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Female Urinary
Incontinence
Dr Ida Mah
Specialist in Urology
Hong Kong Urology Clinic
Pedder Street, Central
Hong Kong
Urinary Incontinence

The involuntary loss of urine per
urethra
Prevalence


Depends on diagnostic criteria and studied
population
34% in Hong Kong women aged 18 and
above reported urinary incontinence
– Ma SS, Urogynecol J Pelvic Floor Dysfunct. 1997; 8 (6): 327-31

49% of female aged 18 and above have
urinary incontinence
– Ngan et al, the Hong Kong Practitioner 2006 vol 28

34% of female age 10-90 experienced
stress incontience
– Pang MW et al, Hong Kong Med J 2005 Jun; 11(3): 158-63
Urinary Incontinence
Urinary Incontinence
Types of Urinary
Incontinence




Stress Urinary Incontinence
Urge Urinary Incontinence
Mixed Urinary Incontinence
Overflow Urinary Incontinence
Stress Urinary
Incontinence

Definition: the
involuntary loss of
urine per urethra
caused by an
increase in intraabdominal pressure
Continence Mechanism

Anatomical support
– Intact pelvic floor that hold the bladder neck and
urethra in place

Intrinsic urethral mechanisms:
– Coaptation


Mucosa
Submucosa
– Compression



Submucosa
Internal sphincter
External sphincter
Causes of SUI


Pelvic floor laxity due to childbirth
Damage to the urethra due to
– Radiation
– Surgery (hx of urethral surgery)
– Neurological
– Trauma
History





SUI is a clinical diagnosis
Association activities
childbirth history
Hx of surgery or injury to the urethra
Effect on Quality of Life
Physical Examination

Abdominal, rectal, vaginal examination
– Look for presence of stress urinary
incontinence
– Look for coexisting pelvic organ prolapse
– Assess pelvic floor muscle tone
Pad test



Semi-qualitative assessment of the severity
of leakage
1 hour, 2 hours or 24 hours
1 hour:
– Patient is asked to drink 500cc of water
– Then perform a series of standard exercise like
climbing stairs and walking
– Weight gain of pad is then measured
– Significant if >2gm
Management of SUI

Conservative

Surgical
How to decide plan of
treatment?

Severity of patients’ symptoms
– Subjective and objective



Fitness for operation
Presence of other pathology
Complications or morbidity of
treatment
Conservative
Management

Behavioral Modification

Pharmacotherapy??

Pelvic floor exercise
Behavioral Modification

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Diet and lifestyle
changes: avoidance
of caffeine, stop
smoking etc
Fluid management
Timed voiding
Bowel habit: avoid
constipation
Pharmacotherapy

Estrogen
– Subjective but no objective improvement

Serotonin(5-HT) and noradrenaline
reuptake inhibitor (Duloxetine)
Duloxetine


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Significantly reduces incontinence frequency and
improve the patient’s QOL
Significant side effects of nausea,dry mouth,
fatique, insomnia & constipation (11-23%)
Approved for use in patients with moderate to
severe SUI in Europe
Not approved in the States for use in SUI by the
FDA because of several suicidal deaths associated
with withdrawal of the drug
Pelvic Floor Exercise
Locate pelvic floor muscles
Squeeze pelvic
floor muscles
as tightly as
possible for a
few seconds
(maximum of
10 seconds)
Repeat, as
recommended
by physician/
continence
advisor
Relax completely for at
least 10 seconds
Pelvic Floor Exercise


Make sure patients
contract the
appropriate muscle
Biofeedback
– Vaginal cone
– Perineometer
Pelvic Floor Exercise

Need a
dedicated
therapist to
supervise the
therapy and
follow up the
patients
Surgical Treatment for
SUI
Goal of Surgery for SUI

Prevention of urethral descent
– Retropubic Suspension

To provide a backboard against which the
bladder neck and proximal urethra can be
compressed during increases in intraabdominal pressure
– Sling Procedure
Surgical Rx of SUI

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
Retropubic Suspensions
Sling Procedures
Injection therapy
Burch Colposuspension



Described in 1961
Lateral fixation of
urethrovaginal tissue to
the Cooper’s ligament
Complications:
– Enterocoele (5-10%)

Disadvantage:
requirement of an
abdominal incision
Surgical Rx of SUI
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Retropubic Suspensions
Sling Procedures
Injection therapy
Sling Procedure

Autologous Sling
– Rectus Fascia
– Fascia Lata

Synthetic Sling
– Polypropylene
Pubovaginal Sling(Autologous)
Tension Free Vaginal
Tape
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First described by
Ulmsten in 1996
A polypropylene tape
placed at mid-urethra
Tension free urethral
support
Minimal invasive
Short hospital stay
Quick return to normal
daily activities
> 1 million tapes have
been implanted
worldwide
Tension Free Vaginal
Tape
Transobturator Tape
Results of Urethral Tape

85% cure rate at 1-3 year follow-up
– Ulmsten U et al Br J Obstet Gynaecol 1999;106:345-350
– Olsson I et al Gynecol Obstet Invest 1999;48:267-269

85% cure rate at 5 year follow-up
– Nilson et al Inter Urogyne Journal 2001(suppl 2): S5-S8

TVT vs Colposuspension: similar
success rate but TVT provides shorter
hospital stay and less days off from
work
Urge Incontinence


Urge incontinence is the involuntary
loss of urine associated with or
preceded by urgency
Caused by involuntary detrusor
contraction (detrusor overactivity)
during the filling phase
Definition

Detrusor overactivity is a urodynamic
observation characterised by involuntary
detrusor contractions during the filling
phase which may be spontaneous or
provoked
– Neurogenic detrusor overactivity
– Idiopathic detrusor overactivity

International Continence Society 2002
Symptom-based definition
of Overactive Bladder

OAB is a syndrome referring to the
symptoms of frequency, urgency, urge
incontinence, either single or in any
combination, when appearing in the
absence of local pathologic or
metabolic factors explaining these
symptoms

Abrams P and Wein AJ: Urology 51(6):1062
Prevalence of OAB




8-35%, depends of studied population
and methods of evaluation
13.7% in Hong Kong
More commonly in the elderly
Urge incontinence affects at least 13
million Americans at a cost to the
economy of $16 billion annually
Bladder Filling & Emptying
Cycle
1. Bladder fills
Detrusor muscle relaxes
Urethral
sphincter
contracts
The cycle of
bladder filling
and emptying
Detrusor muscle
contracts
Urination
Urethral
sphincter
relaxes
3. Urination
voluntarily inhibited
until time and place
are right
2. First desire to
urinate (bladder
half full)
Pathophysiology of OAB

Involuntary
detrusor
contractions occur
during the filling
phase which cause
the sensation of
urgency
Etiology of Detrusor
Overactivity

Neurogenic
– Spinal cord disorder, DM

Local bladder irritation
– Stones, infection, tumour, foreign body

Bladder outlet obstruction
– BPH
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Aging
Idiopathic (OAB)
Etiology of Idiopathic
OAB

Disorder of the micturition reflex
– Loss of cortical or peripheral inhibition

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Disorder of neurotransmission
Myogenic disorder
– Structural changes cause increased
sensitivity to stimulation

Behavioral / psychological
Etiology of OAB

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No single theory explains the
pathophysiology of OAB
Significant advances have been made
but still a long way to go to
Symptoms of OAB
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Frequency (85%)
Urgency (54%)
Urge incontinence (36%)
Nocturia
•Milsom et al 1999
Goals of Evaluations

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Rule out local pathologic and
metabolic factors
Identify other treatable / curable
conditions
Identify other serious underlying
conditions
Initial Evaluation
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History
Physical Examination
Voiding diary
Evaluation: History

Identify the symptoms of OAB
– Frequency, urgency, urge incontinence, nocturia
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Symptoms suggestive of underlying causes
– Haematuria
– Hx of urinary tract stones


Hx suggestive of outlet obstruction
Medical and neurological history
Evaluation:
Physical Examiantion
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General Examination (including
bladder palpation)
Digital rectal examinatioin in males
Pelvic examination in females (observe
for SUI and prolapse
Neurological examination
Evaluation: Voiding Diary
Evaluation: Lab tests

Urinalysis
– MSU to rule out haematuria, pyuria,
bacteruriaand glucosuria
– Urine for cytology

Blood tests
– Fasting blood glucose
– Renal function
Evaluation: Radiology

KUB
– To rule out underlying urinary tract
especially bladder stones

USG kidneys and bladder
– To detect bladder pathology
– To detect upper tract damage in patients
with neurogenic bladder
Urodynamic Study
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Filling cystometry
Involuntary
detrusor contraction
? >15cm water
Associated with
symptoms
Spontaneous or
provoked
Bladder capacity
Assess outlet
obstruction
UD tracing : detrusor
overactivity
Urodynamic Study

False Positives
– 60% of normal volunteers

False Negatives
– 10-40% with negative UDS have positive
ambulatory UDS
Indications for UDS

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Treatment failure
Suspect outlet obstruction
Association with stress incontinence
Suspect neurogenic bladder
Consideration of surgery
Indications for referral to
urologists
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Evidence of bladder outlet obstruction
Haematuria (? Underlying carcinoma)
Associated with neurological disease
Bladder stones
Associated with stress incontinence or
pelvic prolapse
Failed medical treatment/consideration
of surgical Rx
Management of OAB
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Behavioral therapy
Pharmacologic therapy
Surgery
Behavioral Therapy
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Education
Voiding diaries
Fluid/dietary management
Bladder training/timed voiding/delayed
voiding
Pelvic floor training/biofeedback
Education

Education on the
normal bladder
physiology and
pathophysiology of
OAB
Dietary advice
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Fluid management
Avoid stimulants
like coffee, tea and
alcohol
Behavioral Therapy
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Bladder training
Timed voiding/delayed voiding
No standard protocol, teaching
material or technique
Efficacy: low cure rates, improve
efficacy if combined with drug Rx
Results better in urodynamically stable
patients
Pelvic Floor Training


Competent pelvic
floor muscles make
the difference
between wet and
dry OAB
Indicated in
patients with urge
incontinence and
weak pelvic floor
muscle
Pharmacologic Therapy

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Muscarinic cholinergic receptors located on
detrusor muscle respond to parasympathetic
mediated release of acetylcholine to
stimulate detrusor contraction
5 muscarinic receptors have been described
M3 responsible for activating detrusor
contraction
M3 receptors also mediate salivary
secretions and bowel contraction (ie. Side
effects)
Side Effects of Drug Rx

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Mainly due to their anticholinergic
action
Dry mouth
Blurred vision
Constipation
Tachycardia
Drowsiness
Contraindication and
precaution


Contraindicated in patients with
narrow angle glaucoma
Use with caution in patients with
outlet obstruction as the drugs may
precipitate retention
Oxybutynin (ditropan)

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Binds to M2 and M3 receptors
Dosage: 2.5mg bd to 5mg tds
Significant side effects: dry mouth,
decreased gastric motility
18% patients remain on Rx for over 6
months
Less side effects in children
Tolterodine (detrusitol)



Not receptor selective but selective for
bladder tissue over salivary tissue
Efficacy similar to oxybutynin but less
dry mouth and less withdrawals from
drug Rx
Dosage: 2mg bd
Solifenacin (Vesicare)


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Slow release
Plasma level rise over 4-6 hours , then
steady over 24 hours
Demonstrated efficacy at a lower
steady level to reduce side effects
Tricyclic Antideprssants
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Imipramine most commonly used
Central and peripheral anticholinergic effects
Block norepinephrine and serotonin reuptake thereby causing a direct inhibition of
normal excitatory pathways
Sedative
Dosage: 10mg QD to 25mg QID
Side effects: anti-cholinergic side effects,
weakness, fatigue
Acupuncture

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Endorphinergic effects at the sacral
spinal cord level or above
Inhibit somatovesical reflexes
Increase in peripheral circulation
Need randomised control studies
Surgical Treatment for
OAB




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Bladder overdistension
Supratrigonal transection of bladder
Bladder denervation
Neuromodulation: Interstim
BOTOX injection
Augmentation enterocystoplasty
Surgical Treatment for
OAB

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Bladder overdistension
Supratrigonal transection of bladder
Bladder denervation
Neuromodulation: Interstim
BOTOX injection
Augmentation enterocystoplasty
Sacral Neurmodulatioin



A tined lead is
introduced to the
S3 nerve foramen
Lead is then
connected into a
lead generator
Temporary vs
permanent
generator
Sacral Neuromodulation

Outcome
– 47% dry
– 29% improved

Side effects:
– Pain (16%)
– Implant infection (19%)
– Lead migration (7%)

Cost
Surgical Treatment for
OAB
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Bladder overdistension
Supratrigonal transection of bladder
Bladder denervation
Neuromodulation: Interstim
BOTOX injection
Augmentation enterocystoplasty
Injection of BOTOX


BOTOX A blocks
acetylcholine release at
the neuromuscular
junction
Injection of BOTOX at
suburothelial space
modulates the release
of neurotransmitters
from sensory nerve
endings, thus inhibiting
the occurrence of
bladder overactivity
Injection Site

*
Generally
around
* * * * * * * *distributed
*
* * * * * *
*
* * * * * *
bladder
* * * * * * *
*
– Avoid dome
 Potential for intraperitoneal
injection
 Difficulty of injection
Injection of BOTOX

Advantage:
– Effective
– Effect last for 6-8
months
– Minimal invasive
– Outpatient
procedure

Disadvantage
– Effect last for 6-8
months only
– Risk of retention of
urine (10%)
– Limb weakness
Surgical Treatment






Bladder overdistension
Supratrigonal transection of bladder
Bladder denervation
Neuromodulation: Interstim
Injection of BOTOX
Augmentation enterocystoplasty
Augmentation
Enterocystoplasty



Clam cystoplasty
Up to 90% success
rate in DI and
neurogenic bladder
Increase the
bladder capacity
and abolish the
unstable
contraction
Side Effects of
Cystoplasty

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Retention of urine
Mucus plug retention
Stone formation
Electrolyte disturbance
Malignancy
Reserved for patients who have intractable
symptoms and are willing to accept the
possible side effects
Conclusions



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
Urinary incontinence is a common problem
Treatment depends on the nature and severity of
the condition
OAB: important to identify treatable underlying
factors
Patients should be provided with information on
various choices of Rx (conservative & operative)
With appropriate Rx patients could be cured of the
incontinence and thus improving the quality of life