Pocket ObGyn – Overactive Bladder and Urge Incontinence
See Abbreviations
Treatment
- Medical management generally involves antichol or antimuscarinic meds Antichol may be best for MUI
Side effects of anticholinergics include dry mouth, constip, blurry vision (contrain- dicated in pts w/ narrow-angle glaucoma)
| Medications for mixed or urge incontinence | ||
| Name | Drug type | Dosage |
| Oxybutynin (Ditropan) | Antimuscarinic | 2.5–5 mg PO TID |
| Oxybutynin ER (Ditropan XL) | Antimuscarinic | 5–10 mg PO daily |
| Oxybutynin patch (Gelnique) | Antimuscarinic | 1 patch 5 mg twice weekly |
| Tolterodine (Detrol/Detrol LA) | M3 – selective antimuscarinic | 1–2 mg PO BID (short acting) 2–4 mg PO daily (long acting) |
| Trospium chloride (Sanctura) | Antimuscarinic quaternary amine | 20 mg PO BID |
| Darifenacin (Enablex) | M3 – selective antimuscarinic | 7.5–15 mg PO daily |
| Solifenacin (Vesicare) | M3 – selective antimuscarinic | 5–10 mg PO daily |
| Fesoterodine (Toviaz) | M3 – selective antimuscarinic | 4–8 mg PO daily |
| Imipramine (Tofranil) | Antichol, a-adrenergic | 10–25 mg PO daily – QID |
| Mirabegron (Myrbetriq) | b3-adrenergic | 25 mg once daily |
• Surgical management:
Used for refrac urge incontinence
Botulinum toxin type A (Botox) injection:
Act to inhibit periph cholinergic nerve endings by inhibiting ACh release from the presynaptic terminal. Intradetrusor injections typically done by cystoscopy prevent the detrusor muscle from being stimulated thus preventing bladder contractions
May cause postinjection urinary retention requiring self-catheterization May have up to a 73% continence rate (Eur Urol 2004;45:510)
Sacral nerve stimulation:
Performed in two phases: (1) Percutaneous nerve eval to determine resp w/ placement of implantation electrode adj to the 3rd sacral nerve root. Trial of 3 w is typical to determine resp. (2) If >50% resp a permanent electrode is placed attached to a generator.
Up to 80% resp, but 30% removal or revision rate due to pain or complications at the implant or generator site (J Urol 1999;162:352)
Stress Incontinence
Treatment
- Medical management not generally useful Pessary or urethral plugs can be attempted
• Surgical management:
Retropubic colposuspension (Burch & MMK):
Previously considered the gold std for SUI
Involves suspension of the pubocervical fibromuscularis to pubic symphysis peri- osteum (MMK) or Cooper’s ligament (Burch)
Retropubic sling:
Has largely replaced colposuspension & thought to be as effective
Objective cure rates 63–5% for the TVT procedure compared to Burch colpo- suspension 51–87% (AJOG 2004;190:324)
Polypropylene mesh (most common material) is placed under the midurethra w/ minimal tension through the retropubic space
Operative risks include bladder, ureteral, urethral, bowel or bld vessel injury thus mandating cystoscopy postplacement
Transobturator sling:
Directed bilaterally through the obturator foramen & underneath the midurethra Compared to TVT w/ 80.8% cure rate TOT had a 77.7% objective cure rate.
Voiding dysfxn was improved in the TOT group. Nerve & musc pain in the leg is more common in the TOT compared to TVT (NEJM 2010;362:2066)
Designed to reduce complications of retropubic trochar placement
Operative risks of bladder, ureteral, & bld vessel injuries are less than the retro- pubic sling approach; however, pts may experience more groin pain
Minislings (single-incision slings):
Newer slings which include 1 transvaginal incision & either placed into an H position or a U (retropubic position)
Facial bladder neck slings:
Utilizing fascia from the rectus muscle or elsewhere to perform a retropubic bladder neck sling ® preserved for complicated cases
Overflow Incontinence
Definition and Etiology
- Involuntary loss of urine due to inability to adequately empty the bladder AKA chronic retention of urine, neurogenic bladder
Neuromuscular disorders – interfere w/ nml bladder reflexes Multi sclerosis, diabetic neuropathy, CNS trauma, CNS tumors, etc.
Obstructive disorders – urethral obst leads to retention & overdistension POP, anti-incontinence procedures, malig, fecal impaction
Meds – anticholinergics, antimuscarinics
Clinical Manifestations
- Inability to void or fully empty bladder voluntarily
- Loss of small amounts of urine w/o sensation of emptying
- Medication hx important to exclude causes of urinary retention
Physical Exam and Workup/Studies
- Nonpainful bladder that is palpable after voiding
- Signif PVR (typically >300 mL)
- Urodynamics
Treatment
- Therapy directed at treating the underlying cause
- CIC or indwelling catheter to ¯ overdistention
- Sacral nerve stimulation – see OAB section, above
- a blockers are not FDA approved for use in women, but have been useful in BPH in males
Bypass Incontinence and Urogenital Fistula
Definition and Etiology
- Leakage of urine from extraurethral sources AKA extraurethral incontinence
Urogenital fistulae –VVF, ureterovaginal fistula: Most common cause in developed countries is gynecologic Surg (0.1% of all hysterectomies), other causes include radiation, trauma, malig, complications of parturition. Most common cause in developing countries is obstetric trauma (pres necrosis)
Ectopic ureter Urethral diverticulum
Clinical Manifestations
- Continuous leakage of urine common in urogenital fistula
- Pts w/ urethral diverticula may complain of pre- or postvoid “dribbling”
- May present with recurrent UTIs, vaginal candidiasis, perineal irritation
Diagnostic Workup/Studies (Female Pelvic Med Reconstr Surg 2012;18:71)
- Urinalysis, urine culture
- Voiding cystourethrogram – 1st-line imaging
- Cystourethroscopy – helpful to determine location in bladder
- Intravenous pyelogram may be performed if there is a suspicion for ureteral fistula
- CT/MRI may be used to further characterize size & location
Treatment
- Surgical rx to correct the anatomic abnormality
- May consider conservative management of small VVF w/ prolonged bladder drainage
- Genitourinary fistulas can be repaired vaginally, laparoscopically, or abdominally depending on size, location, & surgeon skill set
Vaginal repair preferred for uncomp VVF
Latzko procedure – partial colpocleisis w/o excision of fistulous tract Layered closure – surrounding tissues mobilized, fistulous tract excised, multi
layers closed w/ absorbable interrupted sutures
Martius flap – transposition of labial fat pad, useful for large VVF w/o adequate vaginal tissue
Abdominal or laparoscopic repair may be needed for prox, complex VVF & ure- terovaginal fistulae