Female Urinary Incontinence: Fact and fiction

Dallas Medical Journal 88(5):169-174, 2002
(with permission)

Joseph Schaffer, MD FACOG
Associate Professor, Department of Obstetrics and Gynecology
Director, Division of Urogynecology and Reconstructive Pelvic Surgery
Director, Fellowship Program in Female Pelvic Medicine and Reconstructive Surgery
University of Texas Southwestern Medical Center
Dallas, Texas

Marlene Corton, MD
Assistant Professor, Department of Obstetrics and Gynecology
Division of Urogynecology and Reconstructive Pelvic Surgery
University of Texas Southwestern Medical Center
Dallas, Texas

Mikio Nihira, MD
Assistant Professor, Department of Obstetrics and Gynecology
Division of Urogynecology and Reconstructive Pelvic Surgery
University of Texas Southwestern Medical Center
 Dallas, Texas

As men draw near the common goal
Can anything be sadder
Than he who, master of his soul,
Is servant to his bladder?

The Speculum, Melbourne, No. 140 (1938)

Urinary incontinence is a major health care issue. It is believed that more than 13 million Americans suffer from this disorder, with women being affected twice as frequently as men (1). The prevalence of the disorder increases with age and 15-30% of community dwelling people over 60 are affected. In the nursing home population greater than 50% of people are incontinent. It is estimated that at least 16 billion dollars is spent annually on the direct and indirect costs of caring for patients with this condition.

Quality of life is significantly diminished in women with urinary incontinence. Alterations in daily activities and social disengagement are common by-products of the condition. Unfortunately, many patients with urinary incontinence do not seek the help of health care providers because of embarrassment or the incorrect belief that it is a normal part of aging which cannot be treated. And frequently, when patients do discuss the problem with their physician, these misconceptions are reinforced.

Prior to the 20th century, most references to this condition in the medical literature dealt with incontinence secondary to vesicovaginal fistulas that were the result of obstructed childbirth. In the 20th century, the problem of obstructed childbirth in developed countries was essentially solved and vesicovaginal fistula became uncommon. However, life expectancy in women increased from 40 years in 1900 to 80 years in 2000. As a result, conditions which are more common with aging such as urinary incontinence have become much more prevalent.

Significant advances in non-surgical and surgical therapy now allow for most persons with urinary incontinence to be cured or significantly improved. It is incumbent upon all primary care providers, as well as others caring for patients with incontinence, to become familiar with the basic evaluation and first line therapy.

The types of incontinence are listed in Figure 1. The function of the lower urinary tract is storage and evacuation of urine. Incontinence is a disorder of the storage phase.

Stress incontinence is leakage with increases in intra-abdominal pressure that occur with coughing, sneezing, exercise or physical activity. Stress incontinence occurs when the urethra stops functioning as a sphincter maintaining urine in the bladder. The etiology of stress incontinence is multifactorial and poorly understood. It may be due to poor urethral support (Photo 1), neuromuscular damage to the urethra (Photo 2), or a combination of both (2).

Urge incontinence is defined as leakage when there is an urgent desire to void. Patients with urge incontinence frequently complain of leakage while running to the bathroom. This is usually caused by Detrusor Instability, which is the occurrence of involuntary, uninhibited bladder contractions. Urge incontinence is a part of the overactive bladder syndrome, which also includes patients with frequency, urgency (without leakage) and nocturia. This condition is most often idiopathic and probably due to the loss of normal neurologic inhibitory reflexes which suppress bladder muscle contraction during bladder filling. The prevalence of urge incontinence increases with aging. When uninhibited bladder contractions are caused by neurologic disease such as spinal cord tumors, multiple sclerosis or stroke, the diagnosis is Reflex Incontinence or Detrusor Hyperreflexia.

Mixed incontinence is a combination of stress and urge symptoms. Often, one symptom is much more bothersome to the patient than the other. An example would be the patient who has urge incontinence ten times per day and stress incontinence one time per month when her asthma flares up. In the initial evaluation it is important to identify which symptom is predominant and direct therapy towards treating that symptom.

Overflow incontinence is leakage associated with overdistention of the bladder. In this condition the detrusor muscle may be hypotonic or atonic. The bladder fills until it is unable to hold more urine and then leakage occurs "off the top". This condition is relatively uncommon. It may be associated with diabetes, obstruction or neurologic conditions (neurogenic bladder). It is also associated with chronic bladder overdistention, the so-called "school-teacher's bladder".

Functional incontinence is leakage that occurs because of the physical inability to reach the toilet in a timely fashion. This often occurs at night in elderly people with severe musculoskeletal or vision deficits. There is no specific genitourinary pathophysiology associated with this condition. It is often cured with a bedside commode.

The basic evaluation of women with incontinence should include a detailed history, physical exam, pelvic exam, post void residual (PVR), UA, C&S, and voiding diary (Figure 2).

Because urinary incontinence is a quality of life issue rather than a life-threatening problem, the history should focus on impact on quality of life and severity of symptoms. The patient should be questioned regarding age of onset, number of pads or diapers per day, number of leaks per day and the need to alter daily activities. Stress and urge incontinence symptoms are differentiated by asking whether the leakage occurs with cough, sneeze or laugh versus leakage with urgency. Transient causes of incontinence should be ruled out (Figure 3). Incontinence tends to be a chronic problem so transient causes such as urinary tract infection should be suspected if the patient describes a recent onset of symptoms.

Other important factors to assess are daytime urinary frequency, nocturia, voiding difficulties, fluid intake and diet, mobility, history of recurrent urinary tract infection, constipation, and chronic cough.

The physical exam includes an evaluation for systemic disease and causes of increased intra-abdominal pressure such as obesity and COPD. Pelvic examination is performed initially with a full bladder. The patient is asked to cough or valsalva and the presence of stress incontinence is documented. PVR is checked by catheterization or bladder ultrasound. The PVR measurement at the initial evaluation is important, as this may be the only way to rule out overflow incontinence. Urethral hypermobility is assessed by examining the movement of the uretha with cough (photo 1). A split vaginal speculum is used to assess concurrent prolapse of the anterior and posterior vaginal walls. The examiner then performs a digital vaginal exam to assess the strength of the pelvic floor muscles. A finger is placed at 4 and then 8 o’clock inside the vaginal opening along the pelvic sidewall. The patient is asked to contract the pelvic floor muscles. Patients who are unable to contract these muscles may not be good candidates for routine pelvic floor exercises (Kegel’s). Finally, a rectal exam is performed to rule out fecal impaction and to assess sphincter tone.

History and physical examination are able to successfully diagnose the type of incontinence approximately 70% of the time. Because diagnosis is not readily obtained in a greater majority of patients, urodynamic testing has become an important part of the evaluation of urinary incontinence. However, urodynamic testing is generally performed by a specialist (urogynecologist, gynecologist, or urologist) and may not be available to all health care providers caring for patients with incontinence. Therefore, in the patient whose history and physical exam suggests pure urge, stress or mixed incontinence, it is acceptable to initiate non-surgical therapy prior to obtaining urodynamic testing. Patients who should be referred for further evaluation are listed in Figure 4.

The mainstay of therapy for urge incontinence/overactive bladder has been anticholinergic medication. Cholinergic innervation of the detrusor (bladder) muscle stimulates bladder contraction. Anticholinergics successfully inhibit unstable bladder contractions. Anticholinergics commonly used include Tolterodine, Oxybutynin, Hyoscyamine, and Imipramine. Both Tolterodine and Oxybutynin are available in once-a-day formulations that have been shown to be as efficacious as more frequent dosing. Definitive studies regarding which anti-cholinergic medication is most effective have not been performed.

Consideration should be given to starting Estrogen in conjunction with anticholinergics in peri and postmenopausal women (3). Urogenital atrophy secondary to hypoestrogenism causes symptoms of vaginal dryness, pain, urinary frequency and urgency. Estrogen has been shown to be effective in reversing urogenital atrophy. It is believed that bladder and urethral hypersensitivity decrease with estrogen therapy (4). Vaginal estrogen is more effective than the oral form because it exerts a direct effect on the local tissues.

Common anticholinergic side effects include dry mouth and constipation. Although anticholinergic medications are effective in controlling the symptoms of overactive bladder, the dropout rate is very high because of the side effects. Some studies show that 6 months after beginning therapy only 20% of patients are still on the medications.

Behavioral techniques are also first line therapy for urge incontinence/overactive bladder. Generally these methods require a committed patient willing to participate in her treatment.

Bladder training is a behavioral treatment that aims to lengthen the voiding interval such that bladder control is reestablished and the voiding reflex can be suppressed. The patient is given a voiding diary and the voiding habits are analyzed. Based on the diary she is begun on a voiding schedule. For instance, if she is currently suffering from frequency and urgency every 30 minutes she is placed on a schedule where she is to void every hour on the hour. She is not allowed to void at other times and is taught urge suppression techniques. When she is able to maintain her initial schedule with no leakage between voids, the interval is increased until she is voiding every 3 to 4 hours. The program may take several months and only works with a motivated patient. The patient must return to the office on a regular basis at which time the diary is reviewed, suppression techniques are retaught and the patient is given positive reinforcement. In one study, bladder training was 44-97% successful in the treatment of overactive bladder (5).

Pelvic floor muscle exercise (Kegel’s) and biofeedback are behavioral techniques used for overactive bladder. Contraction of the pelvic floor muscles is known to reflexively cause relaxation of the bladder. In fact, the normal mechanism used to suppress urinary urgency is the initiation of a voluntary pelvic floor contraction. With pelvic floor exercise the patient can be taught to voluntarily contract the pelvic floor muscles thereby suppressing the micturition reflex and bladder contractions. Thirty per cent of women are unable to voluntarily contract the pelvic floor muscles and in these women biofeedback is used.

Biofeedback is a behavioral technique in which information about a normally unconscious physiologic process is presented to the patient as a visual, auditory or tactile signal. A vaginal probe sensor is placed and the patient is able to observe pelvic floor muscle activity on a computer screen. She is then taught how to initiate and control muscle contraction. Biofeedback is a very successful technique, which requires a committed patient. The program takes 6 to 8 weeks.

Urge incontinence/Overactive bladder is most successfully treatment through a combination of behavioral techniques and medications. Frequently, after a successful program of behavioral modification, the medications can be stopped.

Stress Incontinence may be treated with non-surgical or surgical methods. Non-surgical treatment has a success rate of about 50% as opposed to surgical success rates of 70 to 90%. However, non-surgical treatment incurs no risk and should therefore be presented to the patient as an option prior to proceeding with surgery.

The initial evaluation of the patient with stress incontinence may reveal reversible causes of increased intra-abdominal pressure such as chronic cough, constipation, obesity, and heavy lifting. Correcting these problems frequently will improve stress incontinence symptoms. Likewise, if certain types of exercise or activity induce incontinence, modification of these activities will be useful.

Pelvic floor exercises (Kegel’s) can be very effective therapy for stress incontinence (6). The pelvic floor is composed of skeletal muscle which hypertrophies with use and atrophies with disuse. Therefore, exercise is only effective if done on a regular, continual basis. The patient is taught to contract the pelvic floor muscles and then placed on a regular schedule of 30 – 100 contractions per day. In general, the success of this technique depends on patient motivation, compliance, and long-term commitment. Historically, the educational effort in teaching pelvic floor exercises has been poor. Often the patient is simply handed a sheet of directions. Simple written or verbal instruction have been shown to be inadequate and even with intensive individual instruction 30% of patients are unable to do Kegel exercises. A successful program includes hands-on instruction, supervision, monitoring and feedback. It often involves nurses, physical therapists and other health care providers. In the setting of an organized program many studies have shown significant improvement in stress incontinence symptoms.

Biofeedback and functional electrical stimulation may be used in conjunction with the pelvic floor exercise training program. These are particularly effective for those patients who are unable to voluntarily initiate a pelvic floor contraction. Mechanical devices such as pessaries, urethral plugs, and urethral patches have also been occasionally used for stress incontinence however there is little data to support their efficacy.

Mild stress incontinence can sometimes be treated with medications. The smooth muscle of the urethral sphincter is innervated by alpha-agonist receptors. Stimulation of these receptors causes smooth muscle contraction and increased urethral pressure. Estrogen has been shown to upregulate the alpha-receptors in the urethral smooth muscle. Therefore, the combination of an alpha-agonist with estrogen can be effective in the treatment of mild stress incontinence. However, it should be kept in mind that no objective evidence exists to support the use of estrogen as single agent therapy for stress incontinence (7).

Surgery has proven to be the most effective therapy for stress incontinence yet controversy exists regarding the best anti-incontinence procedure. More than 200 procedures have been described which would suggest that the ideal operation has yet to be elucidated. Prior to surgery, it is essential that the correct cause of the incontinence be determined with urodynamic testing.

Patients with stress incontinence have generally been separated into 2 categories: those with poor urethral support or urethral hypermobility (photo 1), and those with a weak urethral sphincter or intrinsic sphincteric deficiency (ISD) (photo 2). These categories have been used to direct surgical therapy. Patients with urethal hypermobility undergo procedures aimed at correcting urethral mobility whereas those with ISD have procedures that obstruct the urethra. Surgeries are performed through abdominal, vaginal and laparoscopic approaches.

The standard abdominal anti-incontinence procedure is the Burch retropubic urethropexy. This procedure is used to correct hypermobility and has an 85% success rate. A variety of vaginal procedures have been used including needle procedures such as the Peyrera and Raz. These procedures have a success rate of 70%. Currently, many different techniques are used to accomplish the correction of hypermobility through the vaginal route (8).

Sling procedures have traditionally been used for patients with ISD. Autologous fascia, cadaveric fascia or artificial material is placed below the urethra and attached to the anterior abdominal wall. This effectively obstructs the urethra and prevents leakage. Many surgeons also use sling procedures to treat patients with urethral hypermobility. The TVT procedure (suburethral sling with tension free vaginal tape) has gained wide popularity in Europe and the United States. This is a simple, minimally invasive procedure that can be performed under local anesthesia. A 1 ½ cm incision is made in the vaginal wall under the urethra and needles are used to pass a permanent mesh material around the urethra, behind the pubic bone, and through the abdominal wall. The TVT procedure shows great promise however definitive studies have yet to be performed.

Peri-urethral collagen injections are also used for patients with ISD. Using a cystoscope, Bovine collagen is injected around the urethra. This closes the urethra and provides resistance to urine leakage. Collagen injection is a simple office procedure that requires local anesthesia and takes a few minutes. There is a reported 70% improvement rate over 2 years. Some patients require more than 1 injection.

The long-term outcomes of the many anti-incontinence procedures have not been well studied nor have the different procedures been compared in well-controlled studies. In response to this, the NIH has developed the Urinary Incontinence Treatment Network (UITN), a group of centers devoted to performing controlled trials of treatments for incontinence. The first study this network has undertaken is a randomized, controlled trial of the Burch retropubic urethropexy and the pubovaginal sling. The Departments of Urogynecology and Urology at UT Southwestern Medical Center in Dallas are members of the UITN .

Surgical procedures are generally very effective in controlling the symptoms of stress incontinence however complications do occur. As many as 20% of patients may develop urge incontinence after surgery. Other patients develop voiding dysfunction, a weak urinary stream or the need to change position to void. These issues should be discussed prior to surgery so that an informed decision can be made. Incontinence is a quality of life problem rather than a life-threatening problem. Therefore, the patient should be fully aware of the risks and benefits, and be a participant in treatment planning.

The patient with mixed incontinence should be initially treated with medications or behavioral therapy. Particularly in the geriatric patient, the urge symptom is frequently predominant and successful treatment will restore a normal quality of life. Some patients with mixed incontinence are treated successfully with a combination of non-surgical and surgical therapy.

If overflow incontinence is suspected, the patient should be referred for urodynamic and neurologic testing. Patients with high post void residuals and inefficient bladder emptying are at risk to develop damage to the upper genitourinary tracts due to chronic reflux of urine. These patients are frequently managed with intermittent self-catheterization.

Female urinary incontinence continues to be a major healthcare problem in the United Stated. The prevalence of incontinence increases with aging; however, incontinence should not be considered a normal part of aging. Most patients can be cured or significantly improved with non-surgical or surgical therapy. All patients deserve a complete evaluation and discussion of the many treatment options.

1. Fantl JA, Newman DK, Colling J, et al. Urinary Incontinence in Adults: Acute and Chronic Management. Clinical Practice Guideline, No. 2, 1996 Update. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service, Agency for Health Care Policy and Research. AHCPR Publication No. 96-0682. March 1996.

2. Schaffer, JI, Fantl JA. Physiology of the Lower Urinary Tract and the Mechanism of Continence in Lentz G ed, Urogynecology, London: Oxford University Press, 2000.

3. Fantl JA, Cardozo L, McClish DK. Estrogen Therapy in the Management of Urinary Incontinence in Postmenopausal Women: A Meta-Analysis. Obstet Gynecol. 1994;83(1):12-8.

4. Schaffer JI, Fantl JA. Urogenital Effects of the Menopause. Bailliere's Clinical Obstetrics and Gynaecology. 1996;10:401-417.

5. Fantl JA, Wyman JF, Harkins SW, Hadley EC. Bladder Training in the Management of Lower Urinary Tract Dysfunction in Women. A Review. Journal of the American Geriatrics Society. 1990;38(3):329-32.

6. Kegel AH. Progressive Resistance Exercise in the Functional Restoration of the Perineal Muscles. Am J Obstet Gynecol. 1948;56(2):238.

7. Ostergard DR, Bent AE, eds. Urogynecology and Urodynamics, 4th ed. Baltimore: Williams and Wilkins, 1996.

8. Walters MD, Karram MM, eds. Urogynecology and Reconstructive Pelvic Surgery, 2nd ed. St. Louis:Mosby-Year Book, 1999.

• Stress Incontinence Leakage with cough, sneeze, exercise, activity
  
  
• Urge Incontinence Leakage with the urgent desire to void
  
  
• Mixed Incontinence Combination of stress and urge
  
  
• Overflow Incontinence Leakage associated with overdistended bladder
  
  
• Functional Incontinence Leakage due to physical inability to get to bathroom
  

Volume voided Leakage Intake

12 – 2 am 200cc_____________________________

2 – 4 am P ________________

4 – 6 am cup of coffee

6 – 8 am___________________________________________

8 – 12 am___________________________________________

12 – 2 pm___________________________________________

2 – 4 pm___________________________________________

4 – 6 pm___________________________________________

6 – 8 pm___________________________________________

8 – 10 pm___________________________________________

10 – 12 pm___________________________________________

•  D elirium
  
  
•  I nfection
  
  
•  A trophic vaginitis/urethritis
  
  
•  P harmaceuticals/psychological
  
  
•  E ndocrine (DM)
  
  
•  R estricted mobility
  
  
•  S tool impaction

•  Uncertain diagnosis
  
  
•  Failure to respond to prior treatment
  
  
•  Surgical candidate
  
  
•  Hematuria without infection
  
  
•  Recurrent UTI
  
  
• Voiding disorder
  
  
• Prior surgery
  
  
• Symptomatic and severe pelvic organ prolapse
  
  
• Abnormal PVR
  
  
• Neurologic abnormality
  

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