Urinary Incontinence in
Adults
Introduction
Urinary incontinence (UI) is an Estimates of prevalence vary
extremely common complaint in according to the definition of
every part of the world. It causes incontinence and the population
studied. However, there is
a great deal of distress and universal agreement about the
embarrassment, as well as importance of the problem in
significant costs, to both terms of human suffering and
individuals and societies. economic cost.
Definition
Urinary incontinence is a storage symptom and defined as the complaint of
any involuntary loss of urine.
Urgency Urinary Stress Urinary
Incontinence (UUI) is Incontinence (SUI) is the
the complaint of complaint of involuntary
involuntary leakage leakage on effort or
accompanied by or exertion, or on sneezing
immediately preceded or coughing.
by urgency.
Mixed Urinary Incontinence (MUI) is the
complaint of involuntary leakage associated
with urgency, and also with effort, exertion,
sneezing and coughing.
Causes
Urologic Causes Non Urologic Causes
- Detrusor over activity - Infection
- Poor bladder compliance - Drug usage
- Psychological issues
- Urethral hypermobility - Polyuria
- Intrinsic sphincter deficiencies - Hydrocephalus
- Stool impaction
- Limited mobility
Caused of Acute Urinary Incontinence
◉ D : Delirium or Acute Confusional State
◉ I : Infection, Urinary
◉ A : Atrophic vaginitis or urethritis
◉ P : Pharmaceutical
■ Sedative Hypnotic
■ Loop Diuretics
■ Anti-Cholinergic agents
■ Alpha Adrenergic agonist ang antagonist
■ Calcium Chanel Blocker
◉ P : Psychologic disorder : Depression
◉ E : Endocrine disorder
◉ R : Restricted Mobility
◉ S : Stool Impaction
PHYSIOLOGY OF THE
URINARY CONTINENCE
Filling and storage
MECHANISM
phase
Next…
Initiation phase
Next..
Voiding phase
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PHYSIOLOGY OF
THE URINARY
CONTINENCE
MECHANISM
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PHYSIOLOGY OF
THE URINARY
CONTINENCE
MECHANISM
DIAGNOSTIC EVALUATION
◉ Initial incontinence evaluation, which includes history, physical
examination, urinary tract infection testing, urinary stress testing,
and assessment of post- void residual.
◉ History and physical examination
◉ The history should include details of the type, timing and
severity of UI, associated voiding and other urinary
symptoms.
◉ The history should allow UI to be categorised into stress
urinary incontinence (SUI), urgency urinary incontinence
(UUI) or mixed urinary incontinence (MUI). It should also
identify patients who need rapid referral to an appropriate
specialist.
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DIAGNOSTIC EVALUATION
• In women, an obstetric and gynaecological history may help to
understand the underlying cause and identify factors that may impact on
treatment decisions. The patient should also be asked about other ill health
and for the details of current medications, as these may impact on symptoms
of UI.
• Pelvic examination is recommended, detection of a pelvic mass,
would alter the planned intervention or influence treatment
selection. In postmenopausal women, clinicians should look for
vaginal atrophy, which can effectively be treated with vaginal
estrogen. In addition, clinicians should look for pelvic organ
prolapse beyond the vagina because it is associated with a higher
risk of urinary retention. Clinicians can assess pelvic floor muscle
integrity and function during the bimanual pelvic examination by
asking the patient to contract her pelvic floor muscles
Pelvic examination 11
DIAGNOSTIC EVALUATION
• Voiding diaries
• Measurement of the frequency and severity of lower urinary tract
symptoms (LUTS) is an important step in the evaluation and
management of lower urinary tract (LUT) dysfunction, including UI.
Voiding diaries are a semiobjective method of quantifying symptoms,
such as frequency of UI episodes. They also quantify urodynamic
variables, such as voided volume and 24-hour or nocturnal total urine
volume.
• Voiding diaries are also known as micturition time charts,
frequency/volume charts and bladder diaries.
• In addition, voided volume measurement can be used to
support diagnoses, such as overactive bladder (OAB) or
polyuria. Diaries can also be used to monitor treatment
response and are widely used in clinical trials.
Voiding
diaries
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DIAGNOSTIC EVALUATION
• Urinalysis and urinary tract infection
• Urinalysis should be used to identify urinary tract infection
and detect hematuria, pyuria, or glycosuria because these
may represent comorbid conditions associated with
incontinence. Reagent strip (‘dipstick’) urinalysis may
indicate UTI, proteinuria, haematuria or glycosuria requiring
further assessment.
• Urodynamics
• Urodynamic testing is used as an adjunct to clinical diagnosis, in the belief
that it may help to provide or confirm diagnosis, predict treatment
outcome, or facilitate discussion during counselling.
• Urodynamics is often performed prior to invasive treatment for UI.
DIAGNOSTIC EVALUATION
• Imaging
• Imaging improves understanding of the anatomical and functional
abnormalities that may cause UI. In clinical research, imaging is used to
understand the relationship between anatomy and function, between
conditions of the central nervous system (CNS) or of the LUT and UI, and
to investigate the relationship between LUT and pelvic floor imaging and
treatment outcome.
• Urodynamics
• Ultrasound and magnetic resonance imaging (MRI) have largely replaced
X-ray imaging. Ultrasound is preferred to MRI because of its ability to
produce three-dimensional and four-dimensional (dynamic) images at
lower cost and wider availability. Studies on LUT imaging in patients with
UI often include an evaluation of surgical outcomes, making design and
conduct of these trials challenging.
MANAGEMENT
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Conservative
management
1. Simple clinical interventions
a. Underlying disease/cognitive impairment
In the elderly, UI has been associated with multiple comorbid conditions
including cardiac failure, chronic renal failure, diabetes, chronic obstructive
pulmonary disease, neurological disease including stroke and multiple
sclerosis, general cognitive impairment, sleep disturbances, e.g. sleep
apnoea, depression, metabolic syndrome.
It is possible that improvement of associated disease may reduce
the severity of urinary symptoms. However, this is often difficult to
assess as patients frequently suffer from more than one condition. In
addition, interventions may be combined and individualised, making it
impossible to decide which alteration in an underlying disease has affected a
Conservative
management
b. Adjustment of other (non-incontinence) medication
UI is listed as an adverse effect of many drugs. In patients, particularly the
elderly, it may be difficult or impossible to distinguish between the
effects of medication, comorbidity or ageing on UI. Although changing
drug regimens for underlying disease may be considered as a
possible early intervention for UI, there is very little evidence of
benefit. There is also a risk that stopping or altering medication may result
in more harm than benefit.
c. Constipation
Several studies have shown strong associations between constipation and UI.
Constipation can be improved by behavioural, physical and medical
treatments.
Conservative
management
d. Lifestyle interventions
Examples of lifestyle factors that may be associated with incontinence
include obesity, smoking, level of physical activity and diet. Modification of
these factors may improve UI.
e. Caffeine reduction
Many drinks contain caffeine, particularly tea, coffee and cola. Anecdotal
evidence of urinary symptoms being aggravated by excessive caffeine intake
has focused attention on whether caffeine reduction may improve UI.
However, a cross-sectional population survey found no statistical
association between caffeine intake and UI. Lack of knowledge about
the caffeine content of different drinks has made the role of caffeine
reduction in alleviating UI difficult to assess.
Conservative
management
f. Physical exercise
Regular physical activity may strengthen the pelvic floor musculature
and possibly decrease the risk of developing UI, especially SUI.
However, it is also possible that heavy physical exercise may
aggravate UI.
g. Fluid intake
Restriction fluid intake is a strategy commonly used by people with UI to
relieve symptoms. Advice on fluid intake given by healthcare professionals
should be based on 24-hour fluid intake and urine output
measurements.
Conservative
management
h. Obesity and weight loss
Being overweight or obese has been identified as a risk factor for UI
in many epidemiological studies. There is evidence that the
prevalence of both UUI and SUI increases proportionately with rising
body mass index. The proportion of patients who undergo surgery for
incontinence who are overweight or obese is higher than that of the general
population.
i. Smoking
Smoking cessation is now a generalised public health measure and has
been shown to be weakly associated with improving urgency
frequency and UI.
Conservative
management
Behavioural and Physical therapies
• Terminology relating to behavioural and physical therapies remains
confusing because of the wide variety of ways in which treatment
regimens and combinations of treatments have been delivered in different
studies.
• Approaches include bladder training (BT) and PFMT, but terms such as
bladder drill, bladder discipline and bladder re-education and behaviour
modification are also used. Almost always in clinical practice, these will be
introduced as part of a package of care including lifestyle changes, patient
education and possibly some cognitive therapy as well.
Conservative
management
Behavioural and Physical therapies
Bladder Training
A programme of patient education along with a scheduled voiding
regimen with gradually adjusted voiding intervals. Specific goals are
to correct faulty habit patterns of frequent urination, improve
control over bladder urgency, prolong voiding intervals, increase
bladder capacity, reduce incontinent episodes and restore patient
confidence in controlling bladder function. The ideal form or intensity of
a BT programme for UI is unclear. It is also unclear whether or not BT can
prevent the development of UI.
Conservative
management
Behavioural and Physical therapies
Pelvic floor muscle training (PFMT)
Pelvic floor muscle training is used to improve function of the pelvic floor, improving
urethral stability. There is some evidence that improving pelvic floor function may inhibit
bladder contraction in patients with OAB.
Pelvic floor muscle training may be used to prevent UI, e.g. in childbearing women before
birth, in men about to undergo radical prostatectomy, or as part of a planned recovery
programme after childbirth or surgery. PFMT is used to treat existing UI, and may be
augmented with biofeedback (using visual, tactile or auditory stimuli), surface electrical
stimulation (ES) or vaginal cones.
Electrical stimulation
The details and methods of delivery of ES vary considerably. Electrical stimulation of the
pelvic floor can also be combined with other forms of conservative therapy, e.g. PFMT and
biofeedback. Electrical stimulation is often used to assist women who cannot initiate
contractions to identify their pelvic floor muscles. ES is also used in patients with OAB and
Conservative
management
Posterior tibial nerve stimulation
• Electrical stimulation of the posterior tibial nerve (PTNS) delivers
electrical stimuli to the sacral micturition centre via the S2-S4
sacral nerve plexus.
• Stimulation is done percutaneously with a fine, 34-G, needle, inserted just
above the medial aspect of the ankle (P-PTNS). Transcutaneous stimulation
is also available (T-PTNS). Treatment cycles typically consist of twelve
weekly treatments of 30 minutes.
Conservative
management
Pharmacological management
Antimuscarinic drugs
• Antimuscarinic (anticholinergic) drugs are currently the mainstay of
treatment for UUI. They differ in their pharmacological profiles, e.g.
muscarinic receptor affinity and other modes of action, in their
pharmacokinetic properties, e.g. lipid solubility and half-life, and
in their formulation. The evaluation of cure or improvement of UI is
made harder by the lack of a standard definition of improvement and the
failure to use cure as a primary outcome
• Side effect : Dry mouth, constipation, blurred vision, fatigue and cognitive
dysfunction
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Conservative
management
Transcutaneous oxybutynin
Transdermal oxybutynin has shown a significant improvement in the number
of incontinence episodes and micturitions per day vs. placebo and other oral
formulations but continence was not reported as an outcome.
Oxybutynin topical gel was superior to placebo for improvement of UUI with a
higher proportion of participants being cured.
Antimuscarinic agents: adherence and persistence
Most studies on antimuscarinic medication are short term (twelve weeks).
Adherence in clinical trials is considered to be much higher than in clinical
practice.
Conservative
management
Mirabegron
• Mirabegron is the first clinically available beta3 agonist. Beta3
adrenoceptors are the predominant beta receptors expressed in the
smooth muscle cells of the detrusor and their stimulation is thought to
induce detrusor relaxation.
• The clinical effectiveness of mirabegron at doses of 25, 50 and 100 mg,
results in significantly greater reduction in incontinence episodes,
urgency episodes and micturition frequency/24 hours. In all trials
the statistically significant difference is consistent only for
improvement but not for cure of UI.
• The most common treatment adverse events in the mirabegron groups
were hypertension (7.3%), nasopharyngitis (3.4%) and UTI (3%).
• Patients on certain concurrent medications (i.e. metroprolol) should be
Conservative
management
Mirabegron
• Evaluation of urodynamic parameters in men with combined bladder outlet
obstruction (BOO) and OAB concluded that mirabegron (50 or 100 mg) did
not adversely affect voiding urodynamic parameters compared to placebo.
• An RCT in patients who had inadequate response to solifenacin
monotherapy 5 mg, demonstrated that combination treatment with
mirabegron 50 mg had a higher chance of achieving clinically meaningful
improvement in UI as compared to dose escalation of solifenacin [238].
Conservative
management
Antimuscarinic and beta3 agonist agents, the elderly and cognition
Trials have been conducted in elderly people with UI. Considerations in this
patient group include the multifactorial aetiology of UI in the elderly,
comorbidities such as cognitive impairment, the effect of co-medications and
the risk of adverse events.
The effects of antimuscarinic agents on cognition have been studied in more
detail.
Oxybutynin
There is evidence that oxybutynin IR may cause/worsen cognitive dysfunction
in adults. Recent evidence has emerged from a prospective cohort study
Conservative
management
Antimuscarinic and beta3 agonist agents, the elderly and cognition
Solifenacin
• One pooled analysis has shown that solifenacin does not increase cognitive
impairment in the elderly. No age-related differences in the
pharmacokinetics of solifenacin in different age groups was found,
although more frequent adverse events in subjects over 80 years of age
were observed.
• No cognitive effect on healthy elderly volunteers was shown. In a
subanalysis of a large trial, solifenacin 5-10 mg improved symptoms and
QoL in people > 75 years who had not responded to tolterodine. In patients
with mild cognitive impairment, > 65 years, solifenacin showed no
difference in efficacy between age groups and a lower incidence of most
side effects compared to oxybutynin IR.
Conservative
management
Tolterodine
No change in efficacy or side effects related to age have been reported,
although a higher discontinuation rate was found for both tolterodine and
placebo in elderly patients. Post-hoc analysis has shown little effect on
cognition.
Darifenacin
Two RCTs in the elderly population (one in patients with UUI and the other in
volunteers) concluded that darifenacin was effective with no risk of cognitive
change, measured as memory scanning tests, compared to placebo. Another
study on darifenacin and oxybutynin ER in elderly subjects concluded that the
Conservative
management
Trospium chloride
Trospium does not appear to cross the blood brain barrier in significant amounts in
healthy individuals due to its molecular characteristics (quaternary amine structure and
hydrophilic properties). Two (EEG) studies in healthy volunteers showed no effect from
trospium whilst tolterodine caused occasional changes and oxybutynin caused
consistent changes. No evidence as to the comparative efficacy and side effect profiles
of trospium in different age groups in available. However, there is some evidence that
trospium does not impair cognitive function and that it is effective compared to placebo
in the elderly.
Fesoterodine
Pooled analyses of the RCTs of fesoterodine confirmed the efficacy of the 8 mg but not
the 4 mg dose in over 75-year olds. Adherence was lower in the over-75 year-old group
Conservative
management
Anti-incontinence drugs in the elderly
Mirabegron
Analysis of pooled data from three RCTs showed efficacy and safety of
mirabegron in elderly patients.
Applicability of evidence to general elderly population
Community-based studies of the prevalence of antimuscarinic side effects
may be the most helpful. When starting anticholinergics in elderly patients,
mental function should be assessed objectively and monitored. No consensus
exists as to the best mental function test to detect changes in cognition.
Conservative
management
Drugs for stress urinary incontinence
Duloxetine
Duloxetine inhibits the presynaptic re-uptake of neurotransmitters,
serotonin (5-HT) and norepinephrine (NE). In the sacral spinal cord, an
increased concentration of 5-HT and NE in the synaptic cleft increases
stimulation of 5-HT and NE receptors on the pudendal motor neurones, which
in turn increases the resting tone and contraction strength of the urethral
striated sphincter.
Conservative
management
Oestrogen
Oestrogenic drugs including conjugated equine oestrogens, oestradiol,
tibolone and raloxifene, are used as hormone replacement therapy (HRT) for
women with natural or therapeutic menopause. Oestrogen treatment for UI
has been tested using oral, transdermal and vaginal routes of administration.
Available evidence suggests that vaginal oestrogen treatment with oestradiol
and oestriol is not associated with the increased risk of thromboembolism,
endometrial hypertrophy, and breast cancer seen with systemic
administration.
Desmopressin
Desmopressin is a synthetic analogue of vasopressin (also known as
antidiuretic hormone). It can be taken orally, nasally or by injection.
Desmopressin is most commonly used to treat diabetes insipidus and, when
Conservative
management
Drug treatment in mixed urinary incontinence
Tolterodine
In an RCT of 854 women with MUI, tolterodine ER was effective for
improvement of UUI, but not SUI suggesting that the efficacy of tolterodine
for UUI was not altered by the presence of SUI. In another study (n = 1380)
tolterodine was equally effective in reducing urgency and UUI symptoms,
regardless of whether there was associated SUI.
Duloxetine
In one RCT of duloxetine vs. placebo in 588 women, subjects were stratified
into either stress-predominant, urgency-predominant or balanced MUI groups.
Duloxetine was effective for improvement of incontinence and QoL in all
subgroups.
Surgical
management
Although the outcome of surgical procedures should be considered in
terms of cure, it is also important to consider any associated
complications, adverse events and costs. The outcome
parameters used to evaluate surgery for SUI have included:
• Continence rate and number of incontinence episodes
• Patient-reported outcome measures;
• General and procedure-specific complications;
• Generic, specific (UI) and correlated (sexual and bowel) QoL.
Surgical management
Women with uncomplicated stress urinary incontinence
1. Mid-urethral slings
Mid-urethral slings are now the most frequently used surgical intervention in
Europe for women with SUI. Early clinical studies identified that non-
autologous slings should be made from monofilament, non-absorbable
material, typically polypropylene, and constructed as a 1-2 cm wide mesh
with a relatively large pore size (macroporous). Safety of mid-urethral
slings
A population-based study performed in Scotland on over 16,000 women
operated on for SUI showed a similar rate of complications between
mesh and non-mesh surgery confirming the safety of mesh procedure for
UI. However, a recent study of over 92,000 patients followed in the National
Health Service (UK) showed a significant (9.8%) rate of complications
Surgical management
Transobturator route vs. retropubic route
• A Cochrane meta-analysis of mid-urethral sling procedures for SUI in
women was performed in 2017 spanning January 1947 to June 2014.
Moderate quality evidence from 55 studies showed variable, but
comparable, subjective cure rates between retropubic and
transobturator slings (62-98% in the transobturator arms and 71-97% in
the retropubic arms) in the short term (up to one year). No difference in
the objective cure rate in the short term was found.
• Although the adverse event rates are low, the retropubic approach was
associated with a higher rate of bladder perforation (4.5% vs.
0.6%) and voiding dysfunction; vascular and visceral injury, mean
operative time, operative blood loss and hospital stay were lower in the
transobturator groups.
Surgical management
Transobturator route vs. retropubic route
• Transobturator surgery was associated with a lower risk of voiding
dysfunction but groin pain was more frequent (6.4% vs. 0.6%). The
opposite occurred for suprapubic pain (0.8% in the transobturator and
2.9% in the retropubic groups, respectively). The overall vaginal erosion
risk was low and comparable in both groups (2.1% in retropubic and 2.4%
in transobturator surgery). Re-do surgery for UI was more common in the
transobturator group (RR = 8.79, 95% CI: 3.36-23) however the data is
limited and of low quality.
• An economic evalution of retropubic vs. transobsturator tapes suggests
that the latter may be cost-effective and cost-saving compared to the
standard tension-free vaginal tape (TVT) approach over a five years period.
Surgical management
2. Single-incision slings (SUI)
• There was evidence to suggest single-incision slings are quicker to perform
and cause less post-operative thigh pain, but there was no difference in
the rate of chronic pain. There was insufficient evidence for direct
comparisons between single-incision slings, and reach any conclusions
about differences.
• The most recent meta-analyses and a re-analysis of the Cochrane review
data by the Panel have demonstrated that there was no difference in
efficacy between available single-incision devices and
conventional mid-urethral slings at one year.
SUI surgery in the elderly
• An RCT of 537 women comparing retropubic to transobturator tape,
Surgical management
3. Open and laparoscopic surgery for stress urinary
incontinence
• Open colposuspension was previously considered the most
appropriate surgical intervention for SUI, and was used as the
comparator in RCTs of newer, less invasive, surgical techniques.
These include laparoscopic techniques, which have enabled
colposuspension to be performed with a minimally invasive
approach.
Surgical management
Open colposuspension
• The Cochrane review included 55 trials in which 5,417 women had open
colposuspension. Within the first year, complete continence rates of
approximately 85-90% were achieved for open colposuspension, while
failure rates for UI were 17% up to five years and 21% over five
years. The re-operation rate for UI was 2%.
• Colposuspension was associated with a higher rate of development, at five
years, of enterocoele/vault/cervical prolapse (42%) and rectocele
(49%) compared to TVT (23% and 32%, respectively) but with a
lower risk of voiding dysfunction compared to sling surgery. The
rate of cystocoele was similar in colposuspension (37%) and with TVT
(41%).
• The Cochrane review concluded that open colposuspension is an effective
Surgical management
Autologous fascial sling
• The Cochrane review described 26 RCTs, including 2,284 women
undergoing autologous sling procedure in comparison to other
operations. The meta-analysis showed that fascial sling and
colposuspension had a similar cure rate at one year.
Colposuspension had a lower risk of voiding difficulty and UTIs, but
a higher risk of bladder perforation.
• In twelve trials of autologous fascial sling vs. mid-urethral
synthetic slings, the procedures showed similar efficacy.
However, use of the synthetic sling resulted in shorter
operating times and lower rates of complications, including
voiding difficulty.
Surgical management
Laparoscopic colposuspension
• The Cochrane review reported on twelve trials comparing laparoscopic
colposuspension to open colposuspension. Although these procedures
had a similar subjective cure rate, there was limited evidence
suggesting the objective outcomes were less good for laparoscopic
colposuspension. However, laparoscopic colposuspension had a lower
risk of complications and shorter duration of hospital stay and
may be slightly more cost-effective when compared with open
colposuspension after 24 months follow-up.
• In eight RCTs comparing laparoscopic colposuspension to MUS, the
subjective cure rates were similar, while the objective cure rate favoured
the mid-urethral sling at eighteen months. Complication rates were similar
for the two procedures and operating times were shorter for the MUS.
Surgical management
Bulking agents
• The concept of this procedure originates from the idea that intra or
periurethral injection of an agent able to solidify under the
submucosa or around the urethra, respectively, will form artificial
cushions which increase the resistance to urine flow and facilitate
continence.
• Bulking agent injection is safe, the most frequent adverse event being UTI.
However, autologous fat or hyaluronic acid should not be used due to the
risk of fatal embolism and local abscess formation, respectively.
Comparison with open surgery
2 RCTs compared collagen injection to conventional surgery for SUI
(autologous sling vs. silicon particles and collagen vs. other surgical
procedures/bulking agents). The studies reported greater efficacy but higher
complication rates for open surgery. In comparison, collagen injections
mplicated stress urinary incontinence in women
This for women who have had previous surgery for SUI, which has failed, or
those women who have undergone previous radiotherapy affecting the
vaginal or urethral tissues.
1. External compression devices
• External compression devices are still widely used in the
treatment of recurrent SUI after the failure of previous surgery
and if there is thought to be profound intrinsic failure of the sphincter
mechanism, characterised by very low leak point pressures or low urethral
closure pressures. This should be confirmed by urodynamic
evaluation.
• 2 intracorporeal external urethral compression devices available
are the adjustable compression therapy (ACT©) device and the
artificial urinary sphincter (AUS). Using ultrasound or fluoroscopic
guidance, the ACT© device is inserted by placement of two inflatable
spherical balloons on either side of the bladder neck. The volume of each
mplicated stress urinary incontinence in women
Artificial urinary sphincter (AUS)
• A previous review of mechanical devices concluded that there was
insufficient evidence to support the use of AUS in women.
• A newly introduced artificial sphincter using an adjustable balloon capacity
through a self-sealing port, and stress responsive design, has been
introduced to clinical use. A series of 100 patients reported 28%
explantation at four years but the device has undergone redesign and
more up-to-date evidence is awaited. Early reports of laparoscopically
implanted AUS do not have sufficient patient populations and/or sufficient
follow-up to be able to draw any conclusions.
n with stress urinary incontinence
In men who fail conservative treatment other treatments can be considered.
Drug therapy
Three RCTs suggest an earlier recovery of continence in men receiving
duloxetine either alone, or in addition to PFMT, for post prostate surgery SUI.
Bulking agents in men
• Injection of bulking agents has been used to try and improve the
coaptation of a damaged sphincter zone. Initial reports showed limited
efficacy in treating incontinence following radical prostatectomy.
• Small cohort studies showed a lack of benefit using a number of different
materials. However, polyacrylamide hydrogel resulted in limited
improvement in QoL without curing the UI. A prospective, randomised
study compared the AUS to silicone particles (MacroplastiqueTM) in 45
patients. 82% of patients receiving an AUS were continent compared to
46% receiving silicone particles. In patients with severe incontinence,
n with stress urinary incontinence
Fixed male sling
In addition to external compression devices and bulking agents, slings have
been introduced to treat post-prostatectomy incontinence. Fixed slings are
positioned under the urethra and fixed by a retropubic or transobturator
approach.
Compression devices in males
• External compression devices divided into 2 types: circumferential and
non-circumferential compression of the urethral lumen.
• The artificial urinary sphincter (AUS) is the standard treatment for
moderate-to-severe male SUI. Most data available on the efficacy and
adverse effects of AUS implantation are from older retrospective cohort
studies with RCTs not performed due to the lack of a comparator. There are
several recognised complications of AUS implantation, e.g. mechanical
dysfunction, urethral constriction by fibrous tissue, erosion and infection.
• The non-circumferential compression devices consist of 2 balloons placed
close to the vesico-urethral anastomotic site. The balloons can be filled
Surgical management
Surgical interventions for refractory detrusor-overactivity
Bladder wall injection of botulinum toxin A
• Onabotulinum toxin A (onabotA; BOTOX®) 100 U dissolved in 10 mL of
saline and injected in 20 points of the bladder wall above the trigone (0.5
mL per injection site) is licenced in Europe to treat OAB with persistent or
refractory UUI in adults of both genders, despite the small number of
males included in the registration trials.
• The continued efficacy of repeat injections is the rule but discontinuation
rate may be high. The most important adverse events related to onabotA
100 U injection detected in the regulatory trials were UTI and an increase
in PVR that may require clean intermittent catheterisation.
Surgical management
Cystoplasty/urinary diversion
Augmentation cystoplasty
• In augmentation cystoplasty (also known as clam cystoplasty), a
detubularised segment of bowel is inserted into the bivalved bladder wall.
The distal ileum is the bowel segment most often used but any bowel
segment can be used if it has the appropriate mesenteric length. The
procedure can be done, with equal success by open or robot techniques,
although the robotic consumes considerably more operative time.
• Most often, bladder augmentation is used to correct neurogenic DO or
small-capacity, low-compliant, bladders caused by fibrosis, chronic
infection such as tuberculosis, radiation or chronic inflammation from
interstitial cystitis.
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Surgical management
Detrusor myectomy (bladder auto-augmentation)
• Detrusor myectomy aims to increase bladder capacity and reduce storage
pressures by incising or excising a portion of the detrusor muscle, to create
a bladder mucosal ‘bulge’ or pseudo-diverticulum. It was initially described
as an alternative to bladder augmentation in children. This technique is
rarely used nowadays.
Urinary diversion
• Urinary diversion remains a reconstructive option for patients with
intractable incontinence after multiple pelvic procedures, radiotherapy or
pelvic pathology leading to irreversible sphincteric incompetence or fistula
formation. These patients may be offered irreversible urinary diversion
surgery. Options include ileal conduit urinary diversion, orthotopic
neobladder and heterotopic neobladder with Mitrofanoff continent
catheterisable conduit. A small study compared ileal with colonic
Conclusions
• Urinary incontinence is common in women or men, although
few seek care despite many effective treatment options.
• Clinicians should prioriize urinary incontinence detection,
identify and treat modifiable factors, incorporate patient
preference into evaluation and treatment, initiate
conservative and medical therapy, and refer to specialists
when underlying pathology is identified or conservative
measures are ineffective.
THANK YOU
