Nima Baradaran, MD
Samuel Walker Nickles, MD
Eric S. Rovner, MD, FACS
BASICS
DESCRIPTION
• Stress urinary incontinence (SUI) is subjectively defined by the International Continence Society as the“the complaint of involuntary leakage on effort or exertion, or on sneezing or coughing” (1)
• Urinary incontinence (UI) should be further described by specifying: Type, frequency, severity, precipitating factors, social impact, effect on hygiene and quality of life, the measures used to contain the leakage and whether or not the individual seeks or desires help because of urinary incontinence (1)
EPIDEMIOLOGY
Incidence
Annual incidence of any type of new UI ranges from 3 to 11% and increases with age, with approximately 50–70% attributed to SUI alone or in association with urge incontinence (mixed urinary incontinence or MUI)
Prevalence
∼30% of women aged 30 to 60 have urinary incontinence, with approximately 50–70% attributed to SUI with or without urge urinary incontinence (UUI). Significant variation is seen in specific populations, eg, community dwelling vs. long-term facility occupants, and nulliparous vs. postpartum females.
RISK FACTORS
Aging, obesity, smoking, pregnancy, and child birth
Genetics
Deficient collagen structures
PATHOPHYSIOLOGY
• Anatomical: Weakness of urethral supportive structures (vaginal wall and surrounding connective tissue) leads to hypermobility and loss of urethral compression (1)
• Intrinsic sphincter deficiency: Loss of intrinsic urethral closure, coaptation, and function
• Neurologic: Rarely, loss of spinal sympathetic reflex and/or pudendal nerve efferents leading to relaxation of the extrinsic and intrinsic closure forces of the urethra.
ASSOCIATED CONDITIONS
• Chronic cough, COPD, obesity
• Pelvic organ prolapse (cystocele, rectocele) and/or anal incontinence
• 40% of women with urethral sphincter incompetence will have a cystocele
• Occult incontinence: Urethral sphincteric incompetence masked by the presence of pelvic prolapse
GENERAL PREVENTION
See treatment
DIAGNOSIS
HISTORY
• Subjective characterization of UI (aggravating factors)
• Duration of symptoms
• Impact on life
• Daytime vs. nocturnal UI
• Urinary frequency, urgency, nocturia
• UTI history
• Pad use
• Past medical/surgical history
– Neurologic conditions (Parkinson, MS, back surgery, etc.)
– Medical conditions (DM, dementia, etc.)
– Radiation and trauma
– Gynecologic history (parity, hormonal status)
– Previous pelvic surgery
• Medications (sympatholytics and diuretics)
PHYSICAL EXAM
• Focused pelvic exam and evaluation of estrogen status (urethral caruncle/prolapse and labial adhesions indicate deficiency)
• Cough stress test to visualize and confirm SUI
• Evaluation of urethral position and mobility
• Presence of pelvic organ prolapse
• Neurologic exam: Gait, cognitive status, sensation, motor, and reflexes (bulbocavernous reflex)
• Digital rectal exam
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Urinalysis
• Routine renal function evaluation unnecessary
Imaging
Diagnosis is mainly based on history and physical exam
Diagnostic Procedures/Surgery
• Postvoid residual measurement
• Voiding diary
• Quality-of-life questionnaires
• Pad test
– A preweighed sanitary pad is examined after a defined period of time
– 1-g increase in weight = 1 mL of urine
The International Continence Society: Weight change of <1 g during its standardized 1-hr test to be negative.
• Cystoscopy in the presence of urinary urgency, hematuria, UTI, or other irritative symptoms, particularly if they have previously undergone a previous anti-incontinence procedure, pelvic radiation, or pelvic prolapse repair
• Urodynamics indicated especially in patients who have failed previous pelvic floor reconstruction or with mixed incontinence, urinary urgency, or obstructive symptoms, and in those who have elevated PVRs or neurologic disease
Pathologic Findings
• Sphincter muscle deficiency is the main pathology.
• SUI may occur in the absence of urethral hypermobility.
DIFFERENTIAL DIAGNOSIS
• Enuresis means any involuntary loss of urine. If it is used to denote incontinence during sleep, it should always be qualified with the adjective “nocturnal”
• Fistula: Vesicovaginal, urethrovaginal
• Mixed urinary incontinence (MUI) is the complaint of involuntary leakage associated with urgency and also with exertion, effort, sneezing, or coughing
• Neurogenic bladder (CNS and spinal cord lesions)
• Pelvic organ prolapse
• Polyuria/polydipsia
• Potentially reversible conditions (DIAPERS):
– Drugs
– Infection
– Atrophic vaginitis
– Psychological (depression, delirium, dementia)
– Endocrine (hyperglycemia, hypercalcemia)
– Restricted mobility
– Stool impaction
• Situational incontinence: eg, the report of incontinence during sexual intercourse, or giggle incontinence.
• Urethral abnormalities (diverticulum)
• Urge vs. stress vs. overflow incontinence
– Urge urinary incontinence: Involuntary leakage accompanied by or immediately preceded by urgency
• Urinary leakage may need to be distinguished from sweating or vaginal discharge
• Urinary tract infection
• Vaginal voiding
TREATMENT
GENERAL MEASURES
• Initial therapy includes behavioral modification and pelvic floor exercise
• Lifestyle modifications
• Weight loss, smoke cessation, moderation of fluid intake, caffeine and/or alcohol
MEDICATION
First Line
• Treatment for pure SUI is generally nonpharmacologic in US.
– However medication may be indicated in MUI when predominant symptoms of OAB or urge incontinence coexist and in such cases antimuscarinic therapy is utilized (see Section I “Overactive Bladder”).
Second Line
• In rare cases an α-adrenergic receptor agonist (phenylpropanolamine) or tricyclic antidepressant (imipramine) may be utilized but this is an off-label use.
• Duloxetine is a serotonin and norepinephrine reuptake inhibitor approved for major depression and other indications and is approved for treatment of SUI in Europe but not in US.
SURGERY/OTHER PROCEDURES
• Surgery is the single most effective long-term treatment (2,3)
• Suburethral slings:
– Midurethral slings:
Currently these are the procedure of choice for primary surgical treatment of SUI
Made from synthetic material (mesh)
As effective as other surgical therapies but associated with less operative time and shorter convalescence rate
3 types include: Retropubic including tension-free vaginal tape (TVT), transobturator, single incision (“mini-sling”)
– Bladder neck (proximal urethral) sling generally fashioned from autologous rectus abdominis fascia or fascia lata (leg)
• Transurethral injectable bulking agents
• Retropubic colposuspension (Burch procedure)
• Artificial urinary sphincter
– Rarely used in US and only reserved for patients with severe intrinsic sphincter deficiency
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
• Behavioral therapy (4)
– Patient education
– Fluid and dietary management
– Timed voiding
– Patient compliance and periodic reinforcement are essential
• Pelvic floor muscle training (PFMT)
– Strong pelvic floor contraction increases intraurethral pressure against increased intra-abdominal pressure
– Inhibits detrusor contractions
• Adjunctive measures for PFMT
– Vaginal cones and weights
– Biofeedback: Helps patients identify and isolate correct pelvic muscles
– Pelvic floor electrical stimulation
– Magnetic therapy
• Intra- or extraurethral and intravaginal support and occlusive devices (pessaries, plugs, urethral inserts, etc.)
Complementary & Alternative Therapies
N/A
ONGOING CARE
PROGNOSIS
• Nonsurgical therapy can be effective in carefully selected, highly motivated, and compliant individuals and in such individuals may improve symptoms and subsequent quality of life in up to 50–80% of mild–moderate cases.
• Excellent outcomes are expected with the use of 1st-line surgical options in uncomplicated patients with all degrees of SUI with success rates in excess of 85–90% at 5–10 yr of follow-up.
COMPLICATIONS
• Untreated SUI may result in skin rash and chronic irritation
• Complications of sling procedures include: Urethral/bladder perforation, mesh exposure in the vagina and erosion into the urinary tract, voiding dysfunction (due to obstruction), UTI, pain, and dyspareunia
• Vaginal, urethral, and intravesical erosion of the midurethral slings is a particularly feared complication
• Vascular injury or intestinal perforations are rare and associated with slings, as well as open abdominal approaches.
FOLLOW-UP
Patient Monitoring
Conservative management requires regular reinforcement and education
Patient Resources
National Association for Continence. http://www.nafc.org
REFERENCES
1. Abrams P, Cardozo L, Fall M, et al. The standardization of terminology of lower urinary tract function: Report from the Standardization Sub-committee of the International Continence Society. Neurourol Urodyn. 2002;21(2):167–178.
2. Dmochowski RR, Blaivas JM, Gormley EA, et al. Update of AUA guideline on the surgical management of female stress urinary incontinence. J Urol. 2010;183(5):1906–1914.
3. Rovner ES, Lebed BD. Stress incontinence surgery: Which operation when? Curr Opin Urol. 2009;19(4):362–367.
4. Dumoulin C, Hay-Smith J. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev. 2010;(1):CD005654.
ADDITIONAL READING
• Burgio KL, Locher JL, Goode PS, et al. Behavioral vs drug treatment for urge urinary incontinence in older women: A randomized controlled trial. JAMA. 1998;280(23):1995–2000.
• Ogah J, Cody JD, Rogerson L. Minimally invasive synthetic suburethral sling operations for stress urinary incontinence in women. Cochrane Database Syst Rev. 2009;(4):CD006375.
See Also (Topic, Algorithm, Media)
• ICIQ (International Consultation on Incontinence Questionnaire), ICIQ-MLUTS
• Incontinence Impact Questionnaire (IIQ-7)
• Incontinence, Urinary, Adult Female
• Pad Test
• SEAPI Incontinence Classification System
• Stress Urinary Incontinence, Female Images 
• Urge Incontinence
• Urinary Retention Following Stress Incontinence Surgery
CODES
ICD9
625.6 Stress incontinence, female
ICD10
N39.3 Stress incontinence (female) (male)
CLINICAL/SURGICAL PEARLS
• It is imperative to distinguish different types of urinary incontinence in female.
• Lifestyle modification and conservative treatment is the 1st step in management.
• Midurethral slings are the standard surgical treatment and are highly effective in properly selected patients.