SUPERStudy: Stress Incontinence

By usmlevideoss

Introduction: The two main types of urinary incontinence are stress incontinence and urge incontinence. Stress incontinence is the involuntary leakage of urine that occurs during activities that increase intra-abdominal pressure, such as coughing, sneezing, laughing, or physical exertion. It is caused by weakened pelvic floor muscles and/or insufficient urethral sphincter function, leading to poor urethral closure under pressure. Urge incontinence is involuntary leakage of urine due to a strong need to urinate that cannot be controlled

Epidemiology

Prevalence: Common in women, particularly after childbirth or during menopause, but can also occur in men following prostate surgery.

Risk Factors:

  • Pregnancy and vaginal delivery.
  • Aging and menopause (due to reduced estrogen levels).
  • Obesity, which increases intra-abdominal pressure.
  • Chronic cough or constipation.
  • Previous pelvic surgery.

Pathophysiology

1.Pelvic Floor Weakness: Pregnancy, childbirth, or aging can weaken the pelvic floor muscles and supportive ligaments, leading to inadequate support of the bladder neck and urethra.

2.Intrinsic Sphincter Deficiency (ISD): The urethral sphincter loses its ability to close completely, resulting in urinary leakage even with minimal pressure.

Clinical Features

  • Involuntary urine leakage during activities that increase intra-abdominal pressure.
  • Absence of urgency, frequency, or nocturia (differentiating it from urge incontinence).
  • No symptoms of bladder fullness or incomplete emptying unless coexisting with other types of incontinence.

Diagnosis

1.History and Physical Examination:

  • Ask about triggers for leakage, childbirth history, and lifestyle factors.
  • Perform a pelvic examination to assess for pelvic organ prolapse or atrophic changes.

2.Stress Test: To test for stress incontinence, have the patient relax the perineum and cough vigorously (a single cough) while standing with a full bladder. Instantaneous leakage indicates stress incontinence.

3.Post-Void Residual Volume: Measured via ultrasound to exclude urinary retention or overflow incontinence.

4.Urodynamic Studies (if needed): Assess urethral sphincter function and bladder pressure.

5.Pad Test: Quantifies urine leakage during physical activity.

Management

1.Conservative Treatments:

  • Pelvic Floor Exercises (Kegels): Strengthen pelvic muscles and improve bladder control.
  • Lifestyle Modifications:
  • Weight loss to reduce intra-abdominal pressure.
  • Avoiding caffeine and alcohol, which can irritate the bladder.
  • Bladder Training: Timed voiding to increase bladder capacity.

2.Pharmacologic Therapy:

  • Topical Estrogen: For postmenopausal women with vaginal atrophy.
  • Duloxetine: A serotonin-norepinephrine reuptake inhibitor that enhances sphincter activity (used off-label).
  • Pseudoephedrine (Sudafed): Pseudoephedrine stimulates alpha-adrenergic receptors in the smooth muscle of the bladder neck and urethra. This causes the contraction of the urethral sphincter, increasing urethral resistance and closure pressure, thereby improving continence.By enhancing the tone of the urethral sphincter, it helps counteract the effects of weakened pelvic floor muscles or intrinsic sphincter deficiency. However, it has not yielded satisfactory results, compared to placebo. 

3.Devices:

  • Pessary: Provides mechanical support for the urethra.
  • Urethral Inserts: Temporary devices to prevent leakage during specific activities.

4.Surgical Treatment:

  • Indicated for severe cases or when conservative measures fail.
  • Sling Procedures (Mid-Urethral Sling): The most common surgery, using synthetic or biological material to support the urethra.
  • Bulking Agents: A transurethral or periurethral injection of bulking agents is indicated for patients with intrinsic sphincter deficiency. Several synthetic injectable agents, such as polydimethylsiloxane and calcium hydroxylapatite are now used.
  • Retropubic urethropexy: Colposuspension (Burch Procedure): Elevates the bladder neck for better support; Marshall-Marchetti-Krantz procedure 

Complications

  • Quality of Life Impacts: Social embarrassment, reduced physical activity, and decreased self-esteem.
  • Recurrent Infections: Increased risk of urinary tract infections due to leakage or residual urine.

Prognosis

  • Stress incontinence is highly treatable with a combination of conservative measures, lifestyle changes, and surgical options.
  • Early diagnosis and intervention lead to significant improvements in quality of life.

Summary: Stress incontinence occurs due to weakened pelvic floor muscles or insufficient urethral sphincter function, leading to involuntary leakage during increased intra-abdominal pressure. Conservative treatments, including pelvic floor exercises and lifestyle modifications, are first-line, with surgical options available for severe cases.

 

Superpoint: Stress incontinence is the involuntary leakage of urine during increased intra-abdominal pressure, commonly due to pelvic floor weakness or urethral sphincter deficiency, and is effectively managed with pelvic floor exercises, lifestyle changes, and, in severe cases, surgical interventions like mid-urethral slings.

 

SUPERFormula: Stress Incontinence

Patient presents with involuntary urine leakage during coughing, sneezing, exertion (activities that increase intra-abdominal pressure) + Caused by weakened pelvic floor muscles (e.g., after childbirth, aging) or intrinsic sphincter deficiency + Risk factors include pregnancy, menopause, obesity, chronic cough, and pelvic surgery + Diagnosed through history, physical exam, stress test, and urodynamic studies if needed + Managed conservatively with pelvic floor exercises (Kegels), weight loss, and bladder training + Pharmacologic options include topical estrogen and duloxetine + Severe cases treated surgically with mid-urethral slings, bulking agents, or colposuspension = Stress Incontinence

 

References: 

CURRENT Diagnosis & Treatment: Obstetrics & Gynecology, 12e > Urinary Incontinence & Pelvic Floor Disorders

Alan H. DeCherney, Lauren Nathan, Neri Laufer, Ashley S. Roman

Schwartz’s Principles of Surgery, 11eCharles Brunicardi, Dana K. Andersen, Timothy R. Billiar, David L. Dunn, Lillian S. Kao, John G. Hunter, Jeffrey B. Matthews, Raphael E. Pollock

Current Diagnosis & Treatment: Surgery, 15e

Gerard M. Doherty