stress urinary incontinence

Introduction

A form of urinary incontinence characterized by the involuntary loss of urine from the urethra during physical exertion; for example, during coughing, laughing, sneezing, exercise, or sudden movements.

Etiology

• childbirth, episiotomy
• surgery/radiation (esp prostate surgery/radiation in men)
• post-menopausal atrophy of mucosa may contribute
• urethral infection may contribute
• women:
  • urethral hypermobility
  • displacement of the urethra & bladder during physical exertion
• men & women
  • intrinsic urethral sphincter deficiency
    • surgery or injury
    • sacral or infrasacral spinal cord lesions
• obesity

Epidemiology

• common among women under age 75
• 40% post radical prostatectomy

Pathology

• weakness & laxity of pelvic floor musculature resulting in hypermobility of the bladder base & proximal urethra
• urethral sphincter insufficiency:
  • urethral sphincter pressure generally inadequate (internal sphincter may prolapse through pelvic floor)
• absence of a detrusor contraction or an overdistended bladder

Clinical manifestations

• momentary loss of small amounts of urine coincident with an increase in abdominal pressure due to
  • coughing
  • laughing
  • sneezing
  • exercise
  • sudden movements
• incontinence occurs in an upright position
• not associated with desire to urinate

Complications

• disease interaction(s) of cough with stress urinary incontinence

Management

• general
  • see urinary incontinence for general measures
  • eliminate contributory medications
    • alpha-1 adrenergic antagonists (doxazosin, prazosin ...)
• pelvic muscle exercises (Kegel exercises)
  • first line
  • more effective than pharmacologic therapy
  • biofeedback may be needed for correct implementation
    • adding biofeedback to pelvic floor muscle training does not improve urinary incontinence outcomes - (GRS11) seems to say it can
    • biofeedback-assisted pelvic muscle training by a physical therapist specializing in pelvic floor dysfunction if needed for correct implementation (GRS11)
  • pelvic yoga no better than Kegel exercises
• pharmacologic agents
  • systemic pharmacologic therapy not recommended
  • alpha adrenergic receptor agonists (first line)
    • increase of smooth muscle tone at bladder outlet
    • pseudoephedrine (Sudafed) 30-60 mg every 6-8 hours
      • minimally effective (GRS11)
  • tricyclic antidepressants (TCA)
    • for combined stress incontinence & urge incontinence
    • decrease in detrusor muscle contractility & increase in bladder outlet resistance
    • imipramine (Tofranil) 25-100 mg QHS
    • doxepine (Sinequan) 25-100 mg QHS
  • duloxetine (Yentreve)
  • topical estrogen if associated atrophic vaginitis
    • vaginal cream (Premarin): 1-2 gm QHS for 1-2 weeks, then 1 g 1-3 times per week
    • systemic premarin 0.625 mg PO QD (+/-) Provera 2.5 mg QD actually may worsen urinary incontinence
• acupuncture may be of benefit
• scheduled toileting (bladder retraining)
• surgery
  • procedures for pelvic prolapse
    • bladder neck suspension
    • urethral sling procedure; mid-urethral sling
    • artificial sphincter implantation
    • fascial sling surgery better than Burch colposuspension
  • artificial urinary sphincter with longest record of satisfactory results for post-prostatectomy stress incontinence
• periurethral collagen injections reserved for older women with intrinsic urethhral sphincter insufficiency
• injection of autologous stem cells (myoblasts & fibroblasts harvested from the uppe arm) into the urinary sphincter region

More general terms

• urinary incontinence (UI)

Additional terms

• hypermobility of bladder neck
• intrinsic urethral sphincter deficiency (ISD)
• pelvic muscle exercise (PMR); Kegel exercises