Stress Incontinence

1. Etiologies
   1. Bladder neck or Urethral injury
   2. Sphincter weakness from neurologic injury
   3. Decreased Pelvic Floor Competence
      1. Normal aging
      2. Surgery
      3. Multiparity
      4. Postpartum (20-30% at 3 months postpartum)
         1. Glazener (2001) BMJ 323:593-6
2. Pathophysiology
   1. Bladder outlet less than intravesicular pressure
   2. Weakness of pelvic floor or Bladder neck support
      1. Bladder neck descends below pelvic floor on exertion
      2. Bladder neck opens
      3. Only sphincter (weak) can hold back urine
3. Symptoms
   1. Small amounts of urine lost
      1. Contrast with large volumes in Urge Incontinence
   2. Urine loss stops immediately after activity stops
   3. Immediately after increased intrabdominal pressure
      1. Cough
      2. Sneeze
      3. Laugh
      4. Heaving or straining
4. Signs
   1. Leakage after Valsalva or cough with full Bladder
      1. See Bladder Stress Test
   2. Weakness or protrusion
      1. Anterior vaginal wall
      2. Urethra
      3. Bladder
5. Labs
   1. Post-void residual under 50 cc
   2. Bladder Capacity under 400 cc
6. Management: General Measures (most effective)
   1. Kegal Exercises
   2. Vaginal weight training (Vaginal cones)
   3. Physical Therapy
      1. Biofeedback (visualize pelvic floor contractions)
      2. Functional electrical stimulation
         1. Transvaginal or Transrectal
      3. Highly effective in elimination of Incontinence
         1. Dumoulin (2004) Obstet Gynecol 104:504-10
   4. Vaginal devices
      1. Pessaries
         1. Consider in older patients
         2. Risk of vaginal infection or local trauma
      2. Diaphragms
      3. Bladder neck support prosthesis (e.g. Milex)
         1. Used temporarily (e.g. during Exercise)
      4. Urethral Occlusion insert
         1. Used temporarily (e.g. during Exercise)
      5. Extracorporeal magnetic innervation (ExMI) chair
         1. FDA approved chair, 2x/week, 20 minutes, 8 weeks
         2. Low-intensity magnetic field stimulates Pelvis
         3. Indicated for mild cases that have not had surgery
   5. Situational
      1. Change diet
      2. Eliminate provocative medications
      3. Collection or absorption products
      4. Timed voiding
7. Management: Medications
   1. General
      1. Medications are not effective in Stress Incontinence
         1. Duloxetine is a possible exception
      2. Avoid anticholinergics (e.g. Oxybutynin)
         1. Not effective in Stress Incontinence
   2. Duloxetine (Yentreve, Cymbalta)
      1. SNRI that stimulates Urethral sphincter contraction
      2. Not FDA approved - but appears effective in some cases
   3. Topical Estrogen
      1. Indicated for Postmenopausal Atrophic Vaginitis
      2. Greater efficacy seen in Urge Incontinence
      3. Estrogen not effective in Stress Incontinence
         1. Fantl (1996) Obstet Gynecol 88:745-9
   4. Alpha adrenergic agonists
      1. No strong evidence supporting use
      2. Preparations
         1. Phenylpropanolamine
         2. Pseudoephedrine
      3. Mechanism
         1. Increases Bladder outlet smooth muscle tone
   5. Tricyclic Antidepressants (Imiprimine)
      1. Indications
         1. Mixed Urge Incontinence and Stress Incontinence
         2. Not indicated in Stress Incontinence alone
      2. Mechanism
         1. Anticholinergic
         2. Direct relaxant of detrussor
         3. Alpha-adrenergic-Bladder outlet tone increased
8. Management: Surgical
   1. Colposuspension (Elevate UVJ above pelvic floor)
      1. Effective, but Incontinence may recur with time
      2. Indicated in Uterine Prolapse
   2. Tension-free vaginal tape (TVT)
      1. Urethral sling placed under Local Anesthesia
      2. More effective than colposuspension
         1. Valpas (2004) Obstet Gynecol 104:42-9
   3. Collagen injection into periurethral area (Durasphere Transurethral injection)
      1. Effective, but Incontinence may recur with time
      2. Indicated for intrinsic sphincter deficiency
9. References
   1. Videla (1998) Obstet Gynecol 91:965-8
   2. Weiss (2005) Am Fam Physician 71:315-22