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145

F. R. Pérez-López (ed.), Postmenopausal Diseases and Disorders,

https://doi.org/10.1007/978-3-030-13936-0_9

G. Capobianco (*) · P. L. Cherchi · S. Dessole

Department of Medical, Surgical and Experimental Sciences,

University of Sassari, Gynecologic and Obstetric Clinic, Sassari, Italy

e-mail: capobia@uniss.it; pcherchi@uniss.it; dessole@uniss.it

Management ofFemale Stress Urinary

Incontinence

GiampieroCapobianco, PierLuigiCherchi,

andSalvatoreDessole

9.1 Introduction

Urinary incontinence is dened as a condition of involuntary loss of urine [1]. The

three most common types of urinary incontinence are the following: stress urinary

incontinence (SUI), characterized by an inadvertent loss of urine occurring as a

result of an increase of intra-abdominal pressure due to effort or exertion or on

sneezing or coughing; urge urinary incontinence (UUI), denoting involuntary leak-

age arising for no apparent reason and associated by urgency; and mixed urinary

incontinence (MUI), when both are occurring. According to Hunskaar etal. [2], the

prevalence and distribution of the types of urinary incontinence in noninstitutional-

ized women are 49%, 21% and 29%, respectively.

SUI has a prevalence between 10 and 40% of the female population, especially

in the postmenopausal age, and has a negative impact on the quality of social, work-

ing and affective life of the patients [2]. The wide prevalence range of urinary incon-

tinence, in general, depends on the denitions used in clinical studies (if the loss of

involuntary urine takes several times in a day or week or if you consider the last

12months), from the methodology (telephone interviews, questionnaires shipped at

home) and in differences between the populations considered in the world.

The objective of this chapter is to report the current state of the art and new thera-

pies on the management of female stress urinary incontinence.

https://t.me/med1917

146

9.2 Methods ofSearch Strategy

A detailed literature research on MEDLINE, Cochrane Library, EMBASE, NLH,

ClinicalTrials.gov and Google Scholar databases was done up to July 2017 with

restriction to English language about articles regarding SUI, medical therapy, surgi-

cal therapy and most recent treatment options. The keywords used for this review

were female stress urinary incontinence, midurethral sling, tension-free vaginal tape

(TVT) and transobturator tape (TOT, TVT-O). Original articles, reviews and meta-

analysis were included. Studies including exclusively devices no longer available

on the market at the date of the review were excluded. Disagreements among authors

as to the studies to include were solved by discussion. In cases of duplication, the

study with the most recent data was included. In case of cohort studies with multiple

publications, the last dataset on efcacy was used.

9.3 Pathogenesis ofStress Urinary Incontinence

Urinary continence is the result of the synergy between the structures that constitute

the pelvic oor and the sympathetic nervous component, parasympathetic and the

motor bres of the pudendal nerves. An alteration of one or both components leads

to an inability of the urethra to counteract increases in abdominal pressure resulting

in loss of urine during physical exercises, even minimal in the most severe cases.

Factors that may promote the onset of the SUI are age, parity, especially vaginal

delivery and obesity as they can facilitate the onset of a weakening of the pelvic

oor support structures resulting in urethral hypermobility. The nerve component

may affect both bladder and urethral innervation. Even in this case, advanced age,

previous pregnancy and parity may inuence this mechanism of urinary continence

following the stretching or compression of nerves during the passage of the foetus

in the birth canal [3, 4].

9.4 Assessment andInvestigation of Female

Urinary Incontinence

The initial clinical evaluation is the categorization of the woman’s urinary inconti-

nence (UI) as SUI, mixed UI or urgency UI/overactive bladder (OAB) because the

initial treatment starts on this basis. According to NICE guidelines, if stress incon-

tinence is the predominant symptom in mixed UI, we should discuss with the

woman the benet of conservative management including OAB drugs before offer-

ing surgery [5].

Before the use of supervised pelvic oor muscle training for the treatment of UI,

routine digital assessment to conrm pelvic muscle contraction is mandatory.

Women with UI who have symptomatic prolapse that is visible at or below the vagi-

nal introitus should be referred to a specialist [5].

All women with UI should undertake a urine dipstick test to detect the presence

of blood, glucose, protein, leucocytes and nitrites in the urine. If a woman does not

G. Capobianco et al.

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147

have symptoms of urinary tract infections (UTI) and her urine tests are negative for

either leucocytes or nitrites, a urine sample for culture is not necessary because she

is unlikely to have UTI [5].

Women should complete a minimum of 3-day bladder diaries covering variations

in their usual activities, such as both working and leisure days [5].

Assessment of post-void residual urine by bladder scan or catheterization in

women with symptoms suggestive of voiding dysfunction or recurrent UTI is good

clinical practice as initial evaluation.

In women with UI, the indications for consideration for referral to a specialist

service include persistent bladder or urethral pain, clinically benign pelvic masses,

associated faecal incontinence, suspected neurological disease, symptoms of void-

ing difculty, suspected urogenital stulae, previous continence surgery, previous

pelvic cancer surgery and previous pelvic radiation therapy [5].

9.5 Conservative Treatment ofStress Urinary Incontinence

Figure 9.1 shows the rst management of urinary incontinence in women and Fig.9.2

the specialized management according to the European Association Urology (EAU)

guidelines [6]. Recently, among the main care options are included exercises aimed

at restoring the strength and muscle tone of the pelvic oor and oestrogenic therapy

with the possibility to also associate the administration of Lactobacillus acidophilus

in a triple therapy that has proven to be effective as the rst therapeutic step [7].

Figure9.3 shows the care pathway of SUI in women. Multichannel urodynamic test-

ing (MUT) should not be performed before starting conservative management [5].

Lifestyle interventions regard reduction of caffeine intake in women with OAB

and advise women with UI, who have BMI >30, to lose weight. Adsorbent products,

urinals and toileting aids should not be considered as a treatment for UI but should

be used only as an adjunct to ongoing therapy and long-term management of UI

only after treatment options have been explored.

We should offer pelvic oor muscle training to women in their rst pregnancy as

preventive strategy for UI [5].

A multidisciplinary team (MDT) for urinary incontinence should include at least

the following healthcare professionals: a urogynaecologist, a urologist with a sub-

specialist interest in female urology, a specialist nurse, a specialist physiotherapist

and a colorectal surgeon with a subspecialist interest in functional bowel problems.

The MDT should inform any woman wishing to consider surgical treatment for UI

on the benets and risks of non-surgical and surgical options and their provisional

plan [5].

9.5.1 Drugs forStress Urinary Incontinence

Duloxetine has been approved in Europe for treatment of SUI.The adverse effects

include mental health problems and suicidality. Duloxetine was effective for SUI in

women, but the rates of associated harms outweighed the benets [8].

9 Management ofFemale Stress Urinary Incontinence

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148

HISTORY

Incontinence on

physical activity

CLINICAL

ASSESSMENT

PRESUMED

DIAGNOSIS

STRESS INCONTINENCE

presumed due to sphincteric

incompetence

MIXED INCONTINENCE

(treat most bothersome symptom first)

TREATMENT

* subject to local

regulatory approval

Incontinence with

mixed symptoms

Incontinence or frequency,

with or without urgency

incontinence

“Complicated” incontinence:

• Recurrent incontinence

• Incontinence associated with :

Pain

Haematuria

Recurrent infections

Voiding symptoms

Pelvic irradiation

Radical pelvic surgery

Suspected fistula

OVERACTIVE BLADDER (OAB)

with or without URGENCY

INCONTINENCE presumed due to

detrusor overactivity

If abnormality found e.g:

• Significant post void residual

• Significant pelvic organ

prolapse

• Pelvic mass

• General assessment

• Urinary symptom assessment (including frequencey-volume chart and questionnaire)

• Assess quality of life and desire of treatment

• Physical examination: abdominal, pelvic and perineal

• Cough test to demonstrate stress incontinence if appropriate

• Urine analysis  urine culture: if infected treat and reassess

When appropriate:

• Assess estrogen status and treat as needed

• Assess voluntary pelvic floor muscle contraction

• Assess post-void redisual function

• Life style interventions

• Pelvic floor muscle training for SUI or OAB

• Bladder retraining for OAB

• Duloxetine* (SUI) or Antimuscarinic (OAB Urgency incontinence)

• Other adjuncts, such as electrical stimulation

• Vaginal devices, urethral insercts

Failure

SPECIALISED MANAGEMENT

Fig. 9.1 First management of urinary incontinence in women [6]

G. Capobianco et al.

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149

HISTORY/SYMPTOMS

ASSESSMENT

CLINICAL

ASSESSMENT

DIAGNOSIS

URODINAMYCS STRESS

INCONTINENCE (USI)

DETRUSOR

OVERACTIVITY

INCONTINENCE (DOI)

Bladder outlet

obstruction

Underactive

detrusor

Correct anatomical

bladder outlet

obstrution (e.g

genito-urinary

prolapse)

Lower urinary tract

anomaly or pathology

INCONTINENCE

Associated with poor

bladder emptying

TREATMENT

Incontinence on

physical activity

Incontinence with

mixed symptoms

Incontinence with

urgency/frequency

“Complicated” incontinence:

• Recurrent incontinence

• Incontinence associated with :

Pain

Haematuria

Recurrent infections

Voiding symptoms

Pelvic irradiation

Radical pelvic surgery

Suspected fistula

• Assess for pelvic organ mobility/prolapse

• Consider imaging of the urinary tract/pelvic floor

• Urodynamics

CONSIDER

• Urethrocystoscopy

• Futher imaging

• Urodynamics

• Intermittent

catheterisation

• Correct anomaly

• Treat pathology

If initially therapy fails:

Stress incontinence surgery

• Bulking agents

• Tapes and slings

• Colposuspension

• Artificial urinary sphincter

If initially therapy fails:

• Botulinum toxin

• Neuromodulation

• Bladder augmentation

MIXED INCONTINENCE

(USI/DOI)

Treat most bothersome

symptoms first

Fig. 9.2 Specialized management of urinary incontinence in women [6]

9 Management ofFemale Stress Urinary Incontinence

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150

Furthermore, the UK National Institute for Health and Care Excellence guideline

states that duloxetine should not be used as a rst-line treatment or routinely offered

as a second-line treatment for stress urinary incontinence, given that pelvic oor

muscle training is more effective and less costly than duloxetine and that surgery is

more cost-effective than duloxetine [5].

9.5.2 Laser Therapy

Now, laser therapy has been introduced in the non-invasive treatment of the SUI,

already used in the gynaecological eld for the treatment of vaginal disorders typi-

cally associated with menopause (vaginal atrophy). The lasers used in the gynaeco-

logical eld are mainly of two types, the CO

laser and the vaginal erbium ER:YAG

laser (VEL) (so-called because it uses an erbium-doped yttrium-aluminium-garnet

medium, (YAG)), which, although not having a microablative function as CO

lasers, can induce changes in genital tissues that can induce benet both in cases of

vaginal dryness and dyspareunia and in the treatment of mild and moderate SUI.This

type of laser can be used in the SUI therapy with a signicant reduction of the symp-

toms reported by the patients [9–12]. The mechanism of action is attributed to the

remodelling, which occurs due to a thermogenic effect of the collagen that consti-

tutes the pelvic oor; with menopause a drastic reduction in the amount produced

occurs thus resulting in the decrease of its physiological function of support causing

not only urinary incontinence but also facilitating the onset or aggravation of the

prolapse of the genital organs. The thermogenic effect is such that it induces in the

target tissues a neoangiogenesis, neoformation of collagen, increased epithelial

thickness and the content of cellular glycogen thus ensuring greater support for the

Women with stress urinary

incontinence (SUI)

Lifestyle modifications, pelvic floor rehabilitation

and local therapy for at least 3 months in mild SUI

Laser therapy in mild-moderate SUI

Surgical therapy with midurethral sling

Bulking agents in patients whit comorbidities

that preclude surgery

In moderate to severe SUI:

first step local therapy and pelvic floor rehabilitation

for at least 3 months.

When failure, depending on patient condition:

Care pathway of female Stress Urinary Incontinence (SUI)

• Characterisation severity of the condition

• Careful medical history

• Exclude UTI, diabetes

• Quality of life assessment and bladder diaries

• Urodynamics

Fig. 9.3 Care pathway of female stress urinary incontinence

G. Capobianco et al.

https://t.me/med1917

151

urethra. All these changes of the tissues are detectable for at least 6months after

treatment [10]. The rst studies on laser therapy in the SUI are due to Fistonic etal.

[11] who evaluated through the questionnaire “Incontinence Questionnaire—

Urinary Incontinence Short Form” (ICIQ-UI SF) the efcacy and safety of the

ER:YAG showing that even in severe SUI, there was a signicant improvement in

symptomatology, without any particular adverse events being recorded. The ef-

cacy of the treatment is already visible after a single session, further increasing after

three sessions with benets lasting for at least the next 6months [11]. Although

there are not currently enough studies investigating the efcacy of the use of laser

in the long term, it appears clear that this represents a therapeutic option that can be

developed in the future, minimally invasive for the patient, and with objective ben-

ets demonstrated, not only with regard to the SUI but the whole spectrum of symp-

toms of the genitourinary syndrome of menopause (GSM). A study of Gambacciani

etal. [12] evaluated the effects of ER:YAG lasers on the symptoms associated with

menopause, demonstrating how patients reported subjective benets, conrmed

objectively by the measurements of VHIS (Vaginal Health Index Score), demon-

strating above all how it is a practice very well tolerated by patients with a possibil-

ity of results achievable quickly and long lasting, up to 24weeks [12]. According to

this study, the ER:YAG treatment is indicated in all those women who present not

only the classic symptoms associated with menopause, such as dryness and vaginal

atrophy, but also in the treatment of mild- moderate SUI in those women who cannot

benet from hormonal treatments as is the case of patients with history of previous

breast cancer [12].

9.5.3 Combination Therapy: Vaginal Topical Medical Therapy

andPelvic Floor Rehabilitation

Signicant importance has vaginal topical medical therapy, since oestrogens, which

in menopause see a physiological and drastic reduction of their levels, have receptors

throughout the genitourinary tract and on the pelvic oor musculature [13].

Oestrogens have an important role in the mechanism of urinary continence since they

affect the synthesis of collagen; their topical (vaginal) administration can also act by

reducing the frequency and amplitude of the detrusor contractions, thus increasing

the sensory threshold of the bladder and promoting relaxation of the detrusor muscle

[14]. These oestrogen-dependent mechanisms explain why, with the fall of their val-

ues after the menopause, disorders of the urogenital apparatus including the SUI

become so frequent. Oestrogenic therapy, in particular estriol, has been extensively

demonstrated in literature as being of valid aid in the treatment of urogenital disor-

ders [15]; it also is free of proliferative effect on the endometrium. Intravaginal local

therapy with estriol has proven to be effective in the therapy of urogenital atrophy,

recurrent infections of the low urinary tract and the SUI in postmenopausal women

[16, 17], especially when combined with exercises aimed at the muscular toning of

the pelvic oor, a combination that is very well tolerated by the patients [17]. But the

effects of combination therapy are only marginal and perhaps not long lasting.

9 Management ofFemale Stress Urinary Incontinence

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152

Pelvic oor muscle training should be done for at least 3months’ duration as

rst-line treatment to women with stress or mixed UI; pelvic oor muscle training

programmes should comprise at least eight contractions performed three times per

day. Electrical stimulation and/or biofeedback should be considered in women who

cannot actively contract pelvic oor muscles in order to aid motivation and adher-

ence to therapy [5].

9.6 Evaluation ofUncomplicated Stress Urinary

Incontinence inWomen Before Surgical Treatment

Counselling about treatment should begin with conservative options. According to

the Committee Opinion of American College of Obstetricians and Gynecologists

(ACOG), the evaluation before primary surgery in women with symptoms of SUI

includes six steps: (1) history; (2) urinalysis; (3) physical examination; (4) demon-

stration of incontinence (cough stress test; if stress test is negative, despite patient

symptoms of SUI, multichannel urodynamic testing is recommended); (5) assess-

ment of urethral mobility (cotton swab test; patients who lack urethral mobility may

be better candidates for urethral bulking agents rather than sling procedures); and

(6) measurement of post-void residual urine volume [18]. Table 9.1 shows basic

evaluation ndings for uncomplicated versus complicated SUI.

9.7 Multichannel Urodynamic Testing

Preoperative multichanel urodynamic testing (MUT) is not necessary before plan-

ning primary anti-incontinence surgery in women with uncomplicated SUI, as indi-

cated by observed urinary leakage from the urethra by provocative stress measures,

a normal urinalysis result (without urinary tract infection), no POP beyond the

hymen and a normal post-void residual urine volume. However, women who have

complicated SUI (Table9.1) may benet from MUT before initiation of treatment,

especially surgery [18].

MUT and voiding cystometry should be performed before surgery, after under-

taking a detailed clinical history and examination, in women who have symptoms of

OAB leading to a clinical suspicion of detrusor overactivity or symptoms suggestive

of voiding dysfunction or anterior compartment prolapse or had previous surgery

for stress incontinence [5].

Videourodynamics should be proposed if diagnosis is unclear after conventional

urodynamics [5].

9.8 Surgical Therapy

The surgery, by techniques such as the retropubic colposuspension by Burch [19],

one of the most widely used until about 15years ago (with abdominal approach in

the past while laparoscopic nowadays), the anterior colporrhaphy by Kelly, or the

G. Capobianco et al.

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153

suspension with needle, is now mostly replaced by the new minimally invasive sur-

gical techniques of midurethral slings (MUSs) including the tension-free vaginal

tape and retropubic (TVT) and the transobturator (TVT-O) tape. Another therapeu-

tic option is the injection of urethral bulking agents (UBAs).

We have not included in this review retropubic colposuspension by Burch or

autologous fascial slings because there have been no recent high-quality publica-

tions relating to these surgical procedures.

Table 9.1 Basic evaluation ndings for uncomplicated versus complicated female stress urinary

incontinence

Evaluation

Findings

Uncomplicated Complicated

History

UI associated with

involuntary loss of urine on

effort, physical exertion,

sneezing or coughing

Symptoms of urgency, incomplete emptying,

incontinence associated with chronic urinary

retention, functional impairment or

continuous leakage

Absence of recurrent

urinary tract infection

No prior extensive pelvic

surgery. No prior surgery

for SUI

Recurrent urinary tract infection

Previous extensive or radical pelvic surgery

(e.g. radical hysterectomy)

Prior anti-incontinence surgery or complex

urethral surgery (e.g. urethral

diverticulectomy or urethrovaginal stula

repair)

Absence of voiding

symptoms

Presence of voiding symptoms

Absence of medical

conditions that can affect

lower urinary tract function

Presence of neurologic disease, poorly

controlled diabetes mellitus or dementia

Physical

examination

Absence of vaginal bulge

beyond the hymen on

examination. Absence of

urethral abnormality

Symptoms of vaginal bulge or known pelvic

organ prolapse beyond the hymen conrmed

by physical examination, presence of

genitourinary stula or urethral diverticulum

Urethral

mobility

assessment

Presence of urethral

mobility

Absence of urethral mobility

Post-void

residual urine

volume

<150mL

≥150mL

Urinalysis/

urine culture

Negative result for urinary

tract infection or haematuria

Table modied from: Committee Opinion. Obstet Gynecol 2014; 123(6): 1403-7 [

18]

A complete list of the patient’s medications should be obtained to determine whether individual

drugs may be inuencing the function of the bladder or urethra, which leads to urinary inconti-

nence or voiding difculties

Recurrent tract urinary infection is dened as three documented infections in 12 months or two

documented infections in 6 months

Hesitancy, slow stream, intermittency, straining to void, spraying of urinary stream, feeling of

incomplete voiding, need to immediately revoid, postmicturition leakage, position-dependent mic-

turition, and dysuria

9 Management ofFemale Stress Urinary Incontinence

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