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Incontinence 尿失禁 Surgical Management of Female Urinary Incontinence • Involuntary leakage of urine • 1 in 4 women : 1 in 9 men will suffer from urinary incontinence at some stage of their lives • Incidence increases with age Dr Bill WONG Specialist in Urology, Pedder Clinic Hon Consultant Urologist, Queen Elizabeth Hospital Hon Director, Urology Centre, St Paul’s Hospital Hong Kong Lower Urinary Tract 下尿路 Bladder & Outflow Tract Anatomy Normal Functions Male • Storage of urine Female • Capacity • Detrusor • End-filling pressure • Closure mechanisms • Voiding urine • Detrusor contraction • Bladder outlet • Post-void residual 400 - 500 ml stable Pdet < 15 cmH2O adequate Pdet 40 - 60 cmH2O patent 0 ml Urinary Incontinence Urinary Incontinence Etiology Definition Bladder Outflow Tract Storage • Overactive bladder • Non compliant bladder • Small fibrotic bladder • Incompetent sphincter / outflow tract • Fistulae Voiding • Chronic retention w/ overflow • BOO (eg BPH) • Dysfunctional outflow (eg post RT) • Involuntary loss of urine, which is a social or hygienic problem, and which is objectively demonstrable International Continence Society, 1988 • Involuntary loss of urine, which is sufficient to be a problem Urinary Incontinence Guideline Panel, 1992 Agency for Health Care Policy and Research U S Department of health and Human Services * 1 Urinary Incontinence Urinary Incontinence Problem Oriented Grouping Prevalence in Elderly • Enuresis in children • Stress incontinence in women • Incontinence in elderly - men - women • ~ 30 % of population older than 60 years • > 50 % of institutionalised elderly persons resident in nursing home Resnick, et al NEJM 320:1-7, 1989 Urinary Incontinence Incontinence 尿失禁 Economic Costs Terminology 分類名稱 • Costs related to urinary incontinence in 1995 US$ 26.3 billion US$ 3,565 per patient Wagner, Hu Urol 51:355-61, 1998 • Urge incontinence 急切性 • Stress incontinence 壓力性 • Overflow incontinence 滿溢性 • Total incontinence • Functional incontinence Urinary Incontinence Urinary Incontinence Urge Incontinence 急切性尿失禁 Stress Incontinence 壓力性尿失禁 • Loss of urine, with urge to urinate and yet inability to postpone voiding • 2 types : - Motor urgency • Leakage of urine, with activities that increase abdominal pressure such as laughing, coughing, sneezing & positional changes accompanied by urodynamically documented involuntary / uninhibited detrusor contraction - Sensory urgency 2 Urinary Incontinence Stress Urinary Incontinence Stress Incontinence 壓力性尿失禁 International Continence Society Terminology • Genuine stress incontinence (in women) Urodynamic stress incontinence • Stress incontinence related to detrusor instability • Urodynamic stress incontinence Loss of urine as a result of an abdominal pressure increase, without detrusor overactivity, during storage phase of urodynamic testing • Detrusor overactivity incontinence Loss of urine as a result of involuntary detrusor activity, during storage phase of urodynamic testing • Urodynamic mixed incontinence Urodynamic stress incontinence in combination with detrusor overactivity incontinence Urinary Incontinence Urinary Incontinence Overflow Incontinence 滿溢性尿失禁 Investigations • Leakage of urine, at greater than bladder capacity; associated with incomplete bladder emptying, due to either impaired detrusor contractility or bladder outlet obstruction • History taking • Voiding diary / frequency volume chart • Urodynamic study International Continence Society, 1997 Voiding Diary 日記 or Frequency Volume Chart Voiding Diary 日記 or Frequency Volume Chart 3 Urodynamics 尿流動力學 Urodynamic Study Video Urodynamic Study Urinary Incontinence Etiology Bladder Outflow Tract Storage • Overactive bladder • Non compliant bladder • Small fibrotic bladder • Incompetent sphincter / outflow tract • Fistulae Voiding • Chronic retention w/ overflow • BOO (eg BPH) • Dysfunctional outflow (eg post RT) 4 Bladder Storage 3 ‘C’s • Capacity • Compliance • Contractions - a capacious reservoir - to store urine at low pressure - w/out involuntary contractions (ie stable bladder) Unstable / Overactive Bladder 膀胱過動 A6378822 Urodynamic Definition • An involuntary rise in detrusor pressure during bladder filling of 15 cmH2O or more International Continence Society Standardisation Committee Urge Syndrome Detrusor Instability • The ‘unstable bladder’ may be defined as a bladder which does not tolerate filling, contracting without its owner’s permission. Clinical Features • • • • Urgency Frequency Nocturia Urge incontinence 尿急 尿頻 夜尿 急切性尿失禁 McGuire EJ Urol Clin N Am 5:335, 1978 5 Urge Syndrome Clinical Features • • • • Urgency Frequency Nocturia Urge incontinence 尿急 尿頻 夜尿 急切性尿失禁 Overactive Bladder 膀胱過動 Urge Syndrome Clinical Features • • • • Urgency Frequency Nocturia Urge incontinence 尿急 尿頻 夜尿 急切性尿失禁 Causes • • • • • • • • Cystitis Bladder stone Bladder tumour Bladder outlet obstruction - substantially higher incidence Idiopathic - up to 10 % of population Children substantially higher incidence Elderly Neuropathic bladder / detrusor hyperreflexia ] × Bladder / ‘catheter’ spasm Overactive Bladder 膀胱過動 Overactive Bladder 膀胱過動 Management Management • Treatment of underlying cause (if any) • Control of detrusor overactivity • Conservative measures / first-line management • Drug therapy • Surgical intervention • Treatment of underlying cause (if any) • Control of detrusor overactivity • Conservative measures / first-line management • Drug therapy • Surgical intervention 6 Overactive Bladder Drug Therapy 1 Overactive Bladder Drug Therapy • Anticholinergic 2 • Anticholinergic (* cont’d) - Propantheline (Probanthine) - Emepronium (Cetiprin Novum) ..… / cont’d * - Oxybutynin (Ditropan)* - Tolterodine (Detrusitol)* - Solifenacin (Vesicare)* • Anticholinergic + Ca++ channel blockade • Smooth muscle relaxant - Flavoxate (Urispas) - Propiverine • Anticholinergic + α-adrenergic - Imipramine (Tofranil) Overactive Bladder Overactive Bladder Oxybutynin vs Tolterodine Oxybutynin vs Tolterodine Mean change from baseline in : Frequency & severity of dry mouth Frequency of micturitions No. of incontinence episodes in 24 h in 24 h Volume voided per micturition Time (weeks) Placebo (dark green) Tolterodine 2mg bd (light green) Oxybutynin 5mg tid (pink) Abrams et al BJU 81:801, 1998 Abrams et al BJU 81:801, 1998 Overactive Bladder Overactive Bladder Tolterodine + Simplified Bladder Training Tolterodine + Simplified Bladder Training • Simplified bladder training (BT) = Written information sheet • Tolterodine 2mg bd + simplified BT vs Tolterodine alone → • median % ↓ in voiding frequency 33% vs 25% • median % ↑ in volume voided per void 31% vs 20% • No significant difference in • median % ↓ in incontinence episodes • median % ↓ in urgency episodes Mattiasson, et al & Tolterodine Scandinavian Study Group BJUI 91:54, 2003 • Conclusion: • Simplified bladder training augments effectiveness of tolterodine in patients with overactive bladder • Caveats: • Insufficient time, funding or qualified staff in clinics → Lack of extensive personal interaction • Patient motivation & mental capability Mattiasson, et al & Tolterodine Scandinavian Study Group BJUI 91:54, 2003 7 Overactive Bladder Overactive Bladder 膀胱過動 Solifenacin Management • Bladder selectivity Drug Selectivity ratio (Bladder selectivity over salivary glands) Solifenacin (Vesicare) Tolterodine (Detrusitol) 2.1 * 0.65 Oxybutynin (Ditropan) 0.51 • Treatment of underlying cause (if any) • Control of detrusor overactivity • Conservative measures / first-line management • Drug therapy • Surgical intervention * p<0.1 (statistically different from Tolterodine & Oxybutynin) • Phase I studies showed no decrease in salivary flow with Solifenacin 5 mg • Once daily dose regimen • 5 – 10 mg daily Uchida, et al (2004) • • • • • Incontinence Incontinence Conservative Management Conservative Management Behavioral modification 行為治療 Bladder retraining 膀胱訓練 Physical therapies 物理治療 Incontinence aids & appliances 尿遺用品 Clean intermittent self catherisation (CISC) 清潔間歇性自助導尿術 • • • • • Behavioral modification 行為治療 Bladder retraining 膀胱訓練 Physical therapies 物理治療 Incontinence aids & appliances 尿遺用品 Clean intermittent self catherisation (CISC) 清潔間歇性自助導尿術 Overactive Bladder 膀胱過動 Detrusor Overactivity Management Surgical Treatment • Treatment of underlying cause (if any) • Control of detrusor overactivity • Conservative measures / first-line management • Drug therapy • Surgical intervention • • • • • • • Prolonged bladder distension Transvesical injection therapy Sacral neurectomy Sacral nerve stimulation / Neuromodulation Bladder transection Detrusor myomectomy / Bladder autoaugmentation Entero-cystoplasty / Bladder augmentation 8 Detrusor Overactivity Detrusor Overactivity Intravesical Therapy Intravesical Capsaicin • Intravesical instillation of capsaicin • Intravesical Botulinum-A toxin injection Detrusor Overactivity Detrusor Overactivity Botulinum-A Toxin Injection Botulinum-A Toxin Injection • Botulinum-A neurotoxin binds to pre-synaptic terminal of motor neurons → selectively inhibits acetylcholine release at neuromuscular junction → detrusor hypocontractility ↓ intravesical pressure • Botox® 300 u in n-saline 30 ml Dysport® 750–1000 u in n-saline 20 ml Toxin equivalence - Botox : Dysport = 1 : 2.5 • Fill bladder to 100–200 ml Inject into bladder wall, sparing trigone ½–1 ml per site Detrusor Overactivity Refractory Detrusor Overactivity Botulinum-A Toxin Injection Surgical Treatment • Effect lasts 9 – 12 months • Repeat injections are as effective Grosse, et al Eur Urol 47:653,2005 • Advantage: • Non invasiveness • Disadvantages: • Transient muscular weakness • Drug resistance • • • • • • • Prolonged bladder distension Transvesical injection therapy Sacral neurectomy Sacral nerve stimulation / Neuromodulation Bladder transection Detrusor myomectomy / Bladder autoaugmentation Entero-cystoplasty / Bladder augmentation 9 Detrusor Overactivity Detrusor Overactivity Neuromodulation Detrusor Myectomy • Removal of overlying detrusor muscle creates ‘diverticulum’ • Results in fibrosis • May be offered for urinary incontinence or irritative symptoms due to refractory detrusor overactivity • Mechanism of action unknown • Predictors of outcome & patient response unknown Level of Evidence: 2 - 3 Grade of Recommendation: B 3rd Int’l Consultation on Incontinence, 2004 Bladder Autoaugmentation Bladder Autoaugmentation Demucosalised Bowel Detrusor Myectomy • Idiopathic detrusor instability or Detrusor hyperreflexia n = 27 - Minimum 1 year followup - Urodynamic variables showed significant improvement - Symptomatic improvement considered inferior to that obtained by enterocystoplasty - Success rate higher with idiopathic detrusor instability - 3 neuropathic patients required conversion to enterocystoplasty Swami et al BJU 81:68, 1998 Detrusor Overactivity Bladder Augmentation Enterocystoplasty for Refractory Urge Incontinence Enterocystoplasty Detrusor overactivity Good or moderate result Bowel segment Clam ileo-cystoplasty Bramble (1982) 15 13 13 colon. 2 ileum Mundy, Stephenson BJU 57:641,1985 Mundy & Stephenson (1985) 40 30 ileum Sethia et al (1991) 11 9 ileum Hasan et al (1995) 33 19 ileum, colon 44 McInerney et al (1995) 50 Leng et al (1999) 2 2 Edlund et al (2001) 25 19 176 136 ( 77 % ) Total 10 Bladder Augmentation Bladder Augmentation Enterocystoplasty Enterocystoplasty • Complications: • Mucus plug retention • 10 % (minimum) require intermittent catheterization for bladder emptying • Idiopathic urge incontinence - n = 51 53 % happy with outcome of surgery, 39 % not happy 39 % required CISC 18 % continued to have incontinence Awad et al BJU 81:569, 1998 • Neurogenic LUTD (mostly incontinence) - n = 59 - 58 / 59 ‘delighted’, ‘pleased’ or ‘mostly satisfied’ - 40 % had complications at 70 months median followup Herschorn, Hewitt Urol 52:672, 1998 Bladder Augmentation Enterocystoplasty • Patients with idiopathic & neurogenic urge incontinence may have quite different expectations of the results of surgery • Generally considered a treatment of last resort for idiopathic detrusor instability Continent Urinary Diversion: Mitrofanoff Principle • Catheterisable conduit to a urinary reservoir • With a continent and catheterisable cutaneous stoma Cystostomie continente trans-appendiculaire dans le traitement des vessies neurologiques. Mitrofanoff P Chir Pediatr 21: 297, 1980 Mitrofanoff Principle Urol Clin N Am 24:796, 1997 11 Urinary Incontinence Etiology Bladder Outflow Tract Storage • Overactive bladder • Non compliant bladder • Small fibrotic bladder • Incompetent sphincter / outflow tract • Fistulae Voiding • Chronic retention w/ overflow • BOO (eg BPH) • Dysfunctional outflow (eg post RT) Lower Urinary Tract 下尿路 Anatomy Female Video Urodynamic Study Urodynamic Stress Incontinence in Women 女性壓カ性尿失禁 Pelvic Floor Support • Levator ani muscle • Levator fascia • Fascial ligaments A640338A TamFY F / 56 9911-062 Δ GSI Type I Filled to capacity (485 ml) → Coughing 12 K2981459 ChauHM F / 53 9909-044 Δ GSI Type II Filled to capacity Female SUI → Valsalva Pathophysiology Decrease in bladder outlet / urethral resistance due to: • Poor anatomical support of bladder neck – urethral hypermobility • Impairment of urethral function / closure – intrinsic sphincter deficiency • Combination of both Radiological Classification Blaivas & Olsson Type At Rest 0 Absence of GSI BN hypermobility <2 cm At Strain I BN closed BN open BN hypermobility <2 cm IIa BN closed BN above inferior margin of pubis BN open BN hypermobility =/>2 cm IIb BN closed BN below inferior margin of pubis BN open Further descent III BN & proximal urethra open Blaivas J Urol 139:727:1988 Childbirth - Vaginal Delivery Urodynamic Stress Incontinence Pelvic Floor Damage Vaginal Weakness 13 Urodynamic Stress Incontinence Weakened Levator Hiatus Urodynamic Stress Incontinence Urodynamic Stress Incontinence Muscle Denervation Vaginal Mobility Urodynamic Stress Incontinence Incontinence Loss of Anatomic Support Conservative Management • • • • • Behavioral modification 行為治療 Bladder retraining 膀胱訓練 Physical therapies 物理治療 Incontinence aids & appliances 尿遺用品 Clean intermittent self catherisation (CISC) 清潔間歇性自助導尿術 14 Urodynamic Stress Incontinence Surgical Treatment Marshall-Marchetti-Kranz Procedure • Retropubic suspension procedures • Marshall-Marchetti-Krantz (MMK) • Burch colposuspension • Laparoscopic colposuspension • Transvaginal suspension procedures • Transvaginal needle suspensions • Pubovaginal sling • Tension-free vaginal tape • Artificial urinary sphincter implant Marshall-Marchetti-Kranz Procedure Recommendations Burch Colposuspension • Longer-term outcome is poor following MMK, and declines further over time Level of Evidence: 1 • MMK procedure is not recommended for the treatment of SUI in women Grade of Recommendation: A 4th Int’l Consultation on Incontinence, 2008 Burch Colposuspension Colposuspension – Variations Raz Bladder Neck Suspension 15 Colposuspension – Variations Open Burch Colposuspension Vagino-Obturator Shelf Procedure Results Open Burch Colposuspension Laparoscopic Colposuspension Recommendations Recommendations • Open retropubic colposuspension is an effective treatment for primary SUI, which has longevity Grade of Recommendation: A • Open colposuspension should still be considered when an open abdominal procedure is required concurrently with surgery for SUI, although it has to a large extent been superseded by the less invasive mid urethral tapes • Comparable subjective outcome, but poorer objective outcome in short to medium term, than both open colposuspension & TVT • Longer term outcomes unknown Level of Evidence: 2 • Laparoscopic colposuspension is not recommended for the routine surgical treatment of SUI in women Grade of Recommendation: D Grade of Recommendation: A 4th Int’l Consultation on Incontinence, 2008 4th Int’l Consultation on Incontinence, 2008 Stamey Needle Suspension 16 Fascial ligaments Needle Suspension Procedures Pubovaginal Sling Recommendations • Needle suspension procedures are less effective than colposuspension even in the short term Level of Evidence: 1 • Needle suspension procedures, endoscopic or nonendoscopic, with or without bone anchors, are not recommended for the treatment of SUI in women Grade of Recommendation: A 4th Int’l Consultation on Incontinence, 2008 Pubovaginal Sling Pubovaginal Sling Sling Materials Type of Material Pros Cons Autologous (fascial sling) • Easily available • Biocompatible • Cost-effective • Harvesting morbidity (pain, wound complications) • Longer operative time Cadaveric • • • • Easily available Length & size adjustable No harvesting Shorter procedure • Tensile strength unknown • Potential risk of infection (HIV, prions) • Durability & efficacy unknown • Cost Synthetic • • • • Easily available Length & size adjustable No harvesting Shorter procedure • Risk of erosion into urethra, bladder neck or vagina, & infection • Durability & efficacy unknown • Cost 17 Pubovaginal Sling Mid Urethral Tapes Recommendations • Autologous rectus fascial sling is an effective • Retropubic placement treatment for SUI, which has longevity Level of Evidence: 1 Grade of Recommendation: A * • Further high quality research is required to clarify the place of ‘traditional’ sling procedures in relation to other procedures, and to establish the optimum sling materials • Tension-free vaginal tape • Intra vaginal sling • Supra pubic arc sling • Transobturator placement • Inside-out procedure • Outside-in procedure TVT IVS SPARC TVT-O TOT Grade of Recommendation: D 4th Int’l Consultation on Incontinence, 2008 Pathophysiology of Female SUI Tension-free Vaginal Tape (TVT) Hammock Theory Principle Colposuspension Endopelvic fascia connects anterior vaginal wall to arcus tendineus bilaterally, forming a hammock-like support structure upon which the bladder & urethra rest TVT Rises in intra-abdominal pressure compresses the urethra against the supporting structures, which act like a stable backboard, & results in occlusive action DeLancey JO Am J Obst Gyne 170:1713,1994 Tension-free Vaginal Tape (TVT) Technique Ulmsten, et al Int Urogyne J 7:81,1996 Mid Urethral Tapes • Retropubic placement • Tension-free vaginal tape • Intra vaginal sling • Supra pubic arc sling • Transobturator placement • Inside-out procedure • Outside-in procedure TVT IVS SPARC TVT-O TOT Ulmsten, et al Int Urogyne J 7:81,1996 18 Tension-free Vaginal Tape (TVT) Tension-free Vaginal Tape (TVT) Technique Technique Minimally invasive : • 3 small incisions • 1 vaginal, 1.5–2 cm long • 2 suprapubic, @ 1 cm long • Duration of operation • 30–45 minutes • Duration of hospitalization • 1–3 days Tension-free Vaginal Tape (TVT) Tension-free Vaginal Tape (TVT) Results Results Patients Follow-up Cure (%) Improved (%) Failed (%) Ulmsten (1998) 131 1 yr 91 7 2 Ulmsten (1998) 50 3 yr 86 12 2 Olsson (1999) 51 3 yr 90 6 4 Haab (2000) 62 1 yr 4 m 87 10 3 Klutke (2000) 20 1 yr 85 10 5 Moran (2000) 40 1 yr 80 17 3 De novo DI (%) 6 12 Tension-free Vaginal Tape (TVT) Tension-free Vaginal Tape (TVT) Recommendations Complications • Retropubic TVT is more effective than Burch colposuspension, and equally effective as traditional fascial sling procedures Level of Evidence: 1/2 • Operation time, hospital stay, & time to resume normal daily activity is shorter with TVT than with colposuspension Level of Evidence: 1/2 4th Int’l Consultation on Incontinence, 2008 Multicentre prospective study N = 100 Urinary infection Bladder injury 10 % 6% Prolonged pain Complete retention >1 month 3% 1% Retropubic haematoma Major labial haematuria 1% 1% Healing problems Bleeding >200 ml 1% 1% Haab, et al Prog Urol 10:47A, 2000 19 Tension-free Vaginal Tape (TVT) Intrinsic Sphincter Deficiency Recommendations Surgical Treatment • Colposuspension is more commonly associated with post-operative voiding problems & need for urogenital prolapse surgery • TVT is more commonly associated with bladder perforation • Sling operation • Urethral bulking agents • AUS implant Level of Evidence: 1/2 4th Int’l Consultation on Incontinence, 2008 B2807039 TongLS F / 63 9901-002 Δ GSI: ISD At capacity Urethral Bulking Agents Pubovaginal Sling Periurethral Injection • Add bulk to increase coaptation of urethral wall at level of bladder neck / distal sphincter • Bulking agents: • Bovine collagen (Contigen®) • Silicone macroparticles (Macroplastique®) • Hyaluronic acid / dextranomer copolymer (Zuidex®) • Carbon coated zirconium oxide beads (Durasphere®) • Dimethyl sulfoxide / ethylene vinyl alcohol copolymer (Uryx®) • Hydoxylapatite spheres in carboxylmethylcellulose carrier (Coapatite®) 20 Artificial Urinary Sphincter X Indwelling Urethral Catheter 留置導尿管 • • • • • • • • • • Urinary Incontinence 尿失禁 X Urostomy Leakage Catheter / bladder spasm Inability to retain catheter Erratic drainage Infection Epididymo-orchitis Pressure necrosis Catheter tumour Encrustation Inability to withdraw catheter Bladder & Sphincter Dysfunction Incontinence 尿失禁 Priorities in Long-term Management Shared Care 醫護分工 • Preservation of renal function → Quantity of life 壽命 • Alleviation of symptomatic problems → Quality of life 生活質素 • Urinary continence • Stoma / appliance free • Specialist consultation - for investigation, diagnosis & appropriate treatment plan • Multi-disciplinary approach in management - urologist, urology nurse specialist & practitioner, continence advisor, other health care providers - eg Continence Clinic Urology Nurse Practitioner Clinic • Involvement of family • Involvement of family physician & primary health care providers 21
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