114 CHAPTER 4 Incontinence
Evaluation
History
Inquire about LUTS (storage or voiding symptoms), triggers for incontinence (cough, sneezing, exercise, position, urgency), and frequency and severity of symptoms. Establish risk factors (abdominal/pelvic surgery; neurological diseases; obstetric and gynecological history; medications).
A validated patient-completed questionnaire may be helpful (e.g., IPSS; see Fig. 1.1, p. 11).
Physical examination
Women
Perform a pelvic examination in the supine and standing position with a speculum while the patient has a full bladder. Ask the patient to cough or strain, and inspect for vaginal wall prolapse (cystocele, rectocele, enterocele), uterine or perineal descent, and urinary leakage (stress test). Eighty percent of SUI patients will leak with a brief squirt during cough in the supine position, while another 20% will leak only in an inclined or standing position.
Urethral hypermobility is assessed with the Q-tip test. A lubricated cot- ton-tipped applicator is introduced through the urethra to bladder neck level. Hypermobility is defined as a resting or straining angle of >30* from horizontal.
The Bonney test is used to assess continence with manual repositioning of the urethra and vesicle neck. Using one or two fingers to elevate the anterior vaginal wall laterally without compressing the urethra, relief of incontinence during cough suggests that surgical correction will be successful.
Both sexes
Examine the abdomen for a palpable bladder (indicating urinary retention). A neurological examination should include assessment of anal tone and reflex, perineal sensation, and lower limb function.
Inspect the underwear for the status of urinary collection pads; for men, a standing or squatting “cough test” gives a good indicator of the presence and severity of stress incontinence.
Investigation
Bladder diaries
Record the frequency and volume of urine voided, incontinent episodes, pad usage, fluid intake, and degree of urgency. Alternatively, pads can be weighed to estimate urine loss (pad testing).
Urinalysis can exclude UTIs.
Blood tests, X-ray imaging, cystoscopy
These are indicated for persistent or severe symptoms, bladder pain, and voiding difficulties. Cystoscopy is useful for evaluating men who have had prostatectomy—it will show the presence of clips, stones, and strictures that may develop after surgery that might need to be addressed concomitantly with anti-incontinence surgery.
EVALUATION 115
Screening tests
Uroflow testing measures the ability of the bladder to empty; a minimum bladder volume of 150 cc is desired. A low flow rate indicates bladder outflow obstruction or reduced bladder contractility. The volume of urine remaining in the bladder after voiding (post-void residual) is also important (<50 mL is normal; >200 mL is abnormal; 50–200 mL requires clinical correlation).
Urodynamic investigations
Valsalva leak point pressure (VLPP) measures the abdominal pressure at which a half-full bladder leaks during straining—normal individuals should not leak. VLPP readings <60 cm H2O suggest ISD; VLPP readings >100 cm H2O suggest hypermobility, while readings of 60–100 cm are indeterminant.
Detrusor leak point pressure (DLPP) measures the bladder pressure at which leakage occurs without valsalva—DLPP >40 cm H2O puts the upper tract at risk.
Videourodynamics can visualize movement of the proximal urethra and bladder neck, and establish the precise anatomical etiology of UI.
Sphincter electromyography (EMG)
EMG measures electrical activity from striated muscles of the urethra or perineal floor and provides information on synchronization between bladder muscle (detrusor) and external sphincter.
116 CHAPTER 4 Incontinence
Treatment of sphincter weakness incontinence: injection therapy
The injection of bulking materials into the bladder neck and periurethral muscles is used to increase outlet resistance. Bulking substances include silicone polymers (Macroplastique); cross-linked bovine collagen (Contigen); Teflon; PTFE; and carbon-coated zirconium beads (Durasphere).
Indications
These include stress incontinence secondary to demonstrable intrinsic sphincter deficiency (ISD), with normal bladder muscle function. Injection therapy is used in adults and children.
Contraindications
These include UTI, untreated bladder dysfunction, and bladder neck stenosis. There is improved outcome in patients without urethral hypermobility (which is better treated with a sling or, less commonly, an artificial urinary sphincter).
Preinjection evaluation
Conduct a stress test and Q-tip test. Use videourodynamics to diagnose ISD and exclude detrusor overactivity.
Injection techniques
Either a local block or a general anesthetic is required, with full antibiotic coverage. Usually a series of injections are given via a transurethral (retrograde) route using a cystoscopically guided injection needle. The bulking agent is injected suburethrally with the aim of achieving urethral muscosal apposition and closure of the lumen.
In men, injection treatment following radical prostatectomy is associated with success rates <10%. In women, a periurethral (percutaneous) technique can also be used, with endoscopic or ultrasound guidance: overall success rate in women is ~50–70%.1,2
Complications
Complications include urinary urgency, urinary retention (which may need ISC or SPC insertion), hematuria, cystitis, migration of the injected particles (PTFE, Macroplastique), and risk of granuloma formation (PTFE). Repeat treatments are the norm.
1 Koelbl H (1998). Transurethral injection of silicone microimplants for intrinsic urethral sphincter deficiency. Obstet Gynaecol 92:332–336.
2 Appell RA (1994). Collagen injection therapy for urinary incontinence. Urol Clin North Am 21:177–182.
TREATMENT OF SPHINCTER WEAKNESS INCONTINENCE 117
Treatment of sphincter weakness incontinence: retropubic suspension
Retropubic suspension procedures are used to treat female stress incontinence caused by urethral hypermobility. The aim of surgery is to elevate and fix the bladder neck and proximal urethra in a retropubic position, to support the bladder neck, and to regain continence.
It is contraindicated in the presence of significant intrinsic sphincter deficiency (ISD).
Types of surgery
Surgery is considered after conservative methods have failed. The main types of operation are via a Pfannenstiel or lower midline abdominal incision to approach the bladder neck and develop the retropubic space. Better results are seen in patients with pure stress incontinence and primary repair (as opposed to “redo” surgery).
Marshall–Marchetti–Krantz (MMK) procedure
Sutures are placed either side of the urethra around the level of the bladder neck and then tied to the hyaline cartilage of the pubic symphysis. Short-term success is about 90%,1 but declines over time.
Complications include osteitis pubis (3%), typically presenting up to 8 weeks postoperatively, with pubic pain radiating to the thigh. Treatment is with simple analgesia, bed rest, and steroids.
Burch colposuspension
This requires good vaginal mobility, to allow the vaginal wall to be elevated and attached to the lateral pelvic wall where the formation of adhesions over time secures its position. The paravaginal fascia is exposed and approximated to the iliopectineal (Cooper) ligament of the superior pubic rami.
Initial success rates are 90%.1 Better long-term results compare with those for other retropubic repairs. A laparoscopic approach can also be performed, but long-term results have proven to be poor.
Vagino-obturator shelf/paravaginal repair
Sutures are placed by the vaginal wall and paravaginal fascia and then passed through the obturator fascia to attach to part of the parietal pelvic fascia below the tendinous arch (arcus tendoneus fascia). Cure rates are up to 85%.
Complications of retropubic suspension procedures
•Urinary retention (5%)
•Bladder overactivity
•Vaginal prolapse
1 Jarvis GJ (1994). Stress incontinence. In Mundy AR, Stephenson TP, Wein AJ (Eds.), Urodynamics: Principles, Practice and Application, 2nd ed. New York: Churchill-Livingstone, pp. 299–326.