An expert commentary on the recently published ACOG Practice Bulletin #155.
COMMITTEE ON PRACTICE BULLETINS-GYNECOLOGY AND THE AMERICAN UROGYNECOLOGIC SOCIETY PRACTICE Bulletin No. 63: Urinary Incontinence in Women (Replaces Practice Bulletin No. 63, June 2005). American College of Obstetricians and Gynecologists. Obstet Gynecol. 2016;126:e66–81. Full text of ACOG Practice Bulletin available to ACOG members at http://www.acog.org/Resources%20And%20Publications/Practice%20Bulletins/Committee%20on%20Practice%20Bulletins%20Gynecology/Urinary%20Incontinence%20in%20Women.aspx.
Urinary Incontinence in Women
Urinary incontinence, the involuntary leakage of urine, is caused by a variety of factors and may result in a wide range of urinary symptoms that can affect women’s physical, psychological, and social well-being and sometimes can impose significant lifestyle restrictions. Identifying the etiology of each woman’s urinary incontinence symptoms and developing an individualized treatment plan is essential for improving her quality of life. The purpose of this joint document of the American College of Obstetricians and Gynecologists and the American Urogynecologic Society is to review information on the current understanding of urinary incontinence in women and to outline guidelines for diagnosis and management that are consistent with the best available scientific evidence.
Taking a systematic approach to urinary incontinence
By John O L DeLancey, MD
Dr Delancey is the Norman F Miller Professor of Gynecology; Director, Pelvic Floor Research; and Group Director, Fellowship in Female Pelvic Medicine and Reconstructive Surgery at University of Michigan Medical School, Ann Arbor. He is also a member of the editorial board of Contemporary OB/GYN.
The recently published ACOG Practice Bulletin #155, Urinary Incontinence in Women, is a well-written piece that provides a well-researched and practical view of contemporary incontinence evaluation and management.1
The committee provides a useful classification for stress and urge urinary incontinence but also appropriately covers other diagnoses such as urethral diverticulum, ectopic ureter and neurologic disease. The authors appropriately support the high value of basic office evaluation of incontinence. All ob/gyns should be comfortable in offering this workup to patients as none of the elements requires special training. This systematic approach establishes a diagnosis in the majority of otherwise healthy women who have mild to moderate degrees of urinary incontinence.
Recommended aspects of the evaluation include: 1) history; 2) urinalysis; 3) physical examination; 4) demonstration of stress urinary incontinence (SUI); 5) assessment of urethral mobility; and 6) measurement of postvoid residual (PVR) urine volume. PADS is an easy-to-remember mnemonic for key elements which stands for Post-void residual urine determination, urine Analysis, voiding Diary, and full bladder Stress test.
In a busy office with a tight schedule, all that is needed at a visit is to identify that a woman has incontinence. She can then be given a voiding diary to complete and scheduled for another visit with a full bladder so that a full-bladder stress test can be done and then a PVR urine can be obtained by catheterization providing sterile urine for evaluation.
The full-bladder stress test is the cornerstone of physical examination because it reliably determines whether the physical finding of SUI is present, and the bulletin appropriately describes proper performance. Leakage must be simultaneous with a cough because a cough sometimes elicits a detrusor contraction that follows the cough. I would add that this test should be done while the bladder is “comfortably full” because if it is over-full-and especially if there is a sense of urgency (probably because of increased detrusor tone)-SUI may be seen when it isn’t present at lower volumes.
Finally, once SUI is demonstrated, a woman should be asked if this is the type of incontinence that she is bothered by. It is not uncommon in a referral practice to see women who have “failed” incontinence surgery because they were troubled by urge incontinence preoperatively but had a positive stress test and rare SUI that was not bothersome.
Two common errors are making the diagnosis of SUI based on the finding of urethral mobility and assuming that a woman has SUI because detrusor contractions are not found on examination. Urodynamics provides important information in women when the cause is not obvious from simpler evaluations and provides valuable information about first urge to void and bladder capacity, and it can document detrusor instability in some patients and be used to evaluate voiding difficulties.
The ACOG guideline emphasizes the importance of behavioral and lifestyle modifications including bladder training, weight loss, and dietary management. SUI is highly associated with obesity, and weight loss not only has been shown to reduce and resolve incontinence but also has many other obvious benefits.
Voiding diary information and institution of appropriate fluid management, especially for the many women who drink excessive amounts of fluid, may resolve complaints in some cases. For example, a woman who takes her Lasix and then gets into her car for an hour-long commute to work only to leak trying to get to the bathroom can be told to take her diuretic at a different time.
The time-honored practice of pelvic muscle exercises is also discussed, and giving appropriate instructions, particularly about when to use muscle contraction to prevent urine leakage, can make a substantial difference for many women. However, just suggesting that a patient contract the muscles a few times a day is not adequate treatment and use of the regimens in the published literature that have been demonstrated to work is needed.
A wide variety of medications is available to treat urgency urinary incontinence and is nicely summarized. Antimuscarinics are the primary class of medications used with the long-acting forms being best. The new β-3 adrenoreceptor agonist, mirabegron, leads to detrusor muscle relaxation and, because it works on a different pathway, may be useful in women for whom anticholinergic medications have not worked or are inappropriate.
The guideline recommends considering combining these treatments with behavioral therapy because of high discontinuation rates for the medications over the long term. The guideline also discusses the demonstrated effectiveness in women with refractory urge incontinence of onabotulinum toxin A (Botox) and sacral neuromodulation, which practitioners should be aware of as an avenue of treatment for overactive bladder when primary and secondary measures have failed.
Surgical management for SUI centers on the role of synthetic midurethral mesh slings for treatment of SUI associated with urethral hypermobility. The important point made is that these slings do not have the same problems as vaginal mesh for pelvic organ prolapse repair. Midurethral tapes work by interacting with a mobile urethra, so they are only appropriate for women whose urethra moves enough to activate the tape. If, as sometimes occurs, there is little or no urethral hypermobility, the treating physician should carefully assess whether other modes of treatment, such as an autologous pubovaginal sling or injection of the urethral bulking agent, are appropriate.
Retropubic and transobturator slings both show good efficacy with rates of subjective cure of about 80%. Careful counseling about the fact that concomitant urge incontinence may not resolve is a key to patients understanding what the operations can and cannot do. Single-incision mini-slings have not had the same consistent good results as full-length slings and their role remains uncertain. Autologous pubovaginal slings remain an important treatment for women who are not candidates for synthetic mesh, those with an immobile urethra, or who have had complications from mesh placed around the urethra.
The guideline has an appropriate discussion of anti-incontinence operations at the time of prolapse repair. Adding a midurethral tape at the time of prolapse surgery shows a reduction in occurrence of SUI on physical examination from 44% to 24%. That can guide a discussion about an initial placement of a sling at the time of repair or staged approach, in which one waits to see if incontinence develops and then places a tape at that time.
Overall, this concise and well-written guide provides a balanced approach to urinary incontinence that should be useful in guiding treatment of the types of patients seen by most gynecologists.
1. Urinary incontinence in women. Practice Bulletin No. 155. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2015;126:e66–81.