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Urinary Incontinence and Urogynecology

About 10% to 25% of women between the ages of 15 and 64 will report experiencing urinary incontinence. About 14% perceive it as a social or hygienic problem. The prevalence is going to exceed 50% in nursing homes. Urinary incontinence costs ten billion dollars a year in direct and indirect costs. Less than half of the women who have urinary incontinence seek help or ask it unless they are directly, specifically asked about incontinence. If you say, "Do you have any problems with your bladder?" in the medical history, many times they will say no. If you say, "Do you lose urine when you cough?" then all of a sudden the history starts to change. Iím sure many of us have had that experience. We have to be very specific in asking questions to elicit a overactive bladder, urinary incontinence, urine leak, bladder leak, wetting

Thereís a number of different reasons for this. One is people consider this to be normal. It happened to their mom, it happened to their sister, it happened to their friends. So itís a consequence of aging, itís part of being a woman and itís considered a normal variation so

So as we move on to talk about incontinence, letís reexamine whatís required to be continent. The bladder is basically a very simple organ. Itís designed to store urine at low pressures and release urine at socially acceptable times. The idea of the low pressure is that you donít

Calcium channel blockers oftentimes will cause a recumbent diuresis, so when the person lays down at night they are mobilizing more fluids, producing more urine and running to the bathroom more often. Not because there is a problem with the bladder but because the bladder is filling faster. So if they are having lots of problems with nocturia, and they are on a calcium channel blocker, you may want to change the timing or the type of medication that they are on.

Finally, a lot of older people are on sedative hypnotic agents, either for sleep or for treating their incontinence and you have to be careful with these because they will have trouble being steady on their feet or being disoriented and have accidents on the way to the bathroom resulting in a trip to the orthopedic surgeonís office. As far as their medical history is concerned, diabetes can cause degeneration of the nerves and the perception of bladder filling. Youíll commonly find women who develop diabetes to have retention that they are unaware of. They will also lack their early warning systems of proprioception as far as when urine is in the bladder and when their bladder is starting to fill. Multiple sclerosis generally can result in three things: urinary retention, involuntary bladder contractions, which would be detrusor hyperreflexia because we know that there is a neurologic lesion causing that, or they can be normal. If they have urinary retention, itís a condition generally called "detrusor sphincter dyssynergia". And what that is is the urethra is contracting as the bladder is contracting so you this push-me-pull-you type system. So basically the bladder is contracting against a closed bladder neck and this generally will only occur in people with MS when they are unable to ambulate without assistance or need to be in a wheelchair. So if they have a normal gait it is unlikely that they are going to have retention. They most likely have detrusor hyperreflexia secondary to their lesions. Strokes, depending on their

As far as treatment is concerned: looking first at stress incontinence. Thereís medications, pelvic floor exercises. Pelvic floor exercises can take the form of Kegelís exercises, the use of vaginal cones - which weíll talk about- along with pelvic floor stimulation and then the use of surgery for restoring the bladder neck to a high retropubic position. Kegelís exercises and vaginal cones and pelvic floor stimulation are all doing the same thing. They are trying to strengthen and build up the levator ani muscles and trying to narrow the genital hiatus. You also are 

Medication has a small role, although I avoid it for the most part because the results tend to be transient and they are reversed immediately after stopping the medications. The model agents for treating stress incontinence are alpha-adrenergic agonists because the bladder is rich in alpha receptors. The model drug here is phenylpropanolamine. You can give it in 25 to 75 mg a day. It comes in timed-release form. Particularly in

We are not sure why estrogen works but it does work. About 5% to 10% of people I see who have pure stress incontinence, who are extremely atrophic, will dramatically improve using estrogen. Thatís because thereís estrogen receptors

Provera, just as if you were giving them oral estrogen. Sometimes I think the estrogen absorption is better through the vagina because of all the dramatic side effects they get. One gram of estrogen cream is equivalent to 0.625 of Premarin, so you have to keep Öthis is a fairly healthy dose for a limited period of time. After the six weeks we will switch them over to a formal estrogen replacement regimen. You have Pelvic floor exercises can be done with the Kegelís exercises, vaginal cones or pelvic floor stimulation. It takes a full 12 weeks to determine 

This is one of the units thatís available. Itís kind of like a TENS unit. This probe is placed in the vagina and then the amperage is increased. One channel has a 50 Hz signal and this channel happens to be 12.5 Hz. And you increase the amperage depending on the patientís ability to feel the contractions of the pelvic floor muscles. So what theyíll do is place this probe at the level of the ischial spine, which is where the pudendal nerve comes around on its way to innervate the levator ani muscles and then stimulate the nerve. It has a built in program so it will stimulate for 20 minutes then stop. The literature that comes in the package is fairly straightforward, easy to understand. Again, competition breeds decreased costs and the price of there units is starting to come downwards, being more reasonable to afford. They used to be in the $1000 range and now some companies have them in the low 400ís. Thereís a fair amount of trouble getting insurance reimbursement for these type units. Itís not recognized as something that the companies want to reimburse for. Although HCFA and then the latest government reports on urinary incontinence are recognizing it as safe and effective therapy, so hopefully we will start to see a little change in the mindset of the insurance companies when it comes to reimbursement for this type of an item.

As far as surgery is concerned, thereís about 200 different operations for incontinence. And when I see 200 of anything to treat a problem that tells me that not much works very well. But weíve learned over time that a couple of operations are more successful. Retropubic suspensions, which are traditionally thought of as the Burch-Couples suspension or the Marshall-Marchetti-Krantz type operation have been around since the 50ís and 60ís. They have a long track record and they have been shown to be effective immediately between 90% and 95% of the time. Five years later about 85% of people are still dry and the ten-year follow-up studies have shown that that maintains itself at about a 85% success rate if they were cured at the time of surgery. Now it is a little more involved. It involves an abdominal incision but for someone who has a normal urethra and a normal bladder neck itís by far the best operation available for treating stress incontinence. There is a number of needle suspensions that are performed. These are the Stamey operation or the Giddes procedure and these are all done 

As far as my own personal prejudices are concerned with surgery, the classic gynecology approach has been to do a Kelly-Kennedy plication, a primary vaginal procedure. Most of the studies that looked at this as a true Kelly-Kennedy plication show failure rates at one year of about 50% and five years at about 90%, so I donít think as a primary incontinence operation bladder neck plication is a good idea. Laparoscopy has been touted as a way of doing retropubic suspensions in a less invasive fashion. The problem with laparoscopic data with type of operation is we donít know what the five and ten year outcome are going to be from these operations or even whether they are being performed correctly. So thereís a fairly steep learning curve. It also takes a fair amount of knowledge of the anatomy, and having done traditional retropubic suspensions and the jury is still out on whether laparoscopy is the best way to approach this either.

Needle-type suspension. The bladder neck is identified and the sutures are placed on either side of the bladder neck and then through a small abdominal incision the sutures are pulled up and tied either directly to the periosteum of the pubic bone or to the fascia of the anterior abdominal wall. This is a picture of a retropubic suspension. This person will be lying on their back. This is the pubic bone, this is the bladder and the urethra going in this direction. Stitches are placed in the vagina on either side of the urethra and then elevated up and fixed to either Coopers ligament or to the pubic symphysis to bring this urethra up and behind the pubic bone. Then this is showing more of the side view. This is a Marshall-Marchetti-Krantz type procedure putting the stitches alongside the urethra and anchoring them directly behind the pubic symphysis. Finally, this is a sling. This is the pubic bone, rectum, vagina. This sling material - which could be fasciculata from the person or from cadaveric specimen, or it can be some other heterologous material - is placed at the level of the bladder neck and then brought up 

Collagen injections are effective in a group of people with type III incontinence, which we define as loss of urethral function with a well supported bladder neck. In these individuals who have type III incontinence they typically have had multiple surgical procedures. The surgical procedures have restored normal anatomy but have failed to compress the urethra enough to maintain continence. If you inject collagen in these individuals about 85% will be dry. The problem is you have to do multiple injections because if you inject too much, then they canít void at all and theyíve traded one problem for another. It can be done in the office. The collagen itself is from a bovine source and then cross-linked with glutaraldehyde. You have to give a skin test 30 days before administering it to make sure they donít have an allergic reaction, which happens less than Ĺ% of the time. The biggest problem with collagen is it sounds quick and easy, but it only really works in

If you give it to a woman who has a bladder neck thatís not well supported, itís not going to work and you are going to spend thousands of dollars on collagen because 2.5 cc cost $310 and it typically takes 6 to 10 amps of that to close the bladder neck for no gain. Itís a very satisfying procedure to do, though. You look with a zero degree cystoscope in the office, looking at the bladder neck. Periurethrally direct a needle to the level of the bladder neck, inject the collagen and then the bladder neck will close and you can just judge about how much to put

Moving on to detrusor instability: medications tend to be the mainstay of this. They tend to be the simplest. Our model drug for this has been oxybutynin. Typically we will dose this as 2.5 mg starting at three times a day and then increasing to four times a day and then increasing to 5 mg up to four times a day. They get incredibly dry mouth by the time we get to that point and usually arenít able to tolerate the medicine. Another alternative class of medications are the tricyclic antidepressants which offer both an anticholinergic effect and an alpha agonistic effect. So they are helpful in people with mixed incontinence. The model drug for this would be imipramine. You start that at about 25 mg at night and increase up to 75 mg at night. I usually do a real slow increase because people all react very different to that class of medications. Recently approved by the FDA is a new medication called tolterodine. Itís marketed under the brand name Detrusal, I think. Itís an Upjohn product and thereís going to be lots of marketing about this. I suspect this will take the same path as Rogaine and Allegra and Wellbutrin are seen now where you are going to have patients coming to you asking about this medicine because they are going to have lots of flashy ads. The advantage of this tolterodine is itís selective for the muscarinic receptors at the bladder. They donít affect the parotid gland. They are 1/5 as active at the parotid gland as Ditropan is, so theoretically you should have a lot less problems with dry mouth. It also has a b.i.d. dosing.

The other therapy that actually works better than medication for involuntary bladder contractions is behavior modification. This takes the form of bladder drills, timed voiding or prompted voids. Weíll talk about those individually in just a little bit. Finally, pelvic floor stimulation

We talked about Ditropan. The main side effect that you are going to see is dry mouth. You may see some blurred vision because it affects the eye muscles. Some people occasionally complain about drowsiness. You have to make sure these individuals donít have narrow angle glaucoma because it will close the angle and exacerbate their glaucoma fairly severely. We talked about imipramine. The same side effect profile, the same contraindication with narrow angle glaucoma. I generally donít go beyond 75 mg. If imipramine doesnít help, sometimes

Pro-Banthine is another anticholinergic that is helpful in the bladder. I reserve this mostly for treating people who have a lot of nocturia and Iíll load them up with between 50 and 60 mg h.s. , just at night. Sixty milligrams is a very large dose. If you take it just at h.s. and they are

Calcium antagonists: when I first started giving this lecture we were waiting for terodiline to come out, which is different than the drug I just talked about which is tolterodine. This is a calcium channel blocker that worked very well at the blocking of the muscarinic receptor. It was already to go in the United States. It was on the cusp of FDA approval and all of a sudden they saw people getting torsades to point and dropping dead in Europe. So it immediately got put to the bottom of the FDA pile and I doubt that we will ever see this medication in this country. But you may have read about tolterodine and terodiline and they are different medications but

In people who have mixed incontinence, both stress incontinence and detrusor instability, a combination of using medications, particularly the tricyclic antidepressants, may be worth a try especially if the urgency and frequency is the main complaint. Pelvic floor stimulation, using a combination of 10 and 50 Hz. With some stimulators you can develop the stimulation at the same time and so itís very convenient to do that. Pelvic floor exercises are very helpful. Anything you can do to contract the bladder neck will inhibit voluntary bladder contractions and

On the horizon there are lots of interesting things available. Most of which are here now. There are some high absorbency sheets that are paper-thin that absorb tremendous amounts of volume that are good for people who donít lose a lot of urine all at once. There is an external occlusive device that is available now. Itís got like a Tegaderm patch with a little foam rubber behind it and they place this right over the front of the urethra. Itís called an "impress patch." You can cut and trim the edges. The shape of the patch is not very good and I donít know how

There is also a continence pessary, which is a pessary placed in the vagina with two prongs on it that support the bladder neck. That also is available. Thatís a little more complicated because thereís a fairly fancy thousand dollar fitting kit that comes with the pessary and the