Treatment for urinary incontinence in women depends on a correct diagnosis
Urinary incontinence affects one in three Australian women who have ever had a child.1
Many suffer in silence, with current evidence suggesting that women wait for five years on average before seeking medical help for incontinence.
While women may be too embarrassed to bring up the topic themselves, targeted questioning from an astute GP can identify some cases earlier.
Once it’s established that a woman has urinary incontinence, a series of questions can help determine the type and severity of the problem, as well as guide management.
The two most common presentations of urinary incontinence are stress urinary incontinence and urge urinary incontinence.
Stress incontinence occurs during exertion, when the urethral closure mechanism fails to sustain sufficient closure to stop urine escaping from the bladder.
Contrary to popular opinion, it is pregnancy that plays a causative role in stress incontinence, rather than the mode of delivery. Genetic predisposition is also a factor, along with chronic cough, advancing age and menopause.
In urge incontinence, the primary pathology involves an overactive detrusor muscle that contracts involuntarily, causing a sensation of urgency and forcing urine into the urethra. It is most commonly idiopathic, with the diagnosis usually arrived at after neurological causes have been ruled out. It is not known why people develop urge incontinence, but afferent nerve density and detrusor muscle contractility are thought to be increased.
Urge incontinence is unrelated to pregnancy, but it may have a genetic predisposition and is associated with advancing age and menopause. Australian data suggests that while stress incontinence is more prevalent in women aged between 40 and 60, (around 40% prevalence), urgency incontinence becomes the main cause in women older than 60, affecting around 40% in that age group.2
Taking the history
Clarifying the complaint is the most important first step in history taking in women presenting with incontinence. They often start by saying, “I have a problem with my bladder” and it’s important to work out whether this statement means, “I have urinary incontinence” or “I have a prolapse/bulge in my vagina”. The two problems are usually independent of each other; for those women complaining of both issues, it is important to determine which one is more problematic, and to manage it first.
An open question, such as, “Can you describe a typical circumstance where you become incontinent?” can reveal the events which lead to incontinence and determine the type of incontinence the woman is experiencing. Questions about how often the episodes of bladder leakage occur, the number of pads used per day and whether or not they are soaked, can reveal the profound way urinary incontinence can affect a woman’s life.
The next question concerns the frequency of voiding and the number of times a woman goes to the toilet at night. Voiding up to six to seven times per day is normal, so further questioning will be required for those who void more frequently, focusing on their fluid intake.
There is a general perception in the community that drinking large amounts of water is beneficial, leading some people to consume up to four litres of water per day. I’ve even seen women complaining they’re voiding every 30 to 60 minutes, while constantly gulping from their water bottles during the consultation.
For the average woman, an intake of 1.6 to two litres daily (eight cups of fluid) is sufficient. Asking about the number of cups of coffee per day is also relevant, as women with urinary incontinence need to be made aware of the diuretic effects of caffeine.
Medications, such as diuretics, should also be reviewed with a view to replacing the offending drug with another agent that may decrease the severity of the incontinence.
History in a woman with urinary incontinence should routinely involve questions about utero-vaginal prolapse. Up to 45% of women have some degree of prolapse, but have no symptoms and therefore require no treatment, but 7% of older Australian women are bothered by the symptoms of utero-vaginal prolapse.3 It is useful to routinely ask “Do you ever feel a bulge or a lump protruding from the vagina?” while emphasising that the prolapse and incontinence are often independent of each other, and that treating one problem doesn’t necessarily fix the other one.
Women complaining of urinary incontinence should be investigated with an MSU sample for M/C/S and a bladder diary. For those with a history of recurrent UTI or who complain of any voiding dysfunction or incomplete emptying, a renal ultrasound with a post-void residual should also be performed.
Bladder diaries are extremely useful for routine investigation of patients with urinary incontinence. They can be downloaded via the Continence Foundation Website (/www.continence.org.au/data/files/Factsheets/bladderdiary.pdf), printed and given to the patient at the first consultation.
A bladder diary is an invaluable tool in assessing the history of incontinence. I ask patients to document, for at least two consecutive days and nights, how much they drink and at what time; and how much they void and at what time. They may find this awkward as they need to void into a measuring jar (any jar with volume markings is suitable) and measure the volume voided each time, day and night, for the duration of the test. In addition, they document fluid intake, including the type of drink and volume, and any episodes of incontinence. While a bladder diary may seem like a simple, low-tech exercise, it provides vital information.
If for instance, she voids every hour and passes 50ml at a time this demonstrates urinary urgency and frequency. If more than 30% of the woman’s cumulative voided volume occurs during sleep (including the morning void) this might explain nocturia.
Referral to a pelvic floor physiotherapist or a specialist referral, if required, can also be made at this point. Remember to include a copy of the bladder diary with the referral. As described above, women who present with urinary incontinence generally have either predominant stress urinary incontinence symptoms or predominant urgency urinary incontinence symptoms. Some women have both types of symptoms, and history taking and examination are needed to work out the predominant type of incontinence.
Stress urinary incontinence
A typical patient, usually in her 40s, presents complaining of urine leakage when walking briskly or exercising at the gym. She tends to wear pads or panty liners, which get wet with activity. She has no urinary urgency, frequency or nocturia; there’s no leakage with the key at the door or while rushing to the toilet. However, the incontinence is distressing to her. She finds it difficult to conceal the leakage and the smell, and is worried she may have to quit jogging. Her underwear is dry at night and she may not get up to void at night at all. A bladder diary reveals normal voided volumes of 300ml or more, three to four hours apart.
On genital examination, there is often a demonstrable stress leak when you ask the patient to cough. She may or may not have a strong pelvic floor contraction when you ask her to tighten her pelvic floor muscles.
In women with predominant stress incontinence symptoms, their severity may decrease with early interventions such as
weight loss, topical oestrogen cream for postmenopausal women, and pelvic floor muscle training. Formal pelvic floor muscle training with a specialised pelvic floor physiotherapist is ideal and can produce significant improvement requiring no further interventions. The Australian Physiotherapy Association Website, www.physiotherapy.asn.au, can help locate a pelvic floor physiotherapist according to a patient’s postcode.
The use of a large tampon during exercise has been shown to decrease incontinence4. The Contiform device can also be beneficial5. A sizing pack, containing three different sizes, can be bought online at www.contiforminternational.com. A GP, pelvic floor physiotherapist, continence nurse or gynaecologist can help choose the appropriate size, and teach insertion and self-removal.
The device can be self-inserted by the woman in preparation for sport, and can be removed and reused up to 30 times. If there are stressors such as a chronic cough, aggressive management of these is also required and may be all that’s needed to improve symptoms.
If conservative treatments fail to produce an acceptable improvement for women, the next step is referral to a urogynaecologist, who will probably perform urodynamic testing in preparation for surgery. Urodynamic testing involves filling the bladder with water and observing the intravesical pressure as it is being filled, looking for involuntary detrusor muscle contraction.
The Urogynaecology Association of Australasia has released a group statement supporting the use of midurethral tapes (such as The Tension Free Vaginal Tape) for SUI: www.ranzcog.edu.au/doc/position-statement-on-midurethral-slings-c-gyn-32.html.
This should not be mistaken for the mesh that has been implanted vaginally to treat vaginal wall prolapse, and has caused a higher than expected complication rate.
In 2011, an FDA11 announcement warned of potential problems such as mesh erosion, mesh contraction and dyspareunia.
Another procedure, the laparoscopic Burch Colposuspension, involves placing permanent sutures on the vaginal fascia on either side of the bladder neck up to the ileopectineal ligament. Its success rate approaches that of the open Burch procedure and The Tension Free Vaginal Tape.
If surgery is considered, women can expect cure rates of about 85%,6 but must be counselled about the rare complications, such as urinary retention (2%), mesh erosion (1% to 2%), and bladder perforation (1% to 2%)7, and the higher rates of rectoenteroceles (20%) which can occur medium-term in the case of Burch colposuspension, due to the anterior movement of the vaginal axis with this operation.
Recently, Erbium and CO2 intravaginal laser treatments have become available in Australia, and are being promoted for the treatment of urinary incontinence. Laser can improve pelvic floor tightness and sexual functioning, especially in post-menopausal women for whom vaginal oestrogen treatment is contraindicated.
Theoretically, it is plausible that laser treatments provide subdermal scarring beneath the urethra, which could possibly decrease urethral descent during coughing.
So far, there have been no randomised controlled trials to evaluate the efficacy and safety of these treatments and their long-term effects. They may be indicated for women with mild incontinence not responding to conservative treatment, but who wish to avoid surgery.
At this stage, based on data from case series, women should be prepared for a modest improvement only, as opposed to a cure.
Urgency Urinary Incontinence
Women of any age can present with symptoms of urgency urinary incontinence, but the typical patient is aged 65 or older and experiences severe incontinence. She feels insecure and never goes out without knowing where the toilets are. She often restricts her fluid intake, voids frequently, and always voids before leaving the house “just in case”. She wears thick pads that absorb large amounts of urine, because leakage in women with this type of incontinence is heavier than in women with stress incontinence. She may or may not get up often at night, but when she gets out of bed the morning, she will leak on the way to the toilet.
Generally, there is no neurological explanation, and a neurological examination will be unremarkable. Urge incontinence is an idiopathic condition; hence on coughing there won’t be a demonstrable stress leak or bladder neck descent. These women often have excellent pelvic floor muscle tone.
In this scenario, the bladder diary reveals frequent voided volumes of 50ml to 100ml every hour, sometimes with episodes of nocturia. Occasionally there is excessive fluid intake, but most commonly the fluid intake is insufficient. An MSU may demonstrate a UTI, the treatment of which may improve the symptoms, though it may not cure them.
Treating urge incontinence can be challenging, and the success rate is lower than for women with stress symptoms. Conservative measures, such as lowering caffeine intake and diuretic use, are important. Long-term vaginal oestrogen can decrease the symptoms of urgency, provided there are no contraindications to oestrogen.
Bladder training is paramount in this condition and has to be distinguished from pelvic floor muscle training.
Bladder training teaches women what to do when they have an urge to void. If half an hour or less had passed from the previous void, rather than rushing to the toilet, women should be advised to sit, tighten their pelvic floor muscles and to wait for a minute while breathing normally, waiting for the spasm in their detrusor muscle to settle. As the detrusor contraction settles, so does the feeling of urgency.
Bladder training has not been extensively researched but is an important tool that can potentially improve quality of life without great financial cost or side effects8,9. Further information and resources can be obtained at www.pelvicfloorunit.com.au.
The mainstay of treatment is anticholinergic treatment, which includes non-selective, but inexpensive, oral oxybutynin (Ditropan). This agent is contraindicated for patients with closed angle glaucoma and severe constipation. Oxybutynin is also available in a twice a week transdermal preparation (Oxytrol).
More expensive options include once-daily oral solifenacin (Vesicare), and sarifenacin (Enablex) M3 receptor antagonists with fewer side effects, such as dry mouth. Failing these, mirabegron (Betmiga) is a beta-3 agonist for detrusor overactivity. It is contraindicated in cases of severe poorly controlled hypertension.
Specialist referral can be considered if conservative treatments fail. For stress incontinence, trialling a six-month course of pelvic-floor training is advisable. For urge incontinence, trialling at least one medication with bladder retraining by a physiotherapist is advisable. It is not unusual at this stage to try higher doses of one tablet, or to try several medications in combination.
Other indications for specialist referral include past continence surgery, or a history of both voiding dysfunction and incomplete bladder emptying. Failed treatments might warrant urodynamic testing or cystoscopy assessment. Further treatment options might include intravesical Botox or sacral nerve modulation, which boasts up to 70% cure rates, but require discussion about potential risks versus benefits.
Intravesical Botox involves 0.5ml injections in 20 sites in the bladder10. This can be performed under general anaesthetic or in an outpatient setting. However, up to one in 20 women may experience significant urine retention, and require clean intermittent self-catheterisation for several months until the Botox wears off. Repeat injections can be administered.
Sacral nerve modulation doesn’t carry the risk of urine retention, but is more invasive, requiring two procedures where a percutaneous lead is inserted posteriorly at the S3 foramen, and a pulse generator implanted under the surface of the buttock. Sacral nerve modulation tends to be reserved for refractory cases, and its use in public hospitals is limited.
Dr Emmanuel Karantanis is a urogynaecologist at the Pelvic Floor Unit, St George Hospital, Kogarah and a Conjoint Senior Lecturer with UNSW
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