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Urinary Incontinence in Women. Clinical management guideline for Obstetrician-Gynecologist Number 63, June 2005 부산백병원 산부인과 R3 서 영 진. ETIOLOGY. 10~70% of women Increase gradually during young adult life, broad peak around middle age, steadily increase in the elderly

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urinary incontinence in women

Urinary Incontinence in Women

Clinical management guideline for

Obstetrician-Gynecologist

Number 63, June 2005

부산백병원 산부인과

R3 서 영 진

etiology
ETIOLOGY
  • 10~70% of women
  • Increase gradually during young adult life,

broad peak around middle age,

steadily increase in the elderly

  • Most women do not seek medical help
  • Cost: $12.43 billion in USA
slide4
Among ambulatory women

: urodynamic stress incontinence (29~75%)

: detrusor overactivity (7~33%)

: mixed forms

  • Among older

: stress incontinence ↓

: detrusor abnormalities & mixed forms↑

  • Increase age (>70 years)

: more severe and troublesome incontinence

diagnosis
DIAGNOSIS
  • History and voiding diary

: voiding daily (3- to 7-day)

-diurnal voiding frequency

nocturnal voiding frequency

number if incontinence episodes

: medical– pulmonary(coughing)bowel(constipation)

neurologic- diabetes, stroke, lumbar disk disease

gynecologic- pelvic organ prolapse

obstetric

surgical- hysterectomy, vaginal repair, RTx ...

slide7
Physical examination

: palpation of the ant. vaginal wall & urethra

- urethral discharge or tenderness

→ diverticulum, inflammation, neoplasm

: pelvic examination

- vulvar, vaginal atrophy in menopausal state

 ant. vaginal relaxation, prox. urethral detachment,

ant. vaginal scarring, prolapse, cystocele, recto-

cele

slide8
: bimanual & rectal examination

- anal sphincter tone, laceration

anorectal pathology

fecal impaction

: neurologic examination

- S2~S4 (controlling micturition)

bulbocavernosus m. levators, ext. anal sphincter

lower extremity motor (along sacral dermatomes)

slide9
Measuring urethral mobility

: aids in the diagnosis of incontinence &

in planning treatment

: predicting mobility by examination- inaccurate

: Q-tip test

- placement of a cotton swab in the urethra to

the level of the vesical neck and measurement

of the axis change with straining

slide11
: stress incontinence- urethral hypermobility

: but, when abnormality of voiding or detrusor

→ require the measurement of detrusor pressure

during filling and emptying

: other test (perineal USG, MRI)

- be used for assessment of bladder neck

mobility

slide12
Laboratory tests

: urinalysis- bacteriuria

: blood test (BUN, Cr, glucose, Ca)

- renal function

: urine cytology- not recommended in incontinence

- but, hematuria or acute onset of irritative voiding

 cistoscopy & cytology to exclude neoplasm

slide13
Office evaluation of bladder filling and voiding

: office setting

- the amount of urine

the time of normal voiding

residual urine volume (catheter, ultrasound)

- bladder capacity (syringe, bulb)

cough stress test

slide14
Urodynamic test

: cystometry

- test of detrusor function

- assess bladder sensation, capacity, compliance

- determine the presence of both voluntary and

involuntary detrusor contractions

: uroflowmetry

- electronic measure of urine flow rate and pattern

slide15
: electromyography

- striated urethral sphincter

- assess neurogenic voiding dysfunction

: postvoid residual urine volume

- < 50 mL adequate voiding

> 200 mL inadequate voiding

- 50~200 mL

→ repeat test

slide16
Cystourethroscopy

: bladder lesion (diverticula, fistula, stricture …)

foreign bodies

: evaluation of postop. Incontinence and

other intraop. or postop. lower urinary tract

complication

management options
MANAGEMENT OPTIONS

: absorbent products are most common method

: but, with mild symptoms

 cannot be cured depend on barrier management

slide18
Behavioral approaches

: lifestyle intervention

- weight loss, caffeine reduction, fluid manage,

reduction of physical force (work, exercise),

cessation smoking, relief of constipation

: bladder training

- bladder drills or timed voiding

- increase the interval between voiding

- patient education, scheduled voiding

slide19
: pelvic muscle exercise

- ‘Kegel’ exercise

- strengthen the voluntary peritrethral and peri-

vaginal muscles (urethral sphincter, levator ani)

- with bladder training, bio feedback, electrical

stimulation

slide20
케겔운동의 방법

▶1단계 : 소변을 참을 때를 연상하며 질을 1초 동안 수축했다가

긴장을 푸는 것을 반복합니다.

▶2단계 : 1단계가 익숙해지면 질을 5∼10초 동안 수축했다가

긴장을 푸는 것을 반복합니다.

▶3단계 :질의 근육을 마치 질이 물을 빨아올리듯이 뒤에서 앞

으로 수축하고 다시 물을 내뱉듯이 풀어버립니다. 한

번에 10회씩 하루 다섯 번 반복합니다.

:케겔운동은 쉽게 말해 소변을 참을 때를 연상하며 질을 조였다 풀기를 반복하는 것입니다. 이 때, 질근육만을 수축하고 다리 엉덩이 근육은 움직이지 않는 것이 요령입니다. 하루에 20회 정도로 시작해서 점차 400회 정도까지 늘려나갑니다

slide21
Medical management

: urethra and bladder contain a rich supply to

estrogens receptors

- estrogen affects postmenopausal urogenic

symptoms

→however, increase in urinary incontinence

: other agents for frequency, urgency, incontinence

- unpredictable response, side effect ↑

slide22
: drugs improve detrusor overactivity by inhibiting

the contractile activity of bladder

- anticholinergic agents

tricyclic antidepressants

musculotropic drugs

slide23
Surgical treatments

I. retropubic colposuspension

- suspend and stabilize the ant. vaginal wall,

bladder neck and prox. urethra

→ prevent their descents and allows for urethral

compression against a stable urethral layer

- technique

two or three nonabsorbable sutures on each

side of the mid urethra and bladder neck

slide24
II. tension-free vaginal tape

- impairment of the pubourethral ligaments

- polypropylene mesh is placed at the mid urethra

- other material and modified methods

III. bulking agents(collagen, carbon beads, fat) inject

- around bladder neck and prox. urethra

- transurethrally, periurethrally

- usually, second line therapy, nonmobile bladder

neck and high risk of operation

slide25
: complications

- lower urinary tract injury, hemorrhage, bowel

injury, wound complications, retention, UTI

- perform cystoscopy

to verify urethral patency and the absence of

sutures or sling material in the bladder

: incontinence with pelvic organ prolapse

- uterine prolapse, cystocele

- reduced or repaired (potential incontinence)

clinical considerations and recommendations
CLINICAL CONSIDERATIONS AND RECOMMENDATIONS
  • When is office evaluation of bladder filling, voiding,

or cystometry useful for evaluation of incontinence?

:whenever objective clinical findings do not

correlate with symptoms, bladder filling and

cough stress tests are useful

: monitored periodically to evaluate response

: patient fails to improve to her satisfaction

slide28
: retrograde bladder filling

- bladder sensation and capacity

- normal range : 300~700 mL

but, large capacity are not always pathologic

(33% of >800mL capacity:urodynamically normal)

(13% : true bladder atony)

: loss of urine with coughing and absence of urge

- suggests urodynamic stress incontinence

: prolonged loss of urine(5~10 seconds after cough)

no urine loss with provocation

- other cause (detrusor ovaractivity)

slide29
: artifact introduced by increases in intraabdominal

pressure caused by straining or movement

- so, tests should be repeated

: cystometric test

- more complex disorder (ex. neurogenic)

- measurements of detrusor pressure

slide30
When are urethral pressure profilometry and leak

point pressure measurements useful for evaluation

of incontinence?

: urethral pressure profilometry

- not standardized

able to contribute to the DDx.

: leak point pressure measurement

- amount of increase in intraabdominal pressure

that cause stress incontinence

slide31
When is cystoscopy useful for evaluation of

incontinence?

: sterile hematuria, pyuria, irritative voiding, pain,

recurrent cystitis, in the absence of any reversible

causes, suburethral mass, when urodynamic

testing fails to duplicate symptoms

: bladder lesion - < 2%

: not routinely

slide32
Are pessaries and medical devices effective for

the treatment of urinary incontinence?

: support bladder neck

- may be effective for some cases

: replacement of the prolapsed ant. vaginal wall

with a pessary

- responsible for either continence or some

degree of urinary retention

slide33
Are behavior modifications (eg, bladder retraining,

biofeedback, weight loss) effective for the

treatment of urinary incontinence?

: individualized scheduled voiding, diary keeping,

pelvic muscle exercise

- 50 % reduction of incontinence episodes

(15% in controls)

- this was maintained for 6 months

- no differences in treatment efficacy by type of

incontinence (stress, urge, mixed)

slide34
: behavior training with biofeedback

-63% mean reduction

: with pelvic floor electrical stimulation

-did not result in significantly greater improvement

 behavior therapy can be recommended as a

noninvasive treatment in many women

slide35
: combining drugs therapy- not enough evidence

: obesity

- 4.2-fold greater risk of stress incontinence

slide36
Are pelvic muscle exercises effective for the

treatment of urinary incontinence?

: better than no treatment or placebo

: reduces incontinence

and increases vaginal pressure

slide37
Is pharmacotherapy (eg, estrogen, tolterodine,

oxybutynin, imipramine) effective for the treatment

of urinary incontinence?

: post menopausal women with at least one episode

if incontinence weekly

- exacerbation incontinence

hormone therapy :39%

placebo: 27%

: another study

- both combination HT or unopposed estrogen

→ increase the incidence of incontinence

slide38
 oral estrogen regimen cannot be recommended

as treatment or prevention for incontinence

: anticholinergics (oxybutin chloride, tolteridine)

- therapy for bladder overactivity

→ small benefit

but, side effect (dry mouth, blurred vision,

constipation, nausea, dizziness, headache)

slide39
Is ther a role for bulking agents in the treatment

of urinary incontinence?

: gultaraldehyde cross-linked collagen

- cure rate : 7~83% over 10-year period

- limitation : durability and long-term results

- two or three injections are likely to be required

to achieve a satisfactory result

slide40
When is surgery indicated for

urinary incontinenece?

: conservative treatments have failed

patient wishes further treatment

: not all patients need urodynamic testing before

surgery

: if detrusor overactivity patient

- appropriate behavioral and medical therapy

slide41
Which type of surgery is indicated in the treatment

of urinary incontinence?

: retropubic colposuspension

- urodynamic stress incontinence

hypermobile prox. urethra and bladder neck

- depend on many factor

need for laparotomy for other pelvic desease

pelvic organ prolapse, age and health

- but long term result (sling op. is better)

- add hysterectomy

→ little to the efficacy in curing incontinence

slide42
: retropubic suspension and sling procedure

more efficacious than transvaginal needle susp-

ension or anterior colporrhaphy with slightly higher

complication rates

: Burch colposuspension vs. tension-free tape

- cure rate (57% vs. 66%)

- Burch : delayed voiding, op. time↑, return time

to normal activity ↑

tension-free tape : bladder injury ↑

slide43
: paravaginal defect repair

vs. Burch colposuspension

- after 3 years continent rate (62% vs. 100%)

: laparocopic Burch op. is better?

- inconclusive

: tension-free tape

- cured 85% , improved 10.6%, failure 4.7%

similar cure rate with Burch colposuspension

slide44
for the patients with both prolapse and urinary incontinence, what surgical procedures are

appropriate?

: have a number of treatment options

: abdominally, sacral colpopexy or retropubic

clposuspension

transvaginally, sling placed operation

summary
SUMMARY
  • Behavioral therapy (bladder training and prompt

voiding) improved incontinence and can be

recommended in many women

  • Pelvic floor training

: to be an effective treatment for stress and mixed

incontinenece

  • Pharmacologic agents(oxybutynin, tolterodine)

: small benefit in detrusor overactivity women

slide46
Cytometric test

: nor routinely

  • Bulking agent

: relatively noninvasive

: when operation is contraindication

  • Burch colposuspension and sling procedure

: long-term data is similar

: depend on patient characteristics and surgeon’s

exrerience

slide47
Combination of hysterectomy and Burch op.

: not result in higher continence rates than Burch

procedure alone

  • Tension-free vaginal tape and open Burch

colposuspension have similar success rate

  • Ant. colporrhaphy, needle urethropexy, paravaginal

defect repair

: lower cure rates than Burch procedure