A Brief Synopsis of AFPs "Clinical Management of Urinary Incontinence in Women"

A Brief Synopsis of:
Clinical Management of Urinary Incontinence in Women
LAUREN HERSH, MD, and BROOKE SALZMAN, MD, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania 
http://www.aafp.org/afp/2013/0501/p634.pdf

Am Fam Physician. 2013 May 1;87(9):634-640.
     The five types of incontinence in women are urge, stress, mixed, overflow and functional.  Urge incontinence is due to detrUsor overactivity (U for urge!). The patient has an "urge" to pee. There may have frequency and nocturia. It is common in neurologic issues such as spinal cord injuries or stroke. Stress incontinence is from intrinsic Sphincter dysfunction (S for sphincter ) and increased urethral mobility.  The patient losses urine during an increase in intraabdominal pressure (laughing, coughing, sneezing). Mixed is mixed. The last two are less common. Overflow is due to anatomic obstruction or impaired detrusor contractility (Just a reminder that the detrusor is the contractile part of the bladder wall and the sphincter it the little hole at the bottom where the pee pee comes out of). When the detrusor does not contract, the bladder fills to the top. There is also incomplete emptying.  Urine dribbles out as the bladder overflows. A common cause of functional incontinence are anticholinergic drug side effects. The patient may ultimately need catheter drainage as treatment,  In functional incontinence, the patient is unable to get to the toilet due to a functional, cognitive or physical impairment.
    The treatment for urge incontinence starts with behavioral training. Bladder training and pelvic floor strengthening are good first line therapies.  Bladder training starts with rapid pelvic muscle contractions and mental distractions during periods of urgency. relaxation techniques are also effective. The point is to increase the time from onset of urgency to voiding. Kegels are the same as pelvic floor exercises. This is only effective in urge incontinence. Other behavioral techniques are  habit training  scheduled voiding, and prompted voiding. Electric modulation with vaginal or anal stimulators can affect the reflex pathway. Stimulating the posterior tibial nerve (which shares the same nerve root as the bladder) is as effective as medication.
     Medication is effective in conjunction with other modalities. Selective anticholinergics (M2/M3) such as darifenacin or solifenacin are preferred.  Non selective anticholinergics (oxybutynin, tolterodine, fesoterodine) have a worse side effect profile. They are all contraindicated in dementia, narrow angle glaucoma, GI obstruction and gastric retention. The anticholinergic effects may counteract the procholinergic effects of the cholinesterase inhibitors used for the treatment of dementia. Beta adrenergic agents (mirabegron) act on B3 receptors to relax the detrusor. Side effects are nausea, vomiting  diarrhea, constipation, headaches, and increased blood pressure.  Botox injected into the detrusor muscle has been another treatment. It lasts 3-6 months at a time. Estrogen has not been effective.
     Stress incontinence can be seen in patients with obesity, childbirth, chronic cough,  and previous pelvic surgery. Weight loss and pelvic floor exercises are first line therapies. Patients need to learn the proper technique  either through biofeedback or by palpating the the pelvic muscles during contraction. Electric stimulation of the pelvic floor muscles is beneficial in patients unable to contract the muscles on their own. Vaginal inserts (pessaries and incontinence tampons) compress the bladder neck and urethra, reducing urine loss. Urethral plugs have a similar effect. No medications have FDA approval for treatment of stress incontinence, although duloxetine has shown to be helpful. Radiofrequency denaturation is another available treatment. It reduces compliance of the bladder neck and proximal urethra. Patients can also have bulking agents (collagen, fat, carbon beads) injected  into the bladder neck. For surgery, slings and urethropexy are commonly performed. It supports the bladder neck and urethra, which helps with urethral closure. Tension free vaginal tape is a new type of sling that is very effective, and can be done on an outpatient basis.