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OBSTETRICS AND GYNECOLOGY BOARD REVIEW MANUAL STATEMENT OF EDITORIAL PURPOSE The Hospital Physician Obstetrics and Gynecology Board Review Manual is a peer-reviewed study guide for residents and practicing physicians preparing for board examinations in obstetrics and gynecology. Each manual reviews a topic essential to the current practice of obstetrics and gynecology.

PUBLISHING STAFF PRESIDENT, GROUP PUBLISHER

Bruce M. White EDITORIAL DIRECTOR

Debra Dreger ASSOCIATE EDITOR

Rita E. Gould EDITORIAL ASSISTANT

Farrawh Charles

Evaluation and Nonsurgical Management of Urinary Incontinence Editor: Matthew F. Davies, MD, FACOG Associate Professor, Department of Obstetrics and Gynecology, Chief, Division of Women’s Health, Director, Obstetrics and Gynecology Residency Program, Pennsylvania State University, Milton S. Hershey Medical Center, Hershey, PA

Contributor: Christine A. LaSala, MD Director, Division of Urogynecology, Hartford Hospital, Hartford, CT

EXECUTIVE VICE PRESIDENT

Barbara T. White EXECUTIVE DIRECTOR OF OPERATIONS

Jean M. Gaul PRODUCTION DIRECTOR

Suzanne S. Banish PRODUCTION ASSISTANT

Kathryn K. Johnson

Table of Contents

ADVERTISING/PROJECT MANAGER

Patricia Payne Castle

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

SALES & MARKETING MANAGER

Deborah D. Chavis NOTE FROM THE PUBLISHER: This publication has been developed without involvement of or review by the American Board of Obstetrics and Gynecology.

Urinary Incontinence . . . . . . . . . . . . . . . . . . . . . . . .2 Detrusor Overactivity . . . . . . . . . . . . . . . . . . . . . . . .7 Case Examples and Discussion . . . . . . . . . . . . . . . . .8 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Endorsed by the Association for Hospital Medical Education

Cover Illustration by Kathryn K . Johnson

Copyright 2006, Turner White Communications, Inc., Strafford Avenue, Suite 220, Wayne, PA 19087-3391, www.turner-white.com. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, mechanical, electronic, photocopying, recording, or otherwise, without the prior written permission of Turner White Communications. The preparation and distribution of this publication are supported by sponsorship subject to written agreements that stipulate and ensure the editorial independence of Turner White Communications. Turner White Communications retains full control over the design and production of all published materials, including selection of appropriate topics and preparation of editorial content. The authors are solely responsible for substantive content. Statements expressed reflect the views of the authors and not necessarily the opinions or policies of Turner White Communications. Turner White Communications accepts no responsibility for statements made by authors and will not be liable for any errors of omission or inaccuracies. Information contained within this publication should not be used as a substitute for clinical judgment.

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Obstetrics and Gynecology Volume 10, Part 2 1

OBSTETRICS AND GYNECOLOGY BOARD REVIEW MANUAL

Evaluation and Nonsurgical Management of Urinary Incontinence Christine A. LaSala, MD

INTRODUCTION Urinary incontinence is a common disorder that affects approximately 20 million Americans. Its prevalence surpasses that of commonly regarded diseases such as diabetes, asthma, and osteoporosis.1 From 10% to 25% of reproductive-aged women and 30% to 40% of community-dwelling women over age 60 years are affected by urinary incontinence.2 More than 50% of nursing home residents have incontinence,3 and incontinence is a major reason for institutionalization.4 Because the prevalence and severity increase with age,5 the clinical burden of urinary incontinence will continue to grow as the population ages. In 1994, 13% of the female population was over age 65 years; it is estimated that this number will increase to 22% by 2040.6 Nearly 25% of women affected by urinary incontinence describe the symptoms as “daily” or “severe.” The disorder negatively impacts self-esteem and may result in social withdrawal, sexual dysfunction, and depression.7 Despite the quality of life impacts, less than half of those suffering from urinary incontinence consult health care providers for the problem. Therefore, diagnosing and managing incontinence are important components of a gynecologist’s practice.

URINARY INCONTINENCE Urinary incontinence is defined as any involuntary leakage of urine.8 The main types of urinary incontinence are stress, urge, mixed, continuous, and functional (Table 1); other types may be situational (eg, leakage during intercourse or giggling). Urinary incontinence should be further described as to frequency, severity, precipitating factors, impact on quality of life, current management mechanisms, and whether or not treatment is desired.9 • What mechanisms and risk factors contribute to urinary incontinence?

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PATHOPHYSIOLOGY For continence to be achieved, urethral pressure should be greater then vesical pressure. The pubocervical fascia provides a hammock of support for the bladder neck as it inserts along with the levator ani muscles at the symphysis pubis10,11 (Figure 1). The mid-urethra remains closed by active contraction of the urethral striated muscle, which is innervated by the pudendal nerve. Thus, pudendal nerve injury may result in external urethral sphincter muscle damage, contributing to stress urinary incontinence (SUI).12–14 Other neurophysiologic factors also contribute to urethral function. Stimulation of motor neurons located in the lumbosacral spinal cord in Onuf’s nucleus results in contraction of the external urethral sphincter muscle.15 Failure of this reflex may lead to SUI, regardless of the anatomic position of the urethra. RISK FACTORS There is an increasing effort to identify risk factors for urinary incontinence (Table 2)16,17 and other pelvic floor disorders, as not all of these factors are understood with respect to causal relationship or magnitude. Proven risk factors include aging, obesity, and smoking. Inherently logical and basic science research supports a causal relationship between vaginal delivery and SUI.18,19 Some epidemiologic studies demonstrate a significant increase in the risk of pelvic floor disorders in parous versus nulliparous women.20,21 Other studies show no or little increased risk of incontinence in parous women.22,23 Aging16,24 is associated with increasing risk of both stress and urge incontinence, as is obesity.24,25 Smoking increases the relative risk of SUI by 1.8 to 2.9.24,26 • What historical details are important to elicit in the evaluation for incontinence? • How should the physical and urogynecologic examinations be approached? CLINICAL EVALUATION History Patients who complain of urinary incontinence

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Evaluation & Nonsurgical Management of Urinary Incontinence should be asked about the frequency and severity of symptoms, as this information is important in helping to tailor individual treatment. Questions should include: “Does the leakage happen daily? How much do you leak? Does the leakage cause you to refrain from activities you may normally enjoy? Does it interfere with social interactions?” The assessment of the impact of incontinence may differ between a patient and a health care provider. What may seem clinically insignificant to a physician may be particularly bothersome to a patient who seeks treatment, and vice versa. Patients should also be asked about other symptoms of voiding dysfunction, such as urinary hesitancy, an interrupted urinary stream, a sensation of postvoid fullness, or postvoid dribble. These symptoms may suggest an associated anatomic abnormality such as cystourethrocele, leiomyomata, or urethral diverticulum. It is important to ask whether there is an associated sensation of urinary urgency (ie, a sudden compelling desire to pass urine that is difficult to defer) or urge incontinence and, if there is, which symptom is the more bothersome (ie, stress or urge); initial evaluation and treatment should target the primary concern. Bowel dysfunction should also be assessed, as chronic constipation is associated with urinary incontinence.27 Fecal incontinence commonly occurs in association with urinary incontinence as well.28 Family history should be assessed, as incontinence may have a familial predisposition. Additionally, it should be noted that race may affect incontinence. Caucasian women have higher rates of incontinence as compared to African-American and Hispanic women.29,30 Finally, the patient’s medical history should be reviewed to determine if there are any other medical conditions (eg, asthma, allergies), medications (eg, diuretics, α-blockers) or lifestyle risk factors (eg, obesity, smoking history) that may exacerbate the leakage. Physical and Urogynecologic Examination Vital signs including height, weight, and blood pressure should be obtained on all new patient visits. The abdomen should be examined for organomegaly, ascites, hernias, or scars. A focal neurologic examination of the lower extremities assesses motor and sensory function and may identify an unsuspected neurologic problem (ie, peripheral neuropathy or spasticity) contributing to lower urinary tract dysfunction. Motor function can be tested by asking the patient to flex and extend her hip, knee, and ankle as well as to invert and evert her foot; patellar, ankle, and plantar reflexes also should be checked. Sensory function should be tested by asking the patient to discriminate between sharp (ie, pinprick) and soft

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Table 1. Major Types of Urinary Incontinence Stress urinary incontinence: involuntary leakage on effort or exertion, such as sneezing or coughing Urge urinary incontinence: involuntary leakage accompanied by or immediately preceded by urgency Mixed urinary incontinence: involuntary leakage associated with urgency and also with exertion, effort, sneezing, or coughing Continuous incontinence: continuous leakage with minimal provocation Functional incontinence: temporary (eg, recovering from joint replacement), dementia

sensation along the sacral dermatomes. Sacral root integrity should be assessed by testing the anal wink reflex (ie, stroking the skin adjacent to the anus elicits reflex contraction of the anal sphincter) and the bulbocavernosus reflex (ie, tapping the clitoris results in contraction of the bulbocavernosus and ischiocavernosus muscles). However, these reflexes may be absent in the neurologically intact patient. The external genitalia should be inspected for evidence of excoriation or irritation. Contact dermatitis may result from the use of menstrual pads instead of the more absorbent incontinence pads. The vaginal mucosa should be examined for evidence of atrophy or infection. Palpation of the anterior vaginal wall and concomitant inspection of the urethral meatus will assess for a urethral diverticulum. The anterior, posterior, and apical compartments should be assessed for prolapse by having the patient perform the Valsalva maneuver and cough. The speculum should be split in half to visualize each compartment separately. The patient should be asked to cough several times while the physician observes for leakage; leakage from the vagina rather than urethral meatus suggests a fistula tract. If no urinary leakage is observed, the patient should be asked to stand and cough. Urinary leakage should be concomitant with the cough. A several second delay may suggest a cough-induced detrusor contraction. If there is no significant cystourethrocele noted on assessment of the anterior vaginal wall, loss of support to the urethrovesical junction is evaluated by the cottonswab test. A lubricated cotton-swab is inserted into the urethra until resistance is lost; the swab is then pulled backward until it is at the urethrovesical junction. The patient is then asked to perform a Valsalva maneuver while the deflection of the angle from the level of the horizontal is measured using a goniometer. Urethral hypermobility is arbitrarily defined as deflection of the cotton-swab greater than 30 degrees from the horizontal

Obstetrics and Gynecology Volume 10, Part 2 3

Evaluation & Nonsurgical Management of Urinary Incontinence Increased intra-abdominal pressure Closes urethra Opens urethra

A

Torn pubocervical fascial sling

B

Figure 1. (A) Normal pubocervical fascial support of the bladder. Increased intra-abdominal pressure forces the urethra against the intact pubocervical fascia, closing the urethra and maintaining continence. (B) Torn pubocervical fascial sling. Defective fascial support allows posterior rotation of the urethrovesical junction due to increased pressure, thus opening the urethra and causing urine loss. (Reprinted from Smith RP. Netter’s obstetrics, gynecology and women’s health. Philadelphia: ICON Learning Systems; 2002:547–54. Copyright 2002, with permission from Elsevier.)

and is often associated with parity and support defects of the anterior vaginal wall.31 The presence or absence of urethral hypermobility aids in the treatment plan, especially for surgical options (ie, retropubic urethropexy versus sling or injectable bulking agents.) Bimanual examination should be performed to rule out coexisting gynecologic abnormalities. Finally, a rectal examination should be performed to check for rectocele, enterocele, and fecal impaction (the latter being a potential transient cause of urinary incontinence, especially in the elderly). Pelvic Floor Assessment The pelvic floor levator ani muscles (ie, pubococcygeal, puborectalis, and iliococcygeus muscles) are of major importance in pelvic floor function. To assess the strength of the pelvic floor muscles, the physician should insert 2 fingers into the vagina while the patient is in the lithotomy position and gently press down toward the floor while the patient is asked to perform a Kegel contraction (ie, to “squeeze as if you’re trying to prevent gas or urine from coming out”). It is important to assess (1) whether the patient correctly isolates the muscles (or, does she lift her buttocks off the table or adduct her thighs?), (2) whether there is any anterior movement or strong upward or circumferential movement drawing the physi-

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cian’s fingers inward, and (3) how long (in seconds) the patient holds the squeeze. • What laboratory and clinical tests should be performed? • Is a voiding diary recommended? DIAGNOSTIC TESTS Urinalysis and urine culture should be performed on all patients if infection is suspected. In the elderly population, asymptomatic bacteriuria is common but does not cause incontinence.32 Postvoid residual volume may be checked with a bladder scanner or by catheterization. In an otherwise healthy, young woman with no symptoms of postvoid fullness, the likelihood of an elevated postvoid residual volume is low. A postvoid residual volume greater than 100 mL suggests bladder outlet obstruction and/or detrusor muscle underactivity. Complex urodynamic testing is not routinely recommended unless the diagnosis is unclear, the patient has equally bothersome mixed urinary incontinence symptoms, or surgery is planned.2,33 A simple cystometrogram may be performed to assess sensation to filling and bladder capacity and to determine whether any uninhibited bladder contractions occur during the filling phase.

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Evaluation & Nonsurgical Management of Urinary Incontinence This test is performed by filling the bladder via a 60-mL syringe attached to a red rubber catheter in a retrograde fashion with room temperature sterile water or saline. The patient should be in a semi-supine position with hands at her sides and not near her abdomen so as to avoid any false pressure increases to the bladder. The water source is held at the level of the symphysis pubis to avoid false sensations to filling and iatrogenic detrusor irritability. A rise in the meniscus in the syringe associated with urgency suggests detrusor overactivity. At capacity, the catheter is removed and a cough stress test is done. If no leakage has been observed at this point, the patient is asked to stand, bounce on her heels, and cough to see if she demonstrates incontinence. The patient then voids, and the voided volume is measured to assure complete bladder emptying. VOIDING DIARY The patient should be asked to keep a voiding diary that details her symptoms (stress versus urge) and describes her fluid intake (including time, type, and amount of fluid) as well as the time and volumes of her urine output over a 24- to 48-hour period. High fluid intake is associated with worsened stress and urge incontinence; thus, a patient whose voiding diary indicates excessive fluid intake should be counseled that reducing intake can decrease both stress and urge incontinent episodes.34 The patient should also record associated leakage with related events, such as physical activity and sense of urgency. Severity of incontinence also should be recorded, such as number of leakage episodes in the day and amount (ie, dampness, wetness requiring pad change, complete bladder emptying). • What are current treatment options for urinary incontinence? TREATMENT OPTIONS A variety of options are available for treating urinary incontinence. The least invasive options should be reviewed first, particularly in a patient who is young and may not have completed childbearing. While there are no prospective studies in the literature determining pregnancy outcome or continence status after a surgical procedure for treatment of incontinence, most experts would agree with completion of childbearing prior to surgical intervention. Therefore, conservative treatment options should be known and available to the reproductive-aged woman. Behavioral Therapy Upon review of the voiding diary, if the patient voids only 2 to 3 times daily and her leakage episodes occur

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Table 2. Risk Factors for Urinary Incontinence in Women Childbearing* Increasing parity Vaginal delivery Obesity† Age† Comorbid medical conditions Altered fluid balance and urine excretion Increased uninhibited detrusor contractions (structural changes in detrusor muscle and receptor response)16 Reduced bladder capacity Medical conditions Cerebral vascular accident Diabetes Parkinson’s disease Multiple sclerosis Congestive heart failure Chronic obstructive pulmonary disease/asthma Depression Smoking† Medications Sedatives/antipsychotics α Blockers Diuretics Angiotensin-converting-enzyme inhibitors (may cause coughing) Genitourinary surgery Hysterectomy17 Radiation Functional impairment Mobility impediments Dementia *Supported by basic science research. †Proven risk factors.

when her bladder is most full, voiding more frequently (ie, every 3–4 hours instead of every 6–8 hours) should be recommended to avoid high bladder volumes, which may exacerbate SUI. Also, voiding before exercising is common sense. Smoking cessation and weight loss should be encouraged when appropriate. Physical Therapy Pelvic floor rehabilitation is the mainstay of conservative treatment for mild-to-moderate stress and urge incontinence. In 1948, Arnold Kegel demonstrated improvement in muscle strength with long-term contractions of the pelvic floor muscles.35 Strengthening the pelvic floor muscles helps increase urethral resistance, reduce dynamic urethral descent, and decrease SUI episodes. Active participation by the health care provider is absolutely essential for providing the necessary

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Evaluation & Nonsurgical Management of Urinary Incontinence encouragement, education, and feedback; a dedicated physician extender is ideal for this type of therapy. Success with pelvic floor therapy also requires patient motivation and diligent compliance. As long as the patient is able to isolate and contract the pelvic floor muscles properly, the following regimen can be assigned: 40 contractions daily, divided into sets of 10, holding each squeeze for 5 to 10 seconds and relaxing between each squeeze for 10 seconds. Once the patient has established improved muscle tone, she should be instructed to contract the pelvic floor muscles in anticipation of a cough or sneeze, as this will further reduce leakage.36 Results are best obtained through repetitive training sessions with a dedicated provider. Reduction in incontinence episodes of more than 50% may be expected.37 Biofeedback therapy may be particularly helpful for those women who have trouble isolating the correct muscles. Surface abdominal, anal, and vaginal electrodes can be used to identify appropriate muscle contraction while keeping the abdominal muscles relaxed. However, a recent Cochrane review concluded that combining pelvic floor muscle training with biofeedback therapy has no advantage over well-done pelvic floor muscle training alone.38 Functional electrical stimulation is another form of physical therapy that may reduce incontinence. The precise mechanism by which this therapy is efficacious is unclear. One theory is that electrical currents may induce reinnervation of the pelvic floor muscles as well as reflexively inhibit detrusor muscle overactivity. Different studies have reported different success rates ranging from 35% to 70% improvement.39,40 Using weighted vaginal cones is an inexpensive form of pelvic floor muscle rehabilitation. The cone is held in the vagina for 15 minutes once or twice daily. To keep the cone in place, the pelvic floor muscles must contract, thus providing a sensory feedback. Progressively heavier cones are used in addition to holding the cone in place during daily activities. Studies show that vaginal cones are better than no therapy in reducing incontinence, but cones are of no added benefit when added to pelvic floor muscle exercises with or without biofeedback.38 Mechanical Devices Mechanical devices may be used to manage stress incontinence. Specific pessaries have been designed for the treatment of SUI. Pessaries may be fitted by physician extenders, and patients can be taught how to insert, remove, and care for the pessary. A pessary is an ideal option for a woman with exercise-induced incontinence, as she can wear it at her convenience. Success

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rates with pessary use range from 25% to 50%. In a motivated patient who is comfortable with inserting and removing the pessary, this is a good treatment option.41,42 Insertion of a tampon during exercise has also been shown to reduce SUI.43 Occlusive devices, such as Fem Assist (Insight Medical Corporation, Boston MA) and CapSure (Bard Urological, Covington, GA), are dome-shaped silicone devices that are placed over the urethral meatus using an adhesive gel or lubricant. The dome is squeezed before application to ensure a suction-like seal. These devices may be worn for up to 4 hours, removed prior to voiding, and cleansed with soapy water; they are reusable for up to 1 to 2 weeks. An intraurethral device, such as FemSoft (Rochester Medical Corporation, Stewartville, MN) is a single-use, disposable, soft, and flexible insert that is designed to be retained in the urethra without migrating into the bladder; it is removed by squeezing on its end. These devices have demonstrated significant improvement in subjective and objective outcomes. However, costs and adverse effects (eg, discomfort, urinary tract infections, difficulty manipulating the devices) have limited their long-term usefulness. Medical Therapy Currently, the 2 main types of medications used in the treatment of stress incontinence are α-adrenoreceptor agonists and tricyclic antidepressants. The urethra has an abundance of α-adrenergic receptors that induce muscle contraction and increase urethral outlet resistance. The most studied α-adrenergic agonist used in the treatment of incontinence was phenylpropanolamine; however, this agent was withdrawn from the market because of its significant adverse effects. In nonplacebo-controlled trials, pseudoephedrine has improved symptoms of mild SUI.44 Pseudoephedrine is given in 15 to 30 mg doses 2 to 3 times daily. Side effects include elevated blood pressure, anxiety, and insomnia; therefore, judicious use in appropriate patients is necessary.44 Tricyclic antidepressants, such as imipramine, effectively reduce stress incontinent episodes. Imipramine exerts an α-agonist effect on the urethra, thereby increasing urethral outlet resistance; it also exerts an anticholinergic effect on the detrusor muscle. Use of imipramine has resulted in 50% to 60% improvement in incontinence.45 The dosage is 25 to 75 mg, once or twice daily. Duloxetine is a serotonin and norepinephrine reuptake inhibitor that is currently in phase 3 clinical trials for treatment of SUI. Duloxetine stimulates pudendal motor neuron α-adrenergic receptors, thus improving contractility of the urethral sphincter muscle. Preliminary results

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Evaluation & Nonsurgical Management of Urinary Incontinence show that patients receiving an 80-mg dose twice daily experienced a 50% reduction in incontinence compared with a 30% reduction in patients receiving placebo; nausea was a common adverse effect (22% reported).46 Surgery Surgery is generally reserved for women who have completed childbearing. Surgery for SUI aims at restoring support to the urethra with procedures such as retropubic urethropexies (Burch), recreating a supportive hammock under the urethra by way of a midurethral sling (tension-free transvaginal tapes), or by increasing coaptation of the urethra using urethral bulking agents (collagen injections). • What is the role of estrogen in urinary incontinence? Low estrogen levels in postmenopausal patients result in atrophy of the urethral mucosa, reduction of the mucosal seal and its ability to coapt, loss of bladder compliance, and an increase in irritative voiding symptoms. Contrary to previously published randomized trials demonstrating that estrogen therapy was effective in reducing incontinence,47 recent studies suggest that oral estrogen replacement with or without progestins worsens urinary incontinence. The Women’s Health Initiative demonstrated an increased risk of all types of urinary incontinence after 1 year of being on estrogen replacement therapy, and the increased risk persisted after 3 years of treatment; the relative risk of SUI was 1.9 and 2.2 for those on estrogen alone versus estrogen plus progestin, respectively.48 Therefore, current evidence does not support using hormone replacement therapy for treating urinary incontinence.

DETRUSOR OVERACTIVITY Detrusor overactivity is defined as involuntary bladder contractions (spontaneous or provoked) observed on urodynamic studies during the filling phase of the micturition cycle. Overactive bladder is a symptomatic diagnosis defined as urinary urgency with or without urge incontinence and usually with frequency and nocturia. • What mechanisms and risk factors contribute to detrusor overactivity? PATHOPHYSIOLOGY Normally, during the filling and storage stage of the micturition cycle, the bladder accommodates urine and fills without a significant rise in vesical pressure. Urethral and pelvic floor muscles remain contracted. When the

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normal desire to void occurs (at a bladder volume of approximately 300–400 mL) and the setting is appropriate (ie, the woman is on the toilet), the detrusor muscle contracts, the urethra and pelvic floor muscles relax, and micturition occurs. The sympathetic system, via α-adrenergic receptors located primarily on the urethra, promotes storage of urine by increasing urethral contraction. The parasympathetic system, mediated by cholinergic activity on the detrusor muscle, promotes bladder contractility and emptying. The pudendal nerve also contributes to urethral and pelvic floor muscle contraction. The actual pathogenesis of detrusor overactivity is not clear, but various theories exist. The neurogenic theory suggests a reduced peripheral or central inhibition. Elimination of the inhibitory sacral reflex arc from the cerebral cortex may cause uncontrollable detrusor contractions. Increased excitatory neurotransmission to the bladder as well as increased primary afferent (sensory) input from the bladder also are possibilities. The myogenic theory suggests a partial denervation injury to the detrusor muscle, which may result in increased excitability. Detrusor muscles in patients with detrusor overactivity are more sensitive to acetylcholine.49 RISK FACTORS Advanced age is an important risk factor for detrusor overactivity.50,51 Race also appears to be factor: AfricanAmerican women are more likely to have detrusor overactivity with urge incontinence as compared with Caucasian women.52 Women with diabetes are also more likely to have detrusor overactivity.22,53 Obesity (body mass index > 30) increases urge incontinence.50 Neurologic disorders associated with detrusor overactivity include Parkinson’s disease, sacral spinal nerve injury, multiple sclerosis, and cerebrovascular disease.54 Bladder outlet obstruction, which may be due to over-elevation of the urethra during anti-incontinence surgery, results in increased sensitivity of the detrusor muscle to acetylcholine.55,56 • What are treatment options for detrusor overactivity? TREATMENT OPTIONS Behavioral Therapy Reduction of high fluid intake and caffeine and alcohol consumption may be helpful in initial treatment of detrusor overactivity. Although there are limited data available to support this approach,34,57,58 it is reasonable to recommend based on the diuretic and irritant effects on the bladder. Bladder Retraining Bladder retraining is an outpatient therapy involving

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Evaluation & Nonsurgical Management of Urinary Incontinence Table 3. Drugs for Detrusor Overactivity Drug

Dosage

Mechanism of Action

Oxybutynin

5 mg three times daily; extended release: 5 mg, 10 mg, 15 mg once daily Immediate release: 1 and 2 mg twice daily; extended release: 2 and 4 mg once daily 7.5 mg and 15 mg once daily 5 mg and 10 mg once daily 20 mg twice daily

Antispasmodic effects and inhibits action of acetylcholine on smooth muscle

Tolterodine Darifenacin Solifenacin Trospium chloride

Blocks M2 muscarinic receptors more selectively than oxybutynin Selects primarily M3 muscarinic receptors in the bladder Selects primarily M3 muscarinic receptors in the bladder Anticholinerginic effects; cleared by kidneys; hepatic metabolism spared

frequent office visits to monitor progress. The baseline voiding diary is reviewed, and a planned voiding schedule is instituted. A time interval goal is set (eg, time between voids of approximately 2–3 hours), and the patient is instructed not to void before the assigned time. Bladder retraining has resulted in cure rates of 47% to 90% at 6-month follow-up.59,60 In those with significantly hyperreflexic bladders or cognitive dysfunction, timed voids (ie, patient is asked to follow a fixed voiding schedule) or prompted voiding (ie, patient is asked at regular intervals if she needs to void and offered assistance as needed) are other bladder training options.

tion devices are available for daily home use, allowing improved efficacy. The electrical stimulation frequency is set at 10 Hz for 15 to 20 minutes daily. Sacral neuromodulation via an implantable electrode at the level of S2–S3 is effective in women with detrusor overactivity. This device, called Interstim (Medtronic, Minneapolis, MN), is surgically implanted via a 2-stage process such that a trial stimulation can be evaluated for efficacy prior to the actual insertion of the device. A cure rate of 76% that was sustained at 18 months has been demonstrated in patients with refractory urge incontinence.66

Physical Therapy A 3-month program of pelvic floor exercises was shown to decrease the mean number of urge incontinent episodes from 2.8 to 0.5 per day.61 Visual or auditory biofeedback therapy can train patients to contract the pelvic floor muscles at the onset of urgency, thus causing a reflex inhibition of the detrusor muscle. Combining behavioral therapy with biofeedback was not shown to be more effective than behavioral therapy alone nor selfadministered behavioral therapy using a self-help booklet; all groups achieved a 60% reduction in incontinence.62 Additionally, biofeedback-assisted pelvic floor exercises does not seem to be more effective than properly done pelvic floor muscle exercises in treating detrusor overactivity; 50% of participants in each group had a 50% reduction in urge incontinent episodes.37 Functional electrical stimulation therapy is effective in reducing urge incontinent episodes. Intravaginal or perineal electrical stimulation of the sacral somatic afferent nerves may inhibit detrusor contraction. Functional electrical stimulation activates the sympathetic inhibitory response to the detrusor muscle and stimulates the pudendal afferent nerves that cause contraction of the pelvic floor and urethral striated muscles.63 Improvement ranges from 50% to 70% for daily or every other day treatment at 1-year follow-up.64,65 Electrical stimula-

Medical Therapy Drug therapy, alone or in combination with behavioral therapy, may improve urge incontinence.67 Several anticholinergic/antimuscarinic agents are available for use in treating urge incontinence (Table 3); selection depends on efficacy, side effects, patient tolerability, cost, and comorbid conditions. A lack of response to 1 agent does not necessarily mean a lack of response to other agents. A combination of drugs may be effective when side effects preclude the use of higher doses of a single drug. Dry mouth and constipation are common adverse effects, occurring in approximately 20% and 10% of patients, respectively. Treatment with antimuscarinic therapy compared with placebo yielded an approximately 40% higher cure or improvement rate, with a 60% (statistically significant) decrease in the number of voids and incontinent episodes daily.68

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CASE EXAMPLES AND DISCUSSION CASE 1 History A 58-year-old postmenopausal Caucasian woman (gravida 3, parity 3) complains of daily symptoms of

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Evaluation & Nonsurgical Management of Urinary Incontinence leaking with coughing, walking briskly, and laughing as well as urinary urgency, frequency, and urge incontinence if she “waits too long.” The patient reports that she changes her incontinence pad twice daily and that when urge incontinence occurs, she has near complete bladder emptying. Her symptoms, which began more than 2 years ago, have progressed to the point that they significantly interfere with her ability to work. The patient’s medical history is significant for hypertension, controlled by lisinopril. She is overweight and reports that she is currently on a diet and trying to drink more water. Additionally, she smokes 1 pack of cigarettes daily, which is reduced from 2.5 packs previously. Discussion This patient’s combination of stress and urge symptoms suggests that she has mixed urinary incontinence. It is important to determine which of these symptoms, leaking with activity or cough versus urgency and leaking with urge, is most bothersome for her. She also should be asked whether her stress incontinence symptoms have worsened since she began taking lisinopril. Side effects of angiotensin-converting-enzyme inhibitors include coughing, which may exacerbate this patient’s incontinence. Determining whether the patient has received a trial of antimuscarinic therapy and/or previous anti-incontinence surgery will help guide her evaluation and treatment plan. If either of these have been attempted with no significant benefit, complex urodynamic testing may be indicated. Finally, supporting the patient’s weight loss efforts and encouraging her to further reduce her tobacco intake are important, given that smoking and obesity are known risk factors for both stress and urge incontinence. Further History and Clinical Evaluation The patient reports that she consulted her primary care physician about a year ago regarding her incontinence problems, and he suggested she keep a voiding diary. However, she admits that she never returned for follow-up. Based on the diary instructions she received, she has recorded her intake, voiding, and symptoms over 1 day and brought this account with her for review (Figure 2). On urogynecologic examination, the patient demonstrates a positive supine cough stress test. She has an anterior compartment defect with a cystocele to the hymen. Her cervix remains well supported and measures at 8 cm above the hymeneal ring. The posterior compartment shows a stage 2 rectocele, with the furthest descending point during a Valsalva maneuver 2 cm above the hymen. The genital hiatus is slightly widened at 4 cm. Review of pubococcygeal muscle tone reveals

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Figure 2. Voiding diary for case 1 patient.

that, despite instruction, the patient is unable to isolate the muscle. Instead, she bears down or lifts her buttocks. Discussion Although a 2- to 3-day voiding diary is most informative in cases of mixed urinary incontinence, this patient’s 1-day account offers useful information regarding her behavior and lifestyle. Review of the diary reveals an abnormally high fluid intake, totaling 4500 mL, as well as a tendency to experience urgency and some urge incontinence within 1.5 hours of consuming a caffeinated beverage. In addition, the patient recorded 2 episodes of stress incontinence; both episodes were within half an hour prior to voiding, and each of the voided volumes was 600 mL. Behavioral changes in this patient should be the starting point for treatment. Based on the findings in her voiding diary, overall reduction of fluid and caffeine intake is warranted. Because this patient has demonstrable pelvic prolapse with an inability to contract the pelvic floor muscles, pelvic floor exercises may not be as effective. Biofeedback training with visual assistance may be helpful if after a few sessions the patient is able to learn how to contract the pelvic muscles. Otherwise, physical therapy may be limited. Additionally, since the patient smokes and has a chronic cough, she may not be able to consistently contract the pelvic floor muscles in anticipation of a leak.

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Evaluation & Nonsurgical Management of Urinary Incontinence Table 4. Causes of Transient Incontinence Delirium/confusion Infection (urinary tract) Atrophic vaginitis or urethritis Pharmaceutical agents Psychological factors Excess urine output Restricted mobility Stool impaction

The patient demonstrates sufficient prolapse such that an incontinence pessary is another viable treatment option and should be taken into consideration when treatment options are discussed.69 A previous history of tampon or contraceptive diaphragm use is associated with willingness to use an intravaginal device. Follow-up and Referral for Surgical Treatment Treatment options are discussed with the patient. She is not comfortable using intravaginal devices and declines this option but agrees to attempt behavior modification. Six weeks later, her fluid intake is within normal limits at 2250 mL/24 hours. She voids at approximately 4-hour intervals, with average voided volumes of 300 mL. Diet cola has been reduced and replaced by caffeine-free cola, limited to only 12 oz/day. There are no documented urge incontinent episodes. However, stress incontinence persists daily. On examination, review of the pelvic floor muscle tone reveals no improvement in isolation or strength of the pelvic floor, despite a conscious effort by the patient. The patient’s primary care physician is pleased with her blood pressure response to lisinopril and does not want to change her antihypertensive therapy. In light of this patient’s anatomic defect and failed attempts at conservative therapy for treating stress incontinence, the patient is referred to a gynecologic surgeon for consideration of surgical options. CASE 2 History and Clinical Evaluation A 70-year-old African-American woman (gravida 2, para 2) complains of urinary urgency, frequency, urge incontinence, and nocturia. She wears adult diapers for protection daily and places an incontinence pad on top, which she changes twice daily. Once an active woman in the community, the patient has become socially withdrawn and reluctant to leave the house. She has had episodes of complete bladder emptying while at the grocery store and is concerned about having an odor.

10 Hospital Physician Board Review Manual

She awakens 3 times each night with urinary urgency and leaks on the way to the toilet, which is down the hallway. She denies symptoms of stress incontinence. The patient drinks 1 cup of caffeinated coffee in the morning only. She does not smoke but does drink 1 cocktail early in the evening. Review of the patient’s medical history reveals that she has hypertension, for which she is taking hydrochlorothiazide. On further questioning, the patient reports that she is also being evaluated for possible Parkinson’s disease. The patient is 5 ft 5 in tall and weighs 145 lb, with a blood pressure of 154/92 mm Hg. On physical examination, the patient is alert and oriented. Her abdomen is soft and nontender, with no organomegaly and no scars observed. Focal neurologic examination of the lower extremities is within normal limits with respect to motor and sensory reflexes. External genitalia are normal. There is no pelvic organ prolapse. Supine and standing cough stress tests are negative for urinary leakage. Discussion It is always important to consider possible reversible factors that may cause or contribute to incontinence. The mnemonic “DIAPPERS” is helpful in remembering transient causes of urinary incontinence, particularly in elderly patients (Table 4).70 In this patient, diuretics may be contributing to urinary incontinence. Based on her continued elevated blood pressure at presentation, an alternative antihypertensive medication should be considered and contacting her primary care physician is warranted. Additionally, the patient is being evaluated for Parkinson’s disease. Women with Parkinson’s disease and lower urinary tract complaints have a lower urodynamic maximum cystometric capacity and a higher rate of detrusor hyperreflexia at lower bladder volumes.71 In light of this patient’s possible neurologic impairment, a postvoid residual volume should be checked to ensure complete bladder emptying. A voiding diary should also be obtained. Finally, this patient seems to have depressive symptoms. Results from a study of incontinence and depression in the elderly indicated that urinary incontinence had a significantly negative impact on all aspects of quality of life after adjusting for comorbidities and demographic differences.72 This study concluded that elderly patients with urinary incontinence are more depressed and have worse perceived health. Sleep disturbances due to nocturia, impairment in work productivity and social activity, feelings of isolation, and depression are all reported lifestyle-related effects of overactive bladder and urge incontinence.73 Women with moderate-tosevere urinary incontinence should be screened for

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Evaluation & Nonsurgical Management of Urinary Incontinence comorbid major depression and offered treatment if depression is present.74

3.

Results of Diagnostic Tests and Voiding Diary

4.

The residual volume in this patient is 35 mL. The catheterized sample is checked for urinary tract infection and hematuria, both of which are negative. A voiding diary reveals 15 voids in a 24-hour period, including 3 episodes of nocturia. The average voided volume is 100 mL, with a range of 50 to 150 mL. There are 4 documented episodes of urge incontinence on the way to the toilet, 2 of which occur at 2:00 AM and 4:00 AM. Time interval between voids is 45 minutes to 2 hours. Fluid intake is 800 mL, most of which is water or decaffeinated tea, except for a 6 oz martini at 5:00 PM.

5.

6.

7.

8.

Discussion The history and clinical findings thus far for this patient are consistent with detrusor overactivity. Pelvic examination, urinalysis, and a postvoid residual volume are within normal limits, so it is appropriate to consider therapy without proceeding with complex urodynamic testing at this time. A simple cystometrogram could be performed in the office. In this patient, one would expect a rise in the water meniscus in the syringe associated with urgency noted by the patient and leakage beyond the catheter. This patient voids every 45 minutes to 2 hours, and incontinence occurs at the 2-hour mark. Therefore, a voiding schedule can be planned such that the patient initially voids every 1 hour, regardless of whether or not she has an urge. Subsequently, the patient should be instructed to increase the time between voids by 15 minutes every 1 to 2 weeks or until she is comfortable with the time interval. Thus, by voiding at shorter intervals, bladder volumes may be reduced, possibly reducing incontinent episodes due to “overflow”’ incontinence. In addition, a bedside commode may reduce the nocturnal urge incontinent episodes by facilitating mobility. A trial of antimuscarinic medical therapy is also warranted. Expectations should be set to allow 6 to 8 weeks of therapy until symptom improvement is noticed, with a follow-up visit at that time.

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