Urinary Incontinence: Stress

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Chapter 62 Urinary Incontinence: Stress

INTRODUCTION

Description: Urinary incontinence is a sign, a symptom, and a disease all at the same time. Stress incontinence is limited almost exclusively to women. Stress incontinence is the passive loss of urine in response to increased intraabdominal pressure, such as that caused by coughing, laughing, or sneezing.
Prevalence: Stress incontinence affects 10% to 15% of all women and 30% to 60% of women after menopause.
Predominant Age: Mid-reproductive age and onward. Stress incontinence becomes more common during the 40s and beyond and is most common after menopause.
Genetics: No genetic pattern.

ETIOLOGY AND PATHOGENESIS

Causes: Unequal transmission of intraabdominal pressure to the bladder and urethra. Generally associated with an anatomic defect such as a cystocele, urethrocele, or cystourethrocele. The degree of incontinence is often not correlated with the scale of pelvic relaxation.
Risk Factors: Multiparity, obesity, chronic cough, heavy lifting, intrinsic tissue weakness or atrophic changes resulting from estrogen loss.

CLINICAL CHARACTERISTICS

Signs and Symptoms

• Loss of small spurts of urine in association with transient increases in intraabdominal pressure
• Associated cystocele, urethrocele, or cystourethrocele

DIAGNOSTIC APPROACH

Differential Diagnosis

• Mixed incontinence (stress and urge)
• Urge incontinence (detrusor instability)
• Intrinsic sphincter defect (ISD)
• Low pressure urethra
• Urinary tract fistula
• Urinary tract infection
• Urethral diverticulum
• Overflow incontinence

Associated Conditions: Vulvitis, vaginitis, pelvic relaxation, uterine prolapse, other hernias, recurrent urinary tract infection.

Workup and Evaluation

Laboratory: No evaluation indicated. Urinalysis is generally recommended, although results are nonspecific. Abrupt-onset incontinence in older patients should suggest infection, which may be confirmed through urinalysis or culture.
Imaging: Radiographic studies are sometimes performed as a part of complex urodynamics studies but are generally of limited utility.
Special Tests: A “Q-tip test” is generally recommended, although it as a poor predictive value. (A cotton-tipped applicator dipped in 2% lidocaine [Xylocaine] is placed in the urethra and rotation anteriorly with straining is measured. Greater than 30 degrees is abnormal.) An evaluation of urinary function is advisable, especially if surgical therapy is being considered. In the past, the functional significance of a cystourethrocele was gauged by elevating the bladder neck (using fingers or an instrument) and asking the patient to strain (referred to as a Bonney or Marshall-Marchetti test). This test has fallen out of favor as nonspecific and unreliable.
Diagnostic Procedures: The best way to confirm stress incontinence is by pelvic examination—loss is best demonstrated by having the patient strain or cough while the vaginal opening is observed (preferably while the patient is standing). Urodynamics testing (simple or complex) may be used to evaluate other possible causes of incontinence.

Pathologic Findings

Based on cause. Evidence of a loss of support for the urethra and/or bladder is generally apparent on physical examination in patients with stress urinary incontinence.

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Weight reduction, treatment of chronic cough (if present), timed voiding, topical or systemic estrogen replacement or therapy as indicated (rendered controversial by the Women’s Health Initiative [WHI] study).
Specific Measures: Pessary therapy, pelvic muscle exercises (Kegel exercises), collagen injections (for intrinsic sphincter defect), surgical repair; limited role for medical therapy.
Diet: No specific dietary changes indicated.
Activity: No restriction, although some reduction in heavy lifting may be prudent.
Patient Education: Reassurance; American College of Obstetricians and Gynecologists Patient Education Pamphlet AP081 (Urinary Incontinence), AP166 (Surgery for Urinary Incontinence).

Drug(s) of Choice

Phenylpropanolamine (75 to 150 mg PO daily) may improve mild stress incontinence.
Phenylpropanolamine plus chlorpheniramine (75 mg/12 mg PO every 6 hours) is better tolerated than phenylpropanolamine alone.
Imipramine hydrochloride (Tofranil) 50 to 150 mg PO daily is good for mixed incontinence and enuresis. Use with care in elderly patients.
Duloxetine, a potent and relatively balanced serotonin and noradrenaline reuptake inhibitor, has been evaluated in phase II and phase III clinical trials and was found to be efficacious and safe in the treatment of women with moderate to severe stress urinary incontinence symptoms. Approval for use in the United States has been delayed.

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Estrogen, either topically or systemically, is often prescribed to improve tissue tone, reduce irritation, and prepare tissues for surgical or pessary therapy.
Contraindications: Known or suspected sensitivity to medication, undiagnosed vaginal bleeding, breast cancer.
Precautions: Alpha-blocking agents used to treat hypertension may reduce urethral tone sufficiently to result in stress incontinence in patients with reduced pelvic support. Patients treated with angiotensin-converting enzyme inhibitors may develop a cough as a side effect of medication, worsening incontinence symptoms and accelerating the appearance or worsening of a cystourethrocele.
Interactions: See individual agents.
Alternate Therapies: None at this time.

FOLLOW-UP

Patient Monitoring: Normal health maintenance. Patients are at increased risk for urinary tract infections, vaginitis, and vulvitis.
Prevention/Avoidance: The role of elective cesarean delivery in reducing pelvic floor trauma has been debated, but there are data to suggest that nerve damage in the pelvic floor may occur late in pregnancy without the trauma of vaginal delivery, resulting in an increased risk of eventual stress incontinence even with cesarean delivery.
Possible Complications: Social isolation and vulvar and perineal irritation are common complications of any type of urinary incontinence.
Expected Outcome: Generally favorable results may be obtained for patients with symptoms of stress incontinence through the use of a carefully chosen and fitted pessary. Surgical therapy is associated with 40% to 95% success in long-term correction of the anatomic defect and the associated symptoms. (Success rates vary based on the type of procedure performed and duration of follow-up.)

MISCELLANEOUS

Pregnancy Considerations: No effect on pregnancy, although pregnancy (and vaginal delivery) may contribute to a worsening of pelvic support problems.
ICD-9-CM Codes: 625.6.

REFERENCES

Level I

Carey MP, Goh JT, Rosamilia A, et al. Laparoscopic versus open Burch colposuspension: a randomised controlled trial. BJOG. 2006;113:999.

Kinn AC, Lindskog M. Estrogens and phenylpropanolamine in combination for stress urinary incontinence in postmenopausal women. Urology. 1988;32:273.

Kitchener HC, Dunn G, Lawton V, et alCOLPO Study Group. Laparoscopic versus open colposuspension—Results of a prospective randomized controlled trial. BJOG. 2006;113:1007.

Laurikainen E, Valpas A, Kivela A, et al. Retropubic compared with transobturator tape placement in treatment of urinary incontinence: a randomized controlled trial. Obstet Gynecol. 2007;109:4.

Meschia M, Pifarotti P, Bernasconi F, et al. Tension-free vaginal tape (TVT) and intravaginal slingplasty (IVS) for stress urinary incontinence: a multicenter randomized trial. Am J Obstet Gynecol. 2006;195:1338. Epub 2006 Jun 12

Oelke M, Roovers JP, Michel MC. Safety and tolerability of duloxetine in women with stress urinary incontinence. BJOG. 2006;113:22.

Level II

Albo ME, Richter HE, Brubaker L, et alUrinary Incontinence Treatment Network. Burch colposuspension versus fascial sling to reduce urinary stress incontinence. N Engl J Med. 2007;356:2143. Epub 2007 May 21

Atherton MJ, Stanton SL. The tension-free vaginal tape reviewed: an evidence-based review from inception to current status. BJOG. 2005;112:534.

Brubaker L, Cundiff GW, Fine P, et alPelvic Floor Disorders Network. Abdominal sacrocolpopexy with Burch colposuspension to reduce urinary stress incontinence. N Engl J Med. 2006;354:1557.

Dean N, Herbison P, Ellis G, Wilson D. Laparoscopic colposuspension and tension-free vaginal tape: a systematic review. BJOG. 2006;113:1345.

Federkiw DM, Sand PK, Retzky SS, Johnson DC. The cotton swab test. Receiver-operating characteristic curves. J Reprod Med. 1995;40:42.

Freeman RM. The role of pelvic floor muscle training in urinary incontinence. BJOG. 2004;111:37.

Stanton SL. Mid-urethral tapes: which? Review of available commercial mid-urethral tapes for the correction of stress incontinence. BJOG. 2004;111:41.

Level III

Abrams P, Blaivas JG, Stanton SL, Andersen JT. The standardization of terminology of lower urinary tract function produced by the International Continence Society Committee on Standardization of Terminology. Scand J Urol Nephrol. 1988;114:5.

American College of Obstetricians and Gynecologists. Genitourinary tract changes. Obstet Gynecol. 2004;104:56S.

American College of Obstetricians and Gynecologists. Urinary incontinence in women. Obstet Gynecol. 2005;105:15335.

American College of Obstetricians and Gynecologists. Pelvic organ prolapse. ACOG Practice Bulletin 79. Obstet Gynecol. 2007;109:461.

Anders K. Devices for continence and prolapse. BJOG. 2004;111:61.

Bombieri L. Is there a role for colposuspension? BJOG. 2004;111:46.

Consensus Conference. Urinary incontinence in adults. JAMA. 1989;261:2685.

Drutz H. Duloxetine in women awaiting surgery. BJOG. 2006;113:17.

Freeman RM. Initial management of stress urinary incontinence: pelvic floor muscle training and duloxetine. BJOG. 2006;113:10.

Lentz GM. Urogynecology. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, editors. Comprehensive Gynecology. 5th ed. Philadelphia: Mosby/Elsevier; 2007:551.

Mariappan P, Ballantyne Z, N’Dow JM, Alhasso AA. Serotonin and noradrenaline reuptake inhibitors (SNRI) for stress urinary incontinence in adults. Cochrane Database Syst Rev. 2005. CD004742.

Norton P, Brubaker L. Urinary incontinence in women. Lancet. 2006;367:57.

Norton PA. Urinary incontinence. Clin Obstet Gynecol. 1990;33:293.

Nygaard IE, Heit M. Stress urinary incontinence. Obstet Gynecol. 2004;104:607.

Ramsay IN. The treatment of stress incontinence—Is there a role for laparoscopy? BJOG. 2004;111:49.

Smith PP, McCrery RJ, Appell RA. Current trends in the evaluation and management of female urinary incontinence. CMAJ. 2006;175:1233.

Sutherland SE, Goldman HB. Treatment options for female urinary incontinence. Med Clin North Am. 2004;88:345.

Urinary Incontinence Guideline Panel. Urinary incontinence in adults: Clinical Practice Guidelines. Rockville, MD: Agency for Health Care Policy and Research, U.S. Dept of Health and Human Services, 1992. AHCPR publication 92–0038.

Videla FLG, Wall LL. Diagnosing stress incontinence without multichannel urodynamic studies. Obstet Gynecol. 1998;91:965.

Wagg A. Urinary incontinence—Older people: where are we now? BJOG. 2004;111:15.

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