10/26/2016

Disclosures

MANAGEMENT OF STRESS URINARY INCONTINENCE

• None

Michelle Y. Morrill, M.D. Chief of Female Pelvic Medicine and Reconstructive Surgery, TPMG Director of Urogynecology, Kaiser SFO Assistant Professor, Volunteer Faculty, Department of ObGyn UCSF

Goals

Urinary Incontinence

• Review the epidemiology and causes of stress urinary

• Accidental leakage of urine

incontinence (SUI) in women • Discuss appropriate diagnostic tools for SUI • Learn about treatment options for SUI

• Common medical condition • Significant Quality of Life factor

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Bladder Function

Urinary Incontinence

3 Ways to Void : 1. Valsalva

3 Ways to Void : 1. Valsalva

3 Ways to Leak : 1. Valsalva

2. Detrusor Contraction

2. Detrusor Contraction

2. Detrusor Contraction

3. Urethral Relaxation

3. Urethral Relaxation

3. Urethral Relaxation

Urinary Incontinence

Urinary Incontinence

3 Ways to Void : 1. Valsalva

3 Ways to Leak : 1. Valsalva (Stress Incontinence)

3 Ways to Void : 1. Valsalva

3 Ways to Leak : 1. Valsalva (Stress Incontinence)

2. Detrusor Contraction

2. Detrusor Contraction

2. Detrusor Contraction

2. Detrusor Contraction

(Overactive Bladder) 3. Urethral Relaxation

3. Urethral Relaxation

3. Urethral Relaxation

3. Urethral Relaxation

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Urinary Incontinence 3 Ways to Void : 1. Valsalva

3 Ways to Leak : 1. Valsalva (Stress Incontinence)

2. Detrusor Contraction

2. Detrusor Contraction

Function: Bladder and Urethra

(Overactive Bladder) 3. Urethral Relaxation

3. Urethral Relaxation (rare)

October 26, 2016

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Dysfunction: Bladder and Urethra

SUI Symptoms

Stress Incontinence • Stress incontinence: • The complaint of involuntary leakage of urine on effort or exertion,

eg. with sneezing or coughing (valsalva)

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SUI Causes? 1994 DeLancey and Ashton-Miller ‘Hammock Theory’:

SUI Causes? 1990 Petros and Ulmsten ‘Integral Theory’

• Support and elevation at the bladder neck maintains continence

• Urethra opened and closed by interaction of vaginal wall, ligaments and

• Injury to the levator muscles and pubocervical support tissues led to SUI

• Laxity in the tissues leaves the urethra open when these forces attempt to

muscle around the urethra close it • Midurethral sling developed to reinforce the high pressure zone of the

middle urethra

Chermansky CJ, Moalli PA. Role of pelvic floor in lower urinary tract function. Autonomic Neuroscience: Basic and Clinical 200 (2016) 43–48

SUI Causes?

Chermansky CJ, Moalli PA. Role of pelvic floor in lower urinary tract function. Autonomic Neuroscience: Basic and Clinical 200 (2016) 43–48

SUI Causes? • Lack of support or squeeze on the urethra

2008 DeLancey • Study: Women with SUI vs. controls • Maximum urethral closing pressure was lower in SUI • Resting and contracting urethral axis (bladder neck) significantly lower in SUI • Levator ani strength and MRI imaged defects were similar

• Not bladder • Not prolapse • Treatment of prolapse can → stress incontinence1

• Concluded that urethral function is most strongly associated with

SUI. DeLancey, J.O.L., Trowbridge, E.R., Miller, J.M., Morgan, D.M., Guire, K., Fenner, D.E., Weadock, W.J., Ashton-Miller, J.A., 2008. Stress urinary incontinence: relative importance of urethral support and urethral closure pressure. J. Urol. 179, 2286–2290.

1Jelovsek

JE. Predicting urinary incontinence after surgery for pelvic organ prolapse. Curr Opin Obstet Gynecol. 2016 Oct;28(5):399-406.

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Post-Void Dribbling

Urinary Incontinence Epidemiology • Prevalence

Treatment = Double 1. 2. 3.

50%

• Urinary Incontinence in the past year1 :

Voiding

Relax to void Stand and count to 10 Sit briefly for drops

1R

Dooley Y, et al. Urinary Incontinence Prevalence: Results From the National Health and Nutrition Examination Survey. J Urol 2008; 179, 656-661

Urinary Incontinence Epidemiology

Urinary Incontinence Epidemiology

• Prevalence

• Prevalence

• Urinary Incontinence in the past

year1

: 50%

• Urinary Incontinence in the past year1 :

• Bother (EPIQ questionnaire)

• Stress

incontinence2

• Urgency and urge

• Bother (EPIQ questionnaire)

: 15%

incontinence2

50%

• Stress incontinence2 :

: 13%

15%

• Urgency and urge incontinence2 : • Care

Seeking3

13%

: 61%

1R 1R

Dooley Y, et al. Urinary Incontinence Prevalence: Results From the National Health and Nutrition Examination Survey. J Urol 2008; 179, 656-661 2Lukacz et al. Parity, mode of delivery and pelvic floor disorders. Obstet Gynecol 2006;107:1253–60

Dooley Y, et al. Urinary Incontinence Prevalence: Results From the National Health and Nutrition Examination Survey. J Urol 2008; 179, 656-661 et al. Parity, mode of delivery and pelvic floor disorders. Obstet Gynecol 2006;107:1253–60 3Morrill et al. Seeking healthcare for pelvic floor disorders: a population-based study. Am J Obstet Gynecol. 2007 Jul;197(1):86.e1-6. 2Lukacz

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Why do women develop SUI?

Urinary Incontinence Racial Differences ‘Moderate – Severe’ Urinary Incontinence by Race

• Risk Factors • Genetics (Family History) • Age • Pregnancy and Childbirth • Obesity • Chronic straining (cough, constipation,

smoking) • Oral estrogen

(Leakage of at least drops weekly or wet monthly) 20 18 16 14 12 10 8 6 4 2 0 White

Wood LN, Anger JT. Urinary incontinence in women. BMJ. 2014 Sep 15;349:g4531

Urinary Incontinence Racial Differences

Black

Wu JM, et al. Prevalence and Trends of Symptomatic Pelvic Floor Disorders in U.S. Women. Obstet Gynecol 2014;123:141–8

SUI Age Differences

Incontinence Impact : Same severity of incontinence is more bothersome to black women than white women1

SUI or MUI in women age 20 – 90+ 35

30

Percent with SUI or MUI

Possibly due to racial disparities in knowledge of risk factors and treatment options for incontinence2 Or due to low levels of knowledge about UI and a reluctance to discuss symptoms with health care professionals3

Hispanic Mexican American

25

20

15

10

5

0

AGE by 5 year groups

1Lewicky-Gaupp

et al. Racial differences in bother for women with urinary incontinence in the Establishing the Prevalence of Incontinence (EPI) study Am J Obstet Gynecol

2009;201:510.e1-6. 2Mandimika CL, et al. Racial Disparities in Knowledge of Pelvic Floor Disorders Among Community-Dwelling Women. Female Pelvic Med Reconstr Surg. 2015 Sep-Oct;21(5):28792. 3Hatchett L, Hebert-Beirne J, Tenfelde S, Lavender MD, Brubaker L. Knowledge and perceptions of pelvic floor disorders among African American and Latina women. Female Pelvic Med Reconstr Surg. 2011 Jul;17(4):190-4.

Hannestad YS, Rortveit G, Sandvik H, Hunskaar S. A community-based epidemiological survey of female urinary incontinence: The Norwegian EPINCONT Study. Journal of Clinical Epidemiology 53 (2000) 1150–1157

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SUI Age Differences

Screening

Young women and incontinence :

“Some women are bothered by urine leakage or going to the bathroom frequently – is this a concern for you?”

Fozzatti C, et al. Prevalence study of stress urinary incontinence in women who perform high-impact exercises. Int Urogynecol J 2012 ;23:1687-91

• Healthy nulliparous women 20 – 45yo • 25% of regularly physically active and

14% of controls reported UI with effort

Evaluation and Diagnosis

Evaluation and Diagnosis : Pre-op

• Evaluate for Urinary infection (UA +/- Cx)

• Stress Test • Yes / No leak • Delay or prolonged leak suggests Stress Induced Detrusor Overactivity

• Ask • UI associated with physical activity such as coughing, sneezing, lifting or exercise

• Post-void residual

• Sensitivity = 0.86 Specificity = 0.61

• Urethral Mobility / Q-tip test? • OR = 1.9 For failure of MUS1

• Physical Exam • Consider uncommon alternatives eg. urethral diverticulum, vaginal discharge

• Urodynamics? • Not if uncomplicated stress-predominant urinary incontinence2 1Richter

1Brown

JS, et al. The Sensitivity and Specificity of a Simple Test To Distinguish between Urge and Stress Urinary Incontinence. Ann Intern Med. 2006;144:715-723.

HE, et al. Demographic and clinical predictors of treatment failure one year after midurethral sling surgery. Obstet Gynecol. 2011 Apr;117(4):913-21. 2Nager CW, et al. A randomized trial of urodynamic testing before stress-incontinence surgery. N Engl J Med. 2012 May 24;366(21):1987-97.

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Pelvic Floor Exercises Stress Incontinence Treatments

• Daily Pelvic Floor exercises Strengthen and Control pelvic

floor muscles • Pelvic Floor Strength and Control at the proper time

prevents incontinence

Pelvic Floor Muscle Exercises (Kegels)

Weight Loss • Possibly beneficial Imamura M, Williams K, Wells M, McGrother C. Lifestyle interventions for the

• Cochrane: Women with SUI who received treatment (Kegels)

treatment of urinary incontinence in adults. Cochrane Database of Systematic Reviews 2015, Issue 12.

• 8 times more likely to report cure (56.1% v 6.0%) • 17 times more likely to report cure/improvement (55% v 3.2%) • Minimal adverse events

• Test squeeze and give feedback with every pelvic exam

• Subak LL, et al for the PRIDE

Investigators. Weight Loss to Treat Urinary Incontinence in Overweight and Obese Women. N Engl J Med 2009;360:481-90.

Stress incontinence Weight-Loss Group (-8% wt. at 6m)

Control Group (-2% wt. at 6m)

Baseline — SUI episodes/wk

9

10

6 Mo — SUI episodes/wk

4

7

−58%

−33%

% Change Dumoulin C, Hay-Smith EJC, Mac Habée-Séguin G. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database of Systematic Reviews 2014, Issue 5. Art. No.: CD005654. DOI: 10.1002/14651858.CD005654.pub3.

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Pessaries

What is a pessary? Physical device in the vagina Note: a tampon may treat or improve SUI! • Cochrane : Pessaries “might be better than no treatment”

Lipp A, Shaw C, Glavind K. Mechanical devices for urinary incontinence in women. Cochrane Database Syst Rev. 2014 Dec 17;(12):CD001756.

• ATLAS trial:

Richter HE, et al. Continence Pessary Compared With Behavioral Therapy or Combined Therapy for Stress Incontinence A Randomized Controlled Trial.,Obstet Gynecol 2010;115:609–17

• 35% denied bothersome Sx at 12 month • 50% satisfied with treatment

Stress Incontinence Treatments (Support or squeeze the urethra)

Stress Incontinence Treatments (Support or squeeze the urethra)

Impressa by Poise

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Stress Incontinence Treatments (Support or squeeze the urethra)

Silicone Pessaries

Who should use a pessary?

Contraindications

Anyone who wants it

• Active infection

• To avoid surgery

• Non-compliance or inability to follow-up • To treat symptoms while waiting for surgery

So offer them to everyone

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How do I fit it?

After fitting


Whatever way is comfortable and effective for the patient


Pessaries last for years (decades?)


Can use more than 1


May need to change due to change in vagina shape / size
May stain at corners – this is OK
If cracks or feels rough, change for a new one

What about?

What about?

Vaginal bleeding

Vaginal Infections

• Common with fitting and manipulation • Evaluate new vaginal bleeding as you would without pessary

Erosions (These will happen, it’s OK) • Treat with vaginal E2 and check in 1 month, many resolve • Biopsy if persistent

• Discharge is physiologic • Check/remove more frequently • May use estrogen or Trimo-San

UTIs • Likely most significant risk factor is age, not pessary • Manage like recurrent UTIs (UA/Cx, vaginal E2, cranberry, timed voids)

• Pessary checks (more frequently?) confirm it’s not worsening

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Operations for Urinary Incontinence

Urethral Bulking

• Traditional (urethrovesical) slings

• Matsuoka PK, Locali RF, Pacetta AM, Baracat EC, Haddad JM. The efficacy and safety of urethral injection therapy

for urinary incontinence in women: a systematic review. Clinics. 2016;71(2):94-100

• Retropubic colposuspension • Urethral Bulking

• 14 RCTs including urethral bulking in at least one arm • Heterogeneity in outcomes so not able to compare results

• Mid-urethral Slings:

• Urinary retention was the main adverse event in most studies

• Retropubic (1995) • Transobturator (2001) • “Mini Slings” (2006)

1Leach et al. Female stress urinary incontinence guidelines panel summary report on surgical management of female stress urinary incontinence. J Urol 1997;158,875-880.

Urethral bulking

Mid-Urethral Slings:

Polydimethylsiloxane: Ghoniem GM, Miller CJ. A systematic review and meta-analysis of

• Retropubic (RP)

Macroplastique for treating female stress urinary incontinence. Int Urogynecol J. 2013 Jan;24(1):27-36.

• Transobturator (TO)

Short term (18m) improvement 64% cure 36% (10 and 11 studies respectively)

• “Minislings”

• Median reinjection rate (to optimize outcome) = 30 %

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AUGS and SUFU Position Statement: Mesh Midurethral Slings for Stress Urinary Incontinence

AUGS and SUFU Position Statement: Mesh Midurethral Slings for Stress Urinary Incontinence

• http://www.augs.org/index.php?mo=cm&op=ld&fid=814

• http://www.augs.org/index.php?mo=cm&op=ld&fid=814

• Updated 6/2016 • Supported by AAGL, ACOG, NAFC, SGS, WHF

“The purpose of this position statement … is to support the use of the midurethral sling in the surgical management of stress urinary incontinence, the type of urine leakage generally associated with coughing, laughing and sneezing.”

Conclusion “One of the unintended consequences of this polypropylene mesh controversy has been to keep women from receiving any treatment for SUI. This procedure is probably the most important advancement in the treatment of stress urinary incontinence in the last 50 years and has the full support of our organizations which are dedicated to improving the lives of women with urinary incontinence.”

Mid-Urethral Slings Ford AA, Rogerson L, Cody JD, Ogah J. Mid-urethral sling operations for stress urinary incontinence in women. Cochrane Database of Systematic Reviews 2015, Issue 7. Art. No.: CD006375

• Mean long-term subjective cure rate across both groups (714 women)

was 84.3%

• Foss Hansen M, Lose G, Kesmodel US, Gradel KO.

Reoperation for urinary incontinence: a nationwide cohort study, 1998-2007. Am J Obstet Gynecol. 2016 Feb;214(2):263.e1-8.

• Short, medium and long term (>5 years) follow up showed no significant

difference between TO and RP Schimpf MO, Rahn DD, Wheeler TL, et al. Sling surgery for stress urinary incontinence in women: a systematic review and meta analysis. Am J ObstetGynecol 2014;21

• 8671 women with an index surgery for SUI followed for 5 years • Reoperation for RP = 6% • Reoperation for TO = 9% (significantly higher hazard ratio)

• TO vs RP meta analyses favored retropubic slings but not significant • Objective cure (OR, 1.16; 95% CI, 0.93-1.45) • Subjective cure (OR, 1.17; 95% CI, 0.91-1.51)

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Mini-Slings

Conclusions Mid-Urethral Slings

Schimpf et al SR and MA: • Full length slings had better subjective and objective outcomes compared to mini-slings • Adverse Events similar to TO (OAB 5%, mesh exposure 2%) but with less groin pain

• TO and RP have similar short-term efficacy • *but RP may be more effective long term • Mini-sling comparisons are still developing

Cochrane review Nambiar A, Cody JD, Jeffery ST. Single-incision sling operations for urinary incontinence in women. 2014 Jun 1;(6):CD008709.

• Majority of studies performed with one inadequate sling • same as Schimpf. Has been removed from market • Unable to perform reliable comparison

Summary

Future treatment for SUI

• SUI is common

• Intravesical Balloon

• A ‘urethra problem’ • Simple to diagnose • Symptoms • Stress test

• Cell Based Therapy

• Treated with urethral support (mostly) • Kegels • Weight loss • Pessaries • Urethral Bulking • Mid-Urethral Slings

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Thank You

Questions?

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