Marsha K. Guess, MD, MSAssistant professor and Fellowship DirectorSection of Urogynecology & Reconstructive Pelvic SurgeryThe Departments of Obstetrics, Gynecology & Reproductive Sciences & UrologyURINARY INCONTINENCE

Urinary IncontinenceThe involuntary loss of urine

STATISTICS:10-60% of women report urinary incontinence

Only 10-20% seek medical care

Billions of dollars spent annually on incontinence products (in North America)

Nygaard, I. et al. JAMA 2008;300:1311-1316.

PSYCHOSOCIAL IMPACT

Higher prevalence of depression, embarrassment, loss of self esteem, anxiety Decrease in excursions outside home, social interactions, sexual activity

Major factor in the decision to place a relative in a nursing home

TYPES OF URINARY INCONTINENCEGenuine Stress Urinary IncontinenceDetrusor InstabilityIntrinsic Sphincter DeficiencyOverflow IncontinenceFunctional/Transient incontinence

PATHOPHYSIOLOGY OF SUI

ComplaintDefinitionDaytime frequencyvoids too often/day

Nocturia voids too often/night

Nocturnal enuresisloss of urine during sleep

Urgencysudden desire to void

Urinary incontinenceinvoluntary loss of urine with or immediately preceded by urgencyAbrams P et al. Am J Obstet Gynecol. 2002;287(1):116-126.SYMPTOMS ASSOCIATED WITH URGENCY INCONTINENCE

INTRINSIC SPHINCTER DEFICIENCYProblem with ability of urethra to close Drain pipe urethra

ISDRISK FACTORSAge

Trauma/childbirth

Previous Incontinence Surgery

Explore symptoms:

durationprecipitantsfrequencymost bothersome

Focus on medical, surgical, neurological & genitourinary history

diabetes mellitushx of previous incontinence surgery multiple sclerosisfailure of previous pharmacotherapymental statussymptoms of prolapse

Review voiding patterns/fluid intake

Obtain voiding diaryPATIENT EVALUATION

Problem with support of urethraGoal: stabilize urethraNormalAbnormalPHYSICAL EXAMINATION

EVALUATION OF URINARY INCONTINENCEPost-void residual UrinalysisUrine culture Urine cytologyHbA1CVoiding diaryUrodynamicsCystoscopy

VOIDING DIARY

Voiding Diary 11/18/05 TimeAmountLeaksDrinks7:00am100cc0cup with meds7:45am50cc18oz water8:15am25 cc212oz coffee9:00am150cc18oz water9:30am100cc012 oz coffee11:00am150cc01:15am50cc03:00pm75cc15:00pm90cc06:30pm120cc07:30pm100cc0cup with meds8:00pm100cc08oz water8:45pm50cc19:15pm25 cc08oz water10:00pm160cc110:30pm100cc011:00pm150cc11:15am50cc03:00am75cc05:00am90cc06:15am120cc1Total213092160

URODYNAMICS

CYSTOSCOPY

INDICATIONS FOR URODYNAMIC TESTINGPrevious failed surgeryWhen surgery is plannedUncertain etiology to incontinenceConcomitant prolapse (Potential incontinence)Failed medical treatment

Behavior modification

Bladder Training

Physiotherapy

Mechanical devices

Pharmacological TherapyCONSERVATIVE MANAGEMENT OF SUI

BIOFEEDBACK

GSUI PELVIC FLOOR EXERCISESKegels alone vs. Vaginal cones vs. Pressure biofeedback

All improved symptoms and QOL No significant difference between groupsLaycock et al. 2001

GSUI WEIGHT LOSS13 morbidly obese womenResults:9/12 with resolution of urinary symptoms post-opObjective and subjective improvement of stress and urge incontinence Bump et al. 199210 moderately obese women (mean BMI 38.3) 4 or more episodes of incontinence /dayResults:50% in incontinence episode with > 5% weight lossSubak et al. 2002

GSUI PESSARY

SURGICAL MANAGEMENT OF SUI

SLINGS FOR SUI

CONSERVATIVE MANAGEMENT OF UUIBehavior modificationBladder TrainingPharmacological TherapyElectrical Stimulation

ANTICHOLINERGIC SIDE EFFECTSDry mouth

Blurred vision

Drowsiness

Tachycardia

Constipation

ANTICHOLINERGIC CONTRAINDICATIONSNarrow angle glaucoma Intestinal obstruction

Cardiac arrhythmia

Myasthenia gravis

ELECTRICAL STIMULATION FOR UUI

BULKING AGENTS FOR ISD

BULKING AGENTS FOR ISD

BULKING AGENTS FOR ISD

BOTOX

Urogynecology includes a wide variety of lower urinary tract and pelvic floor disorders

Patient satisfaction is optimized when meticulous care is taken to adequately evaluate patients and individualize therapy

Patience is a virtue!!!!CONCLUSION

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