Download Female Urology Curriculum Lecture 2: August

Urinary Incontinence:
Evaluation and Nonsurgical
Treatment
WVU WOMENS HEALTH CURRICULUM
Stanley Zaslau, MD, MBA, FACS
Program Director & Associate Professor
Division of Urology
West Virginia University
Introduction and Terminology
• Urinary incontinence: involuntary urine
loss
• 2 causes: urethral and extraurethral
Introduction and Terminology
• Urethral
• Bladder
– Detrusor overactivity (instability or hypereflexia)
– Low bladder compliance
– Urinary fistula
• Sphincter
– Urethral hypermobility
– Intrinsic sphincter deficiency
• Extraurethral
• Urinary fistula
• Sphincter abnormalities
Signs, symptoms and
conditions causing incontinence
•
•
•
•
•
•
•
Urge incontinence
Stress incontinence
Unaware incontinence
Continuous leakage
Nocturnal enuresis
Post void dribble
Extra-urethral incontinence
Urge Incontinence
• Condition:
– Detrusor overactivity
• Medical/surgical causes:
–
–
–
–
–
Idiopathic
Neurogenic
Urinary tract infection
Bladder cancer
Bladder outlet obstruction
Stress Incontinence
• Condition:
– Urethral hypermobility
– Intrinsic sphincter deficiency
– Stress hyperreflexia (exercise)
• Medical/surgical causes:
– Pelvic floor relaxation
– Prior surgery (urethra, bladder, pelvis)
– Neurogenic
Unaware Incontinence
• Condition:
– Detrusor overactivity
– Sphincter abnormality
– Extraurethral incontinence
• Medical/surgical causes:
– Idiopathic
-- Neurogenic
– Prior surgery
– Vesico, uretero, urethral fistula
– Ectopic ureter
Continuous Leakage
• Condition:
– Sphincter abnormality
– Impaired detrusor contractility
– Extraurethral incontinence
• Medical/surgical causes:
– Neurogenic
– Prior urethral, bladder or pelvic surgery
– Ectopic ureter or urinary/vaginal fistula
Nocturnal Enuresis
• Condition:
– Sphincter abnormality
– Detrusor overactivity
• Medical/surgical cause:
– Idiopathic
– Neurogenic
– Outlet obstruction
Post-Void Dribble
• Condition:
– Post-sphincteric collection of urine
• Medical/surgical causes:
– Idiopathic
– Urethral diverticulum
Extra-Urethral Incontinence
• Condition:
– Vesico, uretero or urethrovaginal fistula
– Ectopic ureter
• Medical/surgical cause:
– Trauma
-- Surgical
– Obstetrical
– Congenital
– Other
Diagnostic Evaluation
•
•
•
•
History of present illness
Past medical history
Physical examination
Laboratory urodynamic evaluation
History of Present Illness
• Patient’s symptoms
– Frequency, urgency, dysuria, incontinence-type
– Incontinence with stress vs. urge
– Difficulty with initiating stream?
• Symptom severity
– Wears pads? -- do they become saturated?
– How often change pads?
Past Medical History
• Neurologic conditions:
– Multiple sclerosis
– Spinal cord injury
– Parkinson’s disease
• Surgical history
– Prostate, vaginal surgery, prior repair for SUI?
– APR, radical hysterectomy
Past Medical History
• Radiation therapy?
• Medications
– Sympathomimetics
– Tricyclic antidepressants
– Parasympatheticomimetics
Physical Examination
• Why?
– Demonstrate incontinence
– Detect prolapse and other pelvic conditions
• interstitial cystitis
– Detect prostate conditions in men
– Detect neurologic abnormalities
Physical Examination
• Key points
–
–
–
–
–
Observe gait
Examine abdomen/flanks for masses
Rectal examination (sphincter tone)
Perineal sensation
Bulbocavernosal reflex
• absence in 30% of normal women
Physical Examination
• Women:
– Vaginal examination with empty and full bladder
– Assess urethral hypermobility (Q tip test)
– Assess prolapse (cystocele, rectocele or enterocele)
• “transverse groove” separates enterocele from
rectocele
– Assess vaginal mucosa
– Assess incontinence (lithotomy vs. standing)
Urodynamic Evaluation
• Why?
– Determine etiology of incontinence
– Evaluate detrusor function
– Determine degree of pelvic floor prolapse
Urodynamic Evaluation
• Why?
– Indentify risk factors for upper tract
deterioration
•
•
•
•
detrusor external sphincter dyssynergia
low compliance
bladder outlet obstruction
vesicoureteral reflux
Urodynamic Evaluation
• When?
– When simpler tests are inconclusive
– When patient complains of incontinence and it
can’t be demonstrated clinically
– History of prior incontinence surgery
– History of APR or radical hysterectomy
– History of known neurologic disorder
Urodynamic Evaluation
• Questions to ask before you start?
–
–
–
–
–
What symptoms do you want to reproduce?
What is the functional bladder capacity?
Does the patient empty their bladder?
Is urinary incontinence a complaint?
Is there a neurologic lesion that can cause
DESD, hyperreflexia or areflexia?
Cystometry
• Graphic representation of intravesical
pressure as a function of bladder volume
• Detrusor activity:
– overactive
– underactive
– normal activity
Nonsurgical Treatment: Overview
• Nonsurgical treatment of lower urinary tract
dysfunction
– Behavioral interventions (Bladder training, habit
training, timed voiding, prompted voiding)
– Biofeedback therapy
– Pelvic floor rehabilitation
– Principles of pharmacologic therapy
Behavioral Interventions for
Urinary Incontinence
•
•
•
•
Bladder training
Habit training
Timed voiding
Prompted voiding
Bladder Training
• Three primary components
– Education
• physiology & pathophysiology of incontinence
– Scheduled voiding
• gradual increase in time between voids
• distraction/relaxation techniques
– Positive reinforcement
• praise: if increase time between voids
Bladder retraining
• Systematic delay in voiding through use of
urge suppression
• Patient must be able to identify urge,
understand how to inhibit the urge and be
motivated to do so!
• Care can be independent or dependent on
caregivers
Bladder retraining
• Urge is suppressed using a pelvic muscle
exercise (Kegel)
• Time between voids is gradually increased
in 15 minute increments, up to goal time of
two to three hours between voids
Habit training
• Must do a voiding diary first!!
• Matches toileting assistance to the patient’s
pattern of voiding
• Pre-empts the incontinence by toileting
before the incontinent episode
• No attempt to delay voiding or resist urge
• Usually caregiver dependent
Timed Voiding
• Set schedule for patient to toilet on a
planned basis
• Schedule is individualized to patient’s
voiding schedule
• Typically patient asked to void every 2
hours regardless of desire to void
Prompted voiding
• Patient is encouraged and assisted to toilet
every 2 hours from 7am to 7 pm
• Must be able to use a toileting device
• Caregiver dependent
• Prompts can be verbal reminders or
physical assistance to the toilet
• Adjust prompt times to meals and qhs
Clinical Uses of Scheduling
Regimens
• Bladder training
– Functionally & mentally intact patients
• Habit retraining
– Functionally & mentally intact patients
• Timed voiding
– Nursing home residents, patients with NGB
• Prompted voiding
– Patients with cognitive/mobility impairment
Conclusions about Behavioral
Therapy
•
•
•
•
•
•
Can treat urinary incontinence (UI> SUI)
Can treat sensory urgency
Inexpensive
Has no side effects
Can be done in inpatient or outpatient setting
No special equipment required
Biofeedback
• Originated in laboratory research 25 years
ago
• Applied to urinary bladder
• ? Mechanism of action: reflex inhibition?
• Programs: voluntary contraction of pelvic
muscles (pubococcygeous & levator)
• Goal: modify visceral control (bladder)
Biofeedback
• Relates to anatomy of pelvic muscles
– identify pubococcygeous muscle
– identify muscles of external anal and urethral
sphincter
• all muscles innervated by S2 via pudendal nerve
– voluntary contraction of EUS can interrupt
incontinence during an episode of urgency and
relax detrusor
Biofeedback
•
•
•
•
•
Bladder Filling
Signal Source
Equipment
Patient Selection
Results
Results for Biofeedback
• Conclusions
– Effective to reduce episodes of urge
incontinence
– Less is known about:
• Frequency: hallmark of bladder training
• Urgency: difficult to measure
• Nocturia: multi-factorial condition
Borgio, JAGS 2000
Electrostimulation
• Transvaginal or transanal
• Effects:
– cause passive contraction of pelvic floor
musculature
• Potential uses:
– “Re-educate” weak muscles to contract
– Relieve symptoms of urge incontinence/pelvic
pain
Electrostimulation
• Home or office use
• Protocol:
– Bladder dysfunction: use low frequencies
– Detrusor instability: use higher frequencies
• 10 or 12.5 Hz
– Stress incontinence: use higher frequencies
• 50 or 100 Hx
– Mixed incontinence: mid frequencies (20 Hz)
Electrostimulation
• Conclusions
– E-stim useful in patients with nonobstructive urinary
retention
– Addition of urecholine did not improve e-stim results
– Subjective success rate stress urge incontinence: 71%
– Subjective success rate detrusor instability: 70%
– Subjective success rate mixed urge incontinence: 52%
Bernier and Davila, 2000 Urol Nursing
Bent, et al. 1993 Int J Urogynecol
E-stim and Biofeedback
Combo?
• Conclusions
– Biofeedback and e-stim are effective to treat
urinary incontinence
– Reasonable initial steps in the management of
urinary incontinence
Aikey, et al Albany Med
Vaginal Weighted Cones
• Inexpensive ($50-200/set)
• Procedure
– cone inserted into vagina above levators
– patient tightens muscles when cone slips down
– sequential increase in cone weight/size
Vaginal Weighted Cones
• Results
– Six series of 189 patients
– Satisfaction rates of 40-70% among those
compliant with therapy
– Cumulative drop out rate of 28%
– Many will not accept this therapy
– Some cannot even retain the lightest cone
Summary of Techniques
• Review of 22 trials:
– Pelvic floor muscle exercises treat SUI
– Biofeedback + PFM no better than PFM alone
– No difference between e-stim and other
therapies
– Weak evidence to suggest bladder retaining is
no more effective than drug therapy
Medical Therapy
• Medications for Stress Incontinence
– Alpha adrenergics
– Estrogens
• Medications for Urge Incontinence
– Tolterodine
– Oxybutynin XL
– Oxybutynin Transdermal
Medical Therapy- Alpha
Agonists
• Phenylpropanolamine(PPA)
– best studied alpha agonist
– taken off market -- hemorrhagic strokes in
young women
– 5/8 studies with PPA demonstrated
improvement in SUI by 19 - 60% vs. placebo
– However, pseudoephedrine is available with
similar efficacy
Medical Therapy - Alpha
Agonists
• Estrogens
– controversial
– receptors in urethra, vagina --> tissue atrophy
with menopause?
– Metaanalysis of 8 trials “superior to control”
– Contrary -- Grady, et al 2000 -- “worsening of
incontinence vs. controls at 4 years)
• problem -- in study only 26% had SUI
Medical Therapy – Overactive
Bladder (OAB)
• Oral oxybutynin
–
–
–
–
proven muscarinic activity of active agent
efficacy similar with XL form
benefit of XL for side effects
dosing magnitude higher
• improved tolerability
Medical Therapy - OAB
• Oral oxybutynin
– compliance benefit with once daily dosing
– steady state pharmacokinetics
• modulated serum peaks
• less variance below threshold levels
– lower discontinuance rates
Medical Therapy - OAB
• Tolterodine tartrate
–
–
–
–
–
active anti-muscarinic compound
binding selectivity for bladder
improved xerostomia
generally well tolerated
extended release formulation -- good for
xerostomia
– ER form works as well as IR form
Medical Therapy - OAB
• Transdermal oxybutynin
– altered metabolism of parent
• avoidance of proximal gut CYP450
– equal efficacy to IR formulation
– substantially less systemic side effects
– compliance benefit
• twice weekly application
Medical Therapy - OAB
• OPERA Trial (Diokno et al), Mayo Clin Proc
–
–
–
–
Tol ER vs. Oxy ER
12 week double-blind study
790 women enrolled
Primary outcomes
• urge incontinence
• total incontinence
• urinary frequency
Medical Therapy - OAB
• OPERA
– Similar effect between active arms
• significant reduction for all outcomes
– Statistical difference
• urinary frequency (28% vs. 25%)
• total continence (23% vs. 17%)
– Adverse events
• total dry mouth greater for OXY ER
• discontinuation rates same
Medical Therapy - OAB
• ACET, Sussman, et al 2002
– Open label direct comparison
• OXY ER 5/10
• TOL ER 2/4
–
–
–
–
–
8 week analysis
1289 patients
TOL ER 4 mg superior to all others (70% vs 60%)
Significantly less dry mouth with TOL ER
Discontinuation rates
• 6% TOL ER vs. 13% OXY ER
Medical Therapy - OAB
• OXY-TDS vs. TOL-LA vs. Placebo
• (Domchowski, et al Urol 2003)
– compare efficacy and safety of OXY-TDS vs.
TOL LA vs. placebo
– Multi-center, double blind, randomized trial for
12 weeks & then 52 week open label
– 361 patients randomized
• OXY-TDS 3.9 mg/d or TOL LA 4mg/d
Medical Therapy - OAB
• Results
Parameter
OXY-TDS
TOL-LA
Placebo
Complete continence
Urinary freq reduction
Voided volume increase
40%
17%
15%
40%
17%
19%
24%
8%
3%
Medical Therapy - OAB
• Adverse Effects
Parameter
OXY-TDS
TOL-LA
Placebo
Dry mouth
Constipation
Blurred vision
Dizziness
Application site issues
Pruritis
Erythema
4.1%
3.3%
2.5%
0.8%
7.3%
5.7%
0.8%
2.4%
1.7%
1.7%
0.9%
0.9%
14%
8.3%
2.4%
0.8%
4.3%
1.7%
Parting Thoughts
• Improvement is attainable in the majority of
patients
– with combined behavioral therapies?
• The ideal agent/non pharmacologic therapy
is not yet available
• Distinguishing criteria and outcomes
– difficult to separate absolute results
References
•
•
•
•
•
•
•
•
Aikey, et al, Albany Med.
Bent et al., Int J Urogynecol 1993.
Bernier F and Davila GW, Urol Nurs 2000:261-4.
Borgio KL, Locher JL, Goode PS. J Am Geriatr Soc
2000:370-4.
Diokno AC et al, Mayo Clin Proc 2003 Jun;78(6):687-95.
Dmochowski RR, et al, Urology 2003 Aug;62(2):237-42.
Grady, et al, 2000.
Sussman D, Garely A. Curr Med Res Opin.
2002;18(4):177-84.