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This page has moved. Click here to view. Urinary IncontinenceIncontinence and urinary tract complaints are common among women. Approximately 10-30% of women between 15 and 64 years of age and 25% more than 65 years of age experience urinary incontinence. About 50% of nursing home residents have urinary incontinence overactive bladder, stool leakage, soiling, incontenence. One in five women with urinary incontinence also suffer from anal incontinence. Many of these symptoms may be relieved by interventions; therefore, patients benefit greatly when their physician understands prevention, pathophysiology, evaluation, and treatment of these common disorders. The obstetrician-gynecologist plays a pivotal role in the initial evaluation and treatment of women with these Urinary Incontinence The two most common forms of urinary incontinence in ambulatory women are genuine stress incontinence and detrusor overactivity. Most women with genuine stress incontinence (loss of urine associated with physical exertion such as coughing, sneezing, running, lifting, and jumping) have loss of support of the urethral sphincter. Vaginal delivery alters the support in the vagina, especially the anterior wall. The use or avoidance of episiotomy does not appear to influence the incidence of stress incontinence. This form of "hypermobility" incontinence responds well to correction of the displacement with either vaginal support devices or repositioning surgery. Genuine stress incontinence also may occur in nulliparous women who have some Glossary
Detection of Urinary Incontinence Every obstetrician-gynecologist has patients with urinary incontinence. Physicians can detect this condition by inquiring about it regularly. Of women who have had a recent vaginal delivery, one fifth will develop incontinence; among this group, early It is estimated that one third of women with urinary incontinence have both detrusor overactivity and genuine stress incontinence. The physician's role is to focus on the symptoms that are most bothersome and reduce the impact of these symptoms for the Initial Evaluation Once urinary incontinence is reported, office evaluation should follow a stepwise progression. Initial evaluation should focus on the severity of urinary leakage and the patient's goals for resolution of the problem. Some women may simply wish to regain sufficient bladder control to participate in certain social or athletic activities. Their goal may not necessarily be complete Identification and Management of Reversible Conditions That Cause or Contribute to Urinary Incontinence
Initial Interventions Behavioral Therapies Behavioral therapies are helpful to virtually every patient with urinary incontinence. Many patients have adopted behavioral changes in their own attempts to control incontinence symptoms. The physician can save time and have a more direct impact by inquiring what the patient has already tried on her own. Simple techniques may be discussed, including adjustment of type and volume of fluid intake after review of the urinary diary. Older patients frequently have nocturnal diuresis. The diaries of these patients reflect several episodes of nighttime voiding, Muscle Training Women with weakened pelvic floor muscles may benefit from muscle-training protocols. These are helpful for patients with detrusor overactivity or stress incontinence. There are two important components to muscle rehabilitation: 1) strength and 2) appropriate timing of contraction of these muscles. The physician's role is critical in identifying muscle weakness and emphasizing the importance of muscle rehabilitation. Strength can be gained through a variety of exercise programs. There is little scientific evidence to suggest any specific muscle-training Kegel Exercises Pelvic muscle exercises (Kegel exercises) help improve urinary control in 40-75% of patients. The patient performs the exercise by contracting the pubococcygeus muscle, thus improving the tone of the voluntary external urethral musculature. Exercises are indicated in patients with either stress or urge incontinence. The success of pelvic muscle exercises depends on the Electrical Stimulation Electrical stimulation with a transvaginal probe reduces detrusor overactivity in approximately 50% of affected women. Like timed voiding and muscle training, this treatment is free of systemic side effects. The main drawback is the cost of rental or Vaginal and Urethral Devices An increasing selection of vaginal and urethral devices are available in North America. This appears to be the fastest-growing type of incontinence therapy. Pessaries that are modified for incontinence (Fig. 14) provide additional suburethral pressure and are safe and reasonably effective. A bladder support prosthesis is significantly more expensive and more cumbersome to fit than Intrinsic urethral sphincter dysfunction has been treated by periurethral bulking injections to improve urethral coaptation. Injections have been used in women with a well-supported but poorly functioning intrinsic urethra; short-term cure rates approach 70-90%. Periurethral collagen injections are not indicated in women with urethral hypermobility because Pharmacotherapy There is no ideal medication for the treatment of incontinence. In general, drug treatment is used for detrusor overactivity and is aimed at reducing inappropriate detru-sor contractions. Less commonly, (z-receptor stimulants are used to increase urethral tone in an effort to reduce stress incontinence episodes. These medications stimulate ct receptors throughout the body (eg, cardiovascular system) and may cause hypertension. Drugs for detrusor overactivity are typically anticholinergic agents. Thus, the side effect profile includes dry mouth and worsening constipation. Narrow-angle glaucoma is an absolute contraindication to use of this class of medications; they should be used cautiously in women with significant cardiovascular disease. Oxybutynin chloride and tolterodine are the only medications in this class with scientific evidence for efficacy for detrusor overactivity. Oxybutynin chloride is available in generic formulations and, therefore, has the advantage of reduced cost. Tolterodine may have fewer side effects and is a reasonable second-line Women with mixed urinary incontinence may benefit from imipramine hydrochloride. This medication offers a combination of anticholinergic medication for detrusor suppression and (z-receptor sympathomimetic activity to Fecal Incontinence The estimates of the prevalence of fecal incontinence in the adult female population range between 1% and 17%. This disorder, defined as involuntary passage of gas, liquid, or solid stool, is even more stigmatized than urinary incontinence. Approximately one in five women with urinary incontinence also have some form of anal incontinence. For most women seeking care for Therapy Therapeutic considerations depend on the diagnosis discovered by the evaluation. If no surgical defect is demonstrated, the goal of therapy is to help the patient maintain a state of formed stool and to make every effort to keep the rectum empty. Recommendations will include dietary modifications (mostly to increase fiber) and muscle exercises, much as are |
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