Berek and Novak's Gynecology 15th Ed.

26 Lower Urinary Tract Disorders

Shawn A. Menefee

Ingrid Nygaard

Lewis Wall

• Bladder storage and emptying depend on a complex interplay between the brain, spinal cord, bladder, urethra, and pelvic floor.

• Urinary incontinence is common in women and generally is treated successfully with a range of nonsurgical and surgical treatments.

• Stress urinary incontinence occurs with increases in abdominal pressure (such as coughing, running, lifting) and can be treated with pelvic muscle exercises, vaginal devices, lifestyle changes, and surgery.

• Urgency urinary incontinence occurs with a sudden sense of urgency (such as on the way to the bathroom or when washing hands) and can be treated with bladder training, medications, lifestyle changes, and neuromodulation.

• Bladder pain remains a challenging and poorly understood entity.

Physiology of Micturition

The bladder is a complex organ that has a relatively simple function: to store urine effortlessly, painlessly, and without leakage and to discharge urine voluntarily, effortlessly, completely, and painlessly. To meet these demands, the bladder must have normal anatomic support and normal neurophysiologic function.

Normal Urethral Closure

Normal urethral closure is maintained by a combination of intrinsic and extrinsic factors. The extrinsic factors include the levator ani muscles, the endopelvic fascia, and their attachments to the pelvic sidewalls and the urethra. This structure forms a hammock beneath the urethra that responds to increases in intra-abdominal pressure by tensing, allowing the urethra to be closed against the posterior supporting shelf (Fig. 26.1). When this supportive mechanism becomes faulty for some reason—the endopelvic fascia has detached from its normal points of fixation, muscular support has weakened, or a combination of these two processes—normal support is lost and anatomic hypermobility of the urethra and bladder neck develops. For many women, this loss of support is severe enough to cause loss of closure during periods of increased intra-abdominal pressure, resulting in stress incontinence. However, many women remain continent in spite of loss of urethral support (1).

Figure 26.1 Lateral view of the pelvic floor drawn from a three-dimensional reconstruction with the urethra, vagina, and fascial tissues transected at the level of the vesical neck. Note how the urethra is compressed against the underlying supportive tissues by the downward force (arrow) generated by a cough or sneeze. (From Delancey J. Structural support of the urethra as it relates to stress urinary incontinence: the hammock hypothesis. Am J Obstet Gynecol 1994;170:1718, with permission.)

The intrinsic factors contributing to urethral closure include the striated muscle of the urethral wall, vascular congestion of the submucosal venous plexus, the smooth muscle of the urethral wall and associated blood vessels, the epithelial coaptation of the folds of the urethral lining, urethral elasticity, and the tone of the urethra as mediated by α-adrenergic receptors of the sympathetic nervous system.

Effective urethral closure is maintained by the interaction of extrinsic urethral support and intrinsic urethral integrity, each of which is influenced by several factors (muscle tone and strength, innervation, fascial integrity, urethral elasticity, coaptation of urothelial folds, urethral vascularity). In the clinical setting, damaged urethral support is manifested clinically by urethral hypermobility, which often results in incompetent urethral closure during physical activity and presents as stress urinary incontinence. Intrinsic urethral functioning is more complicated and is not understood nearly as well as incontinence related to loss of urethral support (2).

Clinical appreciation of the importance of extrinsic support and intrinsic urethral function led to the separation of stress incontinence into two broad types:

1. Incontinence caused by anatomic hypermobility of the urethra

2. Incontinence caused by intrinsic sphincteric weakness or deficiency

Surgical approaches are based on this arbitrary distinction, with a pubovaginal sling recommended for women with intrinsic sphincter deficiency and a colposuspension (also known as retropubic urethropexy) for those with hypermobility. This rationale was based initially on a small study in which women younger than age 50 years with urethral closure pressure less than 20 cm H₂O had a higher failure rate after a Burch colposuspension than did women with a closure pressure greater than 20 cm H₂O (3). No difference in outcome was seen in women older than 50 years. This dichotomy was called into question, based on the observation that all women with stress incontinence have some degree of sphincter weakness, regardless of whether they have hypermobility. Minimally invasive synthetic midurethral slings have largely replaced pubovaginal slings and retropubic urethropexy as the most commonly performed surgical procedures for stress urinary incontinence. The use of midurethral slings would seem to lessen the impact of a poorly functioning urethra; however, a similar debate is ongoing about the impact of poor urethral function with both retropubic and transobturator slings. It appears that women with poor urethral function are more likely to experience treatment failure irrespective of the type of procedure performed (4).

The Bladder

The bladder is a bag of smooth muscle that stores urine and contracts to expel urine under voluntary control. It is a low-pressure system that expands to accommodate increasing volumes of urine without an appreciable rise in pressure. This function appears to be mediated primarily by the sympathetic nervous system. During bladder filling, there is an accompanying increase in outlet resistance. The bladder muscle (the detrusor) should remain inactive during bladder filling, without involuntary contractions. When the bladder has filled to a certain volume, fullness is registered by tension-stretch receptors, which signal the brain to initiate a micturition reflex. This reflex is controlled by cortical control mechanisms, depending on the social circumstances and the state of the patient’s nervous system. Normal voiding is accomplished by voluntary relaxation of the pelvic floor and urethra, accompanied by sustained contraction of the detrusor muscle, leading to complete bladder emptying.

Innervation

The lower urinary tract receives its innervation from three sources: (i) the sympathetic and (ii) parasympathetic divisions of the autonomic nervous system, and (iii) the neurons of the somatic nervous system (external urethral sphincter). The autonomic nervous system consists of all efferent pathways with ganglionic synapses that lie outside the central nervous system. The sympathetic system primarily controls bladder storage, and the parasympathetic nervous system controls bladder emptying. The somatic nervous system plays only a peripheral role in neurologic control of the lower urinary tract through its innervation of the pelvic floor and external urethral sphincter.

The sympathetic nervous system originates in the thoracolumbar spinal cord, principally T11 through L2 or L3 (see Chapter 6). The ganglia of the sympathetic nervous system are located close to the spinal cord and use acetylcholine as the preganglionic neurotransmitter. The postganglionic neurotransmitter in the sympathetic nervous system is norepinephrine, and it acts on two types of receptors: α-receptors, located principally in the urethra and bladder neck, and β-receptors, located principally in the bladder body. Stimulation of α-receptors increases urethral tone and thus promotes closure, whereas α-adrenergic receptor blockers have the opposite effect. Stimulation of β-receptors decreases tone in the bladder body.

The parasympathetic nervous system controls bladder motor function—bladder contraction and bladder emptying. The parasympathetic nervous system originates in the sacral spinal cord, primarily in S2 to S4, as does the somatic innervation of the pelvic floor, urethra, and external anal sphincter. Sensation in the perineum is also controlled by sensory fibers that connect with the spinal cord at this level. For this reason, examination of perineal sensation, pelvic muscle reflexes, and pelvic muscle or anal sphincter tone is relevant to clinical evaluation of the lower urinary tract. The parasympathetic neurons have long preganglionic neurons and short postganglionic neurons, which are located in the end organ. Both the preganglionic and postganglionic synapses use acetylcholine as their neurotransmitter, acting on muscarinic receptors. Because acetylcholine is the main neurotransmitter used in bladder muscle contraction, virtually all drugs used to control detrusor muscle overactivity have anticholinergic properties.

Bladder storage and bladder emptying involve the interplay of the sympathetic and parasympathetic nervous systems. The modulation of these activities appears to be influenced by a variety of nonadrenergic, noncholinergic neurotransmitters and neuropeptides, which fine tune the system at various facilitative and inhibitory levels in the spinal cord and higher areas of the central nervous system (5–7). Neuropathology at almost any level of the neurourologic axis can have an adverse effect on lower urinary tract function.

Micturition

Micturition is triggered by the peripheral nervous system under the control of the central nervous system. It is useful to consider this event as occurring at a micturition threshold, a bladder volume at which reflex detrusor contractions occur. The threshold volume is not fixed; rather, it is variable and can be altered depending on the contributions made by sensory afferents from the perineum, bladder, colon, rectum, and input from the higher centers of the nervous system. The micturition threshold is, therefore, a floating threshold that can be altered or reset by various influences.

The spinal cord and higher centers of the nervous system have complex patterns of inhibition and facilitation. The most important facilitative center above the spinal cord is the pontine-mesencephalic gray matter of the brainstem, often called the pontine micturition center, which serves as the final common pathway for all bladder motor neurons. Transection of the tracts below this level leads to disturbed bladder emptying, whereas destruction of tracts above this level leads to detrusor overactivity. The cerebellum serves as a major center for coordinating pelvic floor relaxation and the rate, force, and range of detrusor contractions, and there are multiple interconnections between the cerebellum and the brainstem reflex centers. Above this level, the cerebral cortex and related structures exert inhibitory influences on the micturition reflex. Thus, the upper cortex exerts facilitative influences that release inhibition, permitting the anterior pontine micturition center to send efferent impulses down the complex pathways of the spinal cord, where a reflex contraction in the sacral micturition center generates a detrusor contraction that causes bladder emptying.

A normal lower urinary tract is one in which the bladder and urethra store urine without pain until a socially acceptable time and place arises, at which point voiding occurs in a coordinated and complete fashion. Lower urinary tract disorders include disorders of storage (such as urinary incontinence), emptying (such as urinary hesitancy and retention), and sensation (such as urgency or pain). Current definitions for these disorders are depicted in Table 26.1.

Table 26.1 Classification and Definition of Lower Urinary Symptoms in Women

I. Abnormal Storage

Incontinence (symptom) The complaint of any involuntary leakage of urine

Stress urinary incontinence (symptom) The complaint of involuntary leakage on effort or exertion, or on sneezing or coughing

Stress urinary incontinence (sign) Observation of involuntary leakage from the urethra, synchronous with exertion/effort, or sneezing or coughing

Urgency urinary incontinence (symptom) The complaint of involuntary loss of urine associated with urgency

Mixed incontinence Complaint of involuntary loss of urine associated with urgency and also with effort or physical exertion or on sneezing or coughing

Continuous urinary incontinence Complaint of continuous involuntary loss of urine

Frequency The number of voids per day, from waking in the morning until falling asleep at night

Increased daytime urinary frequency Complaint that micturition occurs more frequently during waking hours than previously deemed normal by women (traditionally defined as more than seven episodes)

Nocturia Complaint of interruption of sleep one or more times because of the need to micturate (each void is preceded and followed by sleep)

Nocturnal enuresis Complaint of involuntary loss of urine that occurs during sleep

Urgency Compliant of sudden, compelling desire to pass urine, which is difficult to defer

Postural urinary incontinence Compliant of involuntary loss of urine associated with change of body position, for example, rising from a seated or lying position

Insensible urinary incontinence Compliant of urinary incontinence where the women has been unaware of how it occurred

Coital incontinence Compliant of involuntary loss of urine with coitus. This symptoms might be further divided into that occurring with penetration or intromission and that occurring at organism.

Overactive bladder syndrome (OAB) Urinary urgency, usually accompanied by frequency and nocturia, with or without urgency urinary incontinence, in the absence of urinary tract infection or other obvious pathology

II. Abnormal Sensory Symptoms

Increased bladder sensation Complaint that the desire to void during bladder filling occurs earlier or is more persistent from that previous experienced (differs from urgency by the fact that micturition can be postpone despite the desire to void)

Reduced bladder sensation Complaint that the definite desire to void occurs later than that previously experienced, despite an awareness that the bladder is filling

Absent bladder sensation Complaint of both the absence of the sensation of bladder filling and a definite desire to void

III. Abnormal Emptying

Hesitancy Compliant of a delay in initiating micturition

Straining to void Complaint of the need to make an intensive effort (by abdominal straining, Valsalva or suprapubic pressure) to initiate, maintain, or improve urinary stream

Slow stream Complaint of a urinary stream perceived as slower compared to previous performance or in comparison with others

Intermittency Complaint of urine flow that stops and starts on one or more occasions during voiding

Feeling of incomplete bladder emptying Complaint that the bladder does not feel empty after micturition

Postmicturition leakage Complaint of a further involuntary passage of urine following the completion of micturition

Spraying of urinary stream Complaint that the urine passage is a spray or split rather than a single discrete stream

Position-dependent micturition Complaint of having to take specific positions to be able to micturate spontaneously or to improve bladder emptying, for example, leaning forward or backward on the toilet seat or voiding in a semistanding position

Urinary retention Complaint of the inability to pass urine despite persistent effort

From Haylen BT, de Ridder D, Freeman RM, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) Joint Report on the terminology for female pelvic floor dysfunction. Neurourol Urodyn 2010;29:4–20, with permission.

Urinary Incontinence

Definitions

Defining urinary incontinence would seem an easy task: women who leak urine must be “incontinent.” A joint report from the International Urogynecological Association and the International Continence Society made recommendations on the terminology of female pelvic floor dysfunction in an attempt to update the definitions by a female-specific approach and clinically based consensus. This report defined incontinence as “the complaint of any involuntary leakage of urine” (8). This definition does not take into account the wide variation in this symptom and the disruption it causes. For example, half of young nulliparous women report occasional minor urine leakage; for most this is neither a bother nor a symptom for which they would seek treatment. At the other extreme, 5% to 10% of adult women have severe leakage daily. These women often dramatically alter their lives because of leakage, curtailing activities, social outings, and intimacy. Many suffer marked deterioration in self-esteem. In between these two extremes lies another one-third of adult women who report leakage at least weekly, but without the same degree of life-altering severity as the women previously noted.

Collectively, these women assume a substantial cost burden. The total annual cost to care for patients with incontinence in the United States is estimated at $11.2 billion in the community and $5.2 billion in nursing homes (9). In the United States, much of this cost is borne directly by women in the form of incontinence pads and excess laundry costs. Despite the burden imposed by leakage, many women do not discuss this symptom with a health care professional. For some women, this is because the leakage does not bother them, whereas others are embarrassed and suffer in silence. Still others do not raise this issue because they mistakenly believe the only treatment option is surgical. It is incumbent on the provider to ask women about leakage.

Studies show that there is little relationship between the volume of urine lost and the distress that it causes a patient (10). The degree to which women are bothered by leakage is influenced by various factors, including cultural values and expectations regarding urinary continence and incontinence. If the leakage is distressing to the patient, evaluation and treatment should be offered. Incontinence can almost always be improved and frequently can be cured, often using relatively simple, nonsurgical interventions.

Types of Disorders

Stress Urinary Incontinence

Stress urinary incontinence occurs during periods of increased intra-abdominal pressure (e.g., sneezing, coughing, or exercise) when the intravesical pressure rises higher than the pressure that the urethral closure mechanism can withstand. Some advocate the term “activity-related incontinence” in some languages to avoid the confusion with psychological stress (8). Stress urinary incontinence is the most common form of urinary incontinence in women and is particularly common in younger women. Active women are more likely to notice symptoms of stress urinary incontinence. In a survey of 144 collegiate female varsity athletes, 27% reported stress incontinence while participating in their sport (11). The activities most likely to produce urinary loss were jumping, high-impact landings, and running.

Stress incontinence is an interesting “disease” as the same symptoms have varying effects on different women. This condition is best considered in a biobehavioral model that examines the interaction of three variables: (i) the biologic strength of the urethral sphincteric mechanism, (ii) the level of physical stress placed on the closure mechanism, and (iii) the woman’s expectations about urinary control. This model explains the enormous variation that exists among the symptoms, the degree of demonstrable leakage, and a patient’s response to her stress incontinence.Modification of any one of these factors may influence the patient’s clinical status; for example, many patients give up certain physical activities (e.g., running, dancing, aerobics) when they experience stress incontinence. Limiting their activities may eliminate the incontinence problem, but it does so at a certain cost to their quality of life. Other women learn to cope with stress incontinence by adopting new body postures during physical activities that prevent them from leaking or by strengthening their pelvic muscles to compensate for increased exertion. Other women may be profoundly relieved to find out that the small amount of leakage they experience from time to time is not abnormal. In any case, the interaction of these three biopsychosocial factors opens up a variety of strategies for the management of stress incontinence. Surgical intervention is only one strategy, and it addresses only the biologic competence of the sphincteric mechanism rather than either of the other factors that interact to produce the clinical problem.

Urgency Urinary Incontinence and Overactive Bladder

Although stress incontinence is the most common type of urinary continence in all women, urgency incontinence is the most common form of incontinence in older women (12). Urgency urinary incontinence is the involuntary leakage of urine accompanied by or immediately preceded by urgency. The new joint report from the International Urogynecological Association and International Continence Society recommended this symptom be called urgency urinary incontinence to differentiate between the normal urge experienced when the bladder is full from the abnormal response that may require treatment. This is a symptom-based diagnosis; the cause may or may not be detrusor overactivity, based on urodynamic observation characterized by involuntary detrusor contractions during the filling phase.

Women may have other related problems such as urgency, nocturia, and increased daytime frequency. The definition of nocturia is quantifiable: The woman wakes one or more times a night to void (8). Increased daytime frequency occurs when the patient considers that she voids too often. The term pollakisuria is used to describe this condition in many countries.

Urgency is the sudden compelling desire to pass urine that is difficult to defer. Most women have experienced these symptoms during times of voluntary delays in voiding or increased fluid intake. However, urinary urgency implies more than just the feeling that all normal women have if they voluntarily delay voiding beyond a reasonable time (8). When a woman presents for treatment, she generally reports an intrusive, bothersome, persistent need to urinate that takes her attention away from other activities. Increased daytime frequency is often brought up as an issue when a woman experiences a change in her own voiding pattern.

There is very little information about what is “normal” in terms of voiding frequency. Overactive bladder (OAB) is frequently defined in studies of pharmacologic agents as more than eight voids per 24 hours, a definition that was based on the 95th percentile of voids in a small sample of Scandinavian women (13). Data from a broader sample of women in the United States suggest that the median number of voids per day is eight, and 95% of so-called normal women void 12 or fewer times per day (14).

Overactive detrusor function is defined as a urodynamic diagnosis characterized by involuntary detrusor contractions during the filling phase, which may be spontaneous or provoked. It is divided into neurogenic detrusor overactivity, resulting from a relevant neurologic condition and idiopathic detrusor overactivity, when there is no clear cause (15).

The term overactive bladder syndrome is defined as urinary urgency, usually accompanied by frequency and nocturia, with or without urgency urinary incontinence, in the absence of urinary tract infection or other obvious pathology (8). It is often referred to as OAB-dry when women with these symptoms do not leak urine, and OAB-wet when it is accompanied by incontinence. It is important to note that a woman with severe urgency and a sense of impending leakage who remains dry may have the exact same bladder pathology as one with severe urgency and concomitant leakage. A woman with a strong urethral sphincteric mechanism may be able to avoid leakage during uninhibited bladder contractions, and although one with a strong sphincter may remain dry, she still may be disturbed by the urgency and impending sense of leakage.

Mixed Incontinence

As implied by the name, women with mixed incontinence have symptoms of both stress and urge urinary incontinence. Younger women are more likely to have stress incontinence alone, whereas in older women mixed and urge incontinence predominate. In a review of 15 population-based studies of women of all ages with urinary incontinence, a median of 49% (range 24% to 75%) had stress urinary incontinence, 21% (range 7% to 49%) had urge urinary incontinence, and 29% (range 11% to 61%) had mixed urinary incontinence (16).

Functional and Transient Incontinence

Functional incontinence is more common in elderly women and refers to incontinence that occurs because of factors unrelated to the physiologic voiding mechanism. A woman who cannot get to the bathroom quickly enough may often become incontinent. Functional incontinence can be related to such factors as decreased mobility, musculoskeletal pain, or poor vision. Factors leading to transient urinary incontinence are, as the name implies, medically reversible conditions. A useful mnemonic to help remember these factors is DIAPPERS (17,18) (Table 26.2). These factors argue strongly for the inclusion of a thorough medical evaluation as part of the workup of any patient with urinary incontinence.

Table 26.2 Reversible Causes of Incontinence

D Delirium

I Infection

A Atrophic urethritis and vaginitis

P Pharmacologic causes

P Psychological causes

E Excessive urine production

R Restricted mobility

S Stool impaction

From Resnick NM, Yalla SV. Management of urinary incontinence in the elderly. N Engl J Med 1985;313:800–805, with permission.

Extraurethral Incontinence

Although most urinary incontinence represents unwanted urine loss through the urethra (transurethral incontinence), urine loss can also occur through abnormal openings. These openings can be created by congenital defects or some form of trauma. The congenital causes of urinary incontinence are not common and usually are easy to diagnose. The most extreme cases are caused by bladder exstrophy, in which there is a congenital absence of the lower anterior abdominal wall and anterior portion of the bladder, resulting in the entire bladder opening directly to the outside (19). Such cases are diagnosed at birth. Before the advent of modern reconstructive surgery, these infants usually died very early in life from sepsis.

Ectopic ureter, a subtle congenital anomaly causing extraurethral urine loss, generally is detected early in life, but occasionally may escape detection until adolescence or early adulthood (20). In infancy, an ectopic ureter should be suspected when a mother seeks care for her baby, whom she says is never dry. Normally, infants have periods of dryness interspersed with periods of wetness. Most commonly, the ectopic ureter drains into the vagina, but occasionally, it may drain into the urethra distal to the point of continence. This condition can be diagnosed by excretory urography.

A traumatic opening between the urinary tract and the outside is called a fistula. Vesicovaginal fistulas, located between the bladder and urethra, are most common, but fistulas may occur between the vagina, uterus, or bowel, and the urethra, ureter, or bladder.

Worldwide, the most common cause of vesicovaginal fistulas is obstructed labor. This was true in the Western world 150 years ago, but advances in the provision of basic obstetric services and advanced obstetric intervention have virtually eliminated this problem in developed countries.

Obstructed labor can occur in rural areas where girls are married young (sometimes as early as 9 to 10 years of age) and where transportation is poor and access to medical services is limited. In such circumstances, pregnancy often occurs shortly after menstruation begins and before maternal skeletal growth is complete. When labor begins, cephalopelvic disproportion is common and little can be done to correct fetal malpresentations. Women may be in labor as long as 5 to 6 days without intervention, and if they survive, they usually give birth to a stillborn infant. In such cases, the soft tissues of the pelvis are crushed by constant pressure from the fetal head, leading to an ischemic vascular injury and subsequent tissue necrosis. When this tissue sloughs, a genitourinary or rectovaginal fistula develops. Many of these patients have complex or multiple fistulas, involving total destruction of the urethra and sloughing of the entire bladder base (Fig. 26.2). Obstetric fistulas are frequently as large as 5 to 6 cm in diameter.

Figure 26.2 Moderate-sized obstetric vesicovaginal fistula. A metal probe has been placed through the urethra and is clearly visible through the bladder base. (Copyright Worldwide Fistula Fund, used by permission.)

After such fistulas develop, the lives of these young women (most of whom are younger than 20 years of age) are ruined unless they can gain access to curative surgical services. The constant, uncontrolled dribble of urine makes them offensive to their husbands and family members and they are often ostracized from their families. Most of them eventually become destitute social outcasts—and yet these are otherwise healthy young women. The social and economic costs of this problem are enormous, yet the world medical community largely ignores it. The morbidity associated with obstetric fistulas remains, along with the related maternal mortality, one of the single most neglected issues in international women’s health care.

In the industrialized world, the most common causes of genitourinary fistulas are surgery, malignancy, and radiation therapy, alone or in combination. Most often a vesicovaginal fistula develops after an otherwise uncomplicated vaginal or abdominal hysterectomy in which a small portion of the bladder was inadvertently trapped in a surgical clamp or was transfixed by a suture. These fistulas most often occur at the vaginal apex and are no larger than 1 to 2 mm. The amount of urine that can leak through a fistula of any size, however, is enormous. Figure 26.3 shows a cystoscopic view of three small vesicovaginal fistulae, lined up where the cuff suture line would have been. With traditional vaginal and abdominal hysterectomy, many surgeons recommend universal cystoscopy at the completion of the surgical case to assess for urinary tract injury and potentially decrease the incidence of urinary tract fistula. A review of 839 patients undergoing hysterectomy for benign disease followed by universal cystoscopy at completion of the procedure revealed lower urinary tract injury in 4.3%, including bladder injury in 2.9% and ureteral injury in 1.8% (21).

Figure 26.3 Posthysterectomy fistulas. Note three small fistulas in a row.

With the increase in minimally invasive techniques for pelvic surgery, including hysterectomy, the use of electrocautery devices is commonplace. This more frequent use of electrocautery for ligation of vessels and the resulting thermal spread increases concern about the possibility of ureteral damage that may lead to ureterovaginal fistula. When significant urine leakage occurs, often 10 to 14 days following a laparoscopic hysterectomy, ureterovaginal fistula should be strongly considered in the differential diagnosis. As with abdominal and vaginal surgery, careful attention to the location of the ureter, especially in proximity to the uterine arteries, must be a standard precaution. The incidence of ureterovaginal fistula after laparoscopic hysterectomy appears to be 1% to 4% (22).

Although rare, vesicouterine fistulas are increasing in incidence as the rate of cesarean deliveries increases. Such fistulas are almost always associated with repeat cesarean deliveries. The classic triad of vaginal urinary leakage, cyclic hematuria, and amenorrhea is known as Youssef’s syndrome (23).

Nocturia

Nocturia is the number of voids recorded during a night’s sleep; each void is preceded and followed by sleep. To sort out whether nocturia results from heightened urine production at night, the nocturnal urinary volume can be assessed from a bladder chart. Nocturnal urinary volume is defined as the total volume of urine passed between the time the woman goes to bed with the intention of sleeping and the time of waking with the intention of rising. Thus, it excludes the last void before going to bed but includes the first void after rising in the morning. Nocturia can be the result of nocturnal polyuria potentially related to delayed mobilization of fluid especially in the elderly, sleep problems (e.g., sleep apnea), or low volume voids. Nocturnal polyuria is present when an increased proportion of the 24-hour output occurs at night.

Risk Factors for Urinary Incontinence

Most of the data about risk factors for urinary incontinence come from clinical trials or cross-sectional studies using survey design. Some risk factors were more rigorously studied than others. Thus, the information available is limited in its general applicability and one cannot infer causality from it. Despite these limitations, there is some evidence that age, pregnancy, childbirth, obesity, functional impairment, and cognitive impairment are associated with increased rates of incontinence or incontinence severity (16). Some factors pertain more to certain age groups than others. For example, in studies of older women, childbirth no longer increases the risk of incontinence, possibly because of the presence of comorbidities and other factors that promote incontinence. Medical diagnoses that were associated with urinary incontinence include diabetes, strokes, and spinal cord injuries. Other factors about which less is known or findings are contradictory include hysterectomy, constipation, occupational stressors, smoking, and genetics.

Pregnancy and delivery predispose women to stress urinary incontinence, at least during their younger years. Of women who have not borne children, those who are pregnant leak more often than their nonpregnant counterparts; about half of women report symptoms of stress urinary incontinence during pregnancy, but in most, the symptom resolves after delivery. In a prospective study, 32% of 305 primiparas developed stress urinary incontinence during pregnancy and 7% after delivery. By 1 year, only 3% reported stress urinary incontinence (24). However, 5 years later, 19% of women with no symptoms after the first delivery had stress urinary incontinence. Of women reporting stress urinary incontinence 3 months postpartum (in most of whom it had resolved by 1 year), 92% had such leakage 5 years later. Transient postpartum leakage may be a marker for future incontinence.

Various changes happen after delivery that may predispose women to stress urinary incontinence. Levator ani muscle strength decreases (25). About 20% of women develop a visible defect in the levator ani muscles after vaginal delivery (26). The bladder neck descends, and the pelvic muscles undergo partial denervation with pudendal neuropathy (27). In most studies, parity is strongly associated with urinary incontinence in younger women (28). In studies of women 60 years and older, parity is no longer an independent risk factor for incontinence (29). The reason for this is not well elucidated, but it may be because the changes in muscle, nerve, connective tissue, and hormonal function that occur with aging make other women “catch up” to those who developed incontinence at a younger age because of delivery trauma. Alternately, it may be that medical problems more common in older women account for a larger proportion of incontinence risk as women age.

Obesity deserves special mention for its role in causing or exacerbating stress incontinence. Many researchers report an association (that remains after adjusting for age and parity) between increased weight and body mass index (BMI) and urinary incontinence. For example, a dose–response relationship between BMI and severe urinary incontinence was described (30). Compared with women with a BMI less than 25 kg/m², odds ratios (OR) for the following BMI groups were: 25 to 29, OR 2.0 (range 1.7–2.3); 30 to 34, OR 3.1 (2.6–3.7); 35 to 39, OR 4.2 (3.3–5.3); 40+ 5.0 (3.4-7.3). A prospective randomized study evaluating overweight and obese women with at least 10 urinary incontinence episodes per week undergoing an intensive 6-month weight-loss program versus structured education program found that women in the weight-loss program had a mean weight loss of 8.0% and decreased their leakage episodes by 47% compared to mean weight loss of 1.6% and 28% reduction in leakage episodes in the education program group (31).

Initial Evaluation

The initial evaluation of patients with incontinence requires a systematic approach to consider possible causes. The basic evaluation should include the following items: history (including assessment of quality of life and degree of bother from symptoms), physical examination, and simple primary care level tests. Most women can begin nonsurgical treatment after this basic evaluation.

History

A thorough medical history should be obtained from every incontinent patient. The history should include a review of symptoms, general medical history, review of past surgery, and current medications. The woman’s most troubling symptoms must be ascertained—how often she leaks urine, how much urine she leaks, what provokes urine loss, what improves or worsens the problem, and what treatment (if any) she had in the past. It is essential to keep the patient’s chief symptom at the forefront to avoid inappropriate management. Consider, for example, a woman whose chief concern is that once a month, while leading a business seminar, she has a sudden, overwhelming urge to void followed by complete bladder emptying. She finds this leakage devastating and is considering quitting her job because of her acute embarrassment. On occasion, she leaks a few drops of urine during exercise, but this minor leakage does not bother her. During the evaluation, urodynamics reveal minimal stress urinary incontinence at capacity during strong coughing. No detrusor overactivity is seen. The patient is offered, and undergoes, a surgical procedure for her documented urodynamic stress incontinence. Not surprisingly, her chief symptom is not improved and she is devastated.

The general medical history may reveal systemic illnesses that have a direct bearing on urinary incontinence, such as diabetes mellitus (which produces osmotic diuresis if glucose control is poor), vascular insufficiency (which can lead to incontinence at night when peripheral edema is mobilized into the vascular system, resulting in increased diuresis), chronic pulmonary disease (which can lead to stress incontinence from chronic coughing), or a wide variety of neurologic conditions that can affect the neurourologic axis at any point from the cerebral cortex to the peripheral nervous system. Medications that may affect the lower urinary tract are summarized in Table 26.3 (32–35).

Table 26.3 Medications that May Affect the Urinary Tract

1. Sedatives such as the benzodiazepines may cause confusion and secondary incontinence, particularly for elderly patients. 2. Alcohol may have similar effects to benzodiazepines and also impairs mobility and causes diuresis. 3. Anticholinergic drugs may impair detrusor contractility and may lead to voiding difficulty and overflow incontinence. Drugs with anticholinergic properties are widespread and include antihistamines, antidepressants, antipsychotics, opiates, antispasmodics, and drugs used to treat Parkinson’s disease. 4. α-Agonists, which are often found in over-the-counter cold remedies, increase outlet resistance and may lead to voiding difficulty. 5. α-Blockers, sometimes used to treat hypertension (e.g., prazosin, terazosin), may decrease urethral closure pressure and lead to stress incontinence. 6. Calcium-channel blockers may reduce bladder smooth muscle contractility and lead to voiding problems or incontinence; they may also cause peripheral edema, which may lead to nocturia or nighttime urine loss. 7. Angiotensin-converting enzyme inhibitors may result in a chronic and bothersome cough that can result in increasing stress urinary incontinence in an otherwise asymptomatic patient.

Quality-of-Life Measures

Physicians caring for incontinent women should ask them about the way the incontinence specifically affects their lives and to what degree the incontinence bothers them. There often is discord between the objective symptom severity and subjective bother. Only by understanding each woman’s situation can treatment be appropriately planned and response evaluated. Some women may be completely satisfied if they are able to sit through a movie without running to the bathroom, even if they leak urine at other times. Others may be satisfied only if they are 100% dry. Given that the latter is likely an unrealistic goal, knowing that the patient feels this way gives the provider the opportunity to educate her about the likely outcome of treatment.

Physicians may use one of several well-designed, validated quality-of-life measures. An expert summary of the literature in this area conducted for the International Consultation on Incontinence recommended the instruments summarized in Table 26.4. These instruments were found to be valid, reliable, and responsive to change following standard psychometric testing.

Table 26.4 Questionnaires to Assess Urinary Incontinence

The following questionnaires have been recommended by the International Consultation on Incontinence to assess symptoms of incontinence and impact of incontinence on quality of life in women.a

Symptoms

Urogenital Distress Inventory. Shumaker SA, Wyman JF, Uebersax JS, et al. Health-related quality of life measures for women with urinary incontinence: the Incontinence Impact Questionnaire and the Urogenital Distress Inventory. Qual Life Res 1994;3:291–306.

Urogenital Distress Inventory (UDI)-6 (short form). Uebersax JS, Wyman JF, Shumaker SA, et al. Short forms to assess life quality and symptom distress for urinary incontinence in women: the incontinence impact questionnaire and the urogenital distress inventory. Neurourol Urodyn 1995;14:131–139.

Urge-UDI. Lubeck DP, Prebil LA, Peebles P, et al. A health related quality of life measure for use in patient with urge urinary incontinence: a validation study. Qual Life Res 1999;1999:337–344.

King’s Health Questionnaire. Kelleher CJ, Cardozo LD, Khullar V, et al. A new questionnaire to assess the quality of life of urinary incontinent women. Br J Obstet Gynaecol 1997;104:1374–1379.

Incontinence Severity Index. Sandvik H, Hunskaar S, Seim A, et al. Validation of a severity index in female urinary incontinence and its implementation in an epidemiological survey. J Epidemiol Community Health1993;47:497–499.

Quality of Life

Quality of life in persons with urinary incontinence (I-QOL). Wagner TH, Patrick DL, Bavendam TG, et al. Quality of life of persons with urinary incontinence: development of a new measure. Urology1996;47:67–72.

Incontinence Impact Questionnaire. Wyman JF, Harkins SW, Taylor JR, et al. Psychosocial impact of urinary incontinence in women. Obstet Gynecol 1987;70:378–381.

Incontinence Impact Questionnaire (IIQ)-7 (short form). Uebersax JS, Wyman JF, Shumaker SA, et al. Short forms to assess life quality and symptom distress for urinary incontinence in women. The incontinence impact questionnaire and the urogenital distress inventory. Neurourol Urodyn 1995;14:131–139.

Urge-IIQ. Lubeck DP, Prebil LA, Peebles P, et al. A health related quality of life measure for use in patient with urge urinary incontinence: a validation study. Qual Life Res 1999;1999:337–344.

aDonovan JL, Badia X, Corcos J, et al. Symptom and quality of life assessment. In: Abrams P, Cardozo L, Khoury J, et al., eds. Incontinence. Plymouth, UK: Plymbridge Distributors, 2002.

Physical Examination

The physical examination of the patient with incontinence should focus on general medical conditions that may affect the lower urinary tract and problems related to urinary incontinence. Such conditions include cardiovascular insufficiency, pulmonary disease, occult neurologic processes (e.g., multiple sclerosis, stroke, Parkinson’s disease, and anomalies of the spine and lower back), abdominal masses, and mobility. Key factors to assess during the physical examination are summarized in Table 26.5. A cotton swab test has poor predictive value for determining either stress urinary incontinence diagnosis or predicting treatment success (36). It is used by some clinicians to determine movement of the anterior vaginal wall with Valsalva. A woman with a fixed nonmobile urethra is a poor candidate for a surgery (such as a Burch colposuspension) designed to elevate the urethra. It is not possible to increase support for an already well-supported urethra.

Table 26.5 Physical Examination of a Woman with Lower Urinary Tract Dysfunction

Neurologic

Mental status

Perineal sensation

Perineal reflexes

Patellar reflexes

Abdominal examination

Masses

Cardiovascular

Congestive heart failure

Lower extremity edema

Mobility

Gait assessment

Pelvic examination

Prolapse

Atrophy

Levator muscle palpation (symmetry, ability to squeeze)

Anal sphincter function

Test of urethral mobility (e.g., cotton swab test)

Simple (Primary Care Level) Tests

It is important to realize that formal urodynamics tests are neither the only nor the most important tests of bladder function. Other simple tests that can be performed in the primary care setting provide useful information to guide patient care.

Voiding Diary

A frequency/volume bladder chart (often termed a “bladder diary”) is an invaluable aid in the evaluation of patients with urinary incontinence. A frequency/volume chart is a voiding record kept by the patient for several days. Patients are instructed to write down the time of every void on the chart and measure the amount of urine voided. The time of any incontinent episodes, and the specific activities associated with urine loss, should be recorded. If desired, the patient can be instructed to keep a record of fluid intake. Although the type of intake may guide management suggestions, in most cases volume of intake can be estimated with some accuracy from the amount of urine produced.

A frequency/volume bladder chart provides vital information about bladder function that is not provided by formal urodynamics studies: 24-hour urinary output, the total number of daily voids, number of nighttime voids, the average voided volume, and the functional bladder capacity (largest volume voided in normal daily life). This information allows the clinician to confirm reports of urinary frequency with objective data and to determine whether part of the patient’s problem is an abnormally high (or low) urinary output. The chart can be used to calculate the volume of urine generated in nighttime hours versus daytime hours. Nighttime volume is calculated by adding output from voids that occur after the woman has fallen asleep for the night and the first morning void on awakening for the day. Older women sometimes have a marked shift in urine production, with more than half of their urine output generated during sleeping hours (Fig. 26.4). Demonstrating this on the voiding diary may lead to further treatment options.

Figure 26.4 Voiding diary (also called bladder chart). Daytime frequency is seven. The patient has nocturia (gets up to void two times during sleeping hours) and also has nocturnal polyuria (an increased proportion of the 24-hour output occurs at night; note that nighttime urine output excludes the last void before sleep but includes the first void of the morning). She has urge incontinence, likely caused by the relatively larger bladder volumes voided at night, which in turn may be related to her greater fluid, caffeine, and alcohol consumption in the evening.

Urinalysis

Examination of the urine by dipstick testing and microscopy is done to exclude infection, hematuria, and metabolic abnormalities. Hematuria cannot be diagnosed on the results of a dipstick test alone; confirmation by microscopic evaluation is mandatory.

If a urinary tract infection is documented by microscopy or culture, it is reasonable to see whether urinary tract symptoms improved with eradication of bacteriuria. Occasionally, a simple urinary tract infection causes the onset or exacerbation of urinary incontinence. Some women, particularly older ones, have asymptomatic bacteriuria that truly is asymptomatic; thus, if attempted treatment of a woman with bacteriuria but without classic urinary tract infection symptoms (such as dysuria, urgency, or frequency) does not improve incontinence, further antibacterial treatment is generally unnecessary.

If hematuria and bacteriuria are found, the urine should be rechecked after eradication of the bacteriuria. Hematuria found in the absence of bacteriuria may need further evaluation to rule out kidney or bladder tumors; the necessity for and extent of the evaluation depends on concomitant risk factors and the clinical presentation. If malignancy is suspected, bladder biopsy should be performed by the surgeon who would treat the patient in the event a malignancy is discovered.

Routine urinary cytology is not helpful, but testing may be of value in women older than 50 years with irritative urinary tract symptoms, particularly if those symptoms are of sudden onset.

Postvoid Residual Volume

Incomplete bladder emptying may cause incontinence. Patients with a large postvoid residual (PVR) urine volume have a diminished functional bladder capacity because of the dead space occupied in the bladder by retained urine. This stagnant pool of urine is a source of urinary tract infections because the major defense of the bladder against infection is frequent, nearly complete emptying.

A large PVR volume can contribute to urinary incontinence in two ways. If the bladder is overdistended, increases in intra-abdominal pressure can force urine past the urethral sphincter, causing stress incontinence (sometimes termed “overflow incontinence” in the context of a large PVR volume). In some cases, bladder overdistention may provoke an uninhibited contraction of the detrusor muscle, leading to incontinence. These conditions may coexist, further complicating the problem.

The PVR volume can be assessed by either direct catheterization or ultrasonography. Although sufficiently accurate for clinical purposes, ultrasonography measurements of PVR volume have a standard error of 15% to 20%. It is reasonable to confirm an elevated PVR volume detected on ultrasound with a catheterized volume (37). It is important to perform this test within 10 minutes of a void to avoid an artificially elevated result because of diuresis. It is agreed that a PVR level less than 50 mL is normal and greater than 200 mL is abnormal, but there is much debate about values in the midrange. Because many women are unable to void well during an anxiety-ridden first visit, it is helpful to recheck the PVR volume at a future visit before embarking on further diagnostic tests. The value of assessing bladder emptying in neurologically normal women who do not have pelvic organ prolapse or symptoms of voiding dysfunction has not been demonstrated.

Cough Stress Test

Patients should be examined with a full bladder, particularly if stress incontinence is a consideration. Urine egress from the urethra at the time of a cough documents stress incontinence. If leakage is not observed when the woman is supine, she should stand with her feet separated and cough several times.

Pad Tests

Weighing menstrual or bladder pads before and after activity provides another objective way to measure urinary leakage. Such pad tests are widely used in patient-oriented research to assess treatment effectiveness, but rarely are they used in clinical practice. Pad tests can be divided into short-term tests, usually performed under standardized office conditions, and long-term tests, usually performed at home for 24 to 48 hours. Pad tests are generally performed with a symptomatically full bladder or with a certain volume of saline instilled into the bladder before beginning the series of exercises. A pad weight gain of 1 g or more is considered positive for a 1-hour test, and a pad weight gain greater than 4 g is positive for a 24-hour test.

Advanced Testing

Urodynamics

At its most basic level, a urodynamic study is anything that provides objective evidence about lower urinary tract function (38). In this sense, measurement of a patient’s voided urine volume and catheterization to determine her PVR volume are urodynamic studies. A frequency/volume chart is also a valuable urodynamic study. Obtaining clinically valuable information does not always require the use of expensive, complex technology. After basic testing, further testing is recommended in the following circumstances: the diagnosis is uncertain (for example, because of major discrepancies between the history, the voiding diary, and symptom scales); surgery is being considered; an elevated PVR volume, a neurologic condition that may complicate treatment (such as multiple sclerosis), marked pelvic organ prolapse, or numerous prior surgical attempts at correction. Bladder and kidney imaging should be considered if the patient has hematuria in the absence of an infection. Current urodynamic definitions are summarized in Table 26.6.

Table 26.6 Urodynamic Definitions

Uroflowmetry

To assess voiding function, urodynamic testing usually begins with uroflowmetry, a study in which the volume of urine voided is plotted over time. Flow time, peak flow rate, and time to peak flow usually increase as the voided volume increases.

Filling Cystometry

Cystometry is done to assess bladder and urethral function during bladder filling. Simple (or single-channel) cystometry is performed when bladder pressure only is measured during filling. Because the bladder is an intra-abdominal organ, the pressure recorded in the bladder is a combination of several other pressures, most notably the pressure created by the activity of the detrusor muscle itself and the pressure exerted on the bladder by the weight of the surrounding intra-abdominal contents (e.g., uterus, intestines, straining, or exertion). For this reason, the technique of complex (also called multichannel or subtracted) cystometry is used to try to approximate the actual pressure exerted in the bladder by the activity of the detrusor muscle alone. The detrusor pressure (P_det) is obtained by measuring total intravesical pressure (P_ves) with a bladder pressure catheter, approximating intra-abdominal pressure (P_abd) with a rectal or vaginal catheter, and then electronically subtracting the latter from the former:

P_det = P_ves – P_abd.

Measurements can be obtained using electronic microtip transducer pressure catheters, fluid-filled pressure lines, fiberoptic catheters, or air-charged catheters. All are acceptable for clinical use, but it is important to realize that when different types of catheters are used, the correlation between numbers is imperfect. Other technical factors that influence cystometry results include the choice of distending medium, filling rate, and patient position. The steps involved in a multichannel urodynamic study are outlined in Table 26.7. Normal cystometric values for women are shown in Table 26.8.

Table 26.7 Steps in Conducting a Multichannel Urodynamic Study

1. Insert pressure and filling catheter into bladder (may be two catheters or dual catheter) to measure intravesical pressure and to fill bladder. Insert pressure catheter into upper vagina or rectum to approximate abdominal pressure. 2. Infuse fluid (usually sterile water or saline, sometimes radiographic contrast dye) at a rate of 50 to 100 mL/min. Record the volume infused and the pressure measurements continuously. The patient’s bladder may be filled with her lying supine, in a modified lithotomy position, sitting, or standing. When possible, do cystometry in the standing position as most patients with incontinence report this problem more when they are erect. 3. Note the point at which any leakage occurs. 4. During filling, record the first desire to void (that is, the feeling that would lead her to void at the next convenient moment, but voiding can be delayed if necessary) and the strong desire to void (that is, the persistent desire to void without the fear of leakage). The maximum cystometric capacity, in women with normal sensation, is the volume at which the woman can no longer delay micturition; filling should not be continued to the point of pain or severe discomfort. 5. If no detrusor overactivity is noted during filling, have the patient do provocative maneuvers at maximum capacity, such as coughing, heel-bouncing, and listening to the sound of running water to provoke uninhibited detrusor contractions, which may be the cause of the patient’s symptoms.

Table 26.8 Approximate Normal Values of Female Bladder Function

• Residual urine <50 mL • First desire to void occurs between 150 and 250 mL infused • Strong desire to void does not occur until after 250 mL • Cystometric capacity between 400 and 600 mL • Bladder compliance between 20 and 100 mL/cm H2O measured 60 sec after reaching cystometric capacity • No uninhibited detrusor contractions during filling, despite provocation • No stress or urge incontinence demonstrated, despite provocation • Voiding occurs as a result of a voluntarily initiated and sustained detrusor contraction • Flow rate during voiding is >15 mL/sec with a detrusor pressure of <50 cm H2O

From Wall LL, Norton P, Delancey J. Practical urogynecology. Baltimore, MD: Williams & Wilkins, 1993, with permission.

An example of detrusor overactivity seen during complex cystometry is shown in Figure 26.5. Surface or needle electromyography may be performed during filling and voiding to assess muscle activity of the urethral sphincter or pelvic floor. Electromyography as generally performed did not prove useful in neurologically intact women with symptoms of only stress urinary incontinence, and is not required in this patient population.

Figure 26.5 Detrusor overactivity on filling cystometrography. The patient begins to sense urgency, accompanied by an unstable bladder contraction, when 88 mL of water are instilled into the bladder. The detrusor pressure rises, and when 96 mL of water are instilled, she leaks. P_abd, abdominal pressure; P_ves, vesical pressure; P_det, detrusor pressure.

Both false-positive and false-negative results can occur with urodynamic studies. False-positive results occur in patients with asymptomatic detrusor overactivity, detrusor overactivity that is irrelevant to the symptom, or detrusor overactivity that is situational (e.g., caused by test anxiety). False-negative results can occur because a 20- to 40-minute cystometrogram is not always an accurate measure of 24-hour bladder activity. Looking for detrusor overactivity with such a test is like looking for an episodic cardiac arrhythmia using 12-lead electrocardiography, as opposed to looking for the arrhythmia using a 24-hour Holter monitor. The sensitivity of the latter test is far greater than that of the former. Ambulatory urodynamics can be performed and are more likely to detect detrusor overactivity than office-based studies.

Tests of Urethral Function

Several tests of urethral function, including urethral pressure profilometry, Valsalva leak-point pressures, and the fluoroscopic and cystoscopic assessment of the bladder neck, are used in attempts to guide therapy in women with stress urinary incontinence. Women with poor urethral function, evidenced by low Valsalva leak-point pressures, low maximal urethral closure pressures, or a visualized open bladder neck, are thought to be at higher risk of treatment failure using standard retropubic urethropexy (Fig. 26.6). Cutoff values for these tests are poorly defined and remain controversial. Although women with stress urinary incontinence have, on average, significantly lower maximal urethral closure pressures than those without incontinence, there is wide overlap in the values between such women, and no lower limit of urethral closure pressure or leak point pressure is established that diagnoses stress urinary incontinence.

Figure 26.6 Open and scarred bladder neck in an elderly woman who has undergone three anterior colporrhaphies for stress urinary incontinence in the past.

The urethral pressure profile is a test designed to measure urethral closure. Because continence requires the pressure in the urethra to be higher than the pressure in the bladder, it was believed that measuring the pressure differential between the two would provide useful clinical information. The urethral pressure profile is determined by slowly pulling a pressure-sensitive catheter through the urethra from the bladder.

The urethral closure pressure (P_close) is the difference between the urethral pressure (P_ure) and the bladder pressure:

(P_ves): P_close = P_ure – P_ves.

It was suggested that women with stress incontinence with low urethral closure pressure (<20 cm H₂O) have a poorer prognosis for surgical outcome than women who do not have this condition; however, this area is the subject of considerable debate (3,39,40). Because stress incontinence, by definition, occurs during increases in intra-abdominal pressure that are generated by some kind of physical activity, it is not obvious why measurement of resting urethral pressure should be relevant to stress-related leakage, which is a dynamic event. One review concluded that urethral pressure profilometry is not a useful diagnostic test for stress incontinence in women and that its use in clinical management is unsupported by current evidence (41).

Leak-point pressure (LPP) is a urodynamic measure of the minimum intra-abdominal or intravesical pressure required to cause incontinence during abdominal strain or cough. There is no consensus about whether it should be measured from the resting supine baseline (generally near 0) or from the standing resting baseline (which increases depending on body mass). Other factors that may affect the results include the catheter’s type, caliber, and placement (vaginal, rectal, or intravesical), the bladder volume at which the measurement is obtained, the mechanism by which intra-abdominal pressure is increased (coughing versus straining), and patient position (42).

Leak point pressure measurements often are performed at a bladder volume of 200 or 300 mL. Patients are asked to cough with gradually increasing force (cough leak-point pressure) and finally to strain slowly (Valsalva) to increase intravesical pressure gradually. The lowest pressure at which leakage occurs is recorded as the cough or the Valsalva leak-point pressure (Fig. 26.7). If leakage is not demonstrated, the highest pressure that was obtained can be recorded with the notation “no leakage” to the specified pressure as measured in centimeters of water pressure. Many clinicians use a cutoff point of 60 cm water pressure to separate women who have intrinsic sphincter deficiency from those who do not. This is problematic for two reasons: (i) the marked variability of results that depend on all the aforementioned factors and (ii) the lack of prospective studies that demonstrate the predictive value of leak point pressure values on surgical outcomes. Results from this and other urodynamics tests must be evaluated as one piece of the patient’s puzzle, along with the history, physical examination, voiding diary, and other tests. Medicare guidelines require that when bulking agents, such as collagen, are considered to treat stress incontinence, the intra-abdominal leak point pressure when the bladder has been filled with at least 150 mL of fluid must be less than 100 cm H₂O.

Figure 26.7 Leak point pressure. The abdominal leak point pressure (LPP) is 114 cm H₂O (the abdominal pressure at which the patient leaked urine).

Fluoroscopy and cystourethroscopy were used to visualize the bladder neck because many clinicians and investigators believe that a closed bladder neck is important in maintaining continence. However, studies of continent women reveal that many individuals with normal urethral function show evidence of bladder neck opening with physical stress (43). Neither test is recommended in the routine evaluation of women with straightforward incontinence.

Voiding Cystometrogram

Urodynamic testing usually concludes with an instrumented voiding study (also known as a pressure-flow study or voiding cystometrogram), in which the vesical, abdominal, and urethral pressures are measured simultaneously during bladder emptying (Fig. 26.8). Various studies identified Valsalva voiding, low preoperative flow rate, and high preoperative detrusor pressures during voiding as risk factors for postoperative voiding dysfunction; however, findings often are contradictory.

Figure 26.8 Voiding cystometrogram. This patient voids in an uninterrupted flow pattern by means of a prolonged bladder contraction. She does not strain to void, with the exception of minimal straining toward the end of the flow.

Imaging Tests

The role of imaging techniques in studying female urinary incontinence is not yet established. Researchers are evaluating the potential roles of ultrasonography, fluoroscopy, functional neuroimaging, and magnetic resonance imaging (MRI). These tests should not be done routinely but are useful in certain conditions. If the patient’s symptoms (easily remembered by the three Ds: dysuria, dribbling, and dyspareunia) or examination suggests a urethral diverticulum, MRI is the test of choice (44).

Neurophysiologic Tests

The neuromuscular function of the pelvic floor is dependent on the integrity of the nervous system. Injury can theoretically occur anywhere along these nerves, from the cell body located in Onuf’s nucleus in the ventral part of the spinal cord, along its axon, to the neuromuscular junction. Pelvic floor neurophysiology utilizes techniques applied to nerves and skeletal muscles elsewhere in the body to document neuromuscular integrity or evidence of injury. These tests are not routinely used in the clinical evaluation of most incontinent women.

Pudendal Nerve Terminal Motor Latency

The pudendal nerve terminal motor latency (PNTML) indirectly assesses the integrity and patency of the terminal portion of the pudendal nerve, its neuromuscular junction, and the muscle it serves. Using a specialized electrode affixed over the index finger, the pudendal nerve is electrically stimulated near the ischial spine (either transrectally or transvaginally), and the resulting muscular response is measured. The response, termed a compound muscle action potential (CMAP), is detected at the anal sphincter. The interval between the stimulation and the onset of the CMAP is measured. A prolonged latency is noted with injury to large and heavily myelinated axons. The latency time may be within the normal range when only smaller nerve fibers are affected; thus, neurologic dysfunction may exist in the presence of a normal latency time.

Sacral Reflexes

Only the distal efferent arm of the pudendal nerve is analyzed in the PNTML. Similar to the clinically obtained anal wink or bulbocavernosus reflex, electrically induced sacral reflexes can gather information about both the afferent and efferent arc in the pelvic nerves. A short train of dual impulses delivered next to the clitoris and measured at the anal sphincter is termed the clitoroanal reflex and provides information about the integrity of the afferent and efferent arm of the somatic pudendal nerve. A stimulating electrode placed in the bladder sends these signals along the visceral, autonomic fibers to the spinal cord, and a reflex signal will return along the pudendal nerve to the anal sphincter.

Somatosensory Evoked Potentials

Normal pelvic floor and pelvic organ function ultimately is controlled by higher centers in the central nervous system, including the cerebral cortex. Recording electrodes located on the scalp near the motor cortex allow the signal transmission speed between a skeletal muscle and the brain to be measured. Repeated electrical stimuli, called somatosensory evoked potentials, at a muscle of interest are used to assess the integrity of the central afferent limb. In a reverse fashion, electrical or magnetically induced stimuli can be delivered at the motor cortex (or along the spine), and the induced muscle action potentials can be detected. Prolonged latencies not attributable to the peripherally studied nerves (such as with a PNTML or sacral reflex) are evidence of a central nervous system conduction flaw.

Electromyography

Electromyography (EMG) assesses the inherent electrical potentials generated during neuronal activation of skeletal muscle. It can be performed using surface electrodes or needle electrodes. Surface EMG measures the summation of muscle activity in the general area of the applied electrode. It is best used for simply describing the pattern and coordination of muscle activity but is less useful in providing more specific assessments. Needle EMG of the pelvic floor can “map” the anatomic location of muscles but is mostly replaced by ultrasonography. The major value of needle EMG is its ability to assess nerve injury and determine whether the injury is acute and ongoing or chronic. Single-fiber EMG can quantify the ratio of muscle fibers to nerve fibers (the so-called fiber density). An increase in fiber density is evidence of previous nerve injury with successful reinnervation. Concentric needle EMG is more widely available and allows for further neurophysiologic evaluation. Abnormal electrical activity associated with acute injury may be seen, and motor unit action potentials (MUAPs) can be assessed and quantified. Following nerve injury and reinnervation, MUAP parameters—such as duration, amplitude, number of phases, and turns—are typically larger.

Emerging Technologies

Positron emission tomography and functional magnetic resonance imaging studies are yielding preliminary insights into the neural control of continence; these technologies are used in the research setting only.

Nonsurgical Treatment

Treatment of urinary incontinence can be either nonsurgical or surgical. The approach to treatment is based on the clinical findings and the degree of discomfort experienced by the patient, who should be fully informed of the risks and expected outcome.

Lifestyle Changes

Lifestyle interventions can decrease stress urinary incontinence in many women (45). There is good level 1 evidence that weight loss in both morbidly and moderately obese women decreases both stress and urge urinary incontinence (31). Postural changes (such as crossing the legs during periods of increased intra-abdominal pressure) often prevent stress urinary incontinence. There is some evidence that decreasing caffeine intake improves continence; however, fluid intake in general seems to play a minor role in the pathogenesis of incontinence. Although smokers are at greater risk for incontinence, no data were reported on whether smoking cessation resolves incontinence.

Physical Therapy

Medical evidence from well-designed randomized clinical trials shows that supervised pelvic floor muscle training (Kegel exercises) is an effective treatment for stress urinary incontinence. The Cochrane Incontinence Group concluded that pelvic floor muscle training is consistently better than no treatment or placebo treatment for stress incontinence and should be offered as first-line conservative management to women. Intensive training sessions that include personal contact with a health care professional to teach and supervise pelvic floor muscle training may be more beneficial than standard care. Biofeedback provides no added benefit over pelvic floor muscle training alone in women with stress urinary incontinence (46).

Several factors improve the likelihood that pelvic muscle training will relieve stress urinary incontinence. The woman must do the exercises correctly, regularly, and for an adequate duration. Based on exercise training of skeletal muscles elsewhere in the body, many physical therapists recommend training sessions three to four times per week, with three repetitions of eight to ten sustained contractions each time.

Electrical stimulation therapy was used to treat incontinence by delivering low levels of current via a probe placed in the vagina or rectum. When compared with sham devices and pelvic floor exercises, electrostimulation produced mixed results in the treatment of stress urinary incontinence but may be more helpful in women with overactive bladders (47–50). Further research is needed to determine what niche this treatment may fill for women with urinary incontinence.

Behavioral Therapy and Bladder Training

Bladder training focuses on modifying bladder function by changing voiding habits. Behavioral therapy focuses on improving voluntary control rather than bladder function (51). The key component to bladder training is a scheduled toileting program. After reviewing the patient’s voiding diary, an initial voiding interval is chosen that represents the longest interval between voiding that is comfortable. She is instructed to empty her bladder when she awakes, and then every time during the day that the interval is reached (for example, every 30 to 60 minutes). When the patient feels the urge to void during that interval, she is instructed to use urge-suppression strategies, such as distraction or relaxation techniques, until she gets to the stated interval. Effective distraction strategies include mental exercises (such as mathematical problems), deep breathing, or “singing” the words to a song silently. The main goal is to avoid running to the bathroom at the moment of severe urgency. Another strategy is to quickly contract the pelvic muscle several times in a row (“freeze and squeeze”), which often lessens urgency. Gradually, the interval is increased (usually weekly) until the patient voids every 2 to 3 hours. Bladder training is most effective when women record every void and check in (by telephone or in person) with a health care provider weekly. This program lasts for about 6 weeks. Bladder training is effective; in a trial in which bladder training was compared with treatment with oxybutynin, 73% of women in the bladder training group were clinically cured (52).

The primary technique of behavioral training is pelvic floor muscle training, as described previously, but with a focus on urge inhibition. Mastering voluntary pelvic floor muscle contractions helps to strengthen the outlet (decreasing leakage) and inhibit detrusor contractions. Other components of therapy may include voiding schedules, urge-inhibitions strategies, and fluid management.

Patients with neurogenic detrusor overactivity, rather than idiopathic detrusor overactivity, do not respond as well to behavioral therapy because the problem is actually one of neural pathway destruction rather than the need to reestablish cortical control mechanisms. Frequently, these patients have a trigger volume of urine that sets off a contraction that they cannot control voluntarily. They may benefit from a timed schedule in which they void at regular intervals (such as every 2 hours) to keep their bladder volume below the trigger point. Attempting to lengthen the interval between voids often does not work well.

Less-intensive treatments also decrease incontinence episodes. In a randomized trial, the guidance of a simple self-help booklet was only somewhat less effective in reducing leakage (mean reduction in leakage episodes 43%) than behavioral training (mean reduction 69%) or behavioral training plus electrical stimulation (mean reduction 72%) (53).

Vaginal and Urethral Devices

Vaginal devices (pessaries) and urethral inserts are available for treating stress urinary incontinence. In a tertiary care population, approximately two-thirds of women with stress urinary incontinence offered a trial of vaginal devices chose to undergo pessary fitting (54). Most (89%) achieved a successful fit. Of those who took a pessary home to manage their stress urinary incontinence, approximately one-half used it for more than 6 months. Women who stopped using the pessary generally did so within the first month. In an intent-to-treat analysis of a recent large multisite randomized trial, 3 months after beginning either pessary or behavioral therapy, 40% of those randomized to pessary and 49% of those doing behavioral therapy were “very much” or “much” better. By 12 months there were no group differences in outcomes and patient satisfaction was greater than 50% for each group (55). Some women are pleased to be able to avoid surgery or to use a “crutch” while waiting for the effect of pelvic muscle training; others prefer a treatment option (like surgery) that does not require daily intervention. Examples of some vaginal devices are shown in Figure 26.9.

Figure 26.9 Vaginal incontinence pessaries: (clockwise from top): A: Suarez ring (Cook Urological, Spencer, IN), B: PelvX ring (DesChutes Medical Products, Bend, OR), C: Incontinence dish (Milex Inc., Chicago, IL), D: Incontinence dish with support (Mentor Corp., Santa Barbara, CA), E: Introl prosthesis (was Johnson and Johnson; currently not available), F: Incontinence ring with support (Milex Inc., Chicago, IL), (middle): G: Incontinence dish with support (Milex Inc., Chicago, IL).

Urethral inserts are sterile inserts placed into the urethra by the patient and removed before a void, after which a new sterile insert is placed. Such inserts are appropriate for women with relatively pure stress incontinence, no history of recurrent urinary tract infections, and no serious contraindications to bacteriuria (e.g., artificial heart valves). The FemSoft device was U.S. Food and Drug Administration (FDA) approved in 1997 and is the only urethral insert that is available in the United States. Several other urethral inserts and urethral occlusion devices were marketed with good effectiveness but were withdrawn from the market. In a 5-year, multicenter trial involving 150 women with a mean follow-up of 15 months, a statistically significant reduction in incontinence episodes and pad weight were observed with 93% of the women having a negative pad test at 12 months. However, urinary tract infections were common and found in 31.3% of the subjects (56). Urethral inserts have not developed a widespread acceptance but may offer a viable treatment option for some select patients.

Medications

Stress Incontinence

The tone of the urethra and bladder neck is maintained in large part by α-adrenergic activity from the sympathetic nervous system. For this reason, many pharmacologic agents are used with varying degrees of success to treat stress incontinence. These drugs include imipramine (which has a concomitant relaxing effect on the detrusor), ephedrine, pseudoephedrine, phenylpropanolamine, and norepinephrine. Many of these compounds increase vascular tone and may, therefore, lead to problems with hypertension, a condition that afflicts many postmenopausal women with stress incontinence. There is an increased risk for hemorrhagic cerebral vascular accident in women taking phenylpropanolamine, and while the risk is very low, it is not possible to predict who is at risk for this complication (57). The use of these agents in the treatment of stress urinary incontinence appears to be more limited than originally thought (58). No drugs are cleared by the FDA to treat stress incontinence.

Based on a biologic rationale, it was thought that estrogen could effectively treat urinary incontinence, given the presence of estrogen receptors in the bladder, urethra, and levator muscles. In early uncontrolled case series, women using various estrogen preparations experienced less incontinence. However, in several large randomized trials, women assigned to receive estrogen and progesterone did not have less leakage, and were more likely to experience the onset of incontinence or worsening of baseline symptoms (59). In over 23,000 women enrolled in the Women’s Health Initiative double-blind, placebo-controlled, randomized clinical trial, use of menopausal hormone therapy (conjugated estrogen alone in women with a prior hysterectomy, conjugated estrogen and medroxyprogesterone acetate in women with a uterus) increased the incidence of all types of urinary incontinence at 1 year among women who were continent at baseline (60). Among women who reported urinary incontinence at baseline, both frequency and severity of incontinence worsened at 1 year in women taking either hormone preparation compared with those in the placebo group. Thus, conjugated estrogen with or without progestinshould not be prescribed for the prevention or relief of urinary incontinence.

Urge Incontinence and Overactive Bladder

The drugs used for treating detrusor overactivity can be grouped into different categories according to their pharmacologic characteristics; these drugs are anticholinergic agents that exert their effects on the bladder by blocking the activity of acetylcholine at muscarinic receptor sites. All of these drugs have side effects, the most common of which are dry mouth resulting from decreased saliva production, increased heart rate because of vagal blockade, feelings of constipation resulting from decreased gastrointestinal motility, and occasionally, blurred vision caused by blockade of the sphincter of the iris and the ciliary muscle of the lens of the eye.

Medications commonly used to treat these conditions are listed in Table 26.9. The introduction of several new drugs for overactive bladder resulted in significant attention being given to urinary incontinence in the media.

Table 26.9 Commonly Used Medications for Urge Incontinence

Drug	Oral Dose Range
Generic and Brand Names
Oxybutynin
Ditropana	2.5–5 mg tid–qid
Ditropan syrupa	1 tsp (5 mg)
Ditropan XLa	5, 10, or 15 mg qd
Oxytrol patchb	1 patch 2 times per week
Oxybutynin gel (Gelnique)b	1 sachet qd
Tolterodinec
Detrol	1–2 mg bid (immediate release)
Detrol LA	4 mg qd (extended release)
Fesoterodine (Toviaz) [Tolterodine is the active metabolite of fesoterodine]	4 or 8 mg qd
Trospium chlorided
Sanctura	20 mg bid
Sanctura XR	60 mg qd
Solifenacin succinatee
Vesicare	5–20 mg qd (one daily dose; usual dosing is 5–10 mg qd)
Darifenacinf
Enablex	7.5 or 15 mg by mouth qd
tid, three times a day; qid, four times a day; qd, every day; bid, twice a day.
aAvailable as generic. bWatson Pharmaceuticals. cPfizer. dAllergan. eAstellas Pharmaceuticals. f7.5 or 15 mg by mouth

The newer drugs have some advantages over oxybutynin, which was available for decades. These advantages include once- (or sometimes twice-) daily dosing, rather than three to four times per day and, to some degree, a less severe side-effect profile. The latter results from changes in the delivery system and to more selectivity of muscarinic receptors (so that, for example, the bladder may be targeted more than the salivary glands). In addition, quaternary amines (such as trospium chloride) are not distributed into the central nervous system because of their large molecular size and hydrophilicity. The primary disadvantage of the newer agents is cost.

In 2009, the Agency for Healthcare Research and Quality carried out an evidence-based review of the large body of literature on pharmacologic therapies for urinary urgency incontinence and overactive bladder (61). Estimates from their meta-analysis models suggest that immediate-release forms of medications (oxybutynin, short-acting tolterodine) decreased incontinence episodes and voids by 1.46 and 2.16 per day, respectively. Extended-release forms of medications (tolterodine, trospium chloride, solifenacin, oxybutynin) decreased incontinence episodes and voids by 1.78 and 2.24 per day, respectively. However, placebo also impacted continence, decreasing incontinence episodes and voids by 1.08 and 1.48 per day, respectively. Whether or not the improvements observed with medication are clinically significant depends on patients' perceptions and initial level of severity. In the randomized trials reviewed, baseline episodes of incontinence ranged from 1.6 to 5.3; decreasing this by one or two may or may not constitute a successful outcome for a given patient.

When initiating therapy with generic oxybutynin, it is best to start with a lower dose (particularly for elderly patients) and increase it as needed to a higher, more frequent dosage. Patients should be encouraged to titrate their medication to their symptoms and to vary the dosage (within acceptable limits) according to their needs. If this is not effective, the next step is to move to one of the other anticholinergic agents. Some women may respond better to one agent than another. A 2-week trial is sufficient to determine effectiveness. It is helpful to ask patients to record daily episodes of incontinence or urgency before and during therapy so effectiveness can be more accurately determined.

Patients should be warned of the side effects of anticholinergic agents. Patients should be particularly advised about the symptom of a dry mouth and told that this is not caused by thirst. Some patients increase their fluid intake to combat this problem, with a subsequent worsening of their incontinence. If dry mouth is a problem, patients should relieve it by chewing gum, sucking on a piece of hard candy, or eating a piece of moist fruit.

Nocturia and Nocturnal Enuresis

Medications that treat nocturia and nocturnal enuresis have one of three aims: (i) to reduce urine output, (ii) to increase bladder capacity and reduce unstable bladder contractions, and (iii) to act centrally on sleep and micturition centers.

An analogue of arginine vasopressin, DDAVP, is used extensively to treat children with nocturnal enuresis. Some studies suggest that it may be useful in adults (62,63). It is available as a nasal spray and as an oral preparation. When taken orally, the dose required is approximately 10 times greater because of the increased availability of the nasal preparation. Complications associated with the DDAVP include hyponatremia, particularly in patients with excessive fluid intake; therefore, it is essential in higher-risk patients to measure serum sodium levels periodically.

There are few clinical trials that specifically investigate the use of anticholinergic medications to treat nocturia or nocturnal enuresis. Anecdotal evidence supports a trial of a long-acting or extended-release form of an anticholinergic, taken approximately 1 hour before bedtime.

The most extensively studied medications for the treatment of nocturnal enuresis are tricyclic antidepressants, particularly imipramine. These agents may work by altering the sleep mechanism, by providing anticholinergic or antidepressant effects, or by affecting antidiuretic hormone excretion. The typical starting dose of imipramine is 25 mg at bedtime, which may be increased to as high as 75 mg. In the elderly, imipramine should be used cautiously because it increases the risk of hip fracture, presumably related to the potential side effect of orthostatic hypertension (64).

In a randomized, placebo-controlled study comparing nighttime doses of placebo and 1 mg of bumetanide (a loop diuretic), bumetanide decreased nocturia episodes by 25% compared with placebo (65). Patients who produce half of their total urine at night often benefit from the use of a diuretic (e.g., 20 mg furosemide) in the late afternoon to move fluid through the system and decrease their nighttime urine production.

Surgical Treatment for Stress Incontinence

Historically, the body of literature concerning surgical therapy for stress urinary incontinence, while large, is hampered by poor methods, short follow-up, biased outcome observations, and little attention paid to the patients' perceptions of symptoms and quality of life (66). Over the past decade, scientific research in this area evolved; while much of the literature continues to reflect small short-term case series, randomized trials with rigorous follow-up are becoming more common.

Several shifts occurred in recommendations regarding surgical therapy in the past generation. In 1997, the American Urological Association convened a clinical guidelines panel to analyze published outcomes data on surgical procedures to treat female stress urinary incontinence and to produce practice recommendations to guide surgical decision making (67). The panel concluded that colposuspension (e.g., Burch, Marshall-Marchetti-Krantz [MMK]) and slings were more effective than transvaginal needle suspensions or anterior repairs for long-term success (48-month cure/dry rates). The median probability estimates for cure/dry rates at 48 months and longer were 84% (95% confidence interval [CI], 79%–88%) for colposuspension and 83% (95% CI, 75%–88%) for sling procedures, compared with 67% (95% CI, 53%–79%) for transvaginal needle suspensions and 61% (95% CI, 47%–72%) for anterior repairs. Thus, the latter two procedures are no longer recommended as adequate treatments for stress urinary incontinence.

Historical Perspective

Anterior vaginal repair (also termed anterior colporrhaphy) was described by Howard Kelly in 1914, and this operation remained the standard first approach to stress incontinence until the middle of the 20th century (68). Many different operations are lumped together under the term anterior colporrhaphy, including simple plication of the bladder neck, elevation of the bladder neck by plicating the fascia under the urethra, and elevation and fixation of the bladder neck by passing sutures lateral to the urethra and driving the needles anteriorly into the back of the pubic symphysis for fixation. As noted previously, the problem with most techniques of anterior colporrhaphy is that they do not hold up well over time (69–71). In essence, this operation attempts to take weak support from below and push it back up from below, with hope that these structures will maintain their strength and position over time. Although there were excellent long-term results shown with anterior colporrhaphy, most of these cases involve specific techniques requiring skillful dissection of the endopelvic fascia, deep bold bites of suture, and fixation of permanent sutures to the pubic bone from below: in essence, a transvaginal retropubic bladder neck suspension (72,73). Most surgical series that evaluated techniques of anterior colporrhaphy for stress incontinence show long-term success rates of only 35% to 65%, a figure that most would regard as unacceptably low. Anterior colporrhaphy should be reserved primarily for patients requiring cystocele repair who do not have significant stress incontinence.

Needle suspension procedures are so named because they suspend the urethra and bladder neck through a technique that involves passage of sutures between the vagina and anterior abdominal wall using a specially designed long needle carrier. Although initial cure rates are between 70% to 90%, rates decrease significantly over time in many series, with 5-year success rates of 50% or less (67,74–77). Therefore, these operations are no longer recommended.

Retropubic Urethropexy (Colposuspension)

The modern era of retropubic surgery for stress incontinence began in 1949, when Marshall et al. described their technique for urethral suspension in a man with postprostatectomy incontinence (78). A variety of modifications of this operation were described, all of which share at least two characteristics: They are performed through an open low abdominal incision or with laparoscopically assisted exposure of the space of Retzius, and they all involve attachment of the periurethral or perivesical endopelvic fascia to some other supporting structure in the anterior pelvis (Fig. 26.10). In the MMK operation, the periurethral fascia is attached to the back of the pubic symphysis. Another approach, the Burch colposuspension, involves the attachment of the fascia at the level of the bladder neck to the iliopectineal ligament (Cooper’s ligament) (79,80). With the paravaginal repair, the lateral endopelvic fascia along the urethra and bladder is reattached to the arcus tendineus fascia pelvis (81,82). In the Turner-Warwick vagino-obturator shelf procedure, the endopelvic fascia, vagina, or both are attached to the fascia of the obturator internus muscle (83,84).

Figure 26.10 Points of reattachment of the endopelvic fascia during retropubic bladder neck suspensions. A: Arcus tendineus fascia pelvis (for paravaginal repair). B: Periosteum of pubic symphysis (for Marshall-Marchetti-Krantz procedure). C: Ileopectineal, or Cooper's, ligament (for Burch colposuspension). D: Obturator internus fascia (also used for paravaginal, or obturator shelf, repair).

A 2009 Cochrane review found that 69% to 88% of women treated with Burch colposuspension were largely continent, and 5 years after surgery the continence rate remained high at 70%. Twelve trials were available that compared colposuspension with various forms of suburethral slings; there were no significant differences in failure rates between slings and colposuspension at any time interval studied (85).

The long-term success of laparoscopic colposuspension is unclear, but there is limited evidence to suggest the results are less favorable than with open colposuspension, although this may reflect a learning effect and be unreliable in isolation (86).

Traditional Pubovaginal Sling

Sling operations traditionally were performed using a combined vaginal and abdominal approach (Fig. 26.11). The anterior vagina is opened, the space of Retzius is dissected on each side of the bladder neck, and a sling is passed around the bladder neck and urethra and then attached to the anterior rectus fascia or some other structure to cradle the urethra in a supporting hammock. This supports the urethra and allows it to be compressed during periods of increased intra-abdominal pressure (87–97). The sling can be made of organic or inorganic materials. Organic materials can be autologous tissues harvested from the patient (e.g., fascia lata, rectus fascia, tendon, round ligament, rectus muscle, vagina), processed allografts from human donors (e.g., fascia lata, dermis), or heterologous tissues harvested from another species and processed for surgical use (e.g., ox dura mater, porcine dermis). Synthetic materials (e.g., Silastic, Gore-Tex, Marlex) are popular because of their consistent strength and availability, but historically these substances were plagued by problems with erosion and infection when used around the urethra (67,98,99).

Figure 26.11 A completed traditional suburethral sling procedure with the fascia located at the bladder neck with the ends of the sling tied to or above the rectus fascia. The classic procedure uses autologous fascia; however, some surgeons use allograft or xenograft tissue performed in a similar fashion. (Redrawn from original by Jasmine Tan.)

The multicenter Urinary Incontinence Treatment Network conducted a randomized clinical trial comparing Burch colposuspension and fascial pubovaginal sling in 655 women with stress urinary incontinence (100). The primary outcome, success, was rigorously defined as a negative pad test, no urinary incontinence (as recorded in a 3-day diary), a negative cough and Valsalva stress test, no self-reported symptoms, and no retreatment for the condition. At 24 months, success rates were higher for women who underwent the sling procedure than for those who underwent the Burch procedure for the overall category of success (47% vs. 38%; p = .01). However, more women who underwent the sling procedure later had urinary tract infections, difficulty voiding, and postoperative urge incontinence. This study highlights the wide range in success depending on how it is defined: for example, based on a cough stress test, success rates were 71% in the Burch group and 87% in the sling group, while based on a pad test, rates were 84% and 85%, respectively.

Minimally Invasive Sling

In the 1990s, various orthopedic bone anchors were marketed to implant into the pubic bone to suspend the urethra with sutures or slings. Despite a lack of medical evidence to support either the bone anchor or the allograft use, bone anchor systems became the quick and minimally invasive method to suspend allograft slings (101). Although bone anchors were not superior to standard fixation techniques, their use led to increased complications in several series.

In 1996, Falconer et al. described the tension-free vaginal tape (TVT) for correcting stress urinary incontinence (102). In this technique, polypropylene mesh is placed under the midurethra with minimal tension (Fig. 26.12 A). To perform this operation, a small midurethral incision is made in the vaginal epithelium mucosa. A 40- by 1-cm mesh tape covered by a plastic sheath and attached to two 5-mm curved trocars is passed lateral to the urethra and through the endopelvic fascia into the retropubic space. The trocar is passed along the back of the pubic bone, through the rectus fascia, and into two small suprapubic skin incisions. The tension on the tape is adjusted, the sheath is removed, and the remaining tape is cut off at the level of the skin. This technique has the advantage of being performed quickly using limited anesthesia (fewer than 30 minutes in experienced hands). The procedure requires the use of a catheter guide to deviate the urethra and cystoscopy to ensure that bladder or urethral perforations are recognized immediately because the trocar is passed blindly.

Numerous modifications of the TVT were proposed and marketed. Such devices generally circumvent the stringent regulatory control provided by the FDA by gaining approval through a Premarket Notification 510(k). This mechanism is a submission to the FDA demonstrating that a new device is substantially equivalent either to a legally marketed or “predicate” device introduced before 1976 in the United States or to one approved by the FDA through the 510(k) process itself. Substantial equivalence means the new device has the same intended use as the predicate device and has the same technological characteristics or different technological characteristics, but it is as safe and effective as the predicate device. Surgeons should be aware that most new devices for urinary incontinence are not tested in clinical trials before they are marketed.

Since its introduction, there were scores of articles published suggesting that TVT is effective and safe and similar in effectiveness to colposuspension. Larger, multicenter trials provide the most realistic look at outcomes of a surgical procedure performed by many surgeons with varying experience on a wide array of patients. A report of the 2-year follow-up of 344 women with urodynamic stress incontinence enrolled from 14 centers in a multicenter randomized clinical trial compared TVT and open Burch colposuspension. The objective cure rates (defined as a negative 1-hour pad test) ranged from 63% to 85% for the TVT procedure and 51% to 87% for open colposuspension, depending on how missing data were handled, leading the authors to conclude that “TVT may be better, worse, or the same as open colposuspension in the cure of stress incontinence” (103). Subjectively, only 43% of women in the TVT group and 37% of women in the open colposuspension group reported cure of their stress leakage. Women undergoing the TVT were more likely to have a cystocele after surgery, whereas those undergoing the Burch colposuspension were more likely to have apical prolapse. Two years after the index procedure, seven women (4.8%) in the Burch colposuspension group underwent surgery for pelvic organ prolapse, compared with no women in the TVT group. There was no difference in the number of women that underwent repeat surgery for stress incontinence (1.8% in the TVT group and 3.4% in the Burch group). Women who underwent TVT were less likely to have voiding disorders requiring intermittent self-catheterization than those who underwent colposuspension (0% vs. 2.7%).

Another form of minimally invasive sling is the transobturator tape procedure (also known as a TOT) or transobturator suburethral tape. This modification was designed to reduce complications associated with retropubic needle passage. Inserting the trocar through the obturator space theoretically lessens the risk of bladder, bowel, or vascular injury because the procedure involves passing the polypropylene midurethral sling through the obturator membrane along its ischiorectal fossa path, bypassing the pelvic cavity altogether (104,105). In a multicenter trial, 183 women from seven sites underwent a transobturator tape procedure for stress and mixed urinary incontinence. At 1-year follow-up 80.5% patients were cured (defined as absence of subjective report of stress urine leakage and negative cough stress test). Perioperative complications included one bladder perforation, two urethral perforations, and one lateral vaginal perforation. Tape erosion necessitating removal occurred in five cases (three vaginal and two urethral) (106).

A 2009 Cochrane review identified 62 trials with over 7,000 women in which minimally invasive sling was studied in at least one arm (107). Most were of poor to moderate quality with short follow-up. Minimally invasive synthetic suburethral sling operations appeared to be as effective as traditional suburethral slings but with shorter operating time and less postoperative voiding dysfunction and de novourgency symptoms. Similarly, minimally invasive synthetic suburethral slings were as effective as open retropubic colposuspension with fewer perioperative complications, less postoperative voiding dysfunction, shorter operative time and hospital stay, but significantly more bladder perforations (6% vs. 1%). A retropubic bottom-to-top route was more effective than top-to-bottom route and was associated with significantly less voiding dysfunction, fewer bladder perforations, and tape erosions. At the time of this review, 17 trials comprising 2,434 women compared the transobturator route with the retropubic route of sling placement. The transobturator route had a slightly lower objective cure rate (84% vs. 88%) but had less voiding dysfunction, blood loss, bladder perforation, and shorter operating time.

After the publication of this Cochrane review, the largest (597 women) randomized equivalence trial to date comparing retropubic and transobturator sling approaches was published by the Urinary Incontinence Treatment Network (108). Women were randomized in the operating room and were followed for 1 year. The primary outcome was treatment success at 12 months according to both objective criteria (a negative stress test, a negative pad test, and no retreatment) and subjective criteria (self-reported absence of symptoms, no leakage episodes recorded, and no retreatment). Objective success rates were 80.8% and 77.7% and subjective success rates were 62.2% and 55.8%, in the retropubic and transobturator groups, respectively. Women in the retropubic group had more voiding dysfunction (2.7% vs. 0%), while those in the transobturator group had a higher rate of neurologic symptoms (9.4% vs. 4.0%). There were no significant differences between groups in postoperative urge incontinence, satisfaction with the results of the procedure, or quality of life.

A third generation of minimally invasive slings was developed, the so-called minislings. Insertion of the minisling requires only a single vaginal incision, less dissection, and the potential to be placed in a clinic setting. Data are mixed, with some finding equivalent success rates and others up to eightfold higher failure rates in the minisling group than in the full-length synthetic sling (109,110).

Bulking Agents

Injectable (so-called bulking) agents are less invasive than surgery, and although they are less likely than surgery to result in cure, they relieve symptoms in many women. In the United States, glutaraldehyde cross-linked bovine collagen (Contigen), carbon beads (Durasphere), cross-linked polydimethylsiloxane (Macroplastique), and calcium hydroxylapatite (Coaptite) are approved for use to treat stress urinary incontinence and can be injected either peri- or transurethrally. The newer agents were studied primarily by transurethral injection. Injecting a material around the periurethral tissues facilitates coaptation of the urethra under conditions of increased intra-abdominal pressure (111–116). In a 15-article review, the short-term cure or improvement rate was 75% (117). Contigen can be passed easily through small-bore needles under local anesthesia but requires preoperative skin testing to check for possible allergic reactions (3%). Durasphere is nonantigenic (thus no skin testing is required) and does not migrate. As compared with collagen, Durasphere appears to have similar reduction in leakage episodes and is more likely to require only a single injection (112). This bulking agent does require a larger-gauge needle for injection and is somewhat more difficult to inject than collagen. Macroplastique is approved for use in the United States. This material appears to offer better outcomes as defined by improvement and cure rates than Contigen at 12 months (113). A follow-up 24-month study revealed that 84% of patients maintained improvement from the 12-month assessment (114). A recent prospective randomized trial of Coaptite versus Contigen revealed similar improvement and safety profile at 12 months when compared Contigen. Coaptite required less material per injection (4 mL vs. 6.6 mL) and was more likely to require only a single injection (115). These techniques may require several injections to achieve continence, and the long-term success of these operations remains poorly studied.

Complications

In choosing surgical management, surgeons must weigh the chance of cure against the chance of severe complications. In the aforementioned randomized trial comparing TVT and Burch, women undergoing TVT were more likely to experience a bladder perforation than those undergoing the Burch procedure (9% vs. 2%, respectively) but less likely to have a fever (1% vs. 5%) or prolonged catheterization more than 29 days (3% vs. 13%) (118). Less common complications require a large sample size to detect differences. Severe complications reported on the FDA manufacturer and user facility device experience (MAUDE) database include vascular injuries, bowel injuries, and patient deaths after retropubic midurethral slings and groin and leg pain, visceral injuries, and severe infections from transobturator approaches (119). Even though these serious life-threatening complications are rare, surgeons must be cognizant of the risks and use intraoperative safety measures to prevent their occurrence.

Actual complication rates are often difficult to discern because denominators often are not available. In a nationwide analysis of 367 complications associated with 1,455 TVT procedures performed in Finland, there was a 1.9% rate (95% CI, 1.2–2.7) of blood loss over 200 mL, a 1.9% rate (95% CI, 1.2–2.7) of retropubic hematoma, a 0.5% rate (95% CI, 0.2–1.0) of hematoma outside the retropubic area, a 0.1% rate (95% CI, 0.0–0.4) of injury to the epigastric vessel, a 0.1% rate (95% CI, 0.0–0.4) of injury to the obturator nerve, and a 3.8% rate (95% CI, 2.9–5.0) of bladder perforation (120).

A prospective, randomized trial of retropubic versus transobturator slings (the TOMUS trial) involving 597 patients revealed more bladder perforations in the retropubic group (15 vs. 0), more patients with elevated PVR volume (>100 mL at time of discharge), and higher rate of sling release or catheterization for voiding dysfunction after 6 weeks (8 vs. 0). The transobturator group had more vaginal perforations (13 vs. 6) and neurologic symptoms including lower extremity weakness and numbness found immediately following surgery to 6 weeks (31 vs. 15). Otherwise, serious adverse events were similar in both groups (108).

Erosion is unique to surgeries in which a graft is placed, and the rate depends largely on the type of graft used. Tension-free vaginal tape is associated with a low rate of graft erosion, compared with a much higher rate of erosion with certain synthetics previously used for pubovaginal slings. Most midurethral synthetic slings used at this time are made of polypropylene; the main differences in the character of the mesh involve elasticity and rigidity and not the material itself. In the randomized trial comparing TVT to TOT described above, of the 597 women who underwent a sling procedure, 1.8% of the patients were noted to have a mesh erosion or exposure (108).

The most common adverse events (5% to 10% rate for each) after all surgeries for stress urinary incontinence include urinary tract infection, failure to cure, new onset detrusor overactivity, voiding dysfunction, genital prolapse, and bladder perforation. When new onset detrusor overactivity occurs after surgery for incontinence, cystoscopy should be considered to rule out a foreign body in the bladder (Fig. 26.13). Less common events (2% to 5% for each) include excessive blood loss, wound infection, pain, or nerve injury. Events such as sinus tracts and fistulae are rare. Erosion rates depend on the material implanted and, as noted previously, are rare for the midurethral slings. In addition, medical events, such as thromboembolic, cardiac, or pulmonary events, are rare.

Figure 26.12 Midurethral synthetic slings involve the use of large pore, monofilament polypropylene mesh placed after minimal dissection at the midurethra followed by placement of a trocar through the retropubic route. Some surgeons prefer placing the trocar by a suprapubic route beginning with a small abdominal incision. A: The trocar is guided into the previously performed midurethral incision with care to place the trocar against the pubic bone to avoid entry into the peritoneal cavity. The trocar handle has been removed in this view after perforation through the abdominal incision. B: The synthetic sling should rest in the midurethra location and is brought through two stab incisions above the pubic symphysis. (Redrawn from original by Jasmine Tan.)

Figure 26.13 Cystoscopic view of encrusted suture penetrating bladder wall following sling urethropexy.

As midurethral slings largely replace pubovaginal slings and retropubic urethropexies as the primary procedure for stress urinary incontinence, the comparison of complications of these procedures becomes more important. Given the debate on the effectiveness of the different approaches for midurethral slings, the severity and incidence of complications for midurethral slings will become more important when determining the best primary procedure for stress urinary incontinence. Likewise, the uncommon occurrence of intraoperative and long-term complications of these procedures and underreporting of complications demonstrates the need for reliable large registries for midurethral slings and other promising procedures to assess the safety of these procedures.

Procedures for Urgency Urinary Incontinence

Neuromodulation

Even with the development of newer anticholinergic medications with fewer side effects, there continues to be a select group of patients with overactive bladders who remain refractory to standard medical and behavioral treatment. Surgical treatment of this condition traditionally involved substantial morbidity and major urinary denervation, reconstruction, or both to achieve therapeutic benefits. The development of implantable sacral nerve root stimulators led to FDA approval of sacral root neuromodulation in patients with refractory urinary urgency and frequency, urge incontinence, and voiding dysfunction. This therapy offers patients with severe symptoms an alternative to urinary augmentation or diversion. Sacral nerve stimulation therapy is performed in two phases. In the first phase, a percutaneous nerve evaluation test is performed to determine which patients respond to this type of therapy. Those who respond are implanted with a permanent electrode lead adjacent to the third sacral nerve root connected to a pulse generator.

A multicenter prospective study demonstrated that 63% of test patients responded to the initial procedure. After implantation, 47% of patients became completely dry, and 77% were successful in eliminating “heavy” leakage episodes. Despite substantial success in nearly 80% of patients who received implants, 30% of patients required further surgical revision because of pain or other complications at the generator or implant site. No permanent injuries or nerve damage was reported in the initial trials (121,122).

In a group of 96 patients with implants (who responded favorably during the test stimulation period), reductions in urge incontinence episodes and severity were still seen at an average of 31 months after implantation. The device was removed in 11 of the 96 patients because of lack of efficacy, pain, or bowel dysfunction. There were no permanent injuries (123). The technique for this procedure evolved to include the location of a generation implant site on the back and the performance of the procedure in two stages with initial percutaneous implantation of a quadpolar instead of a unipolar stimulator. These modifications may improve success rates and decrease the morbidity associated with these procedures. A recent systematic review evaluating eight randomized trials concluded that continuous sacral neural stimulation offers benefits for carefully selected patients with overactive bladder and urinary retention in the absence of obstruction, but many implants did not work or required revisions. The review recommended trials to assess effectiveness directly compared to other treatment options (124).

Percutaneous Tibial Nerve Stimulation

Percutaneous tibial nerve stimulation (PTNS) was first described in 1987 to treat lower urinary tract symptoms and FDA approved in 2000 for overactive bladder. This therapy uses peripheral neurostimulation technique with small (34-gauge) needle electrode inserted at a 60-degree angle approximately 5 cm cephalad to the medial malleolus and slightly posterior to the tibia. The treatment course typically consists of a weekly 30-minute session for 12 weeks. A multicenter, double-blind, randomized control trial involved 220 women with overactive bladder symptoms randomized 1:1 to 12 weeks of treatment with weekly PTNS or sham therapy. The PTNS treatment group achieved statistically significant improvement in bladder symptoms, with 55% reporting moderate to marked improvement compared to 21% in the sham arm compared to baseline (125). The OrBIT (Overactive Bladder Innovative Therapy) trial compared PTNS to extended-release tolterodine in the treatment of OAB and found similar improvements in both groups (126). A large portion of responders in this trial (96%) had sustained improvement in OAB symptoms at 12-month follow-up when receiving periodic treatments (127,128). PTNS may represent a viable treatment option for patients who cannot tolerate side effects from anticholinergic medications, who do not responded to behavioral therapy, or who decline implantable neurostimulators.

Botox Injections

Botulinum toxin A (BtxA), a neurotoxin produced by the anaerobic bacteria Clostridium botulinum, acts on peripheral cholinergic nerve endings to inhibit calcium-mediated release of acetylcholine vesicles at the presynaptic neuromuscular junctions. In a report from a multicenter study, a 73% continence rate occurred in 180 patients with neurogenic detrusor overactivity incontinence who underwent cystoscopic Botox injections (129). A recent prospective placebo-controlled trial in patients with refractory idiopathic urge incontinence demonstrated a 60% clinical response using the Patient Global Impression of Improvement score of 4 or greater with a median duration of response of 373 days. The Botox group did experience an increase in postvoid residual in 75% of the subjects (130). The off-label use of Botulinum A cystoscopic detrusor injections to treat refractory urge incontinence in women with and without neurologic impairment is gaining popularity. The procedure is done via cystoscopy and involves injecting 15 to 30 different detrusor muscle sites under direct visualization, sparing the bladder trigone and ureteral orifices.

Augmentation Cystoplasty and Urinary Diversion

Surgery to replace the function of a diseased bladder has been done for more than a century and over the past several decades has gained some popularity in treating people with intractable detrusor overactivity not responsive to any other form of management. These surgical options include (i) conduit diversion (creation of various intestinal conduits to the skin) or continent diversion (which includes a rectal reservoir or continent cutaneous diversion), (ii) bladder reconstruction, or (iii) replacement of the bladder with various intestinal segments. For a discussion of these techniques, both historical and current, the interested reader is referred to a review by Greenwell et al. (131). A Cochrane review found only two randomized trials that were of sufficient quality to include and concluded that there were no major differences in outcomes between the techniques and that higher quality research was needed (132). With the advent of sacral neuromodulation and cystoscopic injection with Botulinum A, these procedures are done much less often to treat women with detrusor overactivity.

Surgical Treatment of Fistulae

A wide variety of techniques are available for fistula repair (133,134). Traditionally, fistula repair was performed after a waiting period to allow the resolution of inflammation and formation of scar tissue. This is particularly important in the case of obstetric fistulas, in which the extent of the vascular injury to the soft tissues of the pelvis may not be apparent for many weeks. However, there is a recent trend toward early closure of small gynecologic fistulas (135). The keys to closure of a vesicovaginal fistula include wide mobilization of tissue planes so that the fistula edges can be approximated without any tension, close approximation of tissue edges, closure of the fistula in several layers, and meticulous attention to postoperative bladder drainage for 10 to 14 days. The closure of large fistulas will be enhanced by the use of tissue grafts (e.g., Martius labial fat-pad grafts, gracilis muscle flaps) that provide an additional blood supply to nourish an area that has sustained vascular injury. The Latzko procedure used to close a vesicovaginal fistula is shown in Figure 26.14.

Figure 26.14 Repair of apical vesicovaginal fistula. A: The fistula at the vaginal apex is exposed with adequate retraction. A pediatric foley can be placed into the fistula tract to aid in traction and dissection. B: The vaginal epithelium is dissected from the fistula to mobilize the tissue to allow for tension-free closure. In the classic Latzko procedure, the vaginal epithelium 2 cm around the opening of the fistula is removed. C: The fistula tract may either be completely excised, or in the Latzko procedure, the fistula edge may freshened up slightly but is not excised. D: Interrupted absorbable sutures are placed in an extramucosal location in an interrupted fashion. An additional layer of interrupted sutures is often placed to invert the initial suture line. The vaginal epithelium is then closed over the repair. In the classic Latzko procedure, the initial layer involves closure of the vagina over the fistula tract, then two additional layers with the vaginal epithelium result in an apical colpocleisis. (Redrawn from original by Jasmine Tan.)

Cystoscopy

Scientific evidence does not support routine cystoscopy in women with stress urinary incontinence in the absence of other pathologies (136). Cystoscopy cannot be used to predict intrinsic sphincteric deficiency, stress incontinence, or detrusor overactivity. Cystoscopy can be considered in the following circumstances: (i) in women with urge incontinence to rule out other disorders, especially in women with microscopic hematuria, (ii) in the evaluation of vesicovaginal fistulae, and (iii) intraoperatively to evaluate possible ureteral or vesical injury.

Urologists often use flexible cystoscopy in men; however, women tolerate a rigid cystoscope well, given their short urethras and absence of prostate glands. The view afforded by a rigid cystoscope is clearer than that obtained with a flexible scope, and less technical skill is required to view the entire bladder using a rigid scope. However, with advancement in technology, the efficacy divide between rigid and flexible cystoscopes continues to narrow. Cystoscopes are available with several viewing angles: 0 degree (straight), 30 degrees (forward-oblique), 70 degrees (lateral), and 120 degrees (retroview).The last scope is rarely used in women. Zero-degree lenses are essential for viewing the urethra, whereas a 30-degree lens provides the best view of the bladder base and posterior wall, and the 70-degree lens generally provides the best view of the anterior and lateral walls. For diagnostic cystoscopy, sterile water is an ideal medium because it is readily available and inexpensive.

To evaluate the urethra, the cystoscope, typically with a 0-degree or 30-degree lens, should be advanced with distension medium flowing, keeping the center of the urethral lumen in the center of the visual field. The mucosa is normally pink and smooth and the urethral folds close.

After insertion of the cystoscope into the bladder with a 70-degree lens, an air bubble will be present at the bladder dome, which may assist in proper orientation. Then the remainder of the bladder is examined systematically by making a series of sweeps, slowly rotating the cystoscope between the dome and urethrovesical junction. To view the trigone, the light cord should be oriented toward the ceiling (keeping the camera in an upright position). The scope is pulled back until it is almost in the urethra and the base of the bladder is viewed. Because the trigone is a zone of metaplasia, it looks different from the rest of the urothelium (Fig. 26.15).

Figure 26.15 Cystoscopic view of normal-appearing trigone with left ureteral orifice visible.

Vaginal and abdominal hysterectomies are associated with a 0.02% to 0.85% incidence of ureteral injury (137). The injury rate increases in reconstructive pelvic surgeries, reaching as high as 11% after uterosacral ligament suspension (138). In a study of 46 women who underwent proximal uterosacral ligament vaginal vault suspension, three of the five women with cystoscopic evidence of obstruction were treated successfully by removing and replacing the sutures. This finding emphasizes the importance of confirming ureteral integrity at surgery. The value of cystoscopy to evaluate ureteral injury after minimally invasive hysterectomy is unknown because this injury is often thought to occur in association with thermal injury, and it is unclear whether obstruction or decreased flow will be apparent intraoperatively.

Administering indigo carmine dye intravenously 5 minutes before cystoscopy aides in the assessment of ureteral patency. Quick efflux of stained urine should be seen bilaterally. Sluggish efflux should prompt further investigation. However, preexisting ureteral obstruction may be responsible for lack of flow. In 157 women who underwent complex urogynecologic procedures, 5 cases (3.2%) of unsuspected ureteral obstruction were identified with intraoperative cystoscopy (139). One was caused by ureteral ligation, and the remaining four represented chronic ureteral obstruction resulting from pelvic organ prolapse (two cases), ureteropelvic junction obstruction (one case), and ureterovesical junction stenosis after prior transurethral resection of bladder cancer (one case).

Voiding Dysfunction and Bladder Pain Syndromes

Voiding Dysfunction

Women are afflicted less commonly than men with voiding difficulties, but these disorders do occur in women and can be defined as emptying dysfunction resulting from relaxation of the pelvic floor musculature or failure of the detrusor muscle to contract appropriately. True outflow obstruction (defined as a detrusor pressure of more than 50 cm H₂O in association with a urine flow rate of less than 15 mL/sec) is rare in women and, when seen, is usually found in those who underwent obstructive bladder neck surgery for stress incontinence (140,141). For normal voiding to occur, the pelvic floor and urethral sphincter must relax, which should happen in conjunction with a coordinated contraction of the detrusor muscle that leads to complete bladder emptying. The bladder may be emptied by other mechanisms, such as by abdominal straining in the absence of a detrusor contraction or simply by relaxation of the pelvic floor. Complete bladder emptying is not the same as normal voiding. Some women may empty their bladders completely but only by expending great effort over several minutes. In such cases, voiding is clearly abnormal, even though the bladder is empty when voiding ceases. In the worst cases, voiding is both difficult and incomplete.

Causes

Neurologic diseases, such as multiple sclerosis, may cause voiding difficulty as a result of detrusor-sphincter dyssynergia, in which the urethral sphincter contracts at the same time as the detrusor (143). Great effort is required to overcome urethral resistance; the patient voids with an interrupted stop-and-start stream and usually has a significant amount of residual urine.

Other causes of voiding difficulty include medications (such as antihistamines and anticholinergic agents), infections (in particular, herpes simplex virus, and urinary tract infections), obstruction (following bladder neck surgery, or in women with advanced pelvic organ prolapse), overdistension, severe constipation (particularly in the elderly), and, rarely, psychogenic factors. Fowler’s syndrome refers to unexplained urinary retention occurring as an isolated phenomenon (144). Such women usually are between 20 and 35 years of age. Commonly the first retention episode will be triggered by an event such as surgery or childbirth. Retention rarely resolves but is not associated with the development of other disorders.

Evaluation

Evaluation of a woman with voiding difficulty begins with a careful physical examination. Advanced pelvic organ prolapse may contribute to urinary retention, but it is unlikely that prolapse above the level of the vaginal introitus will be the sole cause of retention. When in doubt, the woman can wear a pessary for a week to see whether elevating the prolapse reduces the voiding difficulty. Occasionally pelvic masses—in particular, low anterior myomas—may cause urinary retention. Abnormal findings detected during neurologic examination of the perineum and lower extremities may suggest the need to focus on the spine. Urodynamic evaluation will help determine whether the woman has an obstruction (manifested by high detrusor pressures during voiding or by no urethral relaxation during voiding) or whether the detrusor muscle is not contracting. The latter is not necessarily indicative of a neurogenic disorder in women, because a large minority of normal healthy women void by urethral and pelvic floor muscle relaxation alone, with no detrusor contraction. Cystourethroscopy may reveal an obstructing lesion, such as a polyp, tumor, ureterocele, or ball-valve stone. Usually, the evaluation reveals no obvious source, and treatment can commence.

Treatment

The mainstay in the treatment of voiding difficulty is clean, intermittent self-catheterization (145). The most important protection against urinary tract infection is frequent and complete bladder emptying rather than avoiding the introduction of a foreign body into the bladder. Self-catheterization allows the patient to accomplish this task using a small (14-Fr) plastic catheter that she inserts through the urethra into the bladder, draining its contents. The catheter is then removed, washed with soap and water, dried, and stored in a clean, dry place. Elaborate sterile procedures are not necessary. Bacteria are introduced into the bladder in this process, and the urine of women after self-catheterization regimens will always be colonized with bacteria; however, this condition should not be treated unless symptomatic infection occurs.

In addition to decreasing urinary urgency and incontinence caused by detrusor overactivity, neuromodulation of the sacral nerve roots may help women with nonobstructive urinary retention (122). In a trial of 177 patients with idiopathic urinary retention, those who had greater than 50% improvement in baseline voiding symptoms during a test stimulation period qualified for surgical implantation of InterStim. Of these, 37 were randomly assigned to early implantation, whereas 31 in the control group delayed implantation for 6 months. Improved voiding occurred in 83% of the implant group compared with 9% of the control group at 6 months (146). It appears that the long-term success rates of InterStim for urinary retention remain high. In a trial following patients for 5-years after implantation, 71% of the patients with urinary retention had successful outcomes (147). Although this technology requires a surgical procedure, many women favor this therapy over lifelong self-catheterization.

Mild sedatives are sometimes helpful in this process, as are α-blockers (e.g., prazosin, phenoxybenzamine, tamsulosin), which reduce urethral tone. Although cholinergic medications such as bethanechol chloride are successful in making strips of bladder muscle contract in a laboratory, there is little evidence that such drugs are helpful clinically (148).

Bladder Pain Syndromes

Most patients with disorders of bladder sensation experience pain rather than lack of bladder sensation. As with the treatment of most chronic pain disorders, the cause of most painful bladder conditions is unknown, and the therapies used are only partially successful. As a result, disorders of bladder sensation are among the most frustrating urogynecologic conditions to manage.

Terminology and Prevalence

Bladder pain syndrome, often termed interstitial cystitis, is a poorly defined heterogeneous syndrome, and diagnostic criteria are changing continuously. The International Continence Society standardization report recommends adapting the term bladder pain syndrome, rather than interstitial cystitis, and defines painful bladder syndrome as “an unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder associated with lower urinary tract symptom(s) of more than 6 weeks duration, in the absence of infection or other identifiable causes”(15). Urgency and pain are the defining characteristics of bladder pain syndrome(149). Several factors have inhibited advances in the understanding of interstitial cystitis, including the lack of specific diagnostic criteria, the lack of specific histopathologic changes, the unpredictable fluctuation in symptoms, and the marked variability among patients in terms of symptoms, objective findings, and treatment responses (150).

The National Institute of Diabetes, Digestive, and Kidney Diseases (NIDDK) developed a research definition for interstitial cystitis that requires objective findings of glomerulations or a classic Hunner’s ulcer during hydrodistention of the bladder and subjective symptoms of bladder pain or urinary urgency in the absence of other urogenital pathology (151). Strict application of NIDDK criteria in one study would have misdiagnosed more than 60% of patients thought to definitely or possibly have interstitial cystitis (152). Many clinicians have challenged the clinical utility of the NIDDK research criteria, and most conceptualize interstitial cystitis as the end point on the spectrum of painful bladder disorders (153).

The prevalence of bladder pain syndrome varies widely depending on the diagnostic criteria utilized. When mild and moderately severe cases are considered, the syndrome is not rare (154). Estimates of prevalence in the United States range from 52 per 100,000 women in the population-based Nurses Health Study to as high as 1 in 4.5 women “with accurate diagnostic records” (155,156). The prevalence appears to be 6 to 15 times more common among women than men (155,157). The identification of risk factors for bladder pain syndrome is particularly challenging because of the typically long delay in diagnosis (154). The Interstitial Cystitis Database study confirms many of the previous epidemiologic observations: affected individuals are predominately female (92%), white (91%), and report an average age of symptom onset of 32.2 years (150,155).

Diagnosis

A careful history should be obtained, along with a sterile urine specimen for analysis and culture. Many women treated repetitively for chronic cystitis take multiple courses of antibiotics on the basis of symptoms without ever having the presence of an infection confirmed by cultures. Detrusor overactivity may be the cause of frequency, urgency, and urge incontinence, but that is not usually a factor in dysuria or painful urination. Women older than 50 years (particularly those who smoke or are exposed to chemicals at work) are at risk for bladder cancer, and this possibility must be considered, especially if hematuria is present. Urinary cytologic assessment is sometimes helpful in detecting early tumors of the urinary tract, and cystoscopy and intravenous urography are mandatory in the evaluation of patients with hematuria.

Other possible causes for painful voiding must be considered in the differential diagnosis, including urethral diverticula; vulvar disease; endometriosis; chemical irritation from soaps, bubble bath, or feminine hygiene products; urinary stones; urogenital atrophy from estrogen deprivation; and sexually transmitted disease.

The diagnosis of bladder pain syndrome or interstitial cystitis is largely one of exclusion. The ideal diagnostic test for interstitial cystitis is not determined, and there are myriad proposed tests.

Treatment

Typically, the evaluation of bladder pain syndrome results in no definitive diagnosis, and management focuses on the treatment of symptoms.

Frequency–urgency syndromes should be managed with a careful voiding regimen (similar to that used in the treatment of urgency urinary incontinence) and local care.

The use of urinary tract analgesics such as Prosed DS may be helpful in reducing urethral irritation. Prosed DS is a polypharmaceutical agent containing a mixture of methenamine, methylene blue, phenyl salicylate, benzoic acid, and hyoscyamine that has a soothing effect on many irritative urinary tract symptoms.

There is no scientific evidence linking diet to painful bladder syndrome, but many doctors and patients find that alcohol, tomatoes, spices, chocolate, caffeinated and citrus beverages, and high-acid foods may contribute to bladder irritation and inflammation. Some patients note that their symptoms worsen after eating or drinking products containing artificial sweeteners. Patients may try eliminating various items from their diet and reintroducing them one at a time to determine which, if any, affect their symptoms. Instruction in the basics of vulvar and perineal hygiene is important (thorough drying; avoidance of most body powders, perfumes, or colored irritating soaps; avoidance of tight-fitting undergarments) to avoid other factors that may contribute to painful voiding.

Hydrodistention of the bladder (usually under anesthesia) is recommended as a treatment option and can result in clinical improvement in some patients. Likewise, bladder installations are commonly used for acute treatment of bladder pain syndrome. The medications used range from local anesthetics to bladder specific medications including resiniferatoxin, dimethyl sulfoxide, BCG, pentosan polysulfate, and oxybutynin. Some patients benefit from the instillation into the bladder of 50 mL of a 50% solution of dimethylsulfoxide (DMSO) for 20 to 30 minutes every other week for four or five sessions. A recent Cochran review found that evidence is limited and randomized controlled trials are needed to adequately assess outcomes. Intravesical installations of BCG and oxybutynin are reasonably well tolerated, and evidence is the most promising for these agents (157).

Tricyclic antidepressants are commonly used in patients with pain. A trial by the Interstitial Cystitis Collaborative Research Network found that amitriptyline plus education and behavioral modification did not significantly improve symptoms in the treatment of naive patients with bladder pain syndrome, but the network did suggest that it may be beneficial in those patients who could tolerate a daily dose of 50 mg or greater (158).

Pentosan polysulfate (Elmiron) is an FDA-approved oral agent with heparin-like activity that attempts to replace the glycosaminoglycan sulfate layer that is believed deficient in these patients. The FDA-recommended oral dosage of pentosan polysulfate is 100 mg, three times a day. Patients may not feel relief from pain for the first 2 to 4 months, and it may take up to 6 months for a decrease in urinary frequency to occur.

It is theorized that bladder pain may result from increased histamine release, and some patients benefit from medications that block these inflammatory mediators, such as diphenhydramine hydrochloride, 25 to 50 mg orally three times per day, in combination with 300 mg of cimetidine three times per day. Tricyclic antidepressants help some women by modulating sensory nerve pain.

Transcutaneous electrical nerve stimulation (TENS), through wires placed on the lower back or just above the symphysis, may help some women, though the mechanism of action is unclear. Ongoing preliminary research suggests that some women with severe bladder pain syndrome may find relief following sacral neuromodulation (InterStim), acupuncture, or intravesical Botox injection associated with hydrodistension.

COMP: please see previous edition (p. 853)–prior to em space please use blue italic throughout

COMP: follow design in previous edition (p. 861)

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