The condition of urinary incontinence is a common problem that dramatically alters the life of men and women affected. These patients may avoid social events or otherwise change their lifestyle because of their requirements to wear pads to collect urinary leakage and concern that leakage of urine may be noticeable by odor or appearance. Fortunately, most individuals with urinary incontinence can have the cause identified and effectively treated today. In rare cases, incontinence may reflect a medical condition that can affect health such as bladder cancers.

Incontinence and Voiding Dysfunction: What's New, 2001

Etiology & evaluation

Vaginal delivery of a child and simple hysterectomy have been identified as potential causative factors of female urethral dysfunction. Morgan et al. (2000) found intrinsic sphincter deficiency in 48% of patients after hysterectomy versus 24% of control patients. Chaliha et al. (2000) found no difference in the prevalence of stress incontinence or detrusor instability before and after delivery. In a comparison of valsalva and cough-induced leak-point pressure evaluation, Peschers et al. (2000) found that cough and valsalva elicited different pelvic floor responses. However, the increase in pressure is so rapid with cough that this measurement may not be as accurate as valsalva leak-point pressure evaluations. A study of general practitioners treating women for incontinence suggested that urodynamic test results have limited value (Holtedahl et al., 2000). However, general practitioners have limited treatment options, so full knowledge of the underlying bladder dysfunction is not as important as it is for urologists evaluating patients referred for evaluation. Blaivas et al. (2000) proposed urodynamic criteria for definition of bladder outlet obstruction in women with LUTS. They defined women with peak flow < 12 mL/second and maximum detrusor pressures > 20 cm as obstructed without validation.

The pathophysiology of post-prostatectomy incontinence has been variably reported as being due to bladder or sphincteric problems. This issue was evaluated in a retrospective review of 83 men after radical retropubic prostatectomy by Groutz et al (2000.) They showed that sphincteric incontinence was the most common urodynamic finding in these patients although other conditions may co-exist. Of note, 30% of men had very low urethral compliance, which was nearly synonymous with urethral scarring associated with surgery.

Sacral nerve stimulation

A novel treatment for detrusor overactivity, sacral nerve stimulation, has recently been evaluated by a number of authors. The process of test stimulation followed by permanent implantation of sacral root (S3) electrodes for incontinence electrodes was described by Janknegt et al. (2001.) Klingler et al. (2000) suggested in a urodynamic study of 11 women and 4 men that the benefits of this treatment were related to afferent stimulation of S3, resulting in reflex inhibition of the peripheral S3 nerve and subsequent relief of urgency-frequency symptoms. Hassouna et al. (2000) reported a multi-center trial of 51 patients treated for urgency-frequency with a dramatic decrease in the number of voids per day, increase in the volume per void and relief of the degree of urgency. Other trials of 14 and 30 patients were reported by Chartier-Kastler et al. (2001) and Edlund et al. (2000) with good overall results. In most series, patient results are reported as pooled urodynamic studies. The chance of an individual patient having a long-term response to this treatment in published literature is not clear. A multi-center trial of 53 patients with overactive bladder reported by Govier et al. (2001) who applied stimulation not to S3, but to the tibial nerve. They noted that 71% of treated patients were improved and were then candidates for permanent implant placement. Sacral nerve stimulation has also been applied for 177 patients with urinary retention refractory to standard therapy (Jonas et al., 2001.) A total of 69% of patients were able to eliminate catheterization at 6 months, with sustained improvement after 18 months of treatment.

Surgical treatment

Sling/suspension procedures for stress urinary incontinence and cystocele are accepted approaches in treatment of these conditions. Tension-free vaginal mesh repair was applied for grade III cystocele repair in 12 women with grade I recurrence in 3 patients. No evidence of erosion, fistula formation or pelvic infection was seen (Migliari et al., 2000.) Weber et al. (2000) compared Burch and sling procedures for stress urinary incontinence in a decision analytic model based on literature review. The overall effectiveness of the Burch procedure was 94.8% with 95.3% for the sling procedures. Complications of the development of detrusor instability or retention had potential limits to the benefits of these procedures. Choe et al. (2000) presented data on 40 consecutive women randomized to synthetic antimicrobial mesh versus vaginal wall sling. No episodes of retention or erosion occurred. The satisfaction rate was 100% for the mesh-treated patients and 80% for the vaginal wall sling patients. Although they are not widely accepted as appropriate clinical treatments any longer, Stamey and Gittes procedures for stress incontinence were compared in a long-term (mean 8.4 year follow-up) study (Nigam et al., 2000.) Progressive decreases in the proportion of successfully treated patients were seen after these procedures with 92-94% dry at 3 months, 38-64% at 1 year and 14-38% at 5 years. These results reflect why Stamey & Gittes procedures should not be applied for management of stress urinary incontinence except in rare cases where patients could not tolerate more involved procedures.

Medical therapy

Initial treatment of the overactive bladder usually involves anticholinergic medications. Treatment effectiveness is often limited by side effects. The development of controlled-release medications was an attempt to limit these side effects while maintaining effectiveness. A trial of controlled-release versus immediate-release oxybutinin suggested that complications (moderate-to-severe dry mouth) were less with controlled-release drugs, whereas efficacy was maintained (Versi et al., 2000.) A novel treatment for detrusor hyperreflexia is intravesical resiniferatoxin, a capsaicin analog. Twenty-four treatments were provided to 14 patients with significant effectiveness and was found to be only minimally irritative (Silva et al., 2000.)

Other treatments

Submucosal collagen injections into periurethral tissue have been applied for stress urinary incontinence in women. Groutz et al. (2000), in a retrospective review of patients referred for tertiary treatment and using a rigorous definition of curative response, reported that only 13% of patients were classified as cured with treatment. A complete failure rate of 20% was seen. Other patients had partial responses. These poor results reflect the relatively low effectiveness of the treatment but also the patient population treated and the rigorous criteria for response applied. Madjar et al. (2000) reported on the long term follow-up of women with urinary retention managed with an intraurethral insert that contains a valve and pump mechanism activated by an external magnetic device. Fifty-six percent of treated patients had the device removed acutely (average 6 days). All patients who maintained the device long term were very satisfied with it. Occasional migration of the device (4 patients), symptomatic UTI (4 patients), dyspareunia (1 patient), and asymptomatic bacteriuria (15 patients) were noted.

The options for bladder management of quadriplegic men was reported by Mitsui et al. (2000.) Their results suggested that use of a chronic suprapubic catheter was associated with a lower rate symptomatic urinary tract infection, higher rate of renal calculus, and higher rate of bladder calculus formation relative to chronic urethral catheterization. The authors suggested that suprapubic catheterization is a viable option for patients with spinal cord injury.

Complications

Clemens et al. (2000) reviewed 14 patients who experienced pubovaginal sling erosion. They recommended that any patient with pain or vaginal discharge after pubovaginal sling should be evaluated for erosion. Evaluation should consist of physical examination and/or cystoscopy. After removal of the sling, about half of the patients will develop recurrent stress incontinence. Urinary retention was studied after surgery for stress urinary incontinence in ten women. A significant component of failure to relax the external urethral sphincter was seen initially in 6 patients, but all patients were able to void within 14 days (Fitzgerald & Brubaker, 2001.)