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Summary of Urinary Incontinence Conference--12/03/10
Introduction: Dr. Hamdy
Urinary incontinence (UI) is common, and is associated with high morbidity.
The “conspiracy of silence”: first the family, then the family hide the
condition. Symptoms worsen, often as cognitive impairment progresses,
until an acute event occurs. Then the patient often is institutionalized
abruptly, and often unnecessarily.
UI is a symptom, not an inevitable consequence of aging.
UI is easier to manage if it is diagnosed early.
Patient’s Perspective: Mr. Michael James
Mr. James recounted his story: Bladder cancer, with poor preparation by his
doctors for UI and other possible sequelae. He had UI daily after surgery-cystectomy/prostatectomy/intestinal reservoir--and felt it “gross”. He has UI
during activities, such as dates and talking on the phone; he gets soaked every
night. He “can’t wait longer than 4 hours”. He limits fluid intake after 7
PM. He has feelings of regression when wearing diapers, but is happy to be
alive. For a week, he has been waking up to void every 3 hours.
Practical Anatomy “Down There”--Dr. Kwasigroch
The “pelvic diaphragm” is a thin structure of muscle and fascia which forms
nearly all the walls and floor of the true pelvis. The “urogenital diaphragm”
fills in the gap in the area of the perineum. Both structures are primarily
muscle, but are very thin and prone to injury. Other soft tissue structures are
very thin, and provide no practical support.
Pelvic innervation is complex, and easily injured.
Bedside Evaluation of UI--Dr. Holt
UI is very common, very costly, and embarrassing: most patients will not
mention it--you must ask!
Do a good history and physical exam to help determine causes of UI.
Reversible causes of UI are very common, and correcting them is Step 1.
Persistent UI types: stress, mixed, urge, overflow, and functional.
Urodynamic Studies in UI--Dr. Muir
Continence, the normal state, describes urethral pressure (Pu) > bladder
pressure (Pv).
Stress UI: Pu < Pv --routine increases in pressure (e.g. sneeze) cause UI
Urge UI: Pv > Pu --detrusor contraction overcomes normal sphincter.
Intrinsic sphincter deficiency (ISD): difficult to define, but important in
selecting appropriate surgery for stress UI.
ISD likely if urethra is large diameter and does not hold partially-inflated
Foley balloon, and if opening sphincter pressure is decreased.
ISD unlikely if leakage not present at pressure of 100 cm water.
Most patients with urge UI have sphincter relaxation before detrusor
contraction, mimicking a normal voiding cycle.
Leakage with full bladder more likely both in stress UI (higher resting Pv) and
in urge UI (lower Pu).
62% of women meet criteria for some form of voiding dysfunction.
Selection for testing: only women with overt stress UI, and no complicating
features, should have surgery without prior urodynamic studies.
Case-Based Medical Management of UI: Panel
Urge UI: best treatment combines scheduled voiding, pelvic floor exercises,
and anticholinergic medications. The meds are equivalent, per evidence.
At hospital discharge, patients have multiple risk factors for UI: general and
pelvic floor weakness; unclear medication lists; new meds such as opioids,
hypnotics, diuretics, and antipsychotics.
Dr. Huffaker discussed counseling before surgery, and the use of pessaries in
those refusing, or unable to tolerate, surgery.
Most panelists would remove a Foley catheter which is not clearly needed.
Routinely evaluate hospital patients at discharge, and nursing home patients at
admission, for need for pelvic floor P.T.
Develop UI resources: support group, self-help booklets, on-line groups/info.
P.T. for Incontinence and Overactive Bladder: Janet Hall, P.T.
Both women with aging and childbirth injury, and men after prostatectomy,
develop pelvic floor dysfunction. Pelvic floor strengthening is needed.
“Teaching pelvic floor exercises without biofeedback is like shooting a
basketball blindfolded.”
Sit-ups and crunches worsen pelvic floor dysfunction.
“Beyond Kegel’s” strengthens the “pelvic muscle force field”--larger
functional units involving the pelvic floor muscles, and often is helpful.
Janet Hall performs strength evaluation of the pelvic floor, including the
ability to give a good squeeze, and check for tenderness or restrictions.
Taught gluteal/abdominal/pelvic contraction for protection and therapy.
Taught hip rotation slowly, with foot-tapping to decrease bladder irritability.
Surgical Mgmt of UI and Pelvic Organ Prolapse: Dr. Huffaker
Pelvic organ prolapse very common; 11% women will have surgery lifetime.
There are minimally invasive and standard surgeries for stress UI; the
minimally invasive procedures include mid-urethral slings, bulking
injections, intravascular Botox (duration 6-12 months), and neuromodulation.
2 types of mid-urethral slings, TOT and TVT; TVT preferred if ISD +
Both TVT and TOT leave small amounts of permanent mesh in the pelvis, but
“mesh kits” using larger amounts placed vaginally risk
infection/controversial.
Surgery which supports the uterus and vaginal apex, e.g. attaching the vaginal
apex to the uterosacral ligament, is more successful than a mid-level repair.
Urinary Catheters--Dr. Townsend
Updated Healthcare Infection Control Practices Advisory Committee
Guidelines on Indwelling Catheter Use basically advise use of Foley catheters
only when truly necessary, and for the shortest time possible; never use them
only for convenience.
Catheters also impose activity limitations, and cause preventable infections.
Recommendations being adopted at Bristol Regional Medical Center:
1) Educate about the harms associated with Foley catheters;
2) Educate on the appropriate use of Foley catheters, and alternative options;
3) Use Quality Control audits to reduce inappropriate Foley use;
4) Develop automatic “stop orders” for Foley catheters; and
5) Encourage a JCAHO initiative to reduce inappropriate Foley use.
Nerve Stimulation Therapy--Dr. Muir
Neuromodulation is a treatment for refractory overactive bladder/urge UI.
Refractory OAB = failure of behavioral therapy, and trial of 2 different drugs.
If > 50% improvement occurs with trial external stimulation, an implantable
unit (battery $15000) is placed in the buttock, with leads into the sacral
plexus. 65-85% respond; ~1/3 require another procedure; safe and
reversible.