Stress Incontinence Mechanism, Prevention, and Treatment I have - PowerPoint PPT Presentation

Speaker Disclosure: Stress Incontinence Mechanism, Prevention, and Treatment I have nothing to disclose Kavita Mishra MD Female Pelvic Medicine & Reconstructive Surgery Division of ObGyn & Gyn Subspecialties October 18-20, 2017 Objectives The Basics  To understand the mechanisms of stress urinary incontinence (SUI)  Definition  To recognize risk factors and preventative strategies • Involuntary leakage of urine with increased abdominal pressure  To perform the appropriate evaluation  Incidence  To provide patients with evidence-based treatment options • Up to 35% of U.S. women • More common than HTN, DM, or depression • 1 of 10 most common chronic conditions in U.S. women  Economic cost • Direct cost $12.4 billion annually • Greater than cost of breast, cervical, uterine, & ovarian cancers combined 3 4

Continence and Mechanism of SUI  Lower urinary tract performs two functions • Storage of urine • Timely expulsion of urine  Coordination of both central and peripheral nervous systems  Requires normal function of: • Bladder wall • Detrusor muscle • Urethra • Pelvic floor musculature 5 10/18/2017 6 Elements of Continence Elements of Continence  SUI: Anatomic or neurologic defects  Simplistically – intraurethral pressure must be greater than intravesical pressure at rest and  At rest during stress conditions • Interaction of urethral smooth muscle • Urethral wall elasticity and vascularity • Periurethral striated muscle  Each contributes 1/3 rd of overall intraurethral pressure  Can be altered by – Age, Parity, Medications 7 8

Elements of Continence Elements of Continence Pubourethral  Urethral support  Urethral Sphincter ligaments • Anterior vaginal wall • Striated and somatic muscle • Lateral attachments to the arcus tendineus fascia pelvis (ATFP)  Urethral Coaptation • Pubourethral ligaments insert • Ability of urethral lumen at midurethra – augment to “seal” suburethral support during strain  Levator Ani muscles • Pubococcygeus pulls pelvic floor up/into pelvic cavity 9 10 Stress incontinence after childbirth Risk Factors A. is as common after Cesarean section as after vaginal delivery 61% B. is reported by more than 50% of women in the first decade after having a baby C. can be prevented by instrumental 31% delivery D. may be related to pudendal nerve 7% injury 1% is as common after Cesare.. is reported by more than... can be prevented by ins... may be related to puden... 11 13

Risk Factors Evaluation  Aging - Unclear mechanism  History: Classify incontinence by type (+functional) • Loss of muscle tone • Long-term effects of denervation injuries • Changes in hormonal stimulation  Pregnancy and childbirth  2014 ACOG Practice Bulletin emphasizes identification of the • Both CS and VD “uncomplicated SUI patient”  Smoking • Typically has urethral mobility on exam  Obesity: both UUI and SUI • Exclude those with prior pelvic/SUI surgeries, voiding  Prior pelvic surgery dysfunction, recurrent UTIs, abnormal PVR, prolapse to hymen 14 15 Evaluation Evaluation on Exam  Demonstrate immediate SUI on cough stress test • Delayed urine loss may be cough-induced detrusor overactivity • Sensitivity of CST increased with full bladder (300 cc) and standing • If testing remains negative, urodynamics recommended  Assess for urethral mobility Cotton swab test Aa value on POPQ Ultrasound Palpation or visualization  PVR assessment: if >150 cc, consider bladder emptying studies 16 17

A 56-year-old P2 woman presents with stress urinary incontinence. Urodynamic Studies She leaks with exercise every day and occasionally with coughing and laughing. On exam, the Aa value on POPQ is 0, PVR is 40 cc, and cough stress test was positive for leakage at 300 cc. Urinalysis  In the uncomplicated patient, simple was normal. You counsel her regarding her options and she desires answer is “No” surgical treatment.  Multicenter RCT of 630 women with True or False: Your next step in her management is to perform uncomplicated SUI randomized to urodynamic studies. UDS vs. basic office exam prior to sling A. True 53%  Subjective treatment success in 77% 47% B. False of both UDS and office exam groups (no significant difference)  Conclusion: Preop office exam was non-inferior to UDS for outcomes at 1 year e e u l s r a T F 18 20 Prevention: Pelvic Floor Exercises Nonsurgical Treatments: Weight Loss  Single-center, RCT of 230 primigravid women with bladder neck  5-10% weight loss in pts with T2DM improves UI incidence/sx’s mobility on ultrasound  Bariatric surgery and associated weight loss  improvement in UI,  PFME with monthly PT visits starting at 20 wks vs. verbal advice UUI, and SUI at 6 months  3 sets of 8 exercises (hold 6 sec; 2 min between sets) twice a day  PRIDE study – 2009 NEJM, 2010 JUrol  Outcome: subjective SUI at 3 months postpartum • 338 overweight or obese women with at least 10 leakage episodes/wk enrolled in  No difference in NSVD, VAVD, FAVD, or CS rates 18-month weight loss program vs. structured education  Subjective SUI rates: 13% PT group vs. 33% control (RR 0.59, CI 0.37-0.92), no difference in pad tests • At 12 months: avg 7.5% weight loss vs. 1.7% • 65% reduction in weekly SUI episodes at 12 months (47% for controls, p<0.001) Other studies have shown possible benefit with prenatal/postpartum PFMEs and PT. Weight loss is an effective strategy for SUI treatment 21 22

Nonsurgical Treatments: Medications Nonsurgical Treatments: Estrogen Therapy  Duloxetine  Clinical efficacy is controversial • 2005 Cochrane review showed improvement in QoL  Systemic ERT worsened UI compared to placebo • Small effect size of subjective cure, meta-analysis of objective • 2012 Cochrane review 17,642 women with UI outcome did not show any benefit  Local ERT (topical use) showed some benefits  Adrenergic drugs • 2014 systematic review, 44 studies • 2005 Cochrane review of 22 trials, 1099 women • Low-quality evidence: improved max • Pad counts/weights: better than placebo urethral pressures • >25% had adverse effects • Moderate-level evidence: improved subjective SUI • PFMT superior to topical estrogen in one trial Topical estrogen may be beneficial in treatment of SUI. 23 24 Nonsurgical Treatments: Nonsurgical Treatments: Pelvic Floor Muscle Exercises Vaginal Laser Therapy  Pelvic floor muscle exercises  Systematic review: 13 studies (2017 Int Urogyn J) • 2014 Cochrane review, 21 trials, 1281 women  818 SUI pts (no RCTs) • 56% cure rate with PFMT (8x improvement from no treatment)  Mild to severe SUI, some urodynamic findings • Long-term effectiveness needs to be studied  Subjective outcomes: This is the most effective, first-line therapy. 12.5-46% cure at 6 months  Range of objective measures: half had 50% reduction of pad weight at 6 months  Vaginal cones  Adverse effects: few cases of mild pain, dysuria, irritation • 2013 Cochrane review of 23 trials, 1800 women Vaginal laser therapy may be a useful, minimally invasive approach • Better than no treatment, no difference compared to PFME or for treating SUI. Cannot make firm conclusions. electrostimulation 25 26

Nonsurgical Treatments: Vaginal Inserts Surgical Treatments: Injectable Urethral Bulking  Poise Impressa Vaginal Inserts  Synthetic and biological materials • Few studies  Frequently used in recurrent SUI • 60 women: 85% had ≥70% reduction  Coaptation of urethral edges, increasing in pad weight gain urethral resistance • Improved QoL and high satisfaction  Few currently available – -Silicone particles (Macroplastique) -Ca Hydroxylaptite (Coaptite)  Incontinence rings/Pessaries -Porcine dermis (Permacol) -Gluteraldehyde cross-linked bovine collagen (Contigen) • 2014 Cochrane review, 8 studies, 787 women  Success: 25-63% (~50%) at 12 months • Different devices used, quantitative synthesis of data impossible  Adverse events: transient urinary retention, de novo urge, dysuria hematuria • Inconclusive benefit 27 28 A 56-year-old P2 woman presents with stress urinary incontinence. Surgical Treatments: Pubo-vaginal Slings She leaks with exercise every day and occasionally with coughing and laughing. On exam, the Aa value on POPQ is 0, PVR is 40 cc, and cough stress test was positive for leakage at 300 cc. Urinalysis  Placement of fascial sling was normal. You counsel her regarding her options. at bladder neck level to correct hypermobility Concerning sling operations for the treatment of stress incontinence, all of the following are true except:  8-10 cm graft of rectus fascia or fascia lata, fixed by fibrosis in retropubic 51% A. They are accepted as first-line space, tied across rectus management fascia B. They result in voiding dysfunction in up to 16% of women  Continence rates: 61-97% 19% 17% C. Synthetic materials can result in erosion 10%  Risk of de novo 3% D. They have good long-term success rates urgency/UI: 2-20% E. Tension-free vaginal tape is a minimally . . . . . . t . . . . . e s y . . . p invasive procedure r r r i d n e a f t t s g a - a n c g a l n d d i s n l o i e o i a l g t i a p v r d e e o v n t o e c i a c t m g e a l r u e f e s c v - r i n a e t a o r e h y y h s i e y n e t e h h n e T y h T T S T 29 31