Stress Urinary Incontinence: Treatment Manisha Patel, MD April 10, 2006

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1 Stress Urinary Incontinence: Treatment Manisha Patel, MD April 10, 2006 What treatment options are available for a woman with stress urinary incontinence (SUI)? Behavioral therapy, medication, pessary, surgery What behavioral changes should be made once the diagnosis of SUI is made? Dietary changes: Eliminate excess fluid intake/alcohol intake/caffeine intake Bladder Training: Frequent voluntary voiding to keep the bladder volume low Pelvic Muscle Exercises (Kegel): Strengthening of the levator ani and pubococcygeal muscles to improve the muscular supports of the bladder. Patients should be told/shown to contract the muscles that would stop her urinary stream when she voids. The patient should contract these muscles in counts of times several times a day. A study by Henalla et al found that 67% of patients achieved either complete continence or a significant improvement of symptoms after 3 months of performing Kegel exercises. The physician needs to ensure that the patient is performing Kegel exercises correctly Vaginal cones: A variation of Kegel exercises in which a set of cones of increasing weight that require pelvic muscle contraction to hold them within the vagina are used to help strengthen the vaginal muscles Pelvic floor electrical stimulation: Stimulation of the levator ani and pubococcygeal muscles strengthen the muscles and has been shown to decrease symptoms of stress urinary incontinence. Studies have showed improvement rates of 50-94% Others: Treat constipation, treat chronic cough, encourage smoking cessation, encourage weight loss What medications can be used to treat SUI? Medications do not play a meaningful role in the treatment of patients of SUI as the do in the treatment of urge incontinence. Local estrogen therapy in postmenopausal women: Increases the vasculature and the tone of the bladder neck which will help increase the urethral closing pressure and improves collagen production. Oral estrogen may actually increase risk of stress urinary incontinence. In the WHI trial, women on Premarin had a relative risk of 1.9 of SUI when compared to placebo after one year of therapy and women on Prempro had a relative risk of 2.2 of SUI. These increases remained even after three years. Alpha adrenergic agonist agents: act on alpha receptors in the bladder neck and urethra causing muscle contraction: however pure alpha agonist are no longer readily used Imipramine: dual alpha agonist and anticholinergic activity therefore can be used to treat SUI and urge incontinence. SUI can worsen if post void residual increases. Not recommended in older patient in whom anticholinergic side effects and orthostatic hypotension may be significant. Duloxetine (Cymbalta): serotonin and norepinephrine reuptake inhibitor that stimulates pudendal motor neuron alpha adrenergic and 5 hydroxytryptamine 2 receptors to decrease SUI. Currently approved in the US for depression but is used in Europe for SUI.

2 Can pessaries be used to treat SUI? Yes: goal is to provide support to the urethrovesical junction Pessaries that can be used include: Milex Incontinence Ring, Cook Continence Ring, Bladder Neck Support Prothesis What surgical options are available to treat SUI? Anterior repair with Kelly-Kennedy plication: involves the placement of two sutures underneath the bladder neck, plicating the endopelvic fascia and providing support to this area. Not routinely used today to treat SUI. Indication: Can be used in women who cannot tolerate potential complications such as post op voiding dysfunction Success Rate: anywhere from 31% - 69% with follow-up in 1-5 years Complication: hemorrhage, pyrexia, urinary retention, recurrent prolapse Retropubic urethropexy (Burch and Marshall-Marchetti-Krantz): Burch: gold standard for treating SUI Endopelvic fascia adjacent to the mid and proximal urethra at the bladder neck is attached to Cooper s ligament on the posterior surface of the superior pubic ramus MMK: attaches the endopelvic fascia next to the bladder neck to the periosteum of the posterior pubic symphsis Indications: genuine SUI secondary to poor anatomic support of the urethral sphincter Success Rate: 75 88%. Retrospective studies have suggested similar success rates for the MMK and Burch, however the MMK was associated with longer hospital stays, later resumption of voiding, and overall more complications Complications: urinary retention, detrusor overactivity, injury to bladder or ureter, infection, hemorrhage, enterocele Urinary retention usually resolves in one week and the incidence of retention depends in part upon how tightly the suspension sutures are pulled. Detrusor overactivity is due to excess elevation by the suspension sutures or disruption of bladder innervation by sutures or from dissection. Retropubic urethropexies may predispose to the development of an enterocele as a result of a space created in the vaginal cul-de-sac from lifting the anterior vaginal wall toward the superior pubic ramus. Osteitis pubis is a unique complication of MMK. Suburethral slings (Autologous fascial slings, cadaveric slings, xenograft slings, synthetic slings including TVT, TOT): Hammock that supports the bladder neck and urethra preventing rotational descent during increases in abdominal pressure and providing a stable platform for urethral compression Indications: uncomplicated SUI, SUI with intrinsic sphincter deficiency, SUI after a previous failed procedure,

3 conditions that increase the risk of recurrent incontinence (COPD, obesity, occupational or athletic stress on the pelvic floor) Success Rate: 61 99%. Success rate decreases if the patient has had a previous incontinence surgery (78% success rate with no previous surgeries vs 60% with previous surgery). Well supported urethra prior to surgery also decreases success rate along with preoperative finding of detrusor instability Complications: Intraoperative: bladder laceration, urethral transection, vascular damage, GI damage, nerve damage Postoperative: urinary retention secondary to sling obstruction, detrusor overactivity, infection of graft material, mesh erosion Transvaginal needle suspensions (Modified Pereyra, Raz, Stamey, Gittes, Muzsnai): Support the bladder neck and proximal urethra by using permanent sutures to attach the endopelvic fascia to the rectus fascia or pubic bone via a transvaginal approach. Indications: may have an easier post-operative course Success Rate: 41 91%. A Cochrane review concluded that needle suspension surgeries had a lower subjective cure rate then Burch (74 versus 86%). Long term failure rate may be due to the result of sutures eroding through the rectus fascia or endopelvic fascia Complications: Detrusor instability, infection, pelvic pain, dyspaurenia How can you treat stress urinary incontinence secondary to intrinsic sphincter deficiency? Intrinsic sphincter deficiency is defined as failure of the internal uretheral sphincter mechanism to maintain mucosal coaptation at rest or during minimal physical stress. During urodynamics, valsalva point pressure would be less than cm water or maximum urethral closure pressure less than 20 cm water. Treatment options include periurethral bulk substance injections, urethral sling procedure, artificial sphincter device A 46 yof p5005 presents with SUI that is documented on office urodynamics. What are treatment options? Dietary changes, bladder training, Kegel exercises. If she has completed childbearing, can consider Burch vs suburethral sling such as TVT. A 80 yof present with multiple comorbidities and SUI that make her a poor surgical candidate. What are treatment options? In addition to behavioral changes, vaginal estrogen therapy and a pessary A 65 yof who had had a anterior repair with Kelly plication 5 years ago presents with recurrent SUI. What surgical method would you choose on her?

4 Burch or suburethral sling. However if she had had failed a Burch in the past or had poor urethral mobility, or compromised urethral sphincter, suburethral sling would be the surgical method of choice. References: McLennan, Mary C. Surgical Management of Genuine Stress Incontinence. In Operative Gynecology, W.B. Saunders Company, Philadelphia, 2001, Stenchever, Morton A et al. Urogynecology. In Comprehensive Gynecology, Mosby Inc, St Louis, 2001,

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