Urinary incontinence- novak.pptx.urge incontinence

urinary incontinence ...urge incontinence...stress incontinence..

1. Urinary Tract 7/8/2024 Dr Ephrem Assefa 1

2. KEY POINTS 1. The lower urinary tract comprises of the bladder and urethra; it is under autonomic and somatic nervous system control, and is anatomically supported by the pelvic floor musculature. 2. Urinary incontinence , although underdiagnosed, is very common, has a significant impact on quality of life, and is generally treated successfully with conservative or surgical treatments. 3. Stress urinary incontinence is the most common subtype and occurs with increases in abdominal pressure ; it can be treated with pelvic floor exercises, pessaries, behavioral modification , and surgery . 7/8/2024 Dr Ephrem Assefa 2

3. 4 . Urgency urinary incontinence occurs with a sudden desire to urinate that cannot be postponed; it can be treated with bladder training, medications, behavioral modification, bladder onabutulinumtoxinA injections, and neuromodulation . 5. Mixed urinary incontinence is the co-occurrence of stress and urgency incontinence; it is the most bothersome and impactful subtype, and most common in late adulthood. 6. Voiding dysfunction and bladder pain syndrome are less common than urinary incontinence, but more challenging to treat successfully. 7/8/2024 Dr Ephrem Assefa 3

4. INTRODUCTION The urinary tract in women is comprised of the bladder that receives and stores urine from the kidneys as it is propelled downstream via the right and left ureters. The bladder expels the urine out of the body through the urethra when it reaches capacity or when it is socially appropriate to do so. To help accomplish this dual role of storage and voiding, the bladder and urethra are enveloped with muscles whose fibers are innervated by an intricate network of autonomous and somatic nerves, and they are anatomically supported by a complex system of pelvic floor muscles, fascia, connective tissues, and nerves within the pelvis. 7/8/2024 Dr Ephrem Assefa 4

5. Anatomy of the Lower Urinary Tract In the supine position , the bladder is positioned between the pubic bone and transversalis fascia anteriorly and the endopelvic fascia, vagina, and uterus posteriorly. The lateral margins of the bladder abut the obturator fascia and the condensation of muscle and connective tissue known as the arcus tendinous muscle fascia (white line). The bladder is comprised of three layers including the mucosa, detrusor (mostly smooth muscle), and serosa. The bladder mucosa consists of the urothelium , basement membrane, and lamina propria . 7/8/2024 Dr Ephrem Assefa 5

6. The latter is composed of an extracellular matrix with different cell types, nerve endings, lymphatic and blood vessels, all of which may play a role in maintaining bladder compliance and act as a communication portal between the nervous system and bladder muscle. The trigone , which is the base of the bladder, gets its name from the triad of the two ureteral orifices and the proximal urethra that make up the three corners of the triangle. The urethra is a 4-cm tubular structure surrounded by skeletal muscles . It travels over the anterior wall of the vagina and exits the urogenital diaphragm under the pubic symphysis as it opens into the top of the introitus (Fig. 29-1) . 7/8/2024 Dr Ephrem Assefa 6

7. Innervation of the Bladder and Urethra The bladder is primarily innervated by the autonomic , the sympathetic and parasympathetic, nervous systems. The sympathetic nervous system originates from the thoracolumbar region of the spinal cord. Signal transmission occurs via the paraspinal ganglia with norepinephrine being the primary postganglionic neurotransmitter stimulating two different adrenergic receptor types: (a) the alpha receptors are mostly located in the urethra and trigone ; and (b) the beta receptors are primarily located in the body of the detrusor muscle . The parasympathetic nervous system originates from the sacral region of the spinal cord. 7/8/2024 Dr Ephrem Assefa 7

8. Unlike the sympathetic system , the parasympathetic system has long neurons that exit from S2 to S4, synapse with their ganglia closer to the end organ (bladder), and transmit their signals via short postganglionic neurons to the body of the detrusor muscle. Here, transmission of messages occurs through acetylcholine neurotransmitters stimulating muscarinic (or cholinergic ) receptors. The somatic nervous system plays a secondary role in the lower urinary tract system. It originates from the sacral (S2–S4) region of the spinal cord via the pudendal nerve; it provides motor innervation to the urethral sphincter and pelvic floor muscles, and sensory innervation to the perineum. 7/8/2024 Dr Ephrem Assefa 8

9. FIGURE 29-1 Lateral view of the pelvic floor showing the anatomic location of the bladder, urethra, vagina, and pelvic floor support structures transected at the level of the vesical neck. 7/8/2024 Dr Ephrem Assefa 9

10. The central command of the sacral micturition center comes from impulses generated at the level of the pontine micturition center located in the brain stem which is regulated by signals that arise from higher levels of the cerebellum and cortex of the brain. This complex interplay between the upper cortex, cerebellum, and brainstem plays a key and dual role of: (a) inhibition that supports the storage function during the filling phase; and (b) stimulation that facilitates the micturition function of the bladder during the voiding phase. 7/8/2024 Dr Ephrem Assefa 10

11. The Physiology of Storage and Voiding The primary role of the bladder is to store urine produced by the kidneys and excreted through the ureters, and to subsequently eliminate the urine outside the body through the urethra. The function of storage is made possible by several factors including: intrinsic factor s to the bladder such as the ability of its elastic smooth muscle fibers to stretch as the volume of urine distends its capacity; (b) extrinsic factors to the bladder including excitatory neurologic stimuli that constrict the proximal urethra and urethral sphincter, and inhibitory neurologic stimuli that inhibit (or relax) the detrusor muscle of the bladder. 7/8/2024 Dr Ephrem Assefa 11

12. This reservoir function of the bladder , which in effect translates into its continence mechanism, is dependent on the proper functioning of the autonomic (sympathetic and parasympathetic) nervous system, and the somatic nervous system . Continence during storage is dependent on the integrity of the bladder muscle, urethra, and the pelvic floor support structures surrounding the lower urinary tract, including the levator ani muscles, endopelvic fascia, and their attachments to the pelvic sidewall and the white line. 7/8/2024 Dr Ephrem Assefa 12

13. The urethra has several components within or around it that play an important role. These include the striated muscles of the urethral sphincter, the smooth muscles of the urethra, and the neurovasculature of the urethral wall, all of which help maintain elasticity and the epithelial coaptation function of the urethra during times of bladder filling. 7/8/2024 Dr Ephrem Assefa 13

14. The extrinsic structures supporting the urethra and the intrinsic urethral function are equally important , to the extent that a defect in the former can lead to urinary incontinence resulting from hypermobility of the urethrovesical junction, and a defect in the latter can lead to urinary incontinence caused by intrinsic sphincter deficiency. 7/8/2024 Dr Ephrem Assefa 14

15. During the filling phase , the sympathetic nervous system through the lumbar region of the spinal cord sends inhibitory signals to the beta receptors in the bladder to relax, and excitatory signals to the smooth muscles of the trigone and urethra to contract. As the bladder gets distended , afferent fibers from the bladder send impulses to the central nervous system through the pelvic nerve to the sacral spinal cord. This initiates two types of impulses: one that is transmitted horizontally via the micturition reflex back to the bladder, and another that is transmitted vertically up to the brain. The latter will make one of two conscious decisions. 7/8/2024 Dr Ephrem Assefa 15

16. If it is socially inappropriate to initiate micturition, it will send excitatory impulses via the pudendal nerve to contract the pelvic floor muscles and external urethral sphincter, and inhibitory impulses to supplement the function of the sympathetic system (Fig. 29-2) . Alternatively, the brain may decide it is an opportune time to eliminate the urine. In this instance, it will send voluntary impulses to the striated muscles to relax the pelvic floor and urethral sphincter. 7/8/2024 Dr Ephrem Assefa 16

17. It will also send facilitative impulses to the pontine micturition center to release its bladder inhibition. This transmits impulses down the spinal cord to activate the sacral micturition reflex via the parasympathetic system, resulting in stimulation of the cholinergic receptors and bladder contraction while the urethra is relaxed. 7/8/2024 Dr Ephrem Assefa 17

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19. FIGURE 29-2 Detrusor–sphincter reflex during urine storage: The sympathetic system promotes the bladder to relax (inhibition) and the outlet to contract (stimulation). Concurrently, the pudendal nerve stimulates the urethral sphincter to contract. ( DeGroat WC. Aneurologic basis for the overactive bladder. Urology 1997;50( Suppl 6A):36–52; Figure 4, need permission.) 7/8/2024 Dr Ephrem Assefa 19

20. URINARY INCONTINENCE Disorders of urine storage are typically expressed by patients with a limited number of bladder control symptoms that include urinary urgency, frequency, nocturia , and urinary incontinence. Urgency is defined as a sudden, compelling desire to pass urine which is difficult to defer . Frequency (i.e., increased daytime voids) and nocturia (increased nighttime voids) are surrogates of urgency, and they are more commonly used than urgency in epidemiologic and clinical trials because they are easier to measure . 7/8/2024 Dr Ephrem Assefa 20

21. The present International Continence Society (ICS) guidelines define nocturia as waking up one or more times to urinate; whereas frequency occurs when the patient considers that she is going to the bathroom more often than her normal . Urinary incontinence , defined as any involuntary leakage of urine , is easier to measure or quantify than urgency. Of all the urinary storage symptoms, it tends to be the most distressing, impactful, and costly. 7/8/2024 Dr Ephrem Assefa 21

22. Although the signs and symptoms of urinary incontinence appear to be a straightforward expression of bladder disorder, its diagnosis and treatment is anything but simple. The complexity of the bladder is in its simplicity . There are many underlying causes that can potentially lead to urinary incontinence . In the following sections, we will define urinary incontinence and its subtypes, describe its epidemiology and impact, discuss the pathophysiology and associated risk factors, discuss evaluation and examination of women with incontinence, explore the various diagnostic tools, and propose available treatment modalities. 7/8/2024 Dr Ephrem Assefa 22

23. Definitions Defining urinary incontinence has been challenging. Should urinary incontinence be defined as any amount of urine loss, then the overwhelming majority of women may fit the definition. Conversely, should urinary incontinence be defined with stricter criteria, such as losing a certain volume of urine with a specific number of episodes in a month, then only a minority of women would fit that definition. A key consideration is to be able to distinguish normal from abnormal lower urinary tract function. While much of the focus of clinical research is on individuals with frank urinary incontinence, the ultimate challenge is to understand when preclinical urinary incontinence starts, and more importantly the trajectory it takes to progress into a clinically relevant and persistent condition. 7/8/2024 Dr Ephrem Assefa 23

24. Historically, urinary incontinence was defined as the involuntary loss of urine represented as an objectively demonstrable event, and described to be a social or hygienic problem. Although highly specific, this definition was clinically impractical. Women who presented with subjective incontinence received little to no attention if it was not observed by their clinicians during an examination, or if it was not reported by patients to be a “hygienic” problem. 7/8/2024 Dr Ephrem Assefa 24

25. Presently, urinary incontinence is defined as the complaint of any involuntary leakage of urine . Paradoxically, this new definition includes a substantial spectrum of women who have experienced rare incidental urine loss events. Consequently, some studies report urinary incontinence prevalence estimates of up to 60% . 7/8/2024 Dr Ephrem Assefa 25

26. Urinary incontinence has two main subtypes , stress and urgency urinary incontinence, that either occur in isolation of each other, or they co-occur and present as mixed urinary incontinence. Stress urinary incontinence is defined as loss of urine associated with activities such as coughing, sneezing, lifting, or laughing. Urgency urinary incontinence is defined as loss of urine associated with a strong desire to urinate. Of note is that the term “urgency” has replaced “urge” as a symptom of storage disorder; the latter is considered to be a normal (non pathologic) desire to void urine when the bladder is full. 7/8/2024 Dr Ephrem Assefa 26

27. Mixed urinary incontinence is defined as urine loss associated with activity and with a strong desire to urinate . Women with urinary incontinence may express their symptoms - continuously (continuous urinary incontinence), with intercourse (coital incontinence), with change in position (postural incontinence), with retention or incomplete bladder emptying (overflow incontinence), during sleep (nocturnal enuresis), or without being aware of it (insensible incontinence). 7/8/2024 Dr Ephrem Assefa 27

28. Finally, the term functional incontinence is used to define women who have an intact bladder function, but still report incontinence caused by factors extrinsic to the bladder Examples include elderly women who have mental, psychological, or mobility ailments that prevent them from making it to the bathroom on time. A summary of current definitions of symptoms of lower urinary tract storage disorders is shown below (Table 29-1) . 7/8/2024 Dr Ephrem Assefa 28

29. Table 29-1 Classification and Definition of Lower Urinary Tract Symptoms in Women 7/8/2024 Dr Ephrem Assefa 29

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31. Although stress and urgency urinary incontinence are regarded as different disease entities, it is important to note that women move among and between stress and urgency urinary incontinence. In one large study of over 10,500 women, significant changes in incontinence status were reported over a 2-year period: of those with baseline urgency urinary incontinence, 34% to 38% remitted, 4% to 9% transitioned to stress urinary incontinence, and 16% to 20% transitioned to mixed urinary incontinence; of those with baseline stress urinary incontinence, 32% to 41% remitted, 4% transitioned to urgency urinary incontinence, and 16% to 23% transitioned to mixed urinary incontinence; of those with baseline mixed urinary incontinence, 22% to 27% remitted, 10% to 11% transitioned to urgency urinary incontinence, and 11% to 15% transitioned to stress urinary incontinence. 7/8/2024 Dr Ephrem Assefa 31

32. Epidemiology of Urinary Incontinence Prevalence Prevalence estimates of urinary incontinence among community-dwelling women range from 2% to 58% . This wide range in estimates results from variation in definitions used, populations surveyed, age of study participants, and other reasons. Over their lifetime, urinary incontinence affects more than one in three women. Recent U.S. population data show that more than 20 million women have urinary incontinence, and this is projected to increase by more than 50% in the coming decade. Although urinary incontinence prevalence overall increases with age, prevalence patterns differ by incontinence subtype. 7/8/2024 Dr Ephrem Assefa 32

33. Stress urinary incontinence peaks in the fifth decade of life and is the most common subtype overall. Prevalence of urgency and mixed urinary incontinence is relatively low up to the fourth decade of life , but gradually increases thereafter . The average prevalence of stress, urgency, and mixed urinary incontinence is 13%, 5%, and 11%, respectively. Mixed urinary incontinence becomes the most dominant subtype in late adulthood (Fig. 29-3) . 7/8/2024 Dr Ephrem Assefa 33

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35. FIGURE 29-3 Prevalence of stress, urgency, and mixed urinary incontinence by age. Note the peak prevalence of stress urinary incontinence at 50 years of age followed by a decline; also note the continuous increase in mixed urinary incontinence into late adulthood where it becomes the most prevalent subtype. SUI, stress urinary incontinence; UUI, urgency urinary incontinence; MUI, mixed urinary incontinence. ( Minassian VA, Stewart WF, Hirsch A. Why do stress and urge incontinence co-occur much more often than expected? Int Urogynecol J Pelvic Floor Dysfunct 2008;19:1429–1440; Figure 1, need permission.) 7/8/2024 Dr Ephrem Assefa 35

36. Incidence and Remission Longitudinal studies report high variations in urinary incontinence incidence rates that range between 5% and 20%. In one meta-analysis, age-specific incidence varied between 2/1,000 person-years before age 40 and increased to 5/1,000 person-years at age 50. Remission rates of urinary incontinence are equally high and range between 3% and 12%. 7/8/2024 Dr Ephrem Assefa 36

37. Data from longitudinal studies suggest that urinary incontinence is highly dynamic where women cycle in and out of active disease . It is noteworthy that most longitudinal studies that describe incidence and remission of urinary incontinence offer little insight on the natural history of the urinary incontinence subtypes and transition rates between stress, urgency, and mixed urinary incontinence 7/8/2024 Dr Ephrem Assefa 37

38. Impact of Urinary Incontinence Urinary incontinence is an emotionally, socially, physically, and economically burdensome condition . It has a significant impact on quality of life (QOL), where urinary incontinence has been shown to be associated with embarrassment, anxiety, and depression . These emotional burdens may lead women to adopt coping strategies that further alienate them from their social environment resulting in further deterioration of QOL. There is a downward cycle of impairment resulting in worsening psychological function. Studies examining the burden of disease have shown that mixed urinary incontinence is more severe, bothersome, and impactful on QOL than stress or urgency urinary incontinence . 7/8/2024 Dr Ephrem Assefa 38

39. Despite the wide-ranging impact of urinary incontinence, only a minority of women seek or receive care for their condition, resulting in underdiagnosis and undertreatment . Since most women with early stages of urinary incontinence (i.e., mild to moderate urinary incontinence) do not seek care, when they finally present with advanced symptoms (severe urinary incontinence), there is lost opportunity to prevent or reverse disease progression . Managing urinary incontinence is a substantial burden and cost for caregivers and the community. Presence of urinary incontinence increases risk of nursing home admissions, and in community-dwelling women, total urinary incontinence costs (direct and indirect) are about $11.2 billion/year. 7/8/2024 Dr Ephrem Assefa 39

40. Pathophysiology Stress Urinary Incontinence Historically, the key urethral support responsible for continence was considered to be at the bladder neck and proximal urethra . The pubourethral ligaments, extending from the undersurface of the pubic bone down to the urethra, were thought to be structurally important to maintain continence . DeLancey used cadaveric studies to formulate the Hammock Theory where he proposed that the primary support of the bladder neck and urethra to be an intact vaginal wall at the base of the bladder . 7/8/2024 Dr Ephrem Assefa 40

41. Through its fibrous and muscular attachments to the pelvic sidewall, namely to the condensation of the levator ani muscles, the vagina was shown to act as a hammock to support the bladder neck , compress the urethra, and therefore maintain continence. Loss of integrity of the hammock resulted in stress urinary incontinence . 7/8/2024 Dr Ephrem Assefa 41

42. Concurrently, Petros and Ulmsten proposed the Integral Theory of continence . They built on the work by DeLancey and others, and hypothesized that stress urinary incontinence occurs as a result of connective tissue laxity in the vagina andits supporting ligaments, namely the pubourethral , cardinal/uterosacral, and arcus tendineus fascia pelvis. The integral theory highlighted the role of the suspensory ligaments supporting the proximal vagina that supports the mid-urethra. 7/8/2024 Dr Ephrem Assefa 42

43. It hypothesized that the multidirectional movement of the pelvic floor muscles coordinated the urethral continence mechanism: (a) the forward direction of the pubococcygeus muscle stretches the mid-vagina forward against the pubourethral ligament to close the urethra from behind; (b) the backward direction of the levator plate stretches the upper vagina and bladder base backward and downwards in a plane around the pubourethral ligament to close off the proximal urethra . 7/8/2024 Dr Ephrem Assefa 43

44. In subsequent years, using urodynamic, radiologic, and clinical observations, DeLancey proposed that the integrity of the urethra is as, if not more, important in maintaining continence than the underlying support structures. These structures include the epithelial coaptation of the urethral mucosa with its neurovasculature , smooth muscles, and the striated sphincteric muscles. Therefore, the current most accepted theory of stress urinary incontinence pathogenesis is loss of integrity of structures intrinsic to the urethra, and, to a lesser extent, the pelvic support structures in close proximity, but extrinsic, to the urethra. 7/8/2024 Dr Ephrem Assefa 44

45. Urgency Urinary Incontinence The pathophysiology of urgency urinary incontinence is not well-developed, as the etiology of this condition in most women remains idiopathic. The term “urgency urinary incontinence” is often used interchangeably with the term “overactive bladder (OAB).” OAB is a syndrome associated with urgency, usually accompanied by frequency, nocturia with (OAB-wet) or without (OAB-dry) urgency urinary incontinence, and in the absence of a urinary tract infection or other obvious pathology . 7/8/2024 Dr Ephrem Assefa 45

46. Certain neurologic conditions are known to be associated with urgency urinary incontinence. Women with multiple sclerosis, Parkinson, or spinal cord injuries have a disruption of the neuronal circuits at different levels of the central nervous system resulting in loss of inhibitory control on the bladder voiding mechanism. The micturition center in the brain maintains continence while the bladder fills up by suppressing the urgency to urinate. Any abnormality in the pathways between the micturition center and the bladder can lead to urgency urinary incontinence . 7/8/2024 Dr Ephrem Assefa 46

47. Several theories have been developed for nonneurogenic OAB or idiopathic urgency urinary incontinence. The epithelial hypersensitivity theory proposes presence of chemosensitizing agents leading to bladder instability. These are believed to be inflammatory substances such as nerve growth factor, prostaglandins, and acetylcholine that increase detrusor muscle sensitivity and neuronal excitability. The influence of these agents may be compounded by the presence of a defective uroepithelium that leads to increased sensitivity of the detrusor muscle. 7/8/2024 Dr Ephrem Assefa 47

48. The myogenic theory suggests that the pelvic floor sustains a physical strain during the developmental years. Myogenic dysfunction ensues secondary to altered structure or disordered function of a group of myocytes within the detrusor smooth muscle independent of its nerve supply. Prolonged bladder outlet obstruction or bladder ischemia (from atherosclerosis or diabetic neuropathy) can lead to denervation of detrusor muscle, muscle damage, and increased hyperexcitability to acetylcholine. These and other proposed theories are likely influenced by psychosocial disturbances, genetic predisposition, inflammatory, and drug-induced conditions. 7/8/2024 Dr Ephrem Assefa 48

49. Mixed Urinary Incontinence Mixed urinary incontinence is the most common incontinence subtype in later adulthood. Women with mixed urinary incontinence tend to have more severe symptoms that are bothersome and with a higher impact on QOL. Mixed urinary incontinence may represent a combination of bladder storage conditions of different etiologies. 7/8/2024 Dr Ephrem Assefa 49

50. These may include women with independently co-occurring stress or urgency urinary incontinence where symptoms of both conditions are expressed on the same day or at different time periods; or stress urinary incontinence that has predated urgency urinary incontinence or resulted in stress-induced urgency urinary incontinence; or stress urinary incontinence associated with urgency (OAB-dry) without incontinence. It is likely that mixed urinary incontinence comprises different pathophysiologic subtypes that are still not well understood. 7/8/2024 Dr Ephrem Assefa 50

51. Other Causes of Urinary Incontinence Other conditions that may be associated with urinary incontinence where urine loss occurs through the urethra include urethral diverticuli , and ectopic urethra . A urethral diverticulum is a localized herniation of urethral mucosa into the surrounding tissues. Diverticuli occur mostly in the distal urethra of women between the ages of 30 and 60 years. The etiology of acquired diverticula is unknown, but one accepted hypothesis is injury and blockage of periurethral glands from repeated urinary tract infections with subsequent rupture into the urethral lumen resulting in formation of a diverticulum. Diverticuli could be congenital in nature likely representing a remnant of Gartner duct . 7/8/2024 Dr Ephrem Assefa 51

52. Although urine loss (dribbling) is reported with urethral diverticuli , women commonly present with symptoms similar to urinary tract infections such as dysuria, urethral pain, dyspareunia, and hematuria. On examination, a tender urethral mass is often palpable (Fig. 29-4) . An ectopic ureter is a congenital anomaly where the ureter opens distally into the urethra or more commonly into the vagina. Here, the mother of a baby girl usually presents to her pediatrician complaining of constant wetness in the perineum of her child resulting from absence of any sphincteric control. 7/8/2024 Dr Ephrem Assefa 52

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54. Extraurethral incontinence occurs when a part of the urinary system drains through an abnormal opening bypassing the urethra. These are conditions that could be either congenital such as bladder extrophy , or traumatic such as a fistula . A bladder extrophy is a rare condition that involves a congenital absence of the anterior vaginal wall and base of the bladder/urethra. This is usually identified at birth and may require several and complicated surgical procedures to reconstruct. 7/8/2024 Dr Ephrem Assefa 54

55. A fistula is an acquired condition where there are one or more direct communications between the vagina and ureter ( ureterovaginal fistula ), bladder ( vesicovaginal fistula ), or the urethra ( urethrovaginal fistula ). The vesicovaginal fistula is the most common, and usually arises from a prolonged obstructed labor, in younger and poorly developed women in rural, underdeveloped regions of the world. With prolonged labor, caused by malpresentation or inadequately sized pelvis, the lower urinary tract and vagina are compressed between the head of the unborn child and the maternal pelvic bones, sometimes for days. 7/8/2024 Dr Ephrem Assefa 55

56. This leads to ischemic injuries resulting in tissue breakdown, necrosis, and development of a fistula (Fig. 29-5) . Another obstetrics-related condition, known as Youssef syndrome, may arise from a fistulous tract developing between the uterus and vagina, commonly after repeated cesarean sections. Here, patients present with cyclic hematuria, urinary incontinence, and amenorrhea. 7/8/2024 Dr Ephrem Assefa 56

57. Unlike obstetric causes of fistula formation, in the developed countries, a genitourinary fistula usually arises from gynecologic causes. These include pelvic malignancies, gynecologic surgeries such as hysterectomy, and pelvic irradiation. Undiagnosed bladder or ureteral trauma, or an inadequately treated injury during a hysterectomy (vaginal, laparoscopic, or abdominal) can result in fistula formation, usually within the first 2 weeks after surgery. An alternate process of fistula formation occurs from an occult injury to the bladder or ureter, typically during a laparoscopic hysterectomy where an energy source is used to transect the uterine pedicles. Here, the fistula may develop as a result of a latent injury from spread of energy to the genitourinary system. 7/8/2024 Dr Ephrem Assefa 57

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59. Risk Factors of Urinary Incontinence To better understand the pathophysiology of urinary incontinence and its subtypes, it is important to identify risk factors associated with, or that mediate onset and progressionof disease. Known risk factors for urinary incontinence include: race, age, parity, obesity, diabetes, chronic cough, COPD and smoking, previous pelvic surgery, medications, and functional and motor impairment (Table 29-2) . Evidence for an association between risk factors and urinary incontinence is strong for some, and inconclusive for others. 7/8/2024 Dr Ephrem Assefa 59

60. Race has been shown to have a variable effect on urinary incontinence by subtype. In general, white women have a higher prevalence and incidence of urinary incontinence than Hispanic, Asian and black women. More specifically, across urinary incontinence subtypes, white women are at a higher risk of developing stress urinary incontinence, whereas black women are at a higher risk of developing urgency urinary incontinence . 7/8/2024 Dr Ephrem Assefa 60

61. Age has a variable effect on urinary incontinence subtypes. Prevalence of stress urinary incontinence peaks in the fifth decade and then declines thereafter. Advancing age past the 50s is not a risk factor for stress urinary incontinence alone . This is because vaginal birth is strongly associated with stress urinary incontinence in the first two decades after childbirth, but has little to no effect beyond that. Hence, as the time interval increases between a woman’s age and the birth of her children, there is decreasing effect of childbirth and onset of stress urinary incontinence. In contrast, advancing age is a strong predictor of both urgency and mixed urinary incontinence. 7/8/2024 Dr Ephrem Assefa 61

62. Pregnancy increases the risk of stress urinary incontinence with about 50% of pregnant women reporting symptoms. Although most women report resolution of their stress incontinence symptoms after birth, recurrence within 5 years is high. Parity , is another strong risk factor of urinary incontinence, and primarily for stress urinary incontinence. A recent 2016 meta-analysis showed that vaginal birth had a twofold increased risk of stress urinary incontinence when compared with cesarean delivery. Parity is a risk factor for mixed urinary incontinence; however, controlling for its association with stress urinary incontinence in women with mixed urinary incontinence, parity is not a risk factor for urgency urinary incontinence. Most epidemiologic data suggest that having a cesarean section reduces the risk of subsequent urinary incontinence. 7/8/2024 Dr Ephrem Assefa 62

63. Table 29-2 Common Risk Factors by Urinary Incontinence Subtype 7/8/2024 Dr Ephrem Assefa 63

64. Obesity is another major risk factor for urinary incontinence and its subtypes . Similar to vaginal birth, the effect of increasing weight on the pelvic floor may lead to pudendal nerve injury with subsequent levator ani muscle atrophy leading to weakening of the pelvic floor urethral support structures. The effect of increased weight is a risk for new-onset stress urinary incontinence, and for urgency urinary incontinence secondary to detrusor overactivity . Diabetes and obesity are strongly correlated, but controlling for obesity, diabetes still stands out as an independent risk factor for urgency urinary incontinence , and to a lesser extent, for stress and mixed urinary incontinence. 7/8/2024 Dr Ephrem Assefa 64

65. The mechanism of action of diabetes is believed to be multifactorial including: (a) its diuretic effect leading to frequency and urgency urinary incontinence; (b) microvascular injury to the nerves supplying the detrusor muscle leading to detrusor overactivity ; and (c) microvascular injury to the pudendal somatic nerve supplying the urethral sphincter. Risk factors such as previous pelvic surgery, chronic cough or pulmonary disease , and smoking have potentially similar detrimental effects on the pelvic floor resulting in urinary incontinence. 7/8/2024 Dr Ephrem Assefa 65

66. For instance , previous hysterectomy has been shown to be associated with stress and urgency urinary incontinence, surgery for prolapse increases risk of new-onset stress urinary incontinence, and surgery for stress urinary incontinence may lead to de novo or worseningurgency urinary incontinence. History of smoking is associated with all urinary incontinence subtypes . 7/8/2024 Dr Ephrem Assefa 66

67. Other risk factors, also referred to urinary incontinence caused by functional or transient causes, are described within the DIAPPERS mnemonic (Table 29-3) . These include certain medications (e.g., psychotropic medications), urinary tract infections , stool impaction , and psychologic and motor impairment . Unlike age, race, and parity, these risk factors are modifiable by directly treating or altering their effect on the individual, and more specifically on the bladder. 7/8/2024 Dr Ephrem Assefa 67

68. Table 29-3 Reversible Causes of Urinary Incontinence 7/8/2024 Dr Ephrem Assefa 68

69. Diagnosis Historically, diagnosis of urinary incontinence required a big workup. First, a detailed history and extensive physical and pelvic examination including Q-tip testing were performed. Exhaustive 7-day long bladder diaries were required of patients, and multiple urogynecologic surveys were administered. Laboratory and bladder testing including urine analysis and urine culture, 24-hour pad test, cystoscopy, urodynamics , and other tests were frequently performed. Mounting evidence indicates that most of these diagnostic modalities are not cost-effective, and unnecessary during the initial workup of a woman with urinary incontinence. 7/8/2024 Dr Ephrem Assefa 69

70. Based on the new AUA and ACOG guidelines, the workup of urinary incontinence has become more streamlined . The urethral Q-tip test has mostly been eliminated, and the 7-day bladder diary has been replaced with a 2- to 3-day diary . Similarly, simpler and shorter forms of QOL, bother, and sexual dysfunction questionnaires, specific to urinary incontinence, have been developed. Cystoscopy is rarely an indication for uncomplicated urinary incontinence, and urodynamics is no longer necessary prior to treatment for simple urgency urinary incontinence, or prior to surgery for uncomplicated stress urinary incontinence. 7/8/2024 Dr Ephrem Assefa 70

71. History Taking Medical history taking from a woman with urinary incontinence should explore the duration of time with urine loss, associated symptoms, and their severity. Questions are asked to identify incontinence subtype based on the circumstances surrounding the urinary incontinence episodes. Urine loss associated mostly with activities such as coughing, sneezing, or laughing is suggestive of stress urinary incontinence; women with stress urinary incontinence report urine loss that occurs while they are on the trampoline with their children, during activities such as running and jumping, and at times, with intercourse. 7/8/2024 Dr Ephrem Assefa 71

72. Symptoms associated with or immediately preceded by an urgency episode are indicative of urgency urinary incontinence. The latter may present with reports of increased urinary frequency, or nocturia . Women describe symptoms of urgency with or without incontinence provoked by the sound of running water (e.g., washing dishes), change in temperature, getting out from the car, or as they open the door to get into their homes. Many women, especially the older age group, report mixed symptoms of stress and urgency urinary incontinence, and information on bother and impact on QOL by subtype should be solicited. 7/8/2024 Dr Ephrem Assefa 72

73. Other relevant clinical information is history of previous medical or surgical treatment for incontinence, coexisting urinary tract infection with symptoms such as dysuria, hematuria, or suprapubic pain, fluid intake, and other health conditions (e.g., neurologic), or medications that may be associated with incontinence. For example, a woman with past history of stress urinary incontinence who underwent a mid-urethral sling may now be presenting with urgency symptoms; another woman presenting with occasional urgency urinary incontinence, a frequency of 15 episodes during the day and only once at night may admit to drinking a gallon (about 4 L) of liquids, including coffee and soda; alternatively, a poorly controlled diabetic woman who is a smoker may present with urgency (diuretic effect of sugar) and stress (chronic cough effect from smoking) urinary incontinence symptoms. Many medications taken for other medical conditions can impact the lower urinary tract and should be discussed with patients as potential contributors to their symptoms (Table 29-4) . 7/8/2024 Dr Ephrem Assefa 73

74. Table 29-4 Medications that May Affect the Function of the Urinary Tract 7/8/2024 Dr Ephrem Assefa 74

75. Physical Examination All women presenting for evaluation of urinary incontinence should undergo a routine general physical examination with particular attention given to conditions that may impact their incontinence. These include: mental and cognitive function (e.g., dementia and its association with urgency, frequency, and enuresis), neurologic function (e.g., Parkinson disease and multiple sclerosis and their effect on urgency urinary incontinence), cardiovascular status (e.g., vascular insufficiency and lower extremity edema and their association with nocturia secondary to night time fluid mobilization in the recumbent position), pulmonary function (e.g., chronic obstructive pulmonary disease and its effect on stress urinary incontinence), nutritional status (effect of obesity on stress and urgency urinary incontinence), mobility, gait, and dexterity (urgency urinary incontinence). 7/8/2024 Dr Ephrem Assefa 75

76. The pelvic examination includes palpation of the pelvis and lower abdomen for presence of masses. Lower extremity (deep tendon reflexes) and perineal sensation and sacral nerve reflexes, including the anal wink and bulbocavernosus reflexes, are evaluated. The latter reflexes are elicited by gently stroking or tapping the clitoral and perianal skin to elicit a contraction of the external anal sphincter. The goal of the pelvic examination is to investigate the underlying cause of urinary incontinence and to identify associated pelvic support defects. Examination is performed in the lithotomy position, but may require a semi-upright or standing position. 7/8/2024 Dr Ephrem Assefa 76

77. Evaluation of the vulva and vagina may reveal atrophy, vaginitis, dermatoses, or pain associated with symptoms of incontinence, urgency, and frequency. Inspection or palpation of the urethra may reveal tenderness or mass, suggestive of an infection or diverticulum. Prolapse staging of the different pelvic floor compartments is performed (see Chapter 30 ). Integrity of the pelvic floor and levator ani muscles can be assessed. With two fingers in the vagina, the patient is asked to contract the muscles used to “hold urine” or to “avoid passing gas.” The ability to contract and strength and duration of the contraction are all measured. Finally, bimanual and rectovaginal examinations are performed to assess for pelvic or adnexal masses, integrity of the anal sphincter, and pelvic tenderness. 7/8/2024 Dr Ephrem Assefa 77

78. Q-tip Test The Q-tip test, which is no longer recommended, involves introducing a cottontipped swab into the urethra and asking the patient to Valsalva to measure the angle deviation of the urethra from baseline. More than a 30-degree deviation is consistent with hypermobility of the urethra, and/or urethrovesical angle. Minimal to no angle deviation in a woman with stress urinary incontinence may indicate intrinsic sphincter deficiency, also known as stove-pipe urethra. The Q-tip test is no longer recommended because of the discomfort associated with inserting the cotton swab into the urethra. Equivalent information can be obtained from a vaginally placed swab to measure urethral mobility while the patient is asked to Valsalva. 7/8/2024 Dr Ephrem Assefa 78

79. Cough Stress Test During the pelvic examination, a cough stress test is performed. This can be done either with a full or an empty bladder. The advantage of doing it with a full bladder is that it is easier to demonstrate urine loss from the urethra in a woman with stress urinary incontinence. If history is suggestive, but urine loss is not observed in the lithotomy position, the patient may be asked to stand up and possibly jump and/or cough vigorously while the examiner observes for urine loss. 7/8/2024 Dr Ephrem Assefa 79

80. Note that a positive cough test with a full bladder cannot rule out overflow incontinence; here, a patient may demonstrate objective evidence of urine loss with a stress activity, but may concurrently have incomplete bladder emptying. Clearly, offering a surgical intervention, like a mid-urethral sling, to such a patient is not ideal because it can result in urinary retention. Alternatively, a cough test can be done after asking the patient to empty her bladder. A positive empty bladder cough test is strongly indicative of stress urinary incontinence and at times may be suggestive of intrinsic sphincter deficiency. 7/8/2024 Dr Ephrem Assefa 80

81. Postvoid Residual The postvoid residual (PVR) volume of urine is the amount of urine remaining in the bladder within 10 minutes from voiding. This can be measured either using a small-caliber catheter during the pelvic examination or via ultrasound. The latter is less invasive and has a standard error of less than 20%, with more accuracy for smaller PVRs (i.e., less than 200 mL). Alternatively, using the catheter to measure a PVR may result in a more exact volume of urine, especially for large bladder volumes, and has the added benefit of testing a more sterile urine specimen for a urine analysis or urine culture, if indicated. Normal values for PVRs are not well established; however, most would consider a PVR <50 mL to be within normal and a PVR >150 mL to be abnormally elevated . 7/8/2024 Dr Ephrem Assefa 81

82. Simple Bladder Testing Other simple tests are available that can be administered before ( bladder diary ), during ( urinalysis ), or after ( pad test ) a clinical encounter to assist the clinician in making a firm diagnosis. 7/8/2024 Dr Ephrem Assefa 82

83. Bladder Diary The bladder diary, also referred to as the voiding diary, is meant to represent the total amount of fluid intake, by type, in a 24-hour period. Historically, voiding diaries were administered over a 7-day period. But these were too inconvenient for patients to complete, and evidence shows that a 2- to 3-day diary is equally reliable. The information gained from fluid intake is important because it helps put into context symptoms of urgency, frequency, and nocturia . In addition to fluid intake, the bladder diary offers information on various measures of urine output, urinary incontinence, and circumstances surrounding the urinary incontinence episode(s). 7/8/2024 Dr Ephrem Assefa 83

84. The patient is asked to measure the amount of voided urine by time of day and night; here, one can assess the 24-hour total urine output, number of voids per day, average voided volume, and bladder capacity (largest voided volume). The patient also documents the time a urine loss occurs, and whether the event is associated with a stress activity (e.g., with a cough, sneeze, or laugh) or with urgency (Fig. 29-6) . 7/8/2024 Dr Ephrem Assefa 84

85. 7/8/2024 Dr Ephrem Assefa 85

86. The bladder diary helps clarify the diagnosis when information gathered during the history and pelvic examination is inconclusive. For example, intake of large fluid volumes or consumption of large amounts of caffeine and alcohol can easily explain why a woman may report a physiologic increase in urinary frequency and urgency. Alternatively, a voiding diary that shows a 24-hour fluid intake of 50 ounces (1.5 L), and nothing to drink 3 hours before bedtime in a patient who reports a daytime frequency of every 2 hours, nocturia of 3 to 4 times, and with small voided volumes may represent a pathologic condition like OAB or urgency urinary incontinence. 7/8/2024 Dr Ephrem Assefa 86

87. Urinalysis The urinalysis by simple dipstick is helpful to rule out a urinary tract infection, especially in the presence of irritative lower urinary tract symptoms such as urgency, frequency, nocturia , and dysuria. Presence of nitrites, leukocytes and/or hematuria on dipstick may indicate the presence of a urinary tract infection. It is important to note that hematuria on a dipstick is not conclusive for presence of blood in the urine and should be confirmed by a formal microscopic evaluation 7/8/2024 Dr Ephrem Assefa 87

88. A urine culture can be sent to confirm the presence of a urinary tract infection. Treatment of a urinary tract infection may help improve these symptoms. It is generally not recommended to treat bacteriuria in a woman who is otherwise asymptomatic. 7/8/2024 Dr Ephrem Assefa 88

89. Pad Tests These are not routinely performed in the clinical setting. They are helpful objective tools used in research since they quantify the volume and frequency of urine loss by counting and weighing the pads used in a 24- to 48-hour period. One research application of pad tests may include a new drug trial to treat urgency urinary incontinence. In this instance, patients may be asked to wear incontinence pads before and after taking the medication, to determine if the drug (compared to placebo) results in a decrease in the volume and frequency of urinary incontinence episodes. Pad tests can be employed to help objectify the presence of urinary incontinence that is not demonstrable in the clinical setting, even with a full bladder (i.e., negative cough stress test). 7/8/2024 Dr Ephrem Assefa 89

90. An example may be a competitive female athlete who reports loss of urine that occurs only during strenuous exercise and which significantly impedes her performance. The patient is given 100 mg of phenazopyridine (changes the color of urine into orange) to take before her exercise routine while wearing a pad. The presence of orange staining on the pad may help in the diagnosis of stress urinary incontinence. 7/8/2024 Dr Ephrem Assefa 90

91. Table 29-5 Symptom Questionnaires for Women with Pelvic Floor Disorders 7/8/2024 Dr Ephrem Assefa 91

92. Quality of Life Measures Although urinary incontinence is a health condition with limited immediate physical sequelae to the individual woman, it can have tremendous psychological, social, and general health effects. Some women stop exercising as a result of constant urine loss with activity; others limit the amount of fluids to reduce their urgency and urinary incontinence episodes; women may stop going out because of fear of not finding a bathroom when one is needed; yet others may not wish to have intercourse with their partner due to embarrassment from having an accident. 7/8/2024 Dr Ephrem Assefa 92

93. Clinical evaluation is not complete without an assessment of these behavioral changes in response to bother from urinary incontinence that can lead to profound consequences on an individual’s psychological, sexual, social, and ultimately her physical well-being. There are several validated questionnaires specifically developed to better assess severity of urinary incontinence, its bother, impact on QOL, and sexual health . 7/8/2024 Dr Ephrem Assefa 93

94. Many of those have short versions that can be easily administered to patients during the initial visit, and repeated in the future after an intervention, to measure change (improvement) over time. The following two tables list a summary of common symptom questionnaires (Table 29-5) and QOL and sexual function scales for women with urinary incontinence pelvic floor disorders (Table 29-6) . 7/8/2024 Dr Ephrem Assefa 94

95. Table 29-6 Quality of Life and Sexual Function Scales for Women with Pelvic Floor Disorders 7/8/2024 Dr Ephrem Assefa 95

96. Advanced Bladder Testing Urodynamics The hallmark of advanced bladder testing is the urodynamics test. This test is an adjunct to history taking, clinical examination, and simple bladder testing. The scope of its indications and use in clinical practice has narrowed over time as clinicians have improved their diagnostic acumen in identifying different bladder control conditions. 7/8/2024 Dr Ephrem Assefa 96

97. Examples where urodynamics are not necessary include: the diagnosis of incontinence is straightforward and consistent with history, physical examination, and simple bladder testing; a woman with predominantly subjective stress urinary incontinence symptoms with positive cough test and minimal PVR , irrespective of whether an anti-incontinence surgery is planned or not; a woman with urgency urinary incontinence symptoms , even prior to initiation of medical treatment. 7/8/2024 Dr Ephrem Assefa 97

98. When performed, urodynamics provides objective data on lower urinary tract function and serves two purposes: the first is to help characterize bladder storage conditions by distinguishing stress, urgency, and mixed urinary incontinence from each other; the second is to assist in establishing a diagnosis for bladder voiding dysfunction . 7/8/2024 Dr Ephrem Assefa 98

99. Urodynamics has many useful applications in situations where: the diagnosis is not clear because of inconsistencies between the history, physical examination, symptom scales, and voiding diary; women have mixed or complex symptoms where conservative treatment options have failed; surgery for prolapse is being planned in a woman without any symptoms of urinary incontinence, or with a negative cough stress test , to elicit the presence or absence of occult stress urinary incontinence; previous surgery for incontinence has failed or symptoms of urinary incontinence have recurred; incomplete bladder emptying is reported (high PVR); symptoms of incontinence are compounded by the presence of neurologic conditions like multiple sclerosis . 7/8/2024 Dr Ephrem Assefa 99

100. Urodynamics can be simple or complex. A summary of all the definitions and terms used in urodynamics is shown (Table 29-7) ( 65 ). A simple urodynamics consists of uroflowmetry , PVR , and simple filling cystometry . This may be the procedure of choice when someone has predominant stress urinary incontinence with a negative cough stress test. 7/8/2024 Dr Ephrem Assefa 100

101. Table 29-7 Urodynamic Definitions 7/8/2024 Dr Ephrem Assefa 101

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104. 7/8/2024 Dr Ephrem Assefa 104

105. 7/8/2024 Dr Ephrem Assefa 105

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107. Uroflowmetry This a study that assess voiding function. Here, the patient is asked to come to the office with a comfortably full bladder and void while sitting on a special commode attached to a funnel that directs the voided volume into a spinning receptacle that measures the amount of voided volume of urine over time. Several data points are obtained through this study that include the total amount of voided urine, the average and peak flow of urine, the time to peak flow, flow time, and total time to void. 7/8/2024 Dr Ephrem Assefa 107

108. A normal uroflow has a continuous bell-shaped configuration, a short time to peak flow, and a high peak flow (Fig. 29-7) ; whereas an obstructed flow may have two or more lower peaks with an interrupted flow pattern or a prolonged tail (Fig. 29-8) . FIGURE 29-8 Abnormal uroflow showing a prolonged and interrupted voiding pattern with an initial high peak followed by several smaller peaks 7/8/2024 Dr Ephrem Assefa 108

109. . 7/8/2024 Dr Ephrem Assefa 109

110. Filling Cystometry After completion of the uroflowmetry , the patient is placed in a lithotomy position and a catheter is placed to measure the PVR volume, which, if normal, is generally less than 50 mL. In a simple urodynamics , filling cystometry involves backfilling the bladder manually through the catheter at 60 mL increments or via a water pump at a rate of 50 to 100 mL per minute. There are several sensory parameters that are measured during the filling phase including (with their typical normal values): first filling sensation (50 mL); first desire to void (150 mL); strong desire to void (250 mL), and maximum cystometric capacity (400 mL). Reduced volumes in several of these parameters may be consistent with OAB or urgency urinary incontinence. 7/8/2024 Dr Ephrem Assefa 110

111. Once the bladder capacity is attained, the catheter is removed, and the patient is asked to cough or Valsalva. Loss of urine associated with an increased abdominal pressure is indicative of stress urinary incontinence. 7/8/2024 Dr Ephrem Assefa 111

112. Complex Urodynamics Women with predominant urgency urinary incontinence, mixed or complex symptoms, with previous failed incontinence surgery, or neurologic conditions may be more suited for a complex urodynamics . In addition to the uroflowmetry , this test includes complex filling cystometry , urethral pressure profilometry , and pressure flow studies. In addition, electromyography (EMG) of the urethral sphincter is commonly performed. Although complex urodynamics is a more advanced form of bladder testing, it is not a perfect test. 7/8/2024 Dr Ephrem Assefa 112

113. A false negative test can occur in a woman with subjective stress urinary incontinence where no urine loss is observed even with a full bladder in the lying or standing position; it can also occur with urgency urinary incontinence where a patient may report sensory urgency, but no detrusor activity is visible. A false positive is uncommon with stress but may happen with urgency urinary incontinence where the presence of the catheter or patient’s anxiety may provoke an iatrogenic bladder contraction. 7/8/2024 Dr Ephrem Assefa 113

114. Filling Cystometry (Complex) Similar to the simple urodynamics , filling cystometry is performed to assess bladder and urethral function during the filling phase. The catheter placed in the bladder has two transducers, one is situated at the tip of the catheter measuring the intravesical pressure, and another is positioned a few centimeters behind the tip measuring the transurethral pressure. A pressure transducer is placed either inside the vagina, or the rectum, to approximate the intra-abdominal pressure. 7/8/2024 Dr Ephrem Assefa 114

115. Since the intravesical pressure ( Pves ) is a measure of the detrusor pressure ( Pdet ) plus the pressure of the abdomen and surrounding organs ( Pabd ), then the true detrusor pressure is obtained by subtracting the value of the abdominal pressure from the intravesical pressure: 7/8/2024 Dr Ephrem Assefa 115

116. The advantage of complex cystometry is a more accurate assessment of the detrusor pressure (activity) during the filling phase. For instance, should the patient inadvertently sneeze, Valsalva, or increase her intra-abdominal pressure during the test, a stable Pdet in the presence of an increased Pves is expected in a normal bladder because the rise in Pves and Pabd cancel each other. Alternatively, if a woman develops an unprovoked bladder contraction, Pabd will remain neutral while Pves and Pdet show a spike. In this situation detrusor overactivity is observed (Fig. 29-9) . 7/8/2024 Dr Ephrem Assefa 116

117. 7/8/2024 Dr Ephrem Assefa 117

118. Urethral Pressure Profilometry The urethral pressure profilometry is a measure of the function of the urethra. When the bladder capacity is attained during cystometry , filling is stopped. The pressure inside the bladder ( Pves ), and that of the urethra (Pure) are noted. In a healthy normal bladder and urethra, the Pure is higher than Pves during filling, the opposite is true during voiding. The difference between the urethral and bladder pressures is denoted as Pclose where: Pclose = Pure - Pves 7/8/2024 Dr Ephrem Assefa 118

119. Because the urethra is approximately 4-cm long and the urethral sphincter is located in the proximal urethra, it is important to identify the maximum urethral closure pressure (MUCP). The catheter inside the bladder is typically attached to a pulley which, when engaged, will pull the catheter in and out of the bladder as the urethral transducer measures the Pure. The MUCP is the highest value of Pclose along the urethral pressure continuum. MUCP values of less than 20 cm of H 2 O may represent intrinsic sphincter deficiency; whereas a normal urethra has MUCP value >40 cm of H 2 O. 7/8/2024 Dr Ephrem Assefa 119

120. Another test of urethral integrity is known as the Valsalva leak point pressure (VLPP) which represents the value of the intra-abdominal or intravesical pressure at which point urine loss occurs. This is usually performed when the bladder is comfortably filled to 200 cc and the patient is asked to Valsalva or cough with gradually increasing force. The point at which leakage of urine is observed during this exercise is marked and denoted as VLPP. Typically, a VLPP >60 cm of H 2 O is used as a cut-off representing normal urethral function, and below which may be consistent with diminished urethral sphincter tone (Fig. 29-10) . 7/8/2024 Dr Ephrem Assefa 120

121. 7/8/2024 Dr Ephrem Assefa 121

122. Electromyography EMG leads are usually placed around the external anus to indirectly assess the activity in the urethral sphincter. Since the anal sphincter and urethra are primarily innervated by the pudendal nerve, the EMG activity generally represents a good estimation of the urethral striated muscle activity. In a normal individual, and during the filling phase, there is increased EMG activity; during the voiding phase, there is decreased EMG activity. In women with neurologic conditions or spinal cord injuries with retention or dysfunctional voiding, there is often dyssynergia between the detrusor function and the urethral muscle activity. 7/8/2024 Dr Ephrem Assefa 122

123. Pressure Flow Studies The final component of a complex urodynamics study is the pressure flow study or voiding cystometrogram . Here the Pves , Pabd , and Pure are measured concurrently as the patient is asked to void. This study offers information on the voiding mechanism of the bladder, presence of dysfunctional voiding, and the potential risk for retention or incomplete bladder emptying after surgery for incontinence. Normative values for all the components of a urodynamics study are shown (Table 29-8) . 7/8/2024 Dr Ephrem Assefa 123

124. Other Bladder Studies Fluoroscopy Fluoroscopy is sometimes used, but generally not recommended, in conjunction with urodynamics (also referred to as video urodynamics ) to assess for a cystocele and hypermobility of the urethrovesical junction. This information could be equally gathered during a pelvic examination; imaging studies do not have any significant added value, and they expose patients to unnecessary radiation. Moreover, the presence of funneling, or bladder neck opening with Valsalva does not necessarily equate to stress urinary incontinence as many women with normal functional urethras, and who are continent, show evidence of bladder neck opening during fluoroscopy. 7/8/2024 Dr Ephrem Assefa 124

125. Cystoscopy A typical office-rigid cystoscope consists of a 17-French caliber sheath, through which the endoscope is introduced. This is attached to a fiber-optic light source, camera, and distending medium (sterile water or normal saline). The lenses on the endoscope are 0, 12, 30, 70, or 120 degrees. The lesser angle lenses are well-suited to inspect the urethra (Fig. 29-11) , and perform office procedures like urethral bulking or bladder botox ; whereas the 30- and 70-degree lenses are best to identify the ureteral orifices, trigone and bladder walls, and stent the ureters. 7/8/2024 Dr Ephrem Assefa 125

126. The 120-degree scope, which is helpful to have a retroview of the bladder neck, is not routinely used in women. Instead, a flexible cystoscope , that has a smaller caliber and is more comfortable to patients, can be used in those instances. In fact, many specialists preferentially use the flexible cystoscope . However, the advantage of a rigid versus a flexible cystoscope is that the former has an operative channel through which it is easier to take a biopsy, should an abnormality be identified. 7/8/2024 Dr Ephrem Assefa 126

127. Table 29-8 Approximate Normal Values of Female Bladder Function 7/8/2024 Dr Ephrem Assefa 127

128. 7/8/2024 Dr Ephrem Assefa 128

129. FIGURE 29-11 Cystoscopic view of a scarred urethra using a smaller angle lens. 7/8/2024 Dr Ephrem Assefa 129

130. Cystoscopy is a simple office procedure that is frequently performed in the evaluation of various bladder conditions. But, it has a limited role in the initial workup of basic urinary incontinence. Instances where cystoscopy is important include stones, bladder tumors, foreign bodies, or chronic cystitis. 7/8/2024 Dr Ephrem Assefa 130

131. Other indications in women include: (a) microscopic hematuria (presence of red blood cells in the urine) that is unrelated to a urinary tract infection; (b) OAB that is refractory to conservative or medical treatment, especially in older women; (c) urinary incontinence with suspected vesicovaginal fistula; (d) symptoms such as frequency, urgency, dysuria, in the absence of a urinary tract infection; (e) women presenting with recurrent urinary tract infections; (f) recurrent urinary incontinence or OAB symptoms following previous anti-incontinence surgery; (g) complications from previous vaginal mesh or sling procedures . 7/8/2024 Dr Ephrem Assefa 131

132. Experts agree that cystoscopy is essential intraoperatively during any prolapse, incontinence, or bladder surgery. Injuries to the bladder and ureters are well documented during such procedures. For instance, incidence of ureteral injury is as high as 11% after a high uterosacral colposuspension; whereas, the incidence of cystotomy could be up to 5% after mid-urethral slings. Identification of these injuries is relatively simple via the cystoscope , and intraoperative or early treatment of the injury results in better long-term outcomes. However, there is no consensus about performing cystoscopy universally at the time of a hysterectomy. Rates of ureteral and bladder injuries after hysterectomies for benign indications are reported to range between 0.02% and 1.8% and 0.85% to 2.9%, respectively. 7/8/2024 Dr Ephrem Assefa 132

133. Ultrasound and MRI of the Pelvis Although pelvic ultrasound has been a gold standard diagnostic tool in many areas of gynecology, its clinical utility in bladder control conditions has been limited to research and experimental purposes. Imaging technologies such as the pelvic ultrasound and MRI have enabled researchers to develop a better understanding of the urinary continence mechanism, and the pathophysiology of stress urinary incontinence. With the advancements of 3D and 4D imaging, diagnostic ultrasound modalities have shown some promise in clinical practice. They help in defining the morphology of the urethra and its sphincter where women with stress urinary incontinence are noted to have shorter urethra and smaller urethral sphincter volumes 7/8/2024 Dr Ephrem Assefa 133

134. Ultrasound can help assess changes in morphology of the urethra, bladder neck mobility, pelvic support structures at rest or with Valsalva, and to quantify these changes. These variations are accentuated in women who have concomitant stress urinary incontinence and pelvic organ prolapse. Moreover, it is possible to assess the integrity and strength of the levator muscles during a pelvic floor contraction, and measure PVR bladder volume . 7/8/2024 Dr Ephrem Assefa 134

135. Other useful properties of the ultrasound include observation of urethral coaptation after an injection of bulking agent for intrinsic sphincter deficiency, identification of previouspubovaginal or mid-urethral sling location and tightness, and detection of urethral diverticulum, foreign bodies or implants in the urinary system. MRI is another radiologic modality that has been used mostly in research to better understand the anatomy of the pelvis and the organs within. It has played a significant role in improving our understanding of the pathophysiology of pelvic organ prolapse and stress urinary incontinence. 7/8/2024 Dr Ephrem Assefa 135

136. Static MRI gives detailed information of the urethral anatomy, the striated sphincter, and its surrounding structures. Dynamic MRI can delineate compartments of the female pelvis, including the urethra, with and without intra-abdominal straining to characterize presence of prolapse. However, MRI is not routinely used in clinical practice because of its expense and the availability of the simple pelvic examination in the office that gives equally valuable information. Nonetheless, one condition for which MRI is the diagnostic modality of choice is a urethral diverticulum. 7/8/2024 Dr Ephrem Assefa 136

137. Neurophysiologic Testing The function of the bladder, urethral sphincter, and pelvic floor are dependent on the integrity of the nervous system, from the brain down to the terminal sensory and motor nerve endings supplying the genitourinary system. Several imaging and nerve conduction techniques are available to study the normal function and pathophysiology of the neuromuscular system. These include modalities such as functional CT and MRI scanning and somatosensory-evoked potentials (mostly for urgency urinary incontinence), and pudendal or sacral nerve motor latency, and EMG (mostly for stress urinary incontinence). These tests are usually performed in specialized centers and are not routinely used in the clinical setting during the workup of most women with urinary incontinence. 7/8/2024 Dr Ephrem Assefa 137

138. Prevention Successful prevention and treatment strategies for all urinary incontinence subtypes exist. Early detection is specially challenging because most patients do not seek care , and specialists see only a small fraction of women with urinary incontinence. Programs to mitigate onset and progression of disease should start at the primary care level . Known risk factors that promote new-onset urinary incontinence, such as age, BMI, and parity, have a long latent period. 7/8/2024 Dr Ephrem Assefa 138

139. There exists some evidence that early interventions may delay or reduce risk of subsequent onset of urinary incontinence symptoms . One such example is the effect of introduction of pelvic muscle training exercises during pregnancy on prevention of urinary incontinence in the short term. Large longitudinal population-based studies show that cesarean delivery , as opposed to vaginal birth, may have a beneficial effect in reducing subsequent risk of stress urinary incontinence . In the absence of other indications, promoting elective cesarean section as the preferred method of delivery to prevent future pelvic floor dysfunction, including stress urinary incontinence, is a topic of debate. Other risk reduction interventions include : (a) weight loss in obese women; (b) management of blood sugar control in diabetics; (c) reduced consumption of high levels of alcohol and caffeine. 7/8/2024 Dr Ephrem Assefa 139

140. Conservative Nonpharmacologic Treatment Conservative options should be offered to all patients as a first-line treatment. To optimize treatment benefits, diagnosis should be made early during the course of disease, and sometimes before onset of overt symptoms. Conservative treatments are generally simple, noninvasive, readily available and inexpensive, relatively effective and with little to no side effects. 7/8/2024 Dr Ephrem Assefa 140

141. Examples of conservative nonpharmacologic interventions include lifestyle modification, counseling and patient education, bladder training (or retraining), relaxation and urgency suppression, exercise training (e.g., pelvic floor muscle exercises), biofeedback, electric stimulation ( Estim ), pessaries, and urethral plugs . 7/8/2024 Dr Ephrem Assefa 141

142. Lifestyle Modification This includes avoidance of risky behavior associated with urinary incontinence, urgency, frequency, and nocturia such as smoking and alcohol consumption. It includes staying healthy, developing an active lifestyle, being physically fit and losing weight (if obese). In obese or overweight women, there is ample evidence that weight loss improves both stress and urgency urinary incontinence symptoms. A 10% weight loss leads to more than 50% improvement in stress urinary incontinence symptoms. 7/8/2024 Dr Ephrem Assefa 142

143. It requires that women modify or alter their dietary habits , mostly the amount and type of fluid intake. The recommended amount of fluid intake in a 24-hour period varies from an individual to another depending on their activity level, their weight, and other comorbidities. An assessment of a 24-hour bladder diary can help individualize optimal amount, type, and timing of fluid intake for a particular patient. Caffeine reduction is helpful in women with urgency and urgency urinary incontinence . 7/8/2024 Dr Ephrem Assefa 143

144. Counseling and Education This usually starts at the physician’s office, be it the patient’s primary care, gynecologist, or female pelvic floor specialist. Patients can further be referred to a dietician, physical therapist, counselor, or others to assist in establishing and maintaining the health lifestyle modifications discussed above. Counseling and education can take the form of different strategies such as supplying them with educational material, motivational interviewing, empowering patients with tools and coping strategies as it relates to their incontinence, and enabling patients to take control of their condition and care for themselves ( self-care or self-help ). 7/8/2024 Dr Ephrem Assefa 144

145. Bladder Training This intervention includes prompted voiding, and timed toileting and it aims at assisting women with idiopathic OAB or urgency urinary incontinence to minimize frequency of uncontrolled bladder urges and improve voluntary control of urine. It is generally coupled with restricting fluids in women who drink large quantities of liquid. Using her voiding diary as a guide, the patient is asked to void at a fixed time interval that is comfortably long enough (e.g., every 2 hours). 7/8/2024 Dr Ephrem Assefa 145

146. Should she develop a strong desire to void before the end of the time interval, she is asked to suppress the urge. Women are instructed to double void. Here, the patient is asked to void normally in the bathroom with a pelvic floor relaxation to allow the urine to flow; when the flow of urine stops, the patient is instructed to voluntarily strain followed by another relaxation period to allow additional unemptied urine to flow. 7/8/2024 Dr Ephrem Assefa 146

147. This regimented schedule of timed toileting and double voiding is continued for a whole week and increased by an interval of 15 minutes every subsequent week. The goal of bladder training is to prolong voiding and improve bladder capacity while reducing urgency and incontinence episodes. The whole intervention program usually takes up to 6 weeks and has been shown to be effective when compared to medications . 7/8/2024 Dr Ephrem Assefa 147

148. Relaxation and Urgency Suppression There are several maneuvers whereby a patient with a strong desire to void can help mitigate the urgency sensation. One technique is to ask the patient to do something that distracts her mind off the bladder urge, such as deep breathing , singing silently , solving a simple mathematical problem , or switching from the activity she was engaged in to a moment of inactivity. Concurrently, the patient is asked to tighten her pelvic floor muscles , knee and ankle flexion, sitting on a chair (if on her feet). Many of these can be applied to women with history of stress urinary incontinence who anticipate a urine loss episode with an imminent stress activity such as coughing or sneezing. 7/8/2024 Dr Ephrem Assefa 148

149. Pelvic Floor Muscle Training Historically, pelvic floor exercises were described by Arnold Kegel in 1948 as a nonsurgical method to restore anatomy and function of genital relaxation . Over time these exercises were structured into a physical therapy routine and collectively termed pelvic floor muscle training (PFMT). There have been several randomized trials demonstrating the benefits of PFMT (vs. placebo or no treatment) in treating urinary incontinence, in general, and stress urinary incontinence, in particular. 7/8/2024 Dr Ephrem Assefa 149

150. A Cochrane review in 2015 showed that women receiving PFMT reported improvement with fewer urine loss episodes or cure, and a better QOL thancontrols . However, since most studies follow patients up to a year or less, there is limited to no robust information on the long-term benefits of PFMT. Commonly, during a PFMT program, women are encouraged to contract their pelvic floor muscles for 3 seconds, 10 to 15 times per session, and 3 times a day. 7/8/2024 Dr Ephrem Assefa 150

151. Helpful hints to contracting the right pelvic floor muscles include: keeping the abdomen and hips relaxed; imagining that one is trying to prevent passing of gas, tightening the rectum, or bringing the buttock cheeks together. They should be done in a comfortable laying or sitting position. It can be done while watching TV, in front of a computer on a desk, or while driving a car. 7/8/2024 Dr Ephrem Assefa 151

152. A common misconception is that women try to do their Kegels in the bathroom every time they are voiding. However, this can lead to voiding dysfunction and worsening OAB symptoms in the long run, and Kegels are best done with an empty bladder. 7/8/2024 Dr Ephrem Assefa 152

153. Physical therapists often use adjunctive aids such as biofeedback and E-stim to supplement the PFMT, especially when patients are not able to generate a good squeeze during the physical therapy session. Biofeedback can be auditory or visual and gives the patient a sensory feedback of the strength of her pelvic floor squeeze. 7/8/2024 Dr Ephrem Assefa 153

154. Electrical stimulation therapy delivers low levels of current via a probe placed in the vagina or rectum. There is no evidence that biofeedback or E-stim are superior to PFMT alone, especially when the latter are done regularly and properly in women with stress urinary incontinence. 7/8/2024 Dr Ephrem Assefa 154

155. Mechanical Devices for Urinary Incontinence Several devices are available to treat mostly women with stress urinary incontinence (Fig. 29-12) . These can be divided into two main groups: urethral and vaginal. The urethral devices create a temporary occlusion of the urethral meatus to prevent urine loss. One example of a urethral device is the urethral insert FemSoft where a woman is instructed to place the insert into the urethra and then remove it before urinating. 7/8/2024 Dr Ephrem Assefa 155

156. These could be beneficial in female competitive athletes who may have stress urinary incontinence episode only during a sporting event (e.g., tennis). Although incontinence episodes are reported to decrease, about one-third of women developed urinary tract infections in one long-term follow-up study. 7/8/2024 Dr Ephrem Assefa 156

157. 7/8/2024 Dr Ephrem Assefa 157

158. Vaginal devices consist of two categories. The first type of device is used as an adjunct to PFMT such as vaginal weights or cones. These devices are placed in the vagina by the patient for short periods of time in an effort to improve the strength of the pelvic floor muscles. Alternatively, the second type of a vaginal device is meant to be used long-term and throughout the day to help support the bladder neck and assist in the urethral closure mechanism of the urethral sphincter. These devices include pessaries, vaginal sponges, or tampons. 7/8/2024 Dr Ephrem Assefa 158

159. One randomized controlled trial comparing pessary use to behavioral therapy to a combination treatment for stress urinary incontinence showed that behavioral therapy produced greater patient satisfaction with fewer incontinence symptoms that were bothersome at 3 months. By 12 months there were no differences, and patient satisfaction persisted similarly in all three groups. Single modality was similar to combination therapy. However, a recent Cochrane review concluded that there is little evidence from controlled trials on the role of mechanical devices on long-term sustained beneficial effects in the management of urinary incontinence. 7/8/2024 Dr Ephrem Assefa 159

160. Other Treatment Options Electric stimulation (E-stim) and magnetic stimulation (M-stim) are two alternative conservative options that are available in specialized centers. Evidence regarding those modalities in the management of urinary incontinence is not well-established and more research is needed to show whether they are more beneficial than the traditional and less costly conservative options available. 7/8/2024 Dr Ephrem Assefa 160

161. Medications for Stress Urinary Incontinence Historically, estrogen replacement therapy was used to treat women with stress and urgency urinary incontinence. Based on large randomized trials including the Women’s Health Initiative (WHI), estrogen (with or without progesterone) has been shown to be associated with increased prevalence (worsening incontinence) and incidence (new-onset incontinence), and with the negative effect being more pronounced for stress than urgency urinary incontinence . 7/8/2024 Dr Ephrem Assefa 161

162. Similar results were found with the Heart Estrogen and Progestin Replacement Study (HERS) comparing oral conjugated equine estrogen and medroxyprogesterone acetate to placebo where 1,525 women were followed for 4 years. More specifically, the HERS study showed that the odds ratio for worsening incontinence was 1.5 among women with baseline urinary incontinence; the odds ratio for developing new stress urinary incontinence was 1.7, and new urgency urinary incontinence was 1.5 . 7/8/2024 Dr Ephrem Assefa 162

163. A Cochrane review on this topic confirmed these findings and concluded that estrogen replacement therapy should not be offered to women as a treatment for urinary incontinence, with the caveat that local (vaginal) use of estrogen may improve symptoms of urgency and frequency in the short term . Other medications have been used to treat stress urinary incontinence. 7/8/2024 Dr Ephrem Assefa 163

164. These are typically drugs that have a stimulating effect on the alpha-adrenergic receptors present in the urethral sphincter. Examples include epinephrine and norepinephrine, ephedrine and pseudoephedrine, and phenylpropanolamine. These alpha-stimulating drugs are nonspecific and can be associated with other systemic effects including on the heart, brain, and blood pressure. 7/8/2024 Dr Ephrem Assefa 164

165. They are not FDA approved and rarely, if ever, used purely for stress urinary incontinence. Imipramine, a tricyclic antidepressant, has been used with variable success, especially in women who have a coexisting stress and urgency urinary incontinence. This may relax the bladder through its anticholinergic effect, and constrict the urethra through its alpha-agonistic effect. One other drug worthy of mention is duloxetine . 7/8/2024 Dr Ephrem Assefa 165

166. It is an FDA-approved serotonin and norepinephrine reuptake inhibitor drug to treat depression, chronic pain, and anxiety, but not for stress urinary incontinence. Its mechanism of action on the bladder is to increase bladder storage and improve urethral sphincter function via its effect on the central nervous system. In one study, duloxetine was shown to be equally effective as PFMT. But, but the presence of side effects (nausea, fatigue, insomnia, somnolence, dizziness, and blurred vision) may preclude it from being used as a first line therapy for stress urinary incontinence. 7/8/2024 Dr Ephrem Assefa 166

167. Medications for Urgency Urinary Incontinence and Overactive Bladder Medical treatment for urgency urinary incontinence and OAB is less controversial than for stress urinary incontinence. Medications are usually offered either when conservative treatment options have failed or in conjunction. Their efficacy, however, is modest. One major medication class represents the anticholinergic drugs. These include drugs that produce their effect by inhibiting the stimulatory effect of the parasympathetic nervous system on the detrusor muscle by blocking the cholinergic (acetylcholine or muscarinic) receptors. Several of these drugs exist with similar efficacy profiles. 7/8/2024 Dr Ephrem Assefa 167

168. These drugs differ in duration of action (immediate release vs. long acting) and route of administration (oral, patch, or gel) (Table 29-9) . In 2009, the Agency for Healthcare Research and Quality published an evidence based review of over 230 publications on the medical treatment modalities for urgency urinary incontinence and OAB . They showed that anticholinergic medications reduced number of voids (and urinary incontinence episodes) by 1.5 to 2.2 per day, with the short-acting drugs being on the lower range, and the longacting drugs on the higher range. Interestingly, a relatively high placebo effect exists in most randomized trials which is as high as 1.5 voids per day reduction. 7/8/2024 Dr Ephrem Assefa 168

169. The immediate-release oxybutinin was the first FDA-approved anticholinergic drug, but it has a short half-life and is taken three times a day to be optimally effective. Extended-release medications tend to be better tolerated because of their once daily administration, and a lower side-effect profile . In general, anticholinergics are administered at a low dose, with subsequent increase in dosage after a period of 4 to 6 weeks should there be no significant improvement. In the presence of side effects, it is reasonable to try another anticholinergic. 7/8/2024 Dr Ephrem Assefa 169

170. Because anticholinergics are not purely specific to the bladder muscarinic receptors, they all produce side effects with a varying degree on other tissues or organs These include the salivary glands resulting in dry mouth, the iris and ciliary muscles of the eyes resulting in blurry vision, the gastrointestinal system resulting in constipation, the heart resulting in altered heart rate, and the brain resulting in memory problems. One exception may be trospium chloride , a quaternary amine anticholinergic, which is hydrophilic with a large molecular size limiting its distribution into the central nervous system and reducing its effect on cognition. 7/8/2024 Dr Ephrem Assefa 170

171. Table 29-9 Pharmacologic Therapies Indicated for Overactive Bladder with or without Urgency Incontinence 7/8/2024 Dr Ephrem Assefa 171

172. There has been increased concern regarding the cumulative effect of anticholinergics on cognition, dementia, and onset of Alzheimer’s disease. In one review study of patients prescribed anticholinergic medications over a follow-up period of 7 years, 797 participants (23%) developed dementia (of whom, 637 developed Alzheimer’s). There was a significant 10-year cumulative dose–response relationship for dementia and Alzheimer disease . 7/8/2024 Dr Ephrem Assefa 172

173. Based on this and other evidences, AUGS published a consensus statement in 2017 recommending behavioral therapies as a first-line treatment for urgency urinary incontinence, followed by medical interventions . More specifically, AUGS recommends “ . . . caution in prescribing anticholinergic medications in frail or cognitively impaired patients” and that “ . . . providers should counsel on the associated risks, prescribe the lowest effective dose, and consider alternative medications in patients at risk” . 7/8/2024 Dr Ephrem Assefa 173

174. A second class of medications to treat urgency urinary incontinence includes the beta agonists . This class currently includes only one FDA-approved (2012) medication known as mirabegron , which is a specific beta-3 receptor agonist. It produces its effect via the sympathetic system by stimulating the beta receptors on the bladder, leading to relaxation of the detrusor muscle. 7/8/2024 Dr Ephrem Assefa 174

175. Unlike anticholinergics, it does not have dry mouth, constipation or blurred vision as side effects, but it ought to be used with caution in women with uncontrolled hypertension (it increases blood pressure), renal or hepatic impairment and urinary retention. It can be used in women with cognitive impairment. In one recent randomized trial comparing mirabegron to tolterodine , patient tolerability for mirabegron was higher than tolterodine which was associated with more side effects, but patient preference and OAB symptom improvements were similar between the two drugs. 7/8/2024 Dr Ephrem Assefa 175

176. Medications for Nocturia and Enuresis Nocturia , especially in the elderly, may be multifactorial . Waking up to go to the bathroom one or more times during the night may be the consequence of increased fluid intake, caused by bladder storage conditions like OAB, or other comorbidities unrelated to the bladder, such as vascular insufficiency, heart disease, or others. Desmopressin , a medication used to treat nocturia or enuresis, is effective mostly through its central inhibitory action on reducing urine production . It is available as a nasal spray and as an oral preparation. 7/8/2024 Dr Ephrem Assefa 176

177. Caution is recommended in the elderly or in women with hypertension; it requires periodic measurement of sodium levels. Imipramine, may work centrally to improve sleep, and peripherally on the bladder and urethra to improve bladder storage. Anticholinergics can be used to help with nocturia , especially in women with OAB. Diuretics like furosemide , can be helpful, especially in the presence of vascular insufficiency and peripheral edema . 7/8/2024 Dr Ephrem Assefa 177

178. Medications to Treat Overflow Urinary Incontinence or Urinary Retention Overflow urinary incontinence or urinary retention is a condition more prevalent in men , and commonly occurs as a result of benign prostatic hyperplasia . In women, in the absence of an anatomic obstruction , such as a urethral stricture, previous anti-incontinence surgery or advanced prolapse, overflow incontinence can occur because of bladder detrusor muscle underactivity , diabetic neuropathy , or central nervous system conditions . 7/8/2024 Dr Ephrem Assefa 178

179. Different drugs have been used, albeit with limited success , to either stimulate the detrusor muscle or to reduce urethral sphincter resistance , and therefore improve voiding. Examples of detrusor muscle stimulants include muscarinic receptor agonists, such as bethanechol , or cholinesterase inhibitors, such as distigmine . There is no evidence from controlled clinical studies that these medications offer substantial benefit, and these drugs may be associated with significant side effects . 7/8/2024 Dr Ephrem Assefa 179

180. A hypoactive or atonic bladder is generally not responsive to medical treatment. Alpha-receptor blockers such as alfuzosin have been shown to be beneficial in men by reducing the resistance in the bladder neck and urethra to facilitate bladder emptying. Although these medications have been used in women with urinary retention, they have produced variable results. 7/8/2024 Dr Ephrem Assefa 180

181. Surgical Treatment of Urinary Incontinence Pubovaginal Slings/PVS At the turn of the 20th century, one of the earliest described surgeries reported in Europe for stress urinary incontinence involved placing an organic sling at the bladder neck. These operations, presently referred to as traditional slings, are performed through two incisions, one in the vagina to pass the sling around the urethra, and one through the abdomen to gain access around the space of Retzius . 7/8/2024 Dr Ephrem Assefa 181

182. The two free ends of the sling material are passed up from the vagina and then attached commonly to the fascia of the rectus muscle (or other pelvic structures) to create a fixed loop around the bladder neck and proximal urethra (Fig. 29-13) . This provides support to the urethral closure mechanism at times of increased abdominal pressure. Over the years, use of different sling materials has been described including autologous (e.g., fascia lata , rectus muscle, or fascia harvested from the patient), allografts obtained from donors (e.g., cadaveric fascia lata ), heterologous obtained from other species (e.g., bovine or porcine), or synthetic (e.g., prolene or Gore-Tex). 7/8/2024 Dr Ephrem Assefa 182

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184. Although successful, the pubovaginal slings can result in urinary retention requiring further surgery to resolve ensuing voiding dysfunction. Synthetic slings can be associated with risk of erosion . In a large randomized surgical study, women with stress urinary incontinence who underwent fascial pubovaginal sling had a higher success rate than a Burch colposuspension at 2-year follow-up (47% vs 38%; P = 0.01). 7/8/2024 Dr Ephrem Assefa 184

185. However, there was a higher rate of complications in the pubovaginal sling group, including voiding dysfunction , urinary tract infections , and new-onset urgency urinary incontinence . Of the original 655 women in the initial randomized clinical trial, 482 (75%) were enrolled in a follow-up study up to 7 years. The vigorously defined composite success rate decreased from 42% to 13% in the Burch group and 52% to 27% in the sling group . 7/8/2024 Dr Ephrem Assefa 185

186. When success was defined using only one criterion (e.g., 1-hour pad test), reported rates were much higher and similar between the two groups (84% for the Burch group and 85% for the sling group) . Based on this and other evidences, the pubovaginal sling using autologous fascia remains a viable option to treat women with predominant stress urinary incontinence . 7/8/2024 Dr Ephrem Assefa 186

187. Anterior Vaginal Wall Repair A few years after the publication of the initial pubovaginal sling procedures to treat stress urinary incontinence, Kelly reported on the anterior vaginal repair (or anterior colporrhaphy ) in 1914. This operation was a simple procedure and based on case series, it was initially thought to be a very successful surgery, and therefore became quite popular for over half a century. 7/8/2024 Dr Ephrem Assefa 187

188. The key concept of the anterior vaginal repair is to plicate the pubovesical fascia around the bladder neck and proximal urethra to give it the necessary support and to assist in the sphincteric closing mechanism by preventing urine loss. Randomized controlled trials comparing the anterior vaginal wall repair to alternative procedures revealed that the former’s long-term success was suboptimal. The Kelly plication (anterior vaginal wall repair) is not recommended to treat women with stress urinary incontinence. 7/8/2024 Dr Ephrem Assefa 188

189. Needle Suspension Surgeries One of the earliest needle suspension procedures was introduced by Pereyra in 1959. The technique of this surgery and several of its subsequent modifications involved passage of a special needle carrier introduced bilaterally through an abdominal incision down into the vagina. Sutures were placed on both sides of the urethra within the vaginal and underlying connective tissue, brought up and then attached to the rectus fascia. 7/8/2024 Dr Ephrem Assefa 189

190. It was presumed that this suspension would provide lasting bladder neck support and help mitigate stress urinary incontinence episodes. However, similar to the Kelly plication, long-term success of needle suspension procedures failed to withstand the test of time in randomized controlled trials, and they are no longer recommended for the treatment of stress urinary incontinence. 7/8/2024 Dr Ephrem Assefa 190

191. Retropubic Colposuspension Surgeries Because most women with stress urinary incontinence have hypermobility of the bladder neck, DeLancey’s Hammock Theory made clinical sense. As a result, retropubic colposuspensions ( urethropexies ), where the endopelvic fascia around the bladder neck and proximal urethra is suspended to structures on the anterior pelvis, were shown to be good surgeries to treat stress urinary incontinence (Fig. 29-14) . 7/8/2024 Dr Ephrem Assefa 191

192. The two most commonly performed retropubic urethropexies are the Marshall– Marchetti – Krantz (MMK) and Burch procedures . The procedures are similar in that the approach is abdominal, requiring entry into the retropubic space. The MMK was initially described in a man with urinary incontinence following prostatectomy where the endopelvic fascia was attached to the pubic bone . With the Burch retropubic urethropexy , the periurethral tissue was fixed to Cooper ligament . Burch followed 143 of his patients up to 9 years and reported a success rate of 82% . 7/8/2024 Dr Ephrem Assefa 192

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194. In a randomized trial comparing the open Burch urethropexy to the mid-urethral sling procedure, success rate (reported as a negative 1-hour pad test) was 44/49 (90%) versus 58/72 (81%), respectively ( P = 0.21) at 5 years. Retropubic urethropexies can be performed laparoscopically, but there are limited data on their long-term efficacy. In one randomized trial, patients were followed for a median of 65 months (range 12 to 88 months). Here, 58% of women reported any urinary incontinence after a laparoscopic Burch compared with 48% after a mid-urethral sling, with no statistically significant difference between the two groups; stress urinary incontinence bother symptoms were reported in only 11% and 8% of women, respectively. 7/8/2024 Dr Ephrem Assefa 194

195. Using strict criteria to define urinary incontinence yields a higher failure rate, but most women report significant improvement in bother symptoms and impact on QOL after colposuspension procedures. A recent 2017 Cochrane review showed that the open Burch and other retropubic colposuspension procedures remain very successful operations to treat stress urinary incontinence, with long-term (5 years or more) success rates of around 70%. Compared to pubovaginal slings, open colposuspension is associated with a lower risk of voiding dysfunction, but with a higher risk of subsequent pelvic organ prolapse . 7/8/2024 Dr Ephrem Assefa 195

196. Mid-Urethral Slings The mid-urethral slings were developed as a direct consequence of the integral theory that was promoted by Petros et al. . The polypropylene tension-free vaginal tape (TVT) was the original mid-urethral sling described by Ulmsten in 1996 as a simple minimally invasive outpatient procedure under local or regional anesthesia . With this procedure, a synthetic sling is placed under the mid-urethra (in contrast to pubovaginal slings that are placed at the bladder neck) in a tension-free manner. 7/8/2024 Dr Ephrem Assefa 196

197. The two ends of the sling are not attached or sutured to a pelvic structure, but rather the urethra is free of any tension upon placement of the sling. The TVT is commonly placed in a bottom-up direction through a small 1 to 2 cm mid-urethral vaginal incision, and the two free ends are passed up and behind the pubic bone through the space of Retzius and out through two suprapubic incisions (Fig. 29-15) . 7/8/2024 Dr Ephrem Assefa 197

198. As each side of the sling is advanced around the urethra using a trocar, the bladder is deviated to the contralateral side via a guide wire placed through a Foley catheter to minimize the risk of a cystotomy . Cystoscopy is performed to confirm the integrity of the bladder. Although mid-urethral slings were initially received with skepticism, over time they have proven to be very effective surgeries with low rates of complications replacing all other procedures as the gold standard to treat stress urinary incontinence. Of the original 90 women who underwent the TVT procedure, 78% were followed-up to 17 years. Of those evaluated either by a clinic visit or by phone, about 90% had objective and 87% had subjective cure or significant improvement . 7/8/2024 Dr Ephrem Assefa 198

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200. In 2001, Delorme reported on the transobturator tape (TOT) where the sling position is still mid-urethral, however its general direction is through the ischiorectal fossa and the free ends exit via the obturator canal and out through the genitofemoral creases bilaterally . The TOT sling can be placed in an outside-in or inside-out direction. The TOT mid-urethral slings were developed in an attempt to reduce complications associated with the TVT procedure, including bowel, bladder, and vascular injury. Subsequent studies have shown that women undergoing TOT procedures are still at risk of vascular and bladder injuries, although rare. 7/8/2024 Dr Ephrem Assefa 200

201. Over the past two decades, there has been an accumulation of a large body of evidence on mid-urethral slings from randomized controlled trials, including several meta-analyses and Cochrane reviews . The overarching summary is that mid-urethral slings have become the procedure of choice in treating women with stress urinary incontinence. They have a good safety profile with a significant improvement of QOL measures, and irrespective of route of placement, they are highly effective in the short, medium, and long term. There is evidence to suggest that the mid-urethral slings are more effective than the Burch colposuspension procedure, and as effective as the autologous pubovaginal sling . 7/8/2024 Dr Ephrem Assefa 201

202. Concerning the choice of mid-urethral sling ( retropubic vs. transobturator ), data show that the retropubic approach may be favored in terms of long-term efficacy, but with the risk of higher overall complication rates. In a large national cohort of more than 8,600 women undergoing mid-urethral slings in Denmark over a 10-year span, the reoperation rate at 5 years was 6% for the TVT and 9% for the TOT. In the adjusted model, the TOT sling was associated with a twofold higher risk of reoperation (HR, 2.1; 95% CI, 1.5–2.9) than the TVT sling. In terms of complications, urinary tract infections occur in up to 10% after mid-urethral slings. 7/8/2024 Dr Ephrem Assefa 202

203. Bladder perforation is another complication that can occur with both approaches but more commonly with the TVT. Of note is that bladder perforations are mostly inconsequential. With universal cystoscopy at the time of sling placement, the cystotomy , typically at the dome of the bladder, is easily identified. Repositioning of the sling, and ensuring subsequent proper placement is generally sufficient. 7/8/2024 Dr Ephrem Assefa 203

204. In certain cases, keeping the Foley catheter in for up to a week may be necessary. Other complications that are more common with the TVT include bleeding (intra and postoperative), and postoperative voiding dysfunction necessitating sling revision; in contrast, the TOT has a higher rate of mesh erosion, and postoperative groin and leg pain. Rare complications include bowel injuries, and patient deaths after retropubic slings, and severe infections after transobturator slings . 7/8/2024 Dr Ephrem Assefa 204

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206. A unique complication associated with mid-urethral slings is erosion of the sling material . Although uncommon, sling erosion into the vagina generally requires surgical repair which involves resection of the segment eroding into the vagina and repairing the vaginal mucosa over the involved site. When the sling erodes into the bladder (and uncommonly into the urethra), this requires more complicated surgery to resect the eroded segment (Fig. 29-16) . Rarely, the whole sling material (TVT or TOT) may need to be removed typically because of chronic pain resulting from placement of the sling. 7/8/2024 Dr Ephrem Assefa 206

207. Certain mid-urethral sling characteristics and indications worthy of mention include the following: (a) with retropubic slings, the bottom-up route may be more effective than top-down route; (b) with the exception of leg and groin pain, fewer adverse events occur with the transobturator than the retropubic approach; 7/8/2024 Dr Ephrem Assefa 207

208. (c) the transobturator may be more cost-effective compared with the retropubic sling, although studies looking at cost do not take into account the potential impact of repeat surgery to address recurrence of incontinence on overall cost; (d) the retropubic sling is favored over the transobturator sling in cases of fixed immobile urethra (intrinsic sphincter deficiency) and mixed urinary incontinence; and (e) the transobturator approach may be favored in cases where there is previous significant bowel or pelvic adhesive disease. 7/8/2024 Dr Ephrem Assefa 208

209. Single incision (mini) slings have been introduced with the goal of further minimizing surgical complications while maintaining efficacy. A mid-urethral incision is made to introduce the sling while fixing (or anchoring) the two shorter arms to the fascia in the obturator or retropubic space. However, their short- to mid-term results are not very promising. 7/8/2024 Dr Ephrem Assefa 209

210. In a recent Cochrane review, mini-slings were reported to be either inferior, or they lacked enough evidence to support their endorsement over the retropubic or transobturator slings . More studies with longer-term follow-up are needed to establish their safety profile in treating women with stress urinary incontinence without compromising surgical success. 7/8/2024 Dr Ephrem Assefa 210

211. When a mid-urethral sling is chosen as a treatment option, the AUA guidelines recommend either a retropubic or transobturator sling as a first choice, and if a mini-sling is to be used, patients are to be informed that not enough short-, medium- and long-term data exist in its support. Over the past century, surgical standards of care for stress urinary incontinence have made a full circle from slings (mostly pubovaginal ) to bladder neck and retropubic suspensions and back to slings (mostly mid-urethral). These transitions in surgical care have occurred mostly on the heels of an in-depth understanding of the anatomy of the pelvic floor and rigorous evidence-based epidemiologic and clinical research. 7/8/2024 Dr Ephrem Assefa 211

212. Bulking Agents Urethral bulking agents are an accepted treatment option for women with stress urinary incontinence. They are typically injected around the proximal urethra submucosally to give it bulk, either transurethrally or periurethrally , using an operative cystoscope . When compared to the mid-urethral slings, the colposuspension, and pubovaginal slings, there exist little data evaluating their long-term success. Repeat operations are common after bulking agent therapy. 7/8/2024 Dr Ephrem Assefa 212

213. However, they are appropriate procedures for patients who are poor surgical candidates, on anticoagulation therapy, with high PVRs, or in older women with high surgical anesthesia risk. The advantage of injectable agents is that they are less invasive and they can potentially be done in a clinic setting without the need for general or regional anesthesia. Available and FDA-approved bulking agents for stress urinary incontinence treatment include pyrolytic carbon–coated zirconium oxide spheres (beads) ( Durasphere ), cross- linked polydimethylsiloxane ( Macroplastique ), and spherical particles of calcium hydroxylapatite ( Coaptite ). 7/8/2024 Dr Ephrem Assefa 213

214. The glutaraldehyde cross-linked bovine collagen ( Contigen ) is not being produced by its manufacturer and is no longer available in the United States market. Injection of the bulking agent into the urethral submucosa produces its coaptation to help maintain continence in the presence of an increased abdominal pressure. In one review article, it was noted that subjective success rates ranged from 66% to 90% at 12-months follow-up, whereas objective improvement ranged from 25% to 73%. 7/8/2024 Dr Ephrem Assefa 214

215. A 2017 Cochrane review showed that limited data exist beyond 2 years posttreatment with urethral bulking agents. Short-term data are suggestive of an improvement, but they lack the robust success or cure rates associated with mid-urethral slings . Reported complications of the urethral bulking agents include urinary tract infections, urinary retention, erosion and migration of the implanted material . 7/8/2024 Dr Ephrem Assefa 215

216. Other Potential Future Therapies Autologous stem cells have been used experimentally to help regain bladder control. Most studies have used stem cells derived from muscle or adipose tissue. The stem cells can be injected periurethrally or into the pelvic floor to regenerate damaged urethral sphincter or repair/reconstruct pelvic support structures using tissue engineering techniques. Although preclinical and early clinical trials have demonstrated safety, efficacy of those techniques to treat stress urinary incontinence is still in question. 7/8/2024 Dr Ephrem Assefa 216

217. Radiofrequency applied transurethrally to promote collagen denaturation is another modality that has been proposed as a nonsurgical procedure to treat stress urinary incontinence. However, a Cochrane review demonstrated no benefit (or insufficient evidence) of radiofrequency when compared with sham treatment. Vaginal laser therapy is another technique that is being marketed as a safe and office based treatment modality for female stress urinary incontinence. There is no evidence to support this use in clinical practice over conventional treatment options . 7/8/2024 Dr Ephrem Assefa 217

218. Procedures for Urgency Urinary Incontinence When conservative and pharmacologic options fail, second-line treatments for urgency urinary incontinence include injection of onabotulinumtoxinA (Botox) in the bladder, percutaneous tibial nerve stimulation (PTNS), and sacral neuromodulation ( Interstim ) . 7/8/2024 Dr Ephrem Assefa 218

219. Botox Injections OnabotulinumtoxinA (Botox) is a neurotoxin that produces its paralytic effect on the detrusor muscle of the bladder by blocking the calcium channels and inhibiting release of acetylcholine at the presynaptic neuromuscular junction. Its use was initially FDA-approved in women with neurogenic detrusor overactivity with a typical injected dose being 200 units (U). In 2013, its use was approved for idiopathic OAB and urgency urinary incontinence. 7/8/2024 Dr Ephrem Assefa 219

220. The typical dose for nonneurogenic OAB is 100 U where injection of onabotulinumtoxinA is performed cystoscopically with about 20 injection points within the detrusor muscle sites and mostly supratrigonal (Fig. 29-17) . When successful, the effect of the injection typically lasts for 6 months to 2 years with repeat injections needed in 50%of women within 12 months . 7/8/2024 Dr Ephrem Assefa 220

221. The FDA approval decision was mostly based on a multicenter double-blind, randomized controlled trial comparing one intradetrusor injection of 100 U of onabotulinumtoxinA to daily oral anticholinergic medication ( solifenacin or trospium ) in 249 women with urgency urinary incontinence over a period of 6 months. This study demonstrated similar reductions in daily urgency, frequency, and urgency urinary incontinence episodes between the two groups. 7/8/2024 Dr Ephrem Assefa 221

222. Complete resolution of urgency urinary incontinence occurred in more than twice of the onabotulinumtoxinA (27%) than the anticholinergic (13%) group, P = 0.003. Side effects with the injection group included catheter use up to 2 months (5%) and urinary tract infections (33%) . A meta-analysis of 56 randomized controlled trials showed that patients receiving onabotulinumtoxinA (100 U) had improvements in urgency, frequency, and incontinence episodes similar or better than medications, and significantly better than placebo. 7/8/2024 Dr Ephrem Assefa 222

223. The AUA currently recommends intradetrusor onabotulinumtoxinA (100 U) when conservative and medical treatments have failed in women with OAB. It is noteworthy that the patient must be taught and be willing to perform self-catheterization, if needed, after the injection. In addition to urinary tract infections and retention, side effects include gross hematuria, dry mouth, dysphagia, impaired vision, and muscle weakness. 7/8/2024 Dr Ephrem Assefa 223

224. Percutaneous Tibial Nerve Stimulation PTNS was approved by the FDA in 2000 for OAB. PTNS involves introducing an acupuncture-type needle electrode (34-gauge) at a 60-degree angle around the ankle, about 3 fingerbreadths above the medial malleolus and posterior to the tibia. The electrode is connected to a battery-charged stimulator, and treatment involves 30-minute weekly sessions for 12 weeks. 7/8/2024 Dr Ephrem Assefa 224

225. If successful, maintenance involves once monthly sessions thereafter. A multicenter trial of 220 women with OAB symptoms randomized to 12 weeks of treatment with PTNS versus sham therapy resulted in marked improvement of symptoms in 55% compared to 21% in the respective groups . 7/8/2024 Dr Ephrem Assefa 225

226. 7/8/2024 Dr Ephrem Assefa 226

227. PTNS has been compared to anticholinergic medications including long-acting toleterodine and oxybutynin in different studies . Similar improvements have been shown in urinary frequency, incontinence, nocturia , bother, and QOL scores in the short term (12 weeks) between the two treatment modalities . At 2- to 3- years follow-up, the medication group reported worsening symptoms especially that many women on anticholinergics are not compliant with taking medications long term because of side effects . 7/8/2024 Dr Ephrem Assefa 227

228. PTNS is considered an acceptable alternative to medical treatment, in the short term in patients who cannot tolerate anticholinergic side effects, or in the long term in patients who show signs of impaired cognition and memory loss. It is important to emphasize to patients that for optimal results, treatment sessions are administered weekly for the initial 12 weeks, and women should have the appropriate resources to make frequent clinic visits. Side effects of PTNS are limited and they include minor bleeding, pain, or tingling sensation at the needle site. 7/8/2024 Dr Ephrem Assefa 228

229. Neuromodulation Sacral nerve stimulation (also known as neuromodulation ) is another FDA approved treatment modality for refractory OAB, urgency urinary incontinence, and voiding dysfunction in women who have failed conventional treatment options. Sacral nerve stimulation involves an initial phase with a 1- to 2-week trial lead placed percutaneously to evaluate response to treatment. Those reporting at least 50% improvement in their OAB symptoms move on to phase two where a permanent electrode lead is introduced through the back and placed around the third sacral nerve root. 7/8/2024 Dr Ephrem Assefa 229

230. This electrode is connected to a pulse generator that is implanted in the patient’s buttock. Unlike PTNS and onabotulinumtoxinA , sacral nerve stimulation is a more complex procedure that generally requires fluoroscopy in an operating room setting and is associated with a different adverse event profile . It is contraindicated to perform an MRI in women with an implanted neurostimulator . 7/8/2024 Dr Ephrem Assefa 230

231. A randomized controlled trial of 147 women compared medical treatment to sacral nerve stimulation over a period of 6 months. At baseline, women reported bothersome symptoms of OAB with more than two urgency incontinence episodes within 3 days and more than eight voids per day. Results showed that women who received the neurostimulator (61%) had significantly higher treatment success than women receiving medical treatment (42%) ( P = 0.02). Adverse events were similar between the two group at 31% and 27%, respectively. 7/8/2024 Dr Ephrem Assefa 231

232. In another prospective multicenter study, 272 patients implanted with the sacral nerve stimulation were followed for a year. Using diary data at 12 months showed a therapeutic improvement rate of 85% including a mean reduction of urgency incontinence episodes of 2.2 leaks/day (down from 3.1) and urinary frequency of 5.1 voids/day (down from 12.6), both P <0.0001. Women reported significant improvement in their QOL measures and decreased interference of urinary symptoms with their daily activities. Device-related adverse events occurred in 30% (82/272) of women with an implanted neurostimulator at 12 months. 7/8/2024 Dr Ephrem Assefa 232

233. These included undesirable change in stimulation (12%), implant site pain (7%), and implant site infection (3%). Of the 26 women with implant site pain, 13 underwent surgical intervention, and two had removal of the stimulator. Of the 13 cases with implant site infection, five received antibiotics and eight required removal. A randomized controlled trial compared 364 women with OAB who underwent treatment either with onabotulinumtoxinA or sacral nerve stimulation. Women who received onabotulinumtoxinA reported greater reduction in 6-month mean number of urgency incontinence episodes per day than those who received sacral neuromodulation (–3.9 vs. –3.3; P = 0.01). 7/8/2024 Dr Ephrem Assefa 233

234. Participants treated with onabotulinumtoxinA showed greater improvement in symptom bother (–46.7 vs. –38.6; P = 0.002) and treatment satisfaction (68 vs. 60; P = 0.01) than those receiving sacral neuromodulation . There were no differences in treatment preference (92% vs. 89%; P = 0.49) or adverse events, except for urinary tract infections which were more frequent in the onabotulinumtoxinA group (35% vs. 11%; P < 0.001). Urinary retention requiring self-catheterization was 2% at 6 months in the onabotulinumtoxinA group, and stimulator device revisions or removals occurred in 3%. 7/8/2024 Dr Ephrem Assefa 234

235. Augmentation Cystoplasty and Urinary Diversion Augmentation cystoplasty and urinary diversion, typically using segments of the patient’s intestine, are procedures that are rarely performed to treat urinary incontinence, and typically fall in the advance urology domain. They have been reported in women with chronic and debilitating detrusor overactivity unresponsive to second or third-line treatment options. A 2012 updated Cochrane review found a handful of small studies with limited information to guide clinical practice. As neuromodulation and cystoscopic injection with onabotulinumtoxinA become more prevalent and better studied, there will be limited, if any, role for augmentation cystoplasty and urinary diversion to treat women with urgency urinary incontinence. 7/8/2024 Dr Ephrem Assefa 235

236. Surgery for Fistula Repair Genitourinary fistula repair is commonly performed vaginally, but can be repaired through an abdominal access, either open, laparoscopic, or robotically. For very small pinpoint fistulae, there may be a role for conservative options with an attempt of 10 to 14 days of transurethral catheterization and to allow the fistula to close spontaneously. If that fails, or for larger fistulae, surgery is the mainstay (Fig. 29-18) . 7/8/2024 Dr Ephrem Assefa 236

237. Proper surgical technique involves: (a) identification of fistula (ae); (b) getting adequate access and exposure (e.g., if a vaginal approach is preferred, a pediatric Foley catheter can be placed vaginally and the balloon inflated to put downward traction on the fistula for better visualization); (c) debridement of nonviable tissue; (d) mobilization of fresh and viable tissue (1 to 2 cm) around and all along the fistulous tract; (e) repair of the fistula in several layers starting at the bladder end and going out to the vagina; (f) minimal tension on the repaired layers; (g) 7 to 14 days of postoperative catheterization; (h) use of tissue grafts (e.g., Martius labial fat-pad) as needed for larger or recurrent fistulae. 7/8/2024 Dr Ephrem Assefa 237

238. Voiding Dysfunction Definition The mechanism of normal bladder emptying is a coordinated effort that is initiated by the individual. It involves a detrusor muscle contraction associated with urethralsphincter relaxation. The pressure generated by the detrusor muscle contraction should be of an appropriate duration and a magnitude that is higher than the pressure in the urethra to produce the desired effect of completely emptying the bladder. The neurophysiology of micturition has previously been described. 7/8/2024 Dr Ephrem Assefa 238

239. In addition to an intact neuromuscular control and support, voiding is dependent on the volume of urine within the bladder and intravascular volume that gets filtered through the kidneys. One study of 165 women with no history of urologic diseases and/or pelvic surgery showed a significant difference in the frequency and volume of urine produced in 24 hours (range between 437 and 3,861 mL). In addition to the bladder volume at the time of voiding, the maximum urine flow rate (range between 16 and 37mL/s) is variable and dependent on patient position, age, and menopausal status among other factors. 7/8/2024 Dr Ephrem Assefa 239

240. Voiding dysfunction occurs when a woman loses the ability to empty her bladder effortlessly and completely within a limited time frame (usually within 60 seconds or less). Objectively, voiding dysfunction can be identified on a uroflow when the voiding time is prolonged, the flow pattern is interrupted (see Fig. 29-8 above), or the maximum flow rate is diminished. 7/8/2024 Dr Ephrem Assefa 240

241. During complex urodynamics , additional objective measures of voiding dysfunction include increased urethral pressure (resistance) with an increased detrusor pressure (detrusor–sphincter dyssynergia ), or a low detrusor pressure with a normal or low urethral pressure (detrusor underactivity) at the time of urination. Patients with voiding dysfunction may express a host of sensory and abnormal bladder emptying symptoms including hesitancy, slow or intermittent urinary stream, straining on urination, feeling of incomplete bladder emptying, reduced bladder sensation and others (Table 29-10) . 7/8/2024 Dr Ephrem Assefa 241

242. Etiology Acute urinary retention is a sudden and often painful inability to void despite the sensation of a full bladder and desire to urinate. It is mostly iatrogenic resulting from neurologic injury after radical pelvic surgery (radical hysterectomy, radical perineal resection, colorectal extensive resections), neurologic injury during spinal surgery or commonly after female pelvic reconstructive surgery, and incontinence surgery (e.g., mid-urethral sling). Rarely, and uniquely in pregnant patients, especially in the peripartum period, the bladder is vulnerable to urinary retention; if undetected, this can lead to bladder underactivity, recurrent urinary tract infection, and incontinence . 7/8/2024 Dr Ephrem Assefa 242

243. Chronic urinary retention may be caused by neurogenic (e.g., multiple sclerosis, diabetic neuropathy) or nonneurogenic conditions (e.g., advanced prolapse) . This can lead to serious conditions like hydronephrosis and chronic renal insufficiency, but is more commonly associated with conditions that impair an individual’s daily activities like recurrent urinary tract infections, feelings of incomplete bladder emptying, and overflow incontinence. 7/8/2024 Dr Ephrem Assefa 243

244. Chronic urinary retention is defined as PVR of more than 300 mL persisting for more than 6 months which has been documented in two separate occasions. Common conditions associated with incomplete bladder emptying and retention in women are outlined below (Table 29-11) . 7/8/2024 Dr Ephrem Assefa 244

245. 7/8/2024 Dr Ephrem Assefa 245

246. An additional layer of interrupted sutures is often placed to invert the initial suture line. The vaginal epithelium is then closed over the repair. In the classic Latzko procedure, the initial layer involves closure of the vagina over the fistula tract, then two additional layers with the vaginal epithelium result in an apical colpocleisis . (Redrawn from original by Jasmine Tan.) 7/8/2024 Dr Ephrem Assefa 246

247. Evaluation Evaluation starts with a careful medical history to eliminate possible conditions associated with voiding dysfunction (e.g., multiple sclerosis, diabetes, psychiatric disorders) and concomitant medications. Should medical history reveal previous surgical treatment for urinary incontinence, it is important to obtain medical records or operative reports to determine the exact nature of the surgery. A careful pelvic examination is conducted with special attention to urethral orifice and anterior wall of vagina to rule out possible pelvic or vaginal masses causing urethral obstruction. 7/8/2024 Dr Ephrem Assefa 247

248. Abdominal palpation or suprapubic percussion may indicate a full bladder. Cystoscopy can help diagnose the presence of urethral polyps or bladder tumors, stones, or foreign bodies causing obstruction. Evaluation of the strength of the detrusor muscle contraction during voiding and urethral outlet relaxation, or lack thereof (i.e., urethral resistance) can be undertaken at the time of urodynamics , including measurement of PVR. 7/8/2024 Dr Ephrem Assefa 248

249. Table 29-10 Classification and Definition of Lower Urinary Tract Symptoms in Women 7/8/2024 Dr Ephrem Assefa 249

250. 7/8/2024 Dr Ephrem Assefa 250

251. Treatment Prior to treatment initiation for chronic urinary retention, the AUA guidelines recommend evaluation of the upper tracts to assess the functional integrity of the kidneys (creatinine clearance) and rule out hydronephrosis (renal ultrasound or CT urogram ) . Low-risk, asymptomatic individuals can be surveilled with yearly urinalysis and urine culture with no unnecessary treatment. In symptomatic patients (e.g., recurrent urinary tract infections), treatment is symptom driven. Patients are encouraged to double void and have frequent trips to the bathroom. Patients can be referred to pelvic floor physical therapy for bladder retraining. 7/8/2024 Dr Ephrem Assefa 251

252. Table 29-11 Conditions Associated with Voiding Dysfunction and Urinary Retention 7/8/2024 Dr Ephrem Assefa 252

253. In high-risk patients, intermittent catheterization is recommended. Although there is lack of evidence comparing intermittent self-catheterization to indwelling catheters, expert opinion, favors intermittent catheterization for better long-term outcomes . Either the patient or her caregiver can be instructed to perform bladder self-catheterization. 7/8/2024 Dr Ephrem Assefa 253

254. In the presence of advanced prolapse, a trial of pessary can be performed with the goal of reducing the prolapse to relieve the obstruction on the urethra resulting in improved voiding and decreased retention. Acute urinary retention is addressed according to the specific situation causing the retention. 7/8/2024 Dr Ephrem Assefa 254

255. This may take the form of expectant management with an indwelling catheter for postradical hysterectomy, pelvic reconstructive, or incontinence surgery. The catheter can be plugged after a week of retention and continued voiding dysfunction to allow the bladder to recover filling sensation. When a full bladder in sensed by the patient, she is instructed to remove the plug and drain the bladder. Alternatively, patients can be instructed to self-catheterize until resolution of the retention (usually a PVR of volume of 100 mL or less is acceptable). 7/8/2024 Dr Ephrem Assefa 255

256. Should the patient continue to have voiding dysfunction for several weeks after surgery, a sling revision and/or urethrolysis may be necessary. In the absence of an obstruction, medications can be used for urinary retention caused by either detrusor underactivity or increased resistance in urethral sphincter. These include alpha blockers or beta agonists, however these drugs have proven to be generally ineffective and there is lack of clear evidence to support their routine use . 7/8/2024 Dr Ephrem Assefa 256

257. Neuromodulation and intravesical electrical stimulation may be effective in select patients. In addition to urgency, frequency, and urgency urinary incontinence, sacral neuromodulation has been used to treat nonobstructive voiding dysfunction in women. Long-term follow-up shows promising results in idiopathic retention (Fowler syndrome, patients with multiple sclerosis and painful bladder syndrome) with a success rate of as high as 73%. 7/8/2024 Dr Ephrem Assefa 257

258. Bladder Pain Syndrome The recent IUGA/ICS report on management of pelvic floor dysfunction defines acute pain as that related to recent trauma, infection or other disease and chronic pain as either persistent or recurring pain for at least 6 months. It is important to differentiate pain which is a sensation expressed subjectively by the individual from tenderness which is a sensation of discomfort, with or without pain, and that may be elucidated by palpation on a physical examination 7/8/2024 Dr Ephrem Assefa 258

259. Definition Bladder pain syndrome is challenging to diagnose, prevent, and treat because its basic science and pathophysiology is poorly understood. Bladder pain is definedas the complaint of suprapubic or retropubic pain, pressure, or discomfort related to the bladder. It usually increases in intensity with bladder filling and may persist or disappear after voiding. Women with bladder pain syndrome usually have other associated urinary symptoms, such as urinary urgency or frequency; the pain is of a duration of at least 6 weeks or more in the absence of urinary tract infections or other identifiable causes . 7/8/2024 Dr Ephrem Assefa 259

260. The prevalence of bladder pain syndrome varies widely, based on definitions used, from less than 1% to as high as 20% . Some authors have developed an interstitial cystitis/bladder pain syndrome questionnaire for use in epidemiologic studies . Based on this questionnaire, the prevalence in adult U.S. females ranges between 3% and 7% with the peak prevalence being in the 50’s. 7/8/2024 Dr Ephrem Assefa 260

261. The terms “bladder pain syndrome” and “interstitial cystitis” have been used interchangeably in the literature, where the latter was first described as an inflammatory bladder condition, sometimes associated with ulceration of the bladder wall, named Hunner lesion . Interstitial cystitis is believed to be associated with a defective glycosaminoglycan sulfate layer that covers the bladder mucosa. To standardize definitions and enable comparative research, the National Institute of Diabetes, Digestive, and Kidney Diseases (NIDDK) developed strict criteria for interstitial cystitis; however, these definitions have been shown to be too restrictive to use in clinical practice. 7/8/2024 Dr Ephrem Assefa 261

262. NIDDK criteria include the presence of pain and urgency associated with objective findings of glomerulations or Hunner ulcers during cystoscopy and hydrodistention of the bladder, including a small bladder capacity and terminal hematuria . Most clinicians prefer to use Looser criteria when treating women with bladder pain syndrome. The understanding of bladder pain syndrome is that it is not limited to an inflammatory mechanism but may encompass a spectrum of conditions including OAB, other chronic pain conditions, somatization disorders, and neurologic diseases. 7/8/2024 Dr Ephrem Assefa 262

263. Diagnosis Basic assessment in a woman with bladder pain syndrome consists of obtaining a detailed medical history, physical examination, bladder diary (frequency/volume chart) and urinalysis with culture . The workup should be supplemented with urine cytology in older women, especially those who report history of smoking or prior exposure to chemical. Bladder pain syndrome is a diagnosis of exclusion. A differential diagnosis includes chronic or recurrent urinary tract infections, urethral diverticulum, vulvovaginal atrophic, inflammatory, allergic, or infectious conditions, chronic pelvic pain related to endometriosis, inflammatory bowel conditions, myofascial pain, and others. Exclusion of these diseases may require further imaging, cystoscopy, urodynamics , and even laparoscopy. 7/8/2024 Dr Ephrem Assefa 263

264. Treatment The initial management of bladder pain syndrome relies on patient education, dietary modification, stress reduction, and pelvic floor relaxation techniques . Women are encouraged to avoid bladder irritants such as caffeinated beverages, alcohol, carbonated drinks, acidic drinks, and spicy foods. When the conservative approach fails, medication, physical therapy or intravesical treatment are implemented. Referral to a pain specialist can be beneficial. 7/8/2024 Dr Ephrem Assefa 264

265. Effectiveness of medical therapy is not well-proven, and long-term follow-up is not well-studied. One study reviewed treatments received by 581 women enrolled in the interstitial cystitis database study group between 1993 and 1997. A total of 183 different types of treatments were reported, with the most commonly prescribed being cystoscopy and hydrodistention , amitriptyline , phenazopyridine , special diet, and intravesical heparin . 7/8/2024 Dr Ephrem Assefa 265

266. Urinary analgesics like phenazopyridine and Prosed DS have been offered to patients with painful bladder syndrome for pain or bladder spasm relief. The latter is a mixture of methenamine , methylene blue, phenyl salicylate, benzoic acid, and hyoscyamine . Amitryptyline , a tricyclic antidepressant, has been studied for symptom relief in women with painful bladder syndrome, and it has been shown to be beneficial only when a dose of 50 mg or more is achieved. 7/8/2024 Dr Ephrem Assefa 266

267. Antihistamines have been proposed as potentially being helpful for bladder pain syndrome since pain may be the consequence of histamine release. Hydroxyzine is a commonly used antihistamine; however, a multicenter, randomized clinical trial showed only a 30% versus 20% response for those who were treated with hydroxyzine versus placebo, respectively. Another antihistamine includes cimetidine; but studies on its use have included a very small number of patients with inconclusive results. 7/8/2024 Dr Ephrem Assefa 267

268. Pentosan polysulfate ( elmiron ) is an FDA-approved heparinoid medication to treat women with bladder pain syndrome/interstitial cystitis. The recommended dose is 100 mg three times per day and symptom relief may not be achieved for at least 3 months. The efficacy of pentosan polysulfate has been brought to question by a placebo-controlled randomized trial showing similar symptom relief between the two groups . As an alternative to oral medications, intravesical treatment may be offered to patients with bladder pain syndrome. 7/8/2024 Dr Ephrem Assefa 268

269. Dimethylsulfoxide (DMSO) is the only FDA-approved intravesical treatment. This involves instilling the bladder with 50 mL of 50% solution of DMSO for 20 to 30 minutes, and to be repeated weekly or every other week for six sessions. It is believed to reduce inflammation, relax muscles, and alleviate pain. As side effects, patients report garlic odor and transient bladder irritation. 7/8/2024 Dr Ephrem Assefa 269

270. Alternative intravesical instillations that have been investigated include hyaluronic acid, chondroitin sulfate, cyclosporine A, bacillus Calmette –Guerin, oxybutynin, bupivacaine/heparin/steroid (mix), and others. Other treatmentoptions include cystoscopy under anesthesia with hydrodistention , neuromodulation , transcutaneous electrical stimulation (TENS), and intradetrusor botulinum toxin A injection. 7/8/2024 Dr Ephrem Assefa 270