Why GPs are central to premises development
One in four women suffers urinary leakage Dr James Balmforth and Professor Linda Cardozo advise on initial management strategies and look at the place of surgery
on initial management strategies and look at the place of surgery
Urinary incontinence is a distressing symptom that has a major impact on a woman's quality of life. While the prevalence of urinary incontinence has been found to vary widely depending on the definition used, a recent large-scale epidemiological study showed that 25 per cent of women complained of urinary leakage and 7 per cent had significant incontinence that was bothersome1. Incontinence frequently leads to embarrassment, anxiety and in some cases, social isolation.
The annual economic cost of managing urinary incontinence in the UK has been estimated at £354 million.
Urodynamic stress incontinence (USI), detrusor overactivity (DO), mixed incontinence, and overflow incontinence are the commonest causes of incontinence in the UK. USI accounts for around 50 per cent, DO for 40 per cent, and overflow for most of the remaining 10 per cent. Many women present with 'mixed incontinence', which is usually a combination of stress and urge-type incontinence. Fistulas are rare in the UK, and are usually secondary to gynaecological surgery, malignancy or radiotherapy.
The overall population prevalence of urinary incontinence peaks at age 45-55, dips slightly thereafter, and increases again after 70. In the reproductive age range, the majority of those affected complain of stress incontinence this is more common in younger gravid women, and its prevalence declines with advancing age and reduced physical activity1.
This is accompanied by a steadily increasing proportion of women who suffer from urge incontinence caused by detrusor overactivity, which increases in a linear fashion with age.
Lower urinary tract symptoms alone are often not sufficient to gain an accurate impression of the underlying pathology. This may lead to inappropriate treatment. Even simple office investigations may be invaluable in identifying associated causal factors not immediately apparent.
Urinalysis may aid in the detection of urinary tract infections (UTI) and diabetes mellitus; urine culture may identify and characterise a UTI; a frequency-volume chart may identify the compulsive fluid drinker, or those drinking excessive alcohol and caffeine. It is appropriate to undertake initial investigation, with advice on simple lifestyle changes and perhaps empirical treatment, before referral to secondary care.
However, objective urodynamic assessment of the lower urinary tract, to establish a firm diagnosis, is mandatory before any incontinence surgery, as the effects of surgery are largely irreversible. When considering surgical treatment it is therefore important to be clear about the underlying pathophysiology. Whereas urodynamic stress incontinence is often successfully treated by surgical intervention, detrusor overactivity is not. Indeed, it may be made worse by incontinence surgery.
The objective demonstration of leaking is essential in reaching a diagnosis of urinary incontinence. Pad testing provides a simple non-invasive, objective method for detecting and quantifying urinary leakage. It should be conducted in a standardised fashion so that results are comparable and reproducible. The International Continence Society (ICS) has produced guidelines for a standardised one-hour pad test. An increase in pad weight of greater than 2g over the course of one hour of standardised activity is considered a significant loss. A weight gain of greater than 10g is categorised as severe incontinence.
A conservative approach is advisable initially, especially if symptoms are mild, or easily manageable. Surgery should especially be avoided when a woman's family is incomplete, or when symptoms manifest during pregnancy.
The mainstay of conservative treatment for stress incontinence is pelvic floor physiotherapy. This should routinely be used as first-line treatment. The advantage of this is that many women's symptoms are cured or improved to the point where they do not require surgery, with its potential complications.
Moreover, the success rate of future operative procedures is not adversely affected as it may be following failed surgical treatment. Pelvic floor exercises (PFE) lead to an increase in the strength and tone of the pelvic floor, enhancement of cortical awareness of muscle groups, and hypertrophy of existing muscle fibres.
Women need instruction, motivation, and an understanding of the pelvic floor musculature. Teaching PFEs is a highly skilled job and is best undertaken by an appropriately trained specialist physiotherapist. A randomised controlled trial showed PFEs to be more effective than no treatment, electrical stimulation, or vaginal cones.
Incontinence surgery should only be considered in women with proven urodynamic stress incontinence who have failed a trial of conservative treatment.
Improvements in our understanding of the underlying pathophysiological mechanisms responsible for USI in women have led to the development of innovative new surgical methods such as the tension-free vaginal tape and peri-urethral injectable bulking agents.
A thorough initial assessment and correct choice of the most suitable individual treatment are essential, as the best chance of a surgical 'cure' is successful primary surgery. Many of the newer surgical procedures are less invasive then previous techniques and appear to offer improved safety and shorter hospital stays, while maintaining the efficacy of traditional open incontinence surgery.
The two most commonly performed operations for urodynamic stress incontinence are the Burch colposuspension and the tension-free vaginal tape (TVT).
They both have a 'cure' rate of around 85-90 per cent in women having their first operation for incontinence. It goes down with each subsequent procedure. Peri-urethral injectables have a lower success rate of 40-60 per cent. It depends very much on how you define 'cure' different studies use different outcome measures of success.
Recently, a new drug has been developed, specifically for the treatment of stress incontinence. Duloxetine is a potent and balanced serotonin and noradrenaline reuptake inhibitor (SNRI) that enhances urethral striated sphincter activity via a centrally mediated pathway.
The evidence reported to date suggests duloxetine offers an effective alternative to surgery and may be complementary to the use of PFEs in the initial management of women with stress incontinence2.
Management of overactive bladder syndrome
The combination of troublesome urinary frequency, urgency and nocturia, with or without urge incontinence, are together known as the overactive bladder syndrome (OAB). In primary care, it is likely that women who complain of such symptoms will be treated empirically before a firm urodynamic diagnosis of detrusor overactivity has been made.
For many, simple reassurance and lifestyle interventions with behavioural modification may suffice. Caffeine has been shown to increase the 'irritability' of the bladder in those who have DO. It is wise to moderate tea, coffee and cola intake, as well as alcohol. Limitation of fluid intake to 1-1.5 litres per day will also lessen the severity of symptoms. Various drugs, such as diuretics and antipsychotics,
function and their use should be reviewed.
For those requiring more than these simple lifestyle measures, there are a variety of effective treatments, including bladder retraining, behavioural therapies and anticholinergic drugs.
The rationale behind bladder retraining is that maladaptive behaviour has been acquired in adult life and that if the bladder can be re-educated, continence can be restored. Several approaches to bladder retraining exist, including bladder drill, biofeedback, maximum electrical stimulation, and hypnotherapy. Local continence advisers are best placed to offer this type of treatment and to co-ordinate other containment strategies.
Where conservative measures or a first-line pharmacological agent have failed to improve symptoms, referral is advised for urodynamic assessment to establish a firm diagnosis and to rule out a sinister cause for the 'overactive bladder' symptoms.
Pads, catheters and containment
Incontinence can be cured or significantly improved in most women providing they are appropriately investigated and treated. But some women may not wish to undergo medical or surgical intervention or may need some adjuvant conservative treatment to help them cope better with their symptoms. For these, containment with pads, devices or even catheters may be an appropriate option.
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The pad is the most common and most readily available form of containment. Pads should not be used as an alternative to other potentially curative medical treatments. They should really be a temporary measure while investigations are undertaken or treatment is awaited. A wide variety of pads has been produced to deal with different types of incontinence. Small pads are for light incontinence or frequent changes. Large pads are for the containment of heavy incontinence or where toileting is not an option.
Women with lower urinary tract symptoms are frequently very worried that they smell offensive to others. Reassurance, good personal hygiene, prompt disposal of products and prevention of urinary infection should be all that is needed.
In recent years a wide variety of devices have been developed. These include external urinary collection devices or appliances, intravaginal devices that support the bladder neck and urethral occlusion devices.The main aim of these devices has been to manage stress incontinence with or without prolapse.
Catheters are widely used for effective bladder drainage, either temporarily or permanently, when physiological and anatomical defects or obstruction of the lower urinary tract are present. The route of catheter insertion can be either urethral or supra-pubic. The urethral catheter is the most frequently used as it can be quickly and easily inserted.
Urethral catheters come in a variety of sizes and materials depending on their intended use. Catheters used in women should range from size 12 to 16 Charriere (Ch). Catheters are available in three lengths; 42cm (male length); 26cm (female length); and a shorter paediatric catheter. A male-length catheter may be more suitable in women who are overweight.
Urinary tract infection is the most frequent complication with long-term indwelling catheters. Most catheter users will have bacteria in the urine within three days. Infections can be difficult to eradicate due to the growth of bacterial populations as an adherent biofilm on the catheter surface. Common pathogens, such as Escherichia coli, are eliminated from the urine but persist as a biofilm on the catheter and restart the cycle of infection.
Clean intermittent self-catheterisation (CISC) is a technique taught to women to facilitate bladder emptying. It is also useful in treating women with idiopathic or neurogenic detrusor overactivity, enabling them to instil anticholinergic drugs intravesically.
Proper assessment, reassurance and continuing support are vital if women are to be motivated to perform catheterisation themselves.
For women who have intractable incontinence, supra-pubic catheterisation is preferred. It is also useful as an alternative to urinary diversion in women with long-term voiding difficulties, who are unable to perform CISC.
The major causes of urinary incontinence
·Urodynamic stress incontinence previously known as 'genuine stress incontinence'
·Detrusor overactivity previously known as 'detrusor instability'
·Functional incontinence such
as infection or constipation (especially in elderly patients and children)
Figure 1 Investigations of urinary incontinence
Basic investigations ·Midstream urine specimen
·Frequency volume chart
·Post void residual
Specialist investigations ·Uroflowmetry
·Urethral pressure profilometry
Figure 2 Simple conservative measures
·Fluid restriction (1.5 litres total fluid input per day)
·Alter medication that may exacerbate lower urinary tract symptoms
·Treat chronic conditions such as cough or constipation
·Reduce intake of caffeinated drinks
·Treat/exclude urinary tract infection
·Bladder drill ·Biofeedback ·Hypnotherapy
·Pelvic floor training
·Exercises ·Vaginal cones
·Tampons ·Pessaries ·Urethral devices
Women undergoing incontinence surgery need to:
·Have had urodynamic assessment to establish that they have urodynamic stress incontinence and to screen them for pre-operative detrusor overactivity and voiding difficulties
·Be informed of likely success rates and general risks of procedure and recovery times
·Specifically be warned of a small (roughly 5 per cent) risk of developing 'de-novo' detrusor overactivity or post-operative voiding difficulties as a result of their surgery
1 Hannestad YS et al. A community-based epidemiological survey of female urinary incontinence: The Norwegian EPINCONT Study. J Clin Epidem 2000; 53:1150-7
2 Drutz H et al. Duloxetine treatment of women with only urodynamic stress incontinence awaiting continence surgery. Neurourol Urodyn 2003;22:523-4
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James Balmforth is subspecialty trainee in urogynaecology, and
Linda Cardozo is professor of urogynaecology, Kings College Hospital, London