet Gynecol 50:709, 2007; Wein AJ: Weighted vaginal cones for urinary incontinence. J Urol 170:1045, 2003.
Educational Objectives
| The goal of this program is to improve the management of urinary incontinence in women. After hearing and assimilating
this program, the clinician will be better able to:
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| 1. Initiate appropriate office evaluation of women presenting with urinary incontinence
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| 2. Review types of behavioral therapy used to manage stress and urge incontinence.
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| 3. Determine the clinical value of pelvic muscle strengthening exercises in the management of stress and urge incontinence
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| 4. Assess mechanical devices used to manage exercise-related incontinence.
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| 5. Describe the clinical characteristics of drugs currently used to manage stress urinary incontinence.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning
committee 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. Davila is
affiliated with Adamed, American Medical Systems, Astellas Pharma, and Watson Pharmaceuticals; Dr. Sand is affiliated
with Allergan, Astellas, American Medical Systems, Boston Scientific, Indevus/Esprit, Ortho-McNeil, Pfizer, and Watson
Pharmaceuticals; Dr. Kho and the planning committee reported nothing to disclose.
Acknowledgments
Dr. Kho gave her scientific lecture at the 16th Annual Urogynecology and Disorders of the Female Pelvic Floor, presented
March 29-31, 2007, in Scottsdale, AZ, by the Mayo Clinic College of Medicine, Scottsdale; Drs. Davila and Sand gave their
scientific lectures at Advances in Urogynecology and Reconstructive Pelvic Surgery, presented June 7-9, 2007, in Chicago,
IL, by Northwestern University’s Feinberg School of Medicine and the Evanston Continence Center, Division of Urogynecology,
Evanston Northwestern Healthcare. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation
in the production of this program.
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