MDNews - Greater Kansas

+++++++++++++++++++++++ + +++ + URoLoGy UPDATE +++ +++++++++++++++++++++++ comprehensive Diagnosis and treatment of Female Urinary Incontinence By James Gilbaugh, M.D. U RINARy INCoNTINENCE, the involuntary loss of urine, is a medical condition that affects more than 30 million American women. There are several types of urinary incontinence. Stress urinary incontinence (SUI) is urinary leakage associated with activities — such as coughing, laughing, sneezing, running and jumping — that increase intra-abdominal pressure. Urge incontinence (UI) is the sudden, uncontrollable sensation of needing to urinate followed by the loss of urine. Many women will have a combination of SUI and UI. Overflow incontinence refers to loss of urine associated with a distended bladder — usually without the sensation that the bladder is full — and functional incontinence describes loss of urine related to decreased mobility or a debilitated state. The initial evaluation of urinary incontinence involves a medical history and physical examination along with a urinalysis and measurement of post-void residual. Frequently, treatment can be initiated without further testing, but in more complicated cases, evaluation with video urodynamics or cystoscopy is needed. Treatments for UI include behavioral therapy, medical therapy and surgical treatments. Behavioral therapy involves timed voiding — voiding at a time interval frequent enough to avoid reaching the bladder's "trigger point." Decreasing fluid intake, especially of caffeinated beverages and alcohol, can be very beneficial in decreasing UI. Traditional medical therapy for UI employs antimuscarinic medications that help relax the smooth muscle of the bladder. There are a myriad of drugs in this class, including oxybutynin, tolterodine, solifenacin, darifenacin, trospium and fesoterodine. These medications are effective in a majority of cases, and many are available as lower-cost generics. Side effects of these drugs include dry mouth and constipation, and can frequently be limiting. A new class of drugs, beta-3 adrenergic agonists, has been shown to be effective in the treatment of UI without anticholinergic side effects. The first of these drugs, Mirabegron, was released in 2012. For cases of severe UI that are not responsive to or are intolerant of medical and behavioral treatments, there are surgical treatments. Botulinum toxin (Botox) injected into the bladder muscle endoscopically has been shown to be safe and efficacious. The effect is typically temporary, with improvement lasting from six to 12 months, but the injection can be repeated. Sacral neuromodulation involves electronic stimulation of the sacral nerves, resulting in inhibition of afferent signals to the spinal cord and brain. The procedure, called InterStim, is typically performed in two stages. Initially, a 12 | Greater Kansas MD News ■ mDNEWS.Com test stimulation called percutaneous nerve evaluation (PNE) is performed under local anesthesia. Temporary leads are placed percutaneously into the S3 sacral foramina and positioned near the S3 sacral nerve roots, and stimulation with an external pulse generator is performed for several days. If significant improvement is seen during the PNE, then a permanent lead and implantable pulse generator are implanted surgically, with the patient under sedation. InterStim has been a very effective treatment modality even in severe cases of UI. Treatments for SUI include both surgical and nonsurgical options. Pelvic floor (Kegel) exercises involve repetitively contracting and relaxing the pelvic floor muscles. Working with a physical therapist who specializes in pelvic floor disorders can improve the success rates of this conservative approach. In postmenopausal women, the use of topical estrogen cream applied nightly at the urethral meatus can be beneficial for mild to moderate SUI. Maximal benefit is usually seen within three months, and there is only slight systemic absorption of the estrogen, making this a very safe treatment. The surgical treatment of SUI has undergone significant evolution during the past 60 years. The current "gold standard" is the mid-urethral sling. The most recent data shows a 90% success rate and an excellent safety profile for synthetic mid-urethral slings, with follow-up longer than 15 years. Periurethral bulking agents can be used in patients with severe deficiency of the urinary sphincter, called intrinsic sphincteric deficiency (ISD). In rare cases of severe SUI, an indwelling catheter or urinary diversion may be the only solution. Urinary incontinence is a common medical condition in women, with prevalence greater than 50%. Patients are often embarrassed about the problem and reluctant to bring up the subject with their physicians. It is therefore incumbent upon the physician to inquire about the problem to let the patient know she is not alone, and that safe, effective treatments are available. Primary care providers can initiate treatments that will often be effective, and in refractory cases, patients can be referred to specialists for more advanced evaluation and treatment. In 2013, medical and surgical treatments can cure or dramatically improve most cases of female urinary incontinence. Dr. Gilbaugh is certified by the American Board of Urology and has been in practice since 1994. For more information, please call Wichita Urology Group at (316) 636-6100. ■

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