Lancaster Physician Spring 2017 - 19

SPRING 2017

Urinary Incontinence

Injury to the pelvic muscles and nerves
and supporting structures makes patients
more susceptible to developing urinary
incontinence. Traumatic vaginal delivery
increases risk, but there are many other reasons
for abnormal functioning of the pelvic and
urinary structures. Causes can also include
infections or fistulae. In addition, personal
functional problems (such as dementia or
difficulty walking) can easily cause great
difficulty. Therefore, it's important to look
for possible neurologic causes, from central
neurogenic abnormalities (such as stroke) to
peripheral nerve injury. Decreased estrogens
in menopause with atrophic changes also
accentuate pelvic structure abnormalities.
Evaluation of urinary incontinence involves
doing a history and physical exam with a urine
dipstick. The physical exam checks for prolapse
and change in strength and sensation. Post void
residual measurements and a bladder diary are
other considerations. The bladder diary checks
drinking and voiding amounts and times, along
with problems such as leaking. These also give
an overview of general daily intake/output/
voiding and identify possible areas to help the
incontinence situation. The diary only needs to
be done for three days, so it is not inconvenient.
Approved questionnaires to evaluate symptoms
are helpful and work well for checking progress
during treatment. Microscopic urine analysis is
not used initially because of cost, but it is used
with cultures when indicated. Urodynamic
studies are also not done, unless the problem
is more complex. Urodynamic testing involves
placing a probe in the vagina and one in the
bladder and then infusing fluid into the bladder,
while checking pressures and symptoms and
stressing with cough. The urethral pressures are
also checked during the study to evaluate the
urethral sphincter functioning.
It's important to educate the patient, discuss
the progressive nature of treatment, and develop
a plan together.
Three main types of urinary incontinence
are 1) stress urinary incontinence, 2) urgency
urinary incontinence, and 3) mixed urinary
incontinence. Evaluation is needed to determine
which type is present. Treatment evolves in a
stepwise fashion starting with less invasive and

becoming more invasive until the patient has
good quality of life.
Stress urinary incontinence occurs when a
patient increases her intra-abdominal pressure
(e.g., cough or sneeze) and then leaks urine.
This happens when the ligaments holding
the urethra are injured or if the urethra has
intrinsic problems and the sphincter does not
prevent leaking. Usually pelvic floor muscle
training with Kegel exercises are tried first to
strengthen the pelvic floor. Weight loss and
pessary and vaginal electrical stimulation can
help. If hypermobility of the urethra is present,
then sling surgery is considered. Sling surgery
is done by loosely implanting a small strip of
graft material under the urethra and, when
coughing, the urethra presses against the sling
and stops leaking.

IT'S IMPORTANT
TO EDUCATE
THE PATIENT,
DISCUSS THE
PROGRESSIVE
NATURE OF
TREATMENT, AND
DEVELOP
A PLAN
TOGETHER.
Urgency urinary incontinence is the complaint of loss of urine associated with urgency.
It occurs with contractions of the bladder that
then cause incontinence because the urethra
does not stop the urine. Usually the volume of
urine lost is larger compared to stress urinary
incontinence. Fluid intake is checked and
modified if needed. Then bladder training and
pelvic floor muscle training are tried. Weight

LANCASTER

19

PHYSICIAN

loss can help (e.g., an 8 percent weight loss
causes 42 percent less urgency). Decreasing
caffeine can also help.
Mixed urinary incontinence is a combination
of stress urinary incontinence and urgency
urinary incontinence. Initial treatments are
similar, but frequently a urodynamic study
is needed to check the bladder and urethral
pressures to determine how much overactive
bladder is present.
Overactive bladder syndrome is urinary
urgency, usually accompanied by frequency
and nocturia, with or without urgency urinary
incontinence, in the absence of urinary tract
infection or other obvious pathology. Overactive
bladder is a clinical diagnosis characterized by the
presence of bothersome urinary symptoms. Overactive bladder overlaps with the urgency urinary
incontinence and involves similar initial therapies.
Patients can also have bladder oversensitivity.
If initial therapies are not helping with
overactive bladder problems, then consider next
level therapies. Medications like imipramine,
anticholinergics, or beta 3 agonists can help. If
these are not working, then neuromodulation
and botulinum toxin type A (Botox®) injections
can be tried. Posterior tibial nerve stimulation
and sacral nerve modulation (neuromodulation)
stimulate sacral nerves to influence the bladder
and pelvic floor. These are more invasive, applying stimulation in the ankle with an electrode
needle or an electrode near S3 in the sacrum.
Interestingly, another medical use of Botox is
office injection in the bladder via cystoscopy.
Botox inhibits acetylcholine release from the
presynaptic cholinergic junction and therefore
relaxes the bladder spasms. Botox results in
significant improvement of overactive bladder
symptoms in the majority of patients.
In summary: 1) Urinary incontinence
is prevalent, and it should be recognized,
addressed, and treated. 2) It is about quality
of life. 3) Start with less invasive evaluation
and treatment, and advance as needed to more
invasive treatment. 4) Listen to the patient and
form a progressive plan.



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