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Incontinence
Urinary incontinence in women is an extremely
common and distressing problem. Prevalence rates
vary between different studies but, overall, it
is estimated that about 15% of women will experience
urinary incontinence on occasions whilst it is
a severe problem requiring treatment in 3 to 5%.
Interestingly, many women will not consult their
general practitioner about this problem as it
is very personal and embarrassing and even in
our modern, open society is seen as a taboo subject.
Those women who do present will have suffered
for four and a half years on average before seeking
help. Often this is because they feel that it
is ‘their lot’ as women and that they
have to put up with the problem or that modern
medicine has little to offer in the form of treatment.
In reality there is much that can be done to improve
the quality of life of these women and there have
been many advances in both medical and surgical
therapy.
Most women with urinary incontinence will have
either detrusor instability (DI) genuine stress
incontinence (GSI) or a combination of the two.
DI is the commonest diagnosis in the younger and
older women whilst GSI is more prevalent in middle
age. DI tends to present with symptoms of the
over active bladder (OAB) whilst GSI tends to
present with stress incontinence as the main symptom.
Symptoms of the OAB are: urinary frequency, urgency
to pass urine, leaking because there is not time
to get to the toilet and having to get up at night
to pass urine. Stress incontinence is when urine
is lost during coughing, sneezing, laughing or
even on walking. The severity of these symptoms
may vary and, unfortunately, there is considerable
overlap in these symptoms such that it is not
possible to make an accurate diagnosis on symptoms
alone. Urodynamics, tests which look at the function
of the bladder are performed to elucidate the
diagnosis but these tests are not always necessary
as many patients can be treated symptomatically.
At the time of Urodynamics the patient is initially
asked to empty her bladder on a special toilet
that records the urine flow. This allows us to
diagnose any urine flow problems and is called
Uroflowmetry. A catheter is then passed into bladder
and another into the rectum to record pressure
changes. The bladder is then filled with fluid
and any pressure changes are recorded as well
as bladder sensation. Once the bladder is full
the woman is put into a vertical position and
asked to cough, heel bounce and strain, in order
to see if there is any urinary leakage. She is
then asked to void again. This part of the test
is called Cystometry
In some centres the bladder is filled using a
contrast medium which shows up on X-rays which
allows the bladder, bladder neck and urethra to
be visualized directly, this may be an advantage,
particularly, in complex cases. This test is called
videocystourethrography.
The tests allow an accurate diagnosis to be made
on which to plan future management.
In addition to a more general history and examination
a detailed urinary history should be taken in
all women and an abdominal and vaginal examination
should also be performed. An accurate history
will allow targeted treatment of individual patient
symptoms. Abdominal examination may reveal associated
intra-abdominal pathology or a large palpable
bladder. Vaginal examination may identify a space
occupying lesion in the pelvis, more importantly
it allows assessment of pelvic organ prolapse
and pelvic floor muscle tone.
Vaginal prolapse may be assessed in many different
ways. The system promoted by the International
Continence Society allows quantifiable, objective
examination of the anterior and posterior walls
of the vagina, the vaginal vault, the cervix,
the genital hiatus and the perineum. This system
is time consuming but does give accurate information
on which to base the decision to perform prolapse
surgery.
The pelvic floor can be assessed by estimating
the tone of the pelvic floor muscle on digital
examination and subjectively measuring pelvic
floor muscle strength and the duration of contraction.
If the pelvic floor muscles are very weak and
the patient is unable to contract them then conservative
treatment in the form of pelvic floor exercises
is unlikely to be effective.
A mid-stream urine specimen should always be examined
for the possibility of infection.
At this point there are a number of possible treatment
options:
Behavioural intervention
Anticholinergic drugs
Hormone replacement therapy
Pelvic floor exercises
Drugs for stress incontinence
Further investigation
Surgery
Behavioural intervention.
This is particularly useful in women with symptoms
of the overactive bladder. Many women drink unnecessarily
large amounts of fluid, therefore ask your patients
to fill out a urinary diary measuring fluid intake
and urine output. A reduction in overall intake
or a restriction at certain times such as in the
evenings can have a dramatic effect on symptoms.
Next, try to rationalise the time between voiding.
Women with GSI might want to ensure that they
void more regularly to avoid becoming full and
increasing the chance of urinary leakage on stress.
Women with DI need to try to increase the time
between voids. This can be achieved either by
trying to hold on for a little longer each time
they feel the urge to pass urine, or by enforcing
a strict regimen by which the time between voids
is gradually increased by half hourly intervals
over a period of 10 days. This may be carried
out as an inpatient under extreme circumstances.
Certain foods and acidic drinks may influence
bladder irritability. Generally it is advised
to reduce caffeine intake and to limit acidic
fruit juice. For a more detailed analysis of this
subject refer patients to one of the many self-help
guides.
Constipation and fetal impaction can affect bladder
function thus this should be managed. Those women
who are severely overweight should be advised
that this may complicate their further management
and should be referred to a dietician.
Anticholinergic
medication.
Detrusor contractions are mediated by parasympathetic,
cholinergic nerves. Thus anticholinergic drugs
may be used
to influence bladder irritability and hyper-contractility.
The main problem with these drugs is that they
often cause anticholinergic side effects elsewhere
in the body. These are most notably, constipation,
dry mouth and blurred vision. In order to minimise
these, selective anticholinergic drugs have been
developed which do not cross the blood brain barrier
to the same extent and have an improved side effect
profile.
Drugs currently available with proven efficacy
are:
Detrusitol XL 4mg OD
Detrusitol 2mg BD
Solifenacin 5mg-10mg OD
Oxybutynin 2-5mg OD – TDS
Trospium Chloride 20mg BD
Literature review reveals that Detrusitol XL is
probably the current drug of choice as it is effective
and has the best side effect profile. Solifenacin,
a new drug produced by Yamanouchi has also recently
beed shown to be effective in a large clinical
trial involving 907 women, and will probably be
on the market within the next 6months.
Where nocturia is the main symptom Amitriptyline
25mg at night may be useful for its’ anticholinergic
and sedative effects. In addition, night time
urine output may be decreased using the synthetic
anti-diuretic hormone Desmopressin.
In post-menopausal women hormone replacement therapy
may prove useful although the available medical
literature on this subject is somewhat contradictory.
If considered then it may be more effective delivered
directly to the urogenital tract in the form of
a cream or pessary rather than systemically as
a pill or patch.
Pelvic floor exercises
Unfortunately, far too few women regularly perform
effective pelvic floor contractions even though
it is known that they are an effective preventative
measure against GSI and pelvic organ prolapse.
They may also be used as a treatment option in
almost all women with urinary symptoms. They have
been shown to decrease the number of incontinence
episodes and thus decrease the need for surgery
for GSI. In DI they also help to suppress detrusor
contractions and to improve patient confidence.
Kegel exercises were developed by Arnold Kegel
MD, a surgeon, in the 1940's as treatment for
stress urinary incontinence. By 1950. Kegel was
reporting a 93% success rate in incontinence treatment
especially when a perineometer was used for biofeedback.
The main problem has been that in order to be
effective, the right muscle has to be contracted
and about 50% of women cannot identify and isolate
the correct muscle with just verbal instructions.
This can be improved if the doctor or physiotherapist
gives instruction by testing with a finger in
the vagina to make sure the correct muscle is
being contracted. The main problem in doing the
exercises is the tendency to increase intra abdominal
pressure (Valsalva) and/or to contract abdominal,
buttock or thigh muscles.
This experience and the difficulty in carrying
out the exercises from just a verbal description
or reading instructions, has lead to the development
of many devices that help a woman isolate the
correct muscle and aid in the discipline required
to perform repetitive, boring exercises. Weighted
vaginal cones are the most common intra vaginal
devices. They have been shown to be as effective
as either electrical stimulation or pelvic floor
exercises alone.
In order to be effective the pelvic floor muscles
must be contracted properly and regularly over
a long period. Women must therefore be carefully
instructed and well motivated if this treatment
is to be effective. An enthusiastic physiotherapist
with an interest in this area is the most appropriate
person to deliver this form of treatment. How
exactly treatment is delivered and whether or
not patients use vaginal cones or biofeedback
as part of their treatment has little effect on
overall outcome.
In general, younger pre-menopausal women with
reasonable pelvic floor muscle strength, without
prolapse, with less severe symptoms and who are
well motivated will be most likely to succeed
with this treatment. Older post-menopausal women
with prolapse and very weak pelvic floor muscles,
severe long term symptoms and poor motivation
are unlikely to find it of benefit and may be
advised that surgery is a more sensible treatment
option.
Most of these treatments will not reach their
maximum effect for two to three months so this
is a sensible time interval before follow up.
Those women who feel satisfied that they have
their symptoms under control should be advised
to continue their exercises in the long term.
Those women who do not respond to treatment should
be further investigated.
Drugs for stress
incontinence
Until recently there were no drugs that could
be used in the treatment of stress incontinence.
New drugs have now been developed and the first
of these is duoloxetine hydrochloride (Yentreve).
This is taken twice daily and is thought to act
by improving the action of the muscle around the
urethra. By doing this it reduces incontinence.
It can be used in women with stress incontinence
and is probably best used in combination with
pelvic floor exercises. Clinical studies have
involved over 2000 women worldwide. They have
shown that Yentreve improves quality of life and
reduces the number of continence episodes by 50-100%
in more than half of women with stress urinary
incontinence. It is hoped that Yentreve will bridge
the gap between pelvic floor exercises, which
not all women can do or find helpful, and surgery,
which is not appropriate or desirable for all
women with stress incontinenc. One drawback of
all medical treatments is the possibility of side
effects. With Yentreve the commonest side effect
is nausea effects about 21% of patients but is
usually transient.
Further investigation
The most commonly performed investigations are
uroflowmetry and a twin channel cystometrogram.
Occasionally a cystoscopy may be performed to
inspect the inside of the bladder.
Uroflowmetry is easy to perform and very helpful
if it demonstrates a normal void. If the urine
flow is very slow or intermittent it is less helpful
as it does not differentiate between outflow obstruction
and a weak detrusor muscle. It should therefore
be combined with a measurement of bladder pressure
as is the case in filling and voiding cystometry.
The cystometrogram allows us to study how the
bladder responds to being filled and how it behaves
during voiding. Abnormal detrusor contractions
or genuine stress incontinence may be demonstrated
(figure). It should always be performed before
surgery in order to aid patient selection and
counselling, and to avoid complications.
Other more specialist investigations may be performed
but are only necessary in a small minority of
cases.
Surgery for GSI
There are many different operations for GSI. Until
the development of the tension-free vaginal tape
system (TVT), colposuspension was generally considered
to be the best operation for stress incontinence.
Other operations such as an anterior vaginal repair
and the Stamey needle suspension are now largely
obsolete as they have been shown to have poor
long term success rates. Recent advances have
lead to the development of Injectables which are
compounds that can be injected around the urethra
to help it to close more effectively. The newest
and most promising of these is called Zuidex.
Zuidex,
a new minimally invasive treatment for Stress
Urinary Incontinence.
Zuidex consists of a combination of non animal
stabilised hyaluronic acid (NASHA) and small dextranomer
beeds (Dx) which together form a thick liquid
which can be injected. It is produced by Q-med
a Swedish based company. It is fully bio-compatible
and, therefore, does not cause any adverse reactions.
The molecule is, as the name suggests produced
in the laboratory; so there are no risks of contamination.
In addition, the stabilisation of the molecule
ensures that it is not quickly reabsorbed.
Hyaluronic acid occurs naturally throughout the
human body where one of its roles is to trap fluid
between cells. It has been widely used in the
cosmetic industry as a bulking agent to improve
the appearance of wrinkles and fine lines. It
has also been used in over 20,000 cases of ureteric
reflux where it is injected into the bladder to
prevent urine from leaking back up into the kidneys
in children.
It use has now been extended to the treatment
of stress urinary incontinence where it is injected
into the urethra, at the bladder neck, to enable
it to close more effectively and thereby form
a more water tight seal and improve or cure incontinence.
The injection, using a special implacer, can be
administered under local anaesthetic in the clinic
setting with minimal discomfort and patients are
allowed home once they are able to pass urine
properly. This is a minor procedure taking only
a few minutes. It is uncomfortable, but as it
does not take long to administer the injection,
most women tolerate the procedure very well.
After treatment about 30% of patients are cured
of their incontinence whilst overall 70% will
see a significant improvement at one year follow
up. No major complications have been associated
with the injection procedure, and there have been
no reported safety concerns up to 7 years following
NASHA/Dx administration.
This procedure will not replace standard, more
major surgical techniques. It does not have as
high success rates as some of the standard operations
where the cure rate is around 70%. The advantage
is that there really is no pain after the procedure
which can be performed in an office location,
and that the women once treated can resume normal
activities immediately. On vaginal examination
after the injection there are no external signs
that the procedure has been carried out though
a small swelling caused by the Zuidex can be felt
on the anterior vaginal wall in the region of
the G-spot on vaginal examination.
The technique would seem to offer a suitable treatment
alternative particularly for younger women who
have stress incontinence which is troublesome
but not severe enough to warrant major surgery.
It may be particularly useful in women who have
not yet completed their family as it does not
create an obstacle for a further vaginal delivery,
which is a problem with all the other more major
surgical techniques.
The success of the procedure is maintained for
up to 3 years and it can easily be repeated when
necessary. If in time the urinary incontinence
becomes worse, as it often does over a period
of years, then standard more invasive operations
can still be carried out without difficulty if
and when required.
Zuidex seems to offer a relatively easy solution
to a problem that affects between 3-10% of women.
The cure rates are not high, but a significant
improvement in symptoms in 70% of women for a
walk in procedure, that takes only a few minutes,
ensures that there is a high risk benefit ratio.
Therefore, this is a treatment which will be very
acceptable to many women who leak urine on exertion
and who currently keep quiet and put up with their
embarrassing problem.
The most widely performed operation for stress
incontinence is the Tension free Vaginal Tape
tape (TVT). The concept behind it is that stress
incontinence results from the failure of the pubourethral
ligaments in the mid-urethra. The aim of the tape
is to reinforce the supports to the mid-urethra
and thus restore continence. The tape is composed
of a knitted Prolene mesh. The instrument and
sling used for the TVT procedure are shown.
The procedure can be performed under local, regional
or general anaesthesia. The aim of the procedure
is to place the tape at the mid-urethra. It is
inserted via a small vaginal incision. Two small
(1 cm) incisions are made in the abdominal wall,
5 cm apart, just above the pubic bone. The tape
is therefore lying in a U-shape around the urethra.
Following TVT insertion, a cystoscopy is performed
to ensure that there has been no damage to the
bladder. The aim is to have the tape lying free
at rest (hence ‘tension-free’) whilst
exerting sufficient pressure on the urethra during
a cough to prevent leakage of urine.
The tape itself is made of knitted prolene and
has very specific qualities. The holes in the
mesh are large enough for the body to heal into
it and through the holes. In addition, because
it is a monofilament the risk of infection is
reduced. Because of this it does not require any
specific fixation once it is in place.
The success rates with this technique are extremely
good. The preliminary results came from Sweden
in 1995 and showed an 84% cure rate. Since then
numerous studies have been performed all over
the world. These have shown similar success rates.
Overall it is reasonable to expect that around
70% of women will not experience any incontinence
after the procedure and that around 95% will be
dry or significantly improved. Worldwide, more
than 250,000 of these operations have been performed.
10 year follow up data are scarce but would tend
to suggest that the operation lasts.
All surgical procedures have potential complications.
These can be divided into intra-operative, postoperative
and long-term complications. The most frequent
intra-operative complications include injury to
the bladder at the time of the tape insertion
(5%), and bleeding (2%). Postoperative complications
include difficulty in bladder emptying which occurs
in around (10 %) which may be long term (2%),
urinary tract infection (4%), and wound infection
(1%). Worrying long-term complications include
the risk of tape rejection and tape erosion, this
does not seem to occur with this particular tape,
probably due to its’ unique properties.
Another major advantage of the TVT is that it
has a very quick recovery time. Patients are treated
as day cases or have an overnight stay in hospital,
and most are fully back to normal within two weeks.
After more traditional surgery, patients stay
in hospital for five to seven days and it is six
weeks before they can resume normal activities.
As the TVT does not involve an abdominal incision
or a general anaesthetic it is possible to perform
the procedure on overweight and elderly women
in whom standard surgery might be difficult or
hazardous.
Recent advances in this technique now allow us
to place the tape slightly differently. This is
called the TVTO which may have advantages over
the previous device.
The key to success with surgery is patient selection
and careful choice of the correct operation. In
general, conservative treatment to strengthen
the pelvic floor is tried first. Surgery is considered
if these do not work, or symptoms are severe.
If there is no associated organ prolapse then
a Zuidex injection or TVT might be considered.
If there is prolapse it may be appropriate to
repair this at the time of continence surgery.
Where there is other pelvic pathology such as
a large fibroid uterus it may be beneficial to
first remove this mass prior to reassessing bladder
function.
Summary
With this individualized patient centered care
most women will respond or be cured. Some women
will respond to medication or improve with pelvic
floor exercises, others will benefit from surgery.
Surgery, when it is performed should be minimally
invasive and effective. Unfortunately, some patients
will get little or no benefit from any treatment
and it is important that these women get the help
that they need. A home visit by a continence advisor
may be appropriate as toilet access may be a problem.
Proper advice on and prescription of continence
pads should also be considered. If the individuals
needs’ can be met, and patient expectations
are properly managed, then quality of life can
be vastly improved even if the underlying problem
cannot be cured.
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