INCONTINENCE

Urinary incontinence affects over 10 million Americans, 85% of whom are women. The Bladder Health Council of the American Foundation for Urologic Disease in a recent national study examined incontinence as a health and life-style issue in the lives of American women age 45 and older. The council reported that:

• One in six women over 45 is affected by incontinence. Two in five wait over a year to discuss this condition with their doctor.
• Six in ten describe urine leakage as a major or always bothersome problem.
• 46% have had to change their life-style by reducing their activities or wearing different clothing.
• 20% totally eliminate some activities.
• The typical woman with incontinence goes through 2.8 pads per day or about 1,000 per year.

Despite the high prevalence of incontinence, women get little information from their doctors concerning this difficult problem. This is especially unfortunate, since almost all of these women can be significantly helped, many with minimally invasive therapies.

Diagnosis
Most incontinence can be attributed to disorders of the bladder, the bladder outlet, or both. Bladder problems include detrusor (bladder) muscle instability or hyperreflexia, decreased compliance, and sensory urgency. Associated symptoms may include urgency, frequency, urge incontinence, and enuresis. Infection, neurologic disease and carcinoma-in-situ must be ruled out as does a previous history of trauma, radiation, or surgery. Unlike men with outflow obstruction, women without neurologic disease rarely have overflow incontinence.

Most outlet disorders in the female are related to stress urinary incontinence (SUI). Women with SUI may have anatomic incontinence (AI), or intrinsic sphincter dysfunction (ISD). Considering the bladder neck and proximal urethra together as the primary sphincter unit, patients with AI are incontinent because the sphincter unit is malpositioned and/or hypermobile. The sphincter is functionally normal but poorly supported. Increases in intra-abdominal pressure thus are inappropriately transmitted to the bladder but not to the urethra, so urine is forced out of the bladder. Patients with ISD have a damaged or incompetent sphincter unit in an normally supported anatomic position. The sphincter is functionally ineffective because of fibrosis, scarring, neurologic, or vascular injuries that prevent the proper coaptation of the walls of the urethra. Women with ISD leak at lower pressures and with minimal activity compared to those with AI. In addition, recent evidence now shows that urinary incontinence in women is often due to combination of AI and ISD.

Urodynamics
A thorough history and physical exam can often help determine disorders of the bladder from the outlet and ISD from AI. However, urodynamic evaluation is often critical in determining definitive treatment recommendations.

Urodynamics involves placing electode pads on the perineum, insertion of a small catheter into the bladder that can fill the bladder with water and also measure bladder pressures. Occasionally a rectal catheter is also used. As the bladder is slowly filled its pressure and compliance are monitored. The sensations of bladder filling are monitored by directly questioning the patient. The patient then voids as pelvic floor muscle activity, bladder pressures, urine flow rate, and other parameters are measured. This is an office procedure that takes 30 minutes to complete.

Treatment
Treatment options for incontinence include behavior modification, exercises, medical therapy, and surgery bladder instability, hyperrelexia, sensory urgency: some patients improve with bladder training and behavioral modification. Medical therapy with anticholinergics or musculotropic agents is usually effective for most women. In rare cases surgical bladder augmentation may be needed to increase bladder capacity and interrupt coordinated involuntary bladder contractions.

Overflow incontinence:
This may sometimes be overcome with timed voiding or using the crede maneuver. Women with more severe retention can be managed with clean intermittent catheterization.

Outlet Disorders: anatomic incontinence.
Strengthening the pelvic floor muscles supporting the bladder may be helpful in some cases. Kegel exercises, when properly used can be very helpful. Biofeedback can also help to strengthen pelvic floor muscles. About 30% of women will show some improvement with exercise.

Medical therapy may include supplemental estrogen to improve the mucosal seal of the urethra and sympathomimetics to increase smooth muscle tone of the bladder neck and proximal urethra.

Surgery for AI is based on repositioning the sphincter unit in a well supported retropubic position. This may be accomplished with a transabdominal (Burch, MMK), transvaginal (RAZ, Vesica) or laparoscopic approach. When properly performed these procedures are effective initially in 90% of patients and in 70% at five years. Recovery time varies depending on the type of procedure performed.

Outlet Disorders: Intrinsic Sphincter Deficiency.
The gold standard for treating ISD has been the pubovaginal sling where a strip of fascia, vaginal mucosa, or synthetic material (i.e. gortex) is brought under the bladder neck and suspended to compress the urethral sphincter. Recent work suggests that a large percentage of women with incontinence have some degree of ISD. The sling is initially successful in about 90% of cases.

Collagen (Trade Name Contigen) is a minimally invasive treatment for ISD that can be done under local anesthesia. Candidate are patients with good anterior vaginal will support (no anatomic incontinence) who do not react to a collagen hypersensitivity skin test given 4 weeks prior to the procedure. The collagen causes coaptation of the lining of the urethra which helps to decrease incontinence. In the initial studies, approximately 80% of patients improved with contigen most after one or two treatments. Retreatments may be needed over time to maintain continence.