MANAGEMENT OF STRESS URINARY INCONTINENCE Michelle Y . Morrill, - - PowerPoint PPT Presentation

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MANAGEMENT OF STRESS URINARY INCONTINENCE Michelle Y . Morrill, - - PowerPoint PPT Presentation

Sep 26, 2022 133 likes •296 views

10/26/2016 Disclosures None MANAGEMENT OF STRESS URINARY INCONTINENCE Michelle Y . Morrill, M.D. Chief of Female Pelvic Medicine and Reconstructive Surgery, TPMG Director of Urogynecology, Kaiser SFO Assistant Professor, Volunteer

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10/26/2016 1

MANAGEMENT OF STRESS URINARY INCONTINENCE

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

Disclosures

  • None

Goals

  • Review the epidemiology and causes of stress urinary

incontinence (SUI) in women

  • Discuss appropriate diagnostic tools for SUI
  • Learn about treatment options for SUI

Urinary Incontinence

  • Accidental leakage of urine
  • Common medical condition
  • Significant Quality of Life factor
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SLIDE 2

10/26/2016 2 Bladder Function

3 Ways to Void :

  • 1. Valsalva
  • 2. Detrusor Contraction
  • 3. Urethral Relaxation

Urinary Incontinence

3 Ways to Void :

  • 1. Valsalva
  • 2. Detrusor Contraction
  • 3. Urethral Relaxation

3 Ways to Leak :

  • 1. Valsalva
  • 2. Detrusor Contraction
  • 3. Urethral Relaxation

Urinary Incontinence

3 Ways to Void :

  • 1. Valsalva
  • 2. Detrusor Contraction
  • 3. Urethral Relaxation

3 Ways to Leak :

  • 1. Valsalva (Stress

Incontinence)

  • 2. Detrusor Contraction
  • 3. Urethral Relaxation

Urinary Incontinence

3 Ways to Void :

  • 1. Valsalva
  • 2. Detrusor Contraction
  • 3. Urethral Relaxation

3 Ways to Leak :

  • 1. Valsalva (Stress

Incontinence)

  • 2. Detrusor Contraction

(Overactive Bladder)

  • 3. Urethral Relaxation
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10/26/2016 3 Urinary Incontinence

3 Ways to Void :

  • 1. Valsalva
  • 2. Detrusor Contraction
  • 3. Urethral Relaxation

3 Ways to Leak :

  • 1. Valsalva (Stress

Incontinence)

  • 2. Detrusor Contraction

(Overactive Bladder)

  • 3. Urethral Relaxation (rare)

Function: Bladder and Urethra

10 October 26, 2016 11

Stress Incontinence

Dysfunction: Bladder and Urethra

SUI Symptoms

  • Stress incontinence:
  • The complaint of involuntary leakage of urine on effort or exertion,
  • eg. with sneezing or coughing (valsalva)
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SLIDE 4

10/26/2016 4 SUI Causes?

1994 DeLancey and Ashton-Miller ‘Hammock Theory’:

  • Support and elevation at the bladder neck maintains continence
  • Injury to the levator muscles and pubocervical support tissues led to SUI

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

SUI Causes?

1990 Petros and Ulmsten ‘Integral Theory’

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

muscle around the urethra

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

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?

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
  • 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.

SUI Causes?

  • Lack of support or squeeze on the urethra
  • Not bladder
  • Not prolapse
  • Treatment of prolapse can → stress incontinence1

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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SLIDE 5

10/26/2016 5 Post-Void Dribbling

Treatment = Double Voiding

1.

Relax to void

2.

Stand and count to 10

3.

Sit briefly for drops

Urinary Incontinence Epidemiology

  • Prevalence
  • Urinary Incontinence in the past year1 : 50%

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

  • Prevalence
  • Urinary Incontinence in the past year1 : 50%
  • Bother (EPIQ questionnaire)
  • Stress incontinence2 : 15%
  • Urgency and urge incontinence2 : 13%

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

Urinary Incontinence Epidemiology

  • Prevalence
  • Urinary Incontinence in the past year1 : 50%
  • Bother (EPIQ questionnaire)
  • Stress incontinence2 : 15%
  • Urgency and urge incontinence2 : 13%
  • Care Seeking3 : 61%

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 3Morrill et al. Seeking healthcare for pelvic floor disorders: a population-based study. Am J Obstet Gynecol. 2007 Jul;197(1):86.e1-6.

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10/26/2016 6

Why do women develop SUI?

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

smoking)

  • Oral estrogen

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

Urinary Incontinence Racial Differences

2 4 6 8 10 12 14 16 18 20 White Hispanic Mexican American Black

‘Moderate – Severe’ Urinary Incontinence by Race

(Leakage of at least drops weekly or wet monthly)

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

Urinary Incontinence Racial Differences

Incontinence Impact : Same severity of incontinence is more bothersome to black women than white women1 Possibly due to racial disparities in knowledge of risk factors and treatment

  • ptions for incontinence2

Or due to low levels of knowledge about UI and a reluctance to discuss symptoms with health care professionals3

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):287-

92.

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.

SUI Age Differences

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

5 10 15 20 25 30 35 Percent with SUI or MUI AGE by 5 year groups

SUI or MUI in women age 20 – 90+

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SLIDE 7

10/26/2016 7 SUI Age Differences

Young women and incontinence :

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

Screening

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

Evaluation and Diagnosis

  • Evaluate for Urinary infection (UA +/- Cx)
  • Ask
  • UI associated with physical activity such as coughing, sneezing, lifting or exercise
  • Sensitivity = 0.86 Specificity = 0.61
  • Physical Exam
  • Consider uncommon alternatives eg. urethral diverticulum, vaginal discharge

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.

Evaluation and Diagnosis : Pre-op

  • Stress Test
  • Yes / No leak
  • Delay or prolonged leak suggests Stress Induced Detrusor Overactivity
  • Post-void residual
  • Urethral Mobility / Q-tip test?
  • OR = 1.9 For failure of MUS1
  • Urodynamics?
  • Not if uncomplicated stress-predominant urinary incontinence2

1Richter 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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10/26/2016 8

Stress Incontinence Treatments

Pelvic Floor Exercises

  • 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)

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

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.

Weight Loss

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

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

  • 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

% Change

−58% −33%

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SLIDE 9

10/26/2016 9 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) Impressa by Poise Stress Incontinence Treatments (Support or squeeze the urethra)

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10/26/2016 10

Stress Incontinence Treatments (Support or squeeze the urethra)

Silicone Pessaries Who should use a pessary?

Anyone who wants it

  • To avoid surgery
  • To treat symptoms while waiting for surgery

So offer them to everyone

Contraindications

  • Active infection
  • Non-compliance or inability to follow-up
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10/26/2016 11 How do I fit it?

Whatever way is comfortable and effective for the patient Can use more than 1

After fitting

Pessaries last for years (decades?)

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?

Vaginal bleeding

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

What about?

Vaginal Infections

  • 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)
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10/26/2016 12 Operations for Urinary Incontinence

  • Traditional (urethrovesical) slings
  • Retropubic colposuspension
  • Urethral Bulking
  • Mid-urethral Slings:
  • 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

  • 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

  • 14 RCTs including urethral bulking in at least one arm
  • Heterogeneity in outcomes so not able to compare results
  • Urinary retention was the main adverse event in most studies

Urethral bulking

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

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

Short term (<6m) improvement 75% cure 43% (12 and 13 studies respectively) Long term (>18m) improvement 64% cure 36% (10 and 11 studies respectively)

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

Mid-Urethral Slings:

  • Retropubic (RP)
  • Transobturator (TO)
  • “Minislings”
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10/26/2016 13

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

  • 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.”

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

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

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%

  • 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

  • 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)
  • 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.

  • 8671 women with an index surgery for SUI followed for 5 years
  • Reoperation for RP = 6%
  • Reoperation for TO = 9% (significantly higher hazard ratio)
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10/26/2016 14 Mini-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 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

Conclusions Mid-Urethral Slings

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

Summary

  • SUI is common
  • A ‘urethra problem’
  • Simple to diagnose
  • Symptoms
  • Stress test
  • Treated with urethral support (mostly)
  • Kegels
  • Weight loss
  • Pessaries
  • Urethral Bulking
  • Mid-Urethral Slings

Future treatment for SUI

  • Intravesical Balloon
  • Cell Based Therapy
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10/26/2016 15 Thank You Questions?