Written Summary: Urology, 32:04 - URINARY INCONTINENCE IN WOMEN

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Volume 32, Issue 04

April 1, 2009

The following is an abstracted summary, not a verbatim transcript, of the lectures/discussions on this audio program. If, after reviewing this written summary, you would like to hear the contents and/or earn CME/CE credit, simply visit the Audio-Digest Foundation website

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Urinary Incontinence in Women

From Northwestern University’s Feinberg School of Medicine’s Symposium on Advances in Urogynecology
and Reconstructive Pelvic Surgery

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:

1. State the signs and symptoms of urodynamic stress urinary incontinence (USUI), and distinguish it from detrusor overactivity, neurogenic voiding dysfunctions, and neoplasia.

2. Describe the features, utility, and cost-effectiveness of the diagnostic procedures for USUI.

3. Discuss the various exercises and devices designed to strengthen the pelvic floor muscles (PFM).

4. Choose appropriate biofeedback and other management techniques for patients undergoing PFM training.

5. Effectively and safely perform surgery for placement of retropubic midurethral slings.

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. Walters receives honoraria as a speaker for American Medical Systems. Ms. Sasso is on the Speaker’s Bureau for Adamed. The planning committee reported nothing to disclose.

Acknowledgements

Lectures by Dr. Walters and Ms. Sasso were recorded at Advances in Urogynecology and Reconstructive Pelvic Surgery, held June 12–14, 2008, in Chicago, IL, and sponsored by the Northwestern University 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.

Diagnosis of Urodynamic Stress Incontinence

Mark D. Walters, MD, Professor and Vice Chair of Gynecology, Department of Obstetrics and Gynecology, Obstetrics, Gynecology, and Women’s Health Institute, Cleveland Clinic, Cleveland, OH

International Continence Society (ICS) definitions: symptom — involuntary leakage of urine (eg, while coughing or sneezing); sign — direct observation of transurethral loss of urine during provocation; indicates stress urinary incontinence (SUI); condition — urodynamic stress urinary incontinence (USUI); true diagnosis made only by filling cystometry in cough stress test; involuntary transurethral loss during increased abdominal pressure in absence of detrusor contraction; presence of simultaneous detrusor contraction not ruled out in cough stress test

Differential diagnosis: includes USUI, detrusor overactivity (idiopathic or neurogenic), mixed types, and fistulas; »66% of healthy women who leak urine have USUI; 25% to 33% have detrusor overactivity

History: leakage while coughing or sneezing indicates SUI; urgency, urge incontinence, frequent voiding, nocturia, and bedwetting suggest overactive bladder; dysuria, difficulty voiding, postvoid fullness, and postvoid dribbling suggest neurogenic voiding dysfunctions; hematuria suggests neoplasia

Physical examination: includes timed measured voiding, residual urine volume, pelvic examination, and screening neurologic examination

Diagnostic tips: almost all patients with USUI have symptom of stress incontinence; the more irritative voiding symptoms woman has, the less likely she has USUI; women without urethral hypermobility or anterior wall prolapse probably do not have USUI, unless they have had previous surgery, eg, sling, Burch, or Marshall-Marchetti-Krantz (MMK) procedures

Simple cystometrography (CMG): perform urinalysis, time measured void, residual urine volume (to rule out hematuria, infection, and gross voiding abnormalities); fill bladder to sensation and measure capacity (rules out areflexic, hyperreflexive, or low-capacity bladder); look for severe urgency or leakage around catheter (occurs in »50% of patients with detrusor overactivity); remove catheter and ask patient to cough; positive cough test suggests SUI; if negative, repeat while patient standing; if still negative, patient does not have SUI

Cough stress test: study shows sensitivity for USUI 92%; however, concordance between multiple cough stress tests <100%

Accurate multichannel urodynamic testing: subtractive CMG with bladder pressure subtracted from rectal pressure to give detrusor pressure; in patient with stable CMG, urethral closure pressure obtained with dual Millar microtransducer catheter; leak indicated when subtraction or closure pressure goes to zero

Urethral pressure profiles (UPPs): pull transducer through urethra to determine maximal closure pressure and urethral length; study showed height of maximal urethral closure pressure (MUCP) predicts cure rate with Burch procedure; outcome prediction less accurate with retropubic midurethral sling (RMS; eg, transvaginal tape [TVT] method)

Case examples: patient with typical USUI had MUCP of 40 cm H₂O; patient with low MUCP of 16 cm H₂O had low-pressure urethra (intrinsic sphincter deficiency); data show RMS works in all ranges of incontinence

Leak point pressure (LPP): proxy for severity of disease; high LPP indicates mild disease; if LPP low (eg, 40-80 cm H₂O), disease more severe; LPP correlates with number of leaks and pads per day

Urodynamic testing studies: reviewed 100 urodynamic tracings (filling, stress test, and voiding assessments) and made diagnoses; tests reread by original specialist then read by other specialists; good reliability and interobserver agreement for SUI; moderate to poor reliability for reading detrusor overactivity and voiding disorders; positive cough stress test most reliable; studies have generally shown UPPs and LPPs not reproducible or reliable and do not predict outcomes well

Intrinsic sphincter deficiency (ISD): proxy for more severe disease; essentially all SUI represents ISD that ranges from mild to severe

Cost-effectiveness of urodynamic tests: compared use of CMG and uroflow before surgery to no CMG or uroflow; in scenario in which women had high pretest probability of SUI, urodynamic testing not cost-effective; in scenario with pretest probability »50%, urodynamic testing more cost-effective in predicting surgical cure; only patients with positive cough stress test should receive surgery

Behavioral Therapy for Stress and Urge Incontinence

Karen Sasso, RN, APN, Urogynecology Clinical Nurse Specialist, and Manager, Evanston Northwestern Healthcare Urogynecology Program, Evanston Continence Center, Evanston, IL

Approach to patients: for motivated patients, introduce all 3 components of behavioral therapy on first visit, ie, pelvic floor exercises, electrical stimulation, and bladder retraining (bladder drill); inexpensive, and improves outcome; patient must have cortical control of bladder

Pelvic floor muscle (PFM) physiology: PFMs (levators) comprise fast-twitch and slow-twitch fibers; important to exercise both; previous therapies focused on slow-twitch fibers with sustained contractions; recently, strong quick contractions added to exercise fast-twitch fibers

Assessment of PFM: baseline examination consists of digital-rectal examination with other hand on patient’s abdomen; assesses strength, duration of contraction, tone, and lift from levators; determine whether patient uses accessory muscles; evaluate 10 sec of contraction followed by 10 sec of relaxation and grade on scale of 1 to 5

Performing exercise: have patient empty bladder and bowel, relax completely, and contract PFM to pull up (feel tugging of vagina and rectum); focus on not using accessory muscles,eg, thigh muscles; contract ³5 to 10 sec and relax for same duration; perform 10 min, twice daily, for 12 to 20 wk; alternate quick and sustained (10 sec) contractions; ultimately, patient develops habit of using quick strong contraction of PFM (“knack”) before sneeze or cough to reduce leakage

Expected outcomes: improved strength and tone of levator muscles; increased urethral and rectal resistance; inhibited involuntary bladder contraction; improved pelvic organ support in patients with prolapse

Biofeedback: for patients unable to perform correct PFM contractions; electrical stimulation useful if patient unable to generate PFM contraction; also decreases urgency and frequency of overactive bladder symptoms (lower Hz setting); objectively demonstrates improvement; vaginal cones used to maintain improvement after PFM therapy complete; procedure — use vaginal probe and EMG electrodes around anus and on abdomen

Biofeedback plus urodynamics: prepare patient for urethrocystometry; when patient experiences decrease in urethral pressure and increase in bladder pressure, she contracts PFM

Study of home biofeedback: 94 women with documented SUI completed 6-mo trial of PFM exercises with or without home biofeedback; compliance in 80% range; rates of cure (£2 g on pad weight test) not significantly different between 2 groups

Electrical stimulation: used for stress, urge, and fecal incontinence; directly stimulates nerves of pelvic floor; set at 50 Hz (lower for detrusor overactivity); shown to decrease urgency and increase bladder capacity in patients with overactive bladder; stimulation set to give desired treatment (eg, 2 sec of contraction and 4 sec of relaxation), 20 to 30 min, twice daily, for 12 to 20 wk (improvement seen at »6 wk); follow with maintenance therapy (daily or every other day)

Vaginal cones: patient should retain cone for 15 min by keeping PFMs contracted; gradually increase weight of cone (range 18-71 g); therapy lasts 6 to 20 wk

Study: 107 women with documented SUI randomized to 4 groups; one group did PFM exercises 8 to 12 times, 3 times daily, with weekly sessions with physical therapist; one had electrical stimulation 30 min/day; one had vaginal cones 20 min/day; control group had no treatment; after 6 mo, group doing PFM exercises had clinically significant improvement (possible bias due to weekly sessions with physical therapist)

Bladder retraining: effective for overactive bladder or dysfunctional voiding syndromes; initially, patients trained to void at frequency »0.5 hr longer than usual interval; gradually increase time between voiding, with instruction on urge inhibition techniques, eg, position change, Kegel exercises; positive reinforcement by bladder coach; studies show 80% rate of success

Management: hydration — overhydration causes urgency, frequency, and nocturia; dehydration causes irritation, urgency, and frequency due to concentrated urine; adequate hydration determined by observing color and odor; daily fluid intake should be 0.5 oz per pound of body weight, depending on weather; food — bladder irritants include caffeine, alcohol, carbonated beverages, and foods high in arylalkylamines (eg, chocolate); absorbent products — patients should use incontinence pads, not menstrual pads; intravaginal support devices — support bladder neck or partially compress bladder (eg, tampons, continence dish/ring, [pessaries less useful]); occlusive or obstructive devices — inconvenient and not as effective; self-management — reduce weight, quit smoking, and prevent constipation

Benefits of behavioral therapy: low risk; noninvasive; decreases or alleviates incontinence; patient participates; less costly

Drawbacks: time-consuming; high motivation needed; slow progress

Tension-free Retropubic Midurethral Slings

Dr. Walters

Retropubic anatomy: integral theory — proposes control of urethral closure achieved by interplay of 3 structures, ie, pubourethral ligaments, suburethral vaginal hammock, and functional pubococcygeus muscle; breakdown of any of these structures causes incontinence; insertion of strip of mesh (ie, RMS) compensates for problems with pubourethral ligaments; allows movement of bladder base; kinking obstructs urethra during coughing, then releases to unobstructed state during rest and voiding

Procedure: outpatient procedure under local anesthesia; quick recovery improves voiding function in »1.5 days; small midurethral incision made under urethra with 2 suprapubic puncture sites; pass device from below up along urethra, through retropubic space and endopelvic fascia; follow back of pubic bone; pass through rectus fascia and skin, and guide up; repeat on other side; few vaginal or urethral erosions from polypropylene mesh

Vascular incidents: study in 10 cadavers; measured position of trocar relative to major vascular and visceral structures; found 3.9 cm of space before epigastrics, 3.2 cm of space up and lateral to obturator vessels; »5 cm to external iliac vessels; but 5° to 10° rotation of handle swings tip out 2 to 3 cm, dangerously close to vessels; safe area of only 3 cm x 4 cm in space of Retzius (near where Burch sutures would go); deviation from pubic bone cephalad brings tip into peritoneal cavity and risks damage to bowel; deviation medial risks bladder; major vascular structures closer to rectus fascia than to urogenital diaphragm; proper tracking critical

Top-down approach: developed because operator has more control at place of insertion than at exit site; reduces risk for vascular injury; provides more control and less chance of bowel injury (<1 in 1000); this approach still has risk for urethral perforation

Studies: trial showed rate of cure >80% with SUI, and very few failures; randomized trial in United Kingdom comparing open Burch and RMS in 344 patients found no significant difference in rate of cure at 2 yr; higher rate of bladder injury with RMS; voiding times and recovery longer with Burch; Cleveland Clinic study also showed RMS superior to laparoscopic Burch procedure; meta-analysis found transobturator slings equivalent to RMS in most patients; RMS possibly superior for patients with ISD

Complications: ³4% chance of puncturing bladder; <10% rate of minor voiding difficulties of low level retention; 2% to 3.5% rate of retention requiring surgical revision; »2% rate of retropubic hematoma; rare injuries to iliac and femoral veins and perforations of obturator artery, including deaths; study of»1500 patients found 3 in 1000 required laparotomy to repair problem; retropubic hematomas may require administration of blood products; RMS may cause more irritative voiding symptoms and urgency than transobturator slings

Editor’s Note

Current information on the June 11 to 13, 2009, Northwestern University Feinberg School of Medicine symposium on Advances in Urogynecology and Reconstructive Pelvic Surgery can be obtained at http://www.cme.northwestern.edu/conferences/brochures/Urogyn%202009%20brochure%20Final.pdf.pdf.