Urinary incontinence (UI) is defined by the International Continence Society as “the complaint of any involuntary loss of urine.” UI is a worldwide health problem that can significantly diminish an individual’s quality of life. On a societal scale, the economic burden is great, with the total direct and indirect cost of UI in the United States in the year 2000 estimated to be greater than $10 billion.
UI is more common in women than in men. It has an increasing prevalence during young adult life, a broad peak around middle age, and then a steady increase in elderly women. Although variable, the prevalence of severe incontinence among most studies is estimated to be between 6% and 11%. The proportion of types of incontinence varies with age. In young and middle-aged women, stress incontinence predominates, and in older women mixed incontinence is most common. Over all age groups, stress incontinence is most common (49%) followed by mixed incontinence (29%) and pure urge incontinence (21%).
Signs and Symptoms
- Stress urinary incontinence: is the complaint of involuntary leakage on exertion or with sneezing or coughing.
- Urge urinary incontinence: is the complaint of involuntary leakage accompanied by or immediately preceded by a sudden compelling desire to urinate which is difficult to defer. Typically, this is described by patients as having a strong, sudden urge to urinate followed by running to get to the nearest bathroom, but often not making it in time, which may result in leakage of urine or complete bladder emptying.
- Mixed urinary incontinence: is a combination of stress and urge incontinence.
- History: symptoms, duration, risk factors, impact on quality of life, medical history including previous surgeries, medications, allergies, and review of symptoms.
- Physical exam: includes abdominal exam, pelvic examination paying special attention to vaginal support and urethral mobility, rectal exam, and limited neurologic examination.
- Urinalysis/urine culture: analysis of urine to rule other causes of urinary symptoms such as a urinary tract infection.
- Post void residual: a measurement of the volume retained in the bladder after a patient voids.
- Intake/voiding/incontinence diary: a patient maintained diary measuring the amount of fluid consumed in a 24 hour period, the type of fluid, the number of voids, the volume of each void, the number of incontinence episodes, and related symptoms such as urinary urgency and pain.
- Quality of life questionnaires: are validated assessments of the impact of urinary incontinence on a patient’s quality of life.
- Pad testing: A pad is used to absorb lost urine during a predetermined length of time or after specific activities. The change in pad weight is an objective measurement of the severity of urinary incontinence and/or and may be used to assess the outcome of an intervention.
- Urodynamics: is a test used to assess the storage and emptying ability of the bladder.
- Cystourethroscopy: is an endoscopic evaluation of the urethra, bladder outlet, and bladder. This is used to rule out an anatomic or mucosal abnormality that may be contributing to urinary symptoms. This is most commonly done in the office.
A number of treatments are available for the management of stress urinary incontinence.
- Synthetic midurethral slings are the most commonly performed surgical procedure for the treatment of stress urinary incontinence and currently would be considered the “gold standard” treatment. This is a minimally invasive operation which is performed on an outpatient basis. This can be performed via a retropubic or a transobturator approach via a vaginal incision and either lower abdominal or groin incisions. In these procedures a strip of polypropylene mesh is place underneath the urethra in a tension free manner. Success rates range from 60-90% and appear to relatively similar in either approach. Presurgical testing may be helpful in determine the best sling approach for any individual patient. The success rates for these procedures do diminish over time like all procedures for UI, however, the long term results available are acceptable. There is some suggestion that elderly and obese patients have slightly worse outcomes than their younger and nonobese cohorts. Some of the potential complications of the procedure include vaginal mesh extrusions, urethral erosions, bladder injury, bleeding, injury to adjacent organs, infection, and voiding dysfunction.
- Injection of a periurethral bulking agent is one of the least invasive options. This procedure consists of the endoscopic injection of a urethral bulking agent into the region of the proximal urethra/bladder neck.. This can be performed under local anesthesia or under sedation as an outpatient procedure. This causes a coaptation of the urethral mucosa thereby increasing outlet resistance. Early outcomes show an approximately 25% cure, 50% improvement, and 25% failure rate. Duration of effect is variable and not permanent. Reinjections will be necessary to maintain efficacy with the timing of this being patient dependent. Urethral bulking agent therapy may be ideally suited for patients who are high risk surgical patients, those wishing to defer or avoid more invasive surgery, and those in whom surgery has failed.
- Autologous fascial slings and retropubic suspensions are also alternative treatments. These are typically performed in specific cases of urethral reconstruction and with concomitant abdominal surgery. They have a long history of reasonable efficacy, but are more invasive than other approaches available.