Stress Urinary Incontinence Management in the Patient With Overactive Bladder

Purpose of the Review

Mixed urinary incontinence is a common diagnosis that has significant impact on patient quality of life and can be more bothersome to patients compared to pure stress incontinence. Given the complexity of concomitant stress incontinence and overactive bladder symptoms, mixed urinary incontinence can often present as a clinically challenging scenario for treating physicians across different subspecialties and primary care medicine. In this review, we discuss the importance of a judicious evaluation and the utility of deciphering stress-predominant versus urge-predominant urinary incontinence in patients with concomitant symptoms.

Recent Findings

The temporal relationship between stress incontinence and urgency symptoms has been explored in recent literature. Although a common pathway has been alluded, characterization of the predominant symptom is essential in treating this difficult diagnosis. As suggested in recent guidelines, emphasis should be placed on setting appropriate patient goals of care and discussing treatment expectations in order to best optimize patient satisfaction and patient-reported treatment success. Risks, benefits, and alternatives for both stress urinary incontinence and overactive bladder treatment options should be reviewed, yet there is lack of a standardized approach in the literature.

Summary

We outline a sequential algorithm to help guide patient counseling, management, and appropriate expectations for treatment of mixed urinary incontinence.

     

Evaluation,Treatment and Management of Urinary Incontinence in Patients with Orthotopic Neobladder

Patients who undergo radical cystectomy for bladder cancer require reconstruction of the lower urinary tract. Orthotopic neobladder in carefully selected patients offers a more physiologic way of voiding. However, daytime and nighttime incontinence are commonly seen in male and female patients following surgery. Evaluation of incontinence requires careful history and physical exam to differentiate stress urinary incontinence from neobladder-vaginal fistula or poorly compliant neobladder with hypercontinence. Treatment of incontinence in patients with ONB may include: placement of retropubic sling, artificial urinary sphincter, or repair of fistula when present.     

Evaluation and Management of Neurogenic Stress Urinary Incontinence

Neurogenic bladder is a broad term that encompasses many different types of neurologic diseases and a wide spectrum of dysfunction of the lower urinary tract. Patient with neurogenic stress urinary incontinence (SUI) have poor urine store storage due to outlet dysfunction. Office examination, cystoscopy, video urodynamics (UDS), and renal imaging all play an important role in evaluating these patients (Wyndaele et al. Neurourol Urodyn. 2009;29:662-669 [27]). Based on patients’ overall function, bladder capacity and compliance, and ability to void or perform clean intermittent catheterizations, outlet procedures such as slings and artificial urinary sphincters may be offered safely (Arun Sahai et al. Curr Urol Rep. 2011;12:404-412 [28??]). Other options for partial or complete urinary diversion exist for patients with limited residual function or low capacity bladders. Improving continence in this population can positively impact quality of life and help with issues such as skin break down and chronic infection from incontinence (Ku. BJU Int. 2006;98:739-745 [26]).     

Use of Injectable Urethral Bulking Agents in the Management of Stress Urinary Incontinence

The use of injectable bulking agents is a well-established approach to management of patients with stress urinary incontinence (SUI). No single bulking agent to date has been shown to be superior or consistently durable in the literature. Novel therapeutic strategies, including the use of injectable, muscle-derived stem cell therapy, have shown promising results in investigational stages. Urethral bulking agent therapy can be helpful in the early management of men with SUI following radical prostatectomy, and in women with SUI due to intrinsic sphincter deficiency, urethral hypermobility, or in the setting of failed midurethral sling placement. Despite their widespread use historically, biocompatible agents have been supplanted in recent years by synthetic agents secondary to their potentially improved durability and nonimmunogenic profiles.     

Evaluation of Stress Predominant Urinary Incontinence

Urodynamic studies (UDS) have been used to objectively characterize a patient’s complaint of urinary incontinence. Presumably, the clinician can utilize the UDS data to guide treatment options. It is even hoped that UDS can help predict which treatments should be utilized to produce the most effective outcomes. However, is this currently the case? The Urinary Incontinence Treatment Network (UITN) has completed four large randomized clinical trials related to treatments for urinary incontinence. Two trials compared outcomes of different surgeries for stress urinary incontinence (SUI) in which standardized UDS protocols were used. Secondary analyses of these UDS data showed that UDS were neither prognostic of treatment outcomes nor correlative with severity of UI symptoms, suggesting limited utility of UDS in the evaluation and management of the uncomplicated SUI patient. A third trial was designed to answer whether a basic office examination is not noninferior to UDS in affecting SUI surgical outcomes. The results of this study are currently in press. A fourth trial examined treatment of urgency urinary incontinence (UUI). Because UDS was not part of this trial, the utility of UDS in management and treatment of UUI could not be assessed. In summary, UDS will need to undergo further refinements to increase its clinical effectiveness in the area of urinary incontinence.     

Management of Recurrent Stress Urinary Incontinence After Failed Mid-Urethral Sling Placement

Purpose of Review

Our objective is to review the current literature on recurrent stress urinary incontinence after mid-urethral sling placement, focusing on evidence-based management considerations for this complex clinical problem.

Recent Findings

Conservative, minimally invasive surgical therapies are currently available for management of persistent or recurrent SUI after a previous mid-urethral sling (MUS).

Summary

Our review of the literature does not show a clear benefit of one approach over others and emphasizes that the ideal management for these complex patients should be determined using an individualized approach with a detailed discussion of patient symptoms, past surgical history, and goals. For symptomatic patients who are surgical candidates and desire intervention, trans-urethral bulking agents, repeat retropubic (RP) MUS, or salvage autologous pubovaginal (PV) sling appear to be the most well-described management strategies.

     

Patient Reported Goal Achievement Following the Midurethral Sling Procedure for Female Stress Urinary Incontinence

Objectives: Patient perspective is very important for evaluating surgical outcomes. We investigated patient reported goal achievement, overall satisfaction and objective outcome following the midurethral sling (MUS) procedure for female stress urinary incontinence (SUI). Methods: The study prospectively enrolled 88 SUI patients who underwent the MUS procedure between August 2006 and December 2006. Patient examination included medical history, physical examination and an urodynamic study prior to surgery. Before surgery, patients were shown a list and asked to nominate one goal which they most wanted to achieve with surgery (i.e., the target goal). The goals were classified as: symptom‐related, daily life‐related, personal relationship‐ and emotion‐related, and others. Before and after the surgery, patients completed a Bristol Female Lower Urinary Tract Symptom‐Short Form questionnaire. At 1 year postoperatively, patients were assessed in terms of achievement of the target goal, overall satisfaction and cure rate. Results: At the 1‐year follow‐up, overall target goals were achieved in 90.1% of patients, 82 (93.2%) patients were satisfied with the treatment, and 82 (93.2%) patients were cured. For most patients, the target goals were symptom‐related (47 patients, 53.4%). The patients whose goal achievement was less than overall goal achievement were significantly less satisfied than those who fully achieved their goal, and goal achievement was also related to objective cure. Conclusion: Achievement of patient goals was high and could be a good measure of surgical success following MUS for female SUI.     

Stress Urinary Incontinence in Women with Neurogenic Lower Urinary Tract Dysfunction

Purpose of Review

The purpose of this review is to discuss the pathophysiology of neurogenic SUI in the female patient, examine the evidence supporting surgical and non-surgical treatment options, and outline our recommendations for the care of this population.

Recent Findings

AFPVS appears to be more efficacious than MUS for this group; however, almost all patients will require self-catheterization after surgery. MUS have a higher probability of maintaining spontaneous voiding but also care the risk mesh complications and higher failure rates. Bladder neck AUS placement may also be considered, but most studies show high reoperation rates and have only a few female subjects. In severe refractory cases of SUI or in the setting of urethral erosion, bladder neck closure has been shown to have good continence outcomes.

Summary

SUI in the setting of neurogenic lower urinary tract dysfunction is often more severe and harder to address than non-neurogenic SUI, due in part to the high rates of ISD in this population. Patients should be screened for other causes of urinary incontinence with UDS prior to any invasive interventions. AFPVS is an appropriate first-line therapy for these patients, particularly in individuals who already perform self-catheterization. Finally, in the setting of moderate to severe urethral erosion, bladder neck closure or urinary diversion should be strongly considered.

     

Evaluation and Management of Urinary Retention and Voiding Dysfunction After Sling Surgery for Female Stress Urinary Incontinence

Female urethral sling surgery is the most common procedure performed to treat stress urinary incontinence with cure rates in excess of 85?%. In a small minority of patients however, postoperative voiding dysfunction develops, in the form of: urinary retention; high post-void residual; poor urinary flow; urinary frequency; urinary urgency; urinary urge incontinence; or pelvic pain. This article reviews the occurrence of voiding dysfunction after sling surgery and outlines the current evaluation and management of patients with these complaints.     

Stress Urinary Incontinence in Women with Neurogenic Voiding Dysfunction

Female neurogenic sphincteric incontinence is a complex and debilitating condition. Stress urinary incontinence in this population is complicated by mixed urinary incontinence caused by functional and structural anomalies, which impacts upon management options. Patients require a full incontinence work-up, including a comprehensive history and physical examination, renal imaging, and videourodynamics. Understanding personal and physical limitations in addition to patient goals of treatment is tantamount in choosing the appropriate course of care. Options range from conservative therapy (behavioral modification) and clean intermittent catheterization with pharmacotherapy to invasive surgical options (bladder neck closure and urinary diversion). Before increasing sphincteric resistance, it is imperative to confirm that the bladder reservoir is well-balanced and filling under safe pressures. The risk of chronic urinary retention following treatment of the sphincter is high in this population. Much of the literature on this topic is anecdotal. Prospective studies comparing treatment options for neurogenic sphincteric incontinence within this population are needed.     

The Role of Urodynamics in Women with Stress Urinary Incontinence

Objective: To examine the role of urodynamic (UDS) investigations in women with stress urinary incontinence (SUI).Methods: Emphasis will be placed on indications for UDS assessment as well as UDS techniques and findings which apply to women with this condition. Topics such as female bladder outlet obstruction (BOO), the utility of urethral pressure (P_ure) and valsalva leak point pressure (VLPP) measurements, and the prognostic value of UDS in this patient population will also be explored.Results: Noninvasive uroflowmetry (NIF), post-void residual (PVR) measurement, filling cystometrogram (CMG), valsalva leak point pressure (VLPP) and pressure-flow studies (PFS) can provide the urologist with a wealth of information which may be used to refine treatment decisions in complex cases of female urinary incontinence. The utility of P_ure measurements in the pre- and postoperative work-up of stress incontinent women does not appear to be supported by the majority of urologic and urogynecologic studies to date.Conclusion: Prospective randomized controlled trials to evaluate the clinical efficacy, cost-effectiveness and effect on quality of life of a full pre-operative UDS assessment compared to a less invasive, more accessible basic office evaluation in different populations of women with SUI need to be conducted before any firm conclusion can be drawn regarding the superiority of one of these clinical approaches over the other.     

Slings for Stress Urinary Incontinence in Men: An Update

Stress urinary incontinence is usually caused by iatrogenic injury during prostate cancer surgery. Most treatment options are surgical in nature and include periurethral bulking, artificial urinary sphincter, and male slings. During the past decade, innovations in male sling surgery have contributed to an increased interest in their use among treating urologists and their patients. Currently, male slings are most efficacious in men with mild to moderate stress incontinence, with no prior history of pelvic radiation, and without prior artificial sphincter placement. In this population, high efficacy rates and low complication rates are typically achieved.     

Influence of Preoperative Detrusor Underactivity on the Continence Rate and Satisfaction after Midurethral Sling Patient with Stress Urinary Incontinence

Objectives: We studied the influence of preoperative detrusor underactivity in patients with stress urinary incontinence on the postoperative continence rates and patient satisfaction. Methods: Medical records of 41 female patients who had detrusor underactivity and had undergone a midurethral sling procedure with a follow up of at least 12 months were reviewed. The preoperative evaluation included a history taking, physical examination, voiding diary for 3 days and an urodynamic study. Detrusor underactivity was defined at pressure flow study by a maximal flow rate (Q_max) less than 15 mL/sec and a detrusor pressure at maximal flow rate (P_detQ_max) less than 20 cmH₂O. The postoperative evaluation included a continence state, questionnaire regarding patient satisfaction (5: very satisfied, 1: very unsatisfied), uroflowmetry and residual urine volume. Results: The mean patient age was 52.9 (range 39–68) years. Preoperatively, mean Q_max was 12.6 ± 2.1 mL/sec, mean residual urine volume was 16.1 ± 32.3 mL and mean P_detQ_max was 13.1 ± 4.7 cmH₂O. Postoperative continence rate was 88% (36/41). Five patients experienced minimal incontinence when they coughed violently. The amount of patients satisfied with postoperative status was 71%. Postoperatively, three patients needed medication with alpha blocker because of voiding difficulty. There was significant differences between preoperative and postoperative Q_max (13.1 ± 0.9 mL/sec vs 17.1 ± 0.9 mL/sec, P < 0.05). In addition postoperative residual urine volume (26.1 ± 27.9 mL) was significantly increased compared to the preoperative residual urine volume (16.1 ± 32.3 mL) (P < 0.05). Conclusion: Midurethral sling can be done safely for the patients with stress urinary incontinence and detrusor underactivity. However, the evaluation of preoperative detrusor function is important since the therapeutic outcome and postoperative voiding pattern may be affected by detrusor underactivity.     

Risk Factors for De Novo Mixed Urinary Incontinence and Stress Urinary Incontinence Following Surgical Removal of a Urethral Diverticulum

Objectives: The aim of the present study was to investigate the risk factors for the development of de novo stress urinary incontinence (SUI) and mixed urinary incontinence (MUI) after surgical removal of a urethral diverticulum (UD). Methods: We identified 35 consecutive women that underwent surgical removal of a UD between November 2002 and December 2009, and we retrospectively reviewed their medical records, including patient demographics, pelvic magnetic resonance imaging (MRI), presenting symptoms related to voiding, and outcomes. Results: Among the 35 patients we identified, 28 were included in the study. After UD removal, five of the 28 patients (17.8%) developed de novo MUI, and four of the 28 patients (14.2%) developed de novo SUI. The incidences of SUI and MUI were significantly higher in patients who had a UD that measured over 3 cm in diameter and in patients in whom the UD was located in the proximal urethra. Of the seven patients with a diverticulum over 3 cm, SUI occurred in three (42.8%) (P = 0.038) and MUI occurred in five (45.4%) (P < 0.001). Of the 11 patients with a diverticulum located in the proximal urethra, SUI occurred in five (45.4%) (P = 0.011) and MUI occurred in four (36.4%) (P = 0.011). Conclusion: Significant risk factors for the development of SUI and MUI after transvaginal simple diverticulectomy include a UD measuring over 3 cm and a UD located in the proximal urethra.     

Evaluation and Management of Urgency and Urge Urinary Incontinence in Men

The overactive bladder (OAB) syndrome is increasingly being recognized as a major contributor to the lower urinary tract symptoms in men previously thought to be only due to bladder outlet obstruction from benign prostatic hyperplasia. Medical and surgical treatments that have historically been used to treat women with OAB are being applied to men with great efficacy and a good safety profile. Additionally, treatments such as the β-3 agonist mirabegron, phosphodiesterase-5 inhibitors, sacral and peripheral neuromodulation, and intravesical botulinum toxin injection are promising emerging therapies for the OAB syndrome. This review discusses the evaluation of the male patient with OAB symptoms such as urgency and urge incontinence, and explores the different therapeutic options available for management of men with OAB.