Overview of Treatment of Urinary Incontinence

Abstract

The most common subtypes of urinary incontinence are stress incontinence, urgency urinary incontinence, and mixed incontinence. Generally, there is a step-wise approach to management with less invasive and lower-risk therapies provided initially including pelvic floor therapy and behavioral modification. For stress urinary incontinence, there are several operative modalities available with midurethral sling being the most commonly used procedure. For overactive bladder (OAB) and urgency urinary incontinence, therapies include medications (anticholinergics and beta-3 agonists) and, if that fails, interventions such as intradetrusor injections of onabotulinumtoxinA and neuromodulation. Mixed urinary incontinence generally includes a multimodal treatment approach with a focus on symptoms that are most bothersome to the patient. This chapter will review incontinence types, evaluation, treatment, and outcomes.

Commentary by John P. Lavelle, Veterans Affairs Palo Alto Health Care System, Department of Surgical Service, Urology Section, Palo Alto, CA, USA

Commentary

• John P. Lavelle 

This is a very interesting case.

“A 45-year-old G2P2 obese woman with type 2 diabetes, hypertension, sleep apnea, and prior hysterectomy presents with urinary incontinence. She states her friend was cured with surgery, and she desires the same. She notes that her primary care provider had given her a medication that ‘didn’t work’ to reduce her leakage.”

The chapter presents a very thorough method for considering the problem of urinary incontinence and the treatment options for this lady. Importantly, the history, and physical exam as it pertains to incontinence, is carefully explained. Many of the various options for treatment of female incontinence are explained. However, when considering this particular case, a number of medical options need to be considered. The problem is that the case is very complex and multifaceted and that one or more factors need to be considered and each one needs to be eliminated or minimized to come to an acceptable treatment plan, which may take many months to execute completely, leading to an acceptable outcome for the patient.

One of the problems is that the lady in the case assumes that her incontinence has the same cause as her friend’s, and thus the procedure should fix her incontinence. This problem requires a lot of patience and education from the physician after a thorough evaluation to determine the precise cause(s) of this patient’s incontinence, with evaluation of her contributing factors, and thus realign her expectations with what is possible, and how she can be helped, and why her expectation of an operation may or may not work for her.

If one, at the outset, considers from the history:

Obesity: Is this severe? Does it contribute to metabolic syndrome? Is there a hormonal problem? Is it related to stress and overeating due to an anxiety disorder or prior psychological or physical trauma? It can add to stress incontinence if present on physical examination. Did she have Sheehan’s syndrome during childbirth, and is she now having problems with the treatment? Is what appears to be obesity really ascites or perhaps some large abdominal mass such as an ovarian cyst causing mass effect in the pelvis?

Diabetes: Is it well controlled? Does she have polyuria? Does she have peripheral neuropathy? Nephropathy with polyuria? Diabetic cystopathy? Are we assuming diabetes mellitus, where in fact she has diabetes insipidus due to lithium use for depression, which might be partly related to her incontinence? Is this diabetes insipidus contributing to her incontinence due to polyuria with urgency and inability to make it to the bathroom?

Hypertension: Is this being treated with diuretics? If so, the drug-induced increase in urine output can exacerbate her urgency and incontinence secondary to a more rapid filling of her bladder.

Sleep apnea: Is her incontinence nocturnal, thus related to untreated sleep apnea, with potential cardiac arrhythmias, and diuresis from ANF release?

G2P2: Was the bladder or pelvic floor injured during childbirth, and is there pudendal neuropathy or prolapse? The possibility of STDs with herpes lesions affecting bladder function might also be considered.

Prior hysterectomy: Is there subsequent prolapse contributing to incontinence, and is there neuropathy of the bladder due to interference with the pelvic nerves on the lateral fornixes innervating the bladder? Have there been other prior anti-incontinence procedures performed concurrently or subsequent to the hysterectomy? Is there a possible vesicovaginal fistula?

Medication that did not work: Was this something for overactive bladder or something different? Was it expected to work? Importantly, why did the medication “not work”? This would need to be explained to her.

In the background: With diabetes, obesity, and hypertension, and being female, is she at risk of serious cardiac event from a surgical procedure? Does she have adequate pulmonary status to manage anesthesia?

In the background: Does she potentially have spinal disorder, due to her obesity, and exacerbating degenerative disc disease, contributing to incontinence?

During the examination, many of these items can be assessed, but ultimately you have to decide whether the problem is related to polyuria, stress, urge, and mixed, overflow, or fistula incontinence or a combination. Each particular problem has to be addressed as a separate entity and treated as such. Ultimately this should be based on objective data and examination. Importantly as pointed out in this chapter, the use of urodynamics should explain the symptoms by the findings and not fit the findings to the symptoms.

This chapter is a great summary of available options to medically or surgically correct urinary incontinence which primarily impact patient’s quality of life. Did we write this section? I do not recall seeing this in the original chapter. So, with Dr. Lavelle also as an author, I am wondering if he was asked to write a summary of the chapter at the end (since he was otherwise not a co-author)? If so, ask him to work on this section. If not, please let me know and I will rewrite as it needs work. We must respect the patient’s rights to autonomy, self-determination, and freedom of will, to decide if and when they do or do not want any or all of these proposed or recommended procedures. However, this should be done in the circumstance of a full, frank, and open discussion(s) of the indications, nature of the treatment(s), and the risks, benefits, alternatives, and consequences of, and of not, performing each procedure as none are ideal. While we strive as physicians to make better options for our patients, they ultimately have to live with the consequences of these decisions. This is best if the patients can go into the procedure(s) “eyes wide open,” fully prepared, and comfortable with their decision, with the full support of their medical and caregiver teams. This is the final most important point of this chapter, where in the discussion of the case, the authors acknowledge the patient’s right to decline treatment.