MANAGEMENT OF STRESS URINARY INCONTINENCE Michelle Y . Morrill, - PowerPoint PPT Presentation

10/26/2016 Disclosures • None MANAGEMENT OF STRESS URINARY INCONTINENCE Michelle Y . Morrill, M.D. Chief of Female Pelvic Medicine and Reconstructive Surgery, TPMG Director of Urogynecology, Kaiser SFO Assistant Professor, Volunteer Faculty, Department of ObGyn UCSF Goals Urinary Incontinence • Review the epidemiology and causes of stress urinary • Accidental leakage of urine incontinence (SUI) in women • Common medical condition • Discuss appropriate diagnostic tools for SUI • Significant Quality of Life factor • Learn about treatment options for SUI 1

10/26/2016 Bladder Function Urinary Incontinence 3 Ways to Void : 3 Ways to Void : 3 Ways to Leak : 1. Valsalva 1. Valsalva 1. Valsalva 2. Detrusor Contraction 2. Detrusor Contraction 2. Detrusor Contraction 3. Urethral Relaxation 3. Urethral Relaxation 3. Urethral Relaxation Urinary Incontinence Urinary Incontinence 3 Ways to Void : 3 Ways to Leak : 3 Ways to Void : 3 Ways to Leak : 1. Valsalva 1. Valsalva (Stress 1. Valsalva 1. Valsalva (Stress Incontinence) Incontinence) 2. Detrusor Contraction 2. Detrusor Contraction 2. Detrusor Contraction 2. Detrusor Contraction (Overactive Bladder) 3. Urethral Relaxation 3. Urethral Relaxation 3. Urethral Relaxation 3. Urethral Relaxation 2

10/26/2016 10 Function: Urinary Incontinence Bladder and Urethra 3 Ways to Void : 3 Ways to Leak : 1. Valsalva 1. Valsalva (Stress Incontinence) 2. Detrusor Contraction 2. Detrusor Contraction (Overactive Bladder) 3. Urethral Relaxation 3. Urethral Relaxation ( rare ) October 26, 2016 11 Dysfunction: SUI Symptoms Bladder and Urethra Stress Incontinence • Stress incontinence : • The complaint of involuntary leakage of urine on effort or exertion, eg. with sneezing or coughing (valsalva) 3

10/26/2016 SUI Causes? SUI Causes? 1994 DeLancey and Ashton-Miller ‘Hammock Theory’: 1990 Petros and Ulmsten ‘Integral Theory’ • Support and elevation at the bladder neck maintains continence • Urethra opened and closed by interaction of vaginal wall, ligaments and muscle around the urethra • Laxity in the tissues leaves the urethra open when these forces attempt to • Injury to the levator muscles and pubocervical support tissues led to SUI close it • Midurethral sling developed to reinforce the high pressure zone of the middle urethra Chermansky CJ, Moalli PA. Role of pelvic floor in lower urinary tract function. Autonomic Neuroscience: Basic and Clinical 200 (2016) Chermansky CJ, Moalli PA. Role of pelvic floor in lower urinary tract function. Autonomic Neuroscience: Basic and Clinical 200 (2016) 43–48 43–48 SUI Causes? SUI Causes? • Lack of support or squeeze on the urethra 2008 DeLancey • Study: Women with SUI vs. controls • Maximum urethral closing pressure was lower in SUI • Not bladder • Resting and contracting urethral axis (bladder neck) significantly lower in SUI • Not prolapse • Levator ani strength and MRI imaged defects were similar • Treatment of prolapse can → stress incontinence 1 • Concluded that urethral function is most strongly associated with SUI. DeLancey, J.O.L., Trowbridge, E.R., Miller, J.M., Morgan, D.M., Guire, K., Fenner, D.E., Weadock, W.J., Ashton-Miller, J.A., 2008. 1 Jelovsek JE. Predicting urinary incontinence after surgery for pelvic organ prolapse . Curr Opin Obstet Gynecol. 2016 Stress urinary incontinence: relative importance of urethral support and urethral closure pressure. J. Urol. 179, 2286–2290. Oct;28(5):399-406. 4

10/26/2016 Post-Void Dribbling Urinary Incontinence Epidemiology • Prevalence • Urinary Incontinence in the past year 1 : 50% Treatment = Double Voiding Relax to void 1. Stand and count to 10 2. Sit briefly for drops 3. 1 R Dooley Y, et al. Urinary Incontinence Prevalence: Results From the National Health and Nutrition Examination Survey. J Urol 2008; 179, 656-661 Urinary Incontinence Epidemiology Urinary Incontinence Epidemiology • Prevalence • Prevalence • Urinary Incontinence in the past year 1 : 50% • Urinary Incontinence in the past year 1 : 50% • Bother (EPIQ questionnaire) • Bother (EPIQ questionnaire) • Stress incontinence 2 : 15% • Stress incontinence 2 : 15% • Urgency and urge incontinence 2 : 13% • Urgency and urge incontinence 2 : 13% • Care Seeking 3 : 61% 1 R Dooley Y, et al. Urinary Incontinence Prevalence: Results From the National Health and Nutrition Examination Survey. J Urol 2008; 1 R Dooley Y, et al. Urinary Incontinence Prevalence: Results From the National Health and Nutrition Examination Survey. J Urol 2008; 179, 656-661 179, 656-661 2 Lukacz et al. Parity, mode of delivery and pelvic floor disorders. Obstet Gynecol 2006;107:1253–60 2 Lukacz et al. Parity, mode of delivery and pelvic floor disorders. Obstet Gynecol 2006;107:1253–60 3 Morrill et al. Seeking healthcare for pelvic floor disorders: a population-based study. Am J Obstet Gynecol . 2007 Jul;197(1):86.e1-6. 5

10/26/2016 Why do women develop SUI? Urinary Incontinence Racial Differences ‘Moderate – Severe’ Urinary Incontinence by Race • Risk Factors (Leakage of at least drops weekly or wet monthly) 20 • Genetics (Family History) 18 • Age 16 14 • Pregnancy and Childbirth 12 • Obesity 10 • Chronic straining (cough, constipation, 8 6 smoking) 4 • Oral estrogen 2 0 White Hispanic Mexican American Black Wood LN, Anger JT. Urinary incontinence in women. BMJ. 2014 Sep 15;349:g4531 Wu JM, et al. Prevalence and Trends of Symptomatic Pelvic Floor Disorders in U.S. Women. Obstet Gynecol 2014;123:141–8 Urinary Incontinence Racial Differences SUI Age Differences Incontinence Impact : SUI or MUI in women age 20 – 90+ 35 Same severity of incontinence is more bothersome to black women than white women 1 30 25 Percent with SUI or MUI Possibly due to racial disparities in knowledge of risk factors and treatment 20 options for incontinence 2 15 Or due to low levels of knowledge about UI and a reluctance to discuss 10 symptoms with health care professionals 3 5 0 AGE by 5 year groups 1 Lewicky-Gaupp et al. Racial differences in bother for women with urinary incontinence in the Establishing the Prevalence of Incontinence (EPI) study Am J Obstet Gynecol 2009;201:510.e1-6. 2 Mandimika CL, et al. Racial Disparities in Knowledge of Pelvic Floor Disorders Among Community-Dwelling Women. Female Pelvic Med Reconstr Surg . 2015 Sep-Oct;21(5):287- 92. Hannestad YS, Rortveit G, Sandvik H, Hunskaar S. A community-based epidemiological survey of female urinary incontinence: The 3 Hatchett L, Hebert-Beirne J, Tenfelde S, Lavender MD, Brubaker L. Knowledge and perceptions of pelvic floor disorders among African American and Latina women. Female Norwegian EPINCONT Study. Journal of Clinical Epidemiology 53 (2000) 1150–1157 Pelvic Med Reconstr Surg . 2011 Jul;17(4):190-4. 6

10/26/2016 SUI Age Differences Screening Young women and incontinence : “Some women are bothered by urine leakage or going Fozzatti C, et al. Prevalence study of stress urinary incontinence in women who perform high-impact to the bathroom frequently – is this a concern for exercises. Int Urogynecol J 2012 ;23:1687-91 you?” • Healthy nulliparous women 20 – 45yo • 25% of regularly physically active and 14% of controls reported UI with effort Evaluation and Diagnosis Evaluation and Diagnosis : Pre-op • Evaluate for Urinary infection (UA +/- Cx) • Stress Test • Yes / No leak • Delay or prolonged leak suggests Stress Induced Detrusor Overactivity • Ask • Post-void residual • UI associated with physical activity such as coughing, sneezing, lifting or exercise • Sensitivity = 0.86 Specificity = 0.6 1 • Urethral Mobility / Q-tip test? • OR = 1.9 For failure of MUS 1 • Physical Exam • Urodynamics? • Consider uncommon alternatives eg. urethral diverticulum, vaginal discharge • Not if uncomplicated stress-predominant urinary incontinence 2 1 Richter HE, et al. Demographic and clinical predictors of treatment failure one year after midurethral sling surgery. Obstet Gynecol. 2011 Apr;117(4):913-21. 1 Brown JS, et al. The Sensitivity and Specificity of a Simple Test To Distinguish between Urge and Stress Urinary Incontinence. Ann 2 Nager CW, et al. A randomized trial of urodynamic testing before stress-incontinence surgery . N Engl J Med. 2012 May Intern Med. 2006;144:715-723 . 24;366(21):1987-97. 7

10/26/2016 Pelvic Floor Exercises Stress Incontinence • Daily Pelvic Floor exercises Strengthen and Control pelvic floor muscles Treatments • Pelvic Floor Strength and Control at the proper time prevents incontinence Pelvic Floor Muscle Exercises (Kegels) Weight Loss • Possibly beneficial Imamura M, Williams K, Wells M, McGrother C. Lifestyle interventions for the treatment of urinary incontinence in adults. Cochrane Database of Systematic Reviews 2015, Issue 12. • Cochrane: Women with SUI who received treatment (Kegels) • 8 times more likely to report cure (56.1% v 6.0%) • 17 times more likely to report cure/improvement (55% v 3.2%) Stress incontinence Weight-Loss Group Control Group • Subak LL, et al for the PRIDE (-8% wt. at 6m) (-2% wt. at 6m) • Minimal adverse events Investigators. Weight Loss to Treat Baseline — 9 10 Urinary Incontinence in Overweight SUI episodes/wk and Obese Women. N Engl J Med 6 Mo — 4 7 • Test squeeze and give feedback with every pelvic exam 2009;360:481-90. SUI episodes/wk % Change −58% −33% Dumoulin C, Hay-Smith EJC, Mac Habée-Séguin G. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database of Systematic Reviews 2014, Issue 5. Art. No.: CD005654. DOI: 10.1002/14651858.CD005654.pub3. 8