4th Annual Jefferson Urology Symposium: Focus on Urinary Incontinence

© The Canadian Journal of Urology TM : International Supplement, August 2021 UI. 5 SUI is defined by the involuntary loss of urine in response to physical exertion or sudden increase in intraabdominal pressure that is generated during such activities as sneezing or coughing. UI places a considerable medical, psychosocial and economic burden on patients. 8.9 Because of this, an understanding of screening, evaluation, and treatment of UI is essential in any clinical practice to adequately address the growing demographic of UI patients. This article will review the evaluation and management of female urinary incontinence including the initial evaluation and considerations for treatment. Initial evaluation of the UI patient The pathophysiology of UI can broadly be divided into issues of urine storage and emptying. 10 Therefore, it is critical to elicit the exact nature of UI symptoms the patient is experiencing to properly manage them. The initial evaluation of any suspected UI should always begin with a thorough history and physical exam. 11 A focused history should include the type of incontinence, duration, severity, bother, previous evaluation/testing, and prior treatments. Having the patient log a voiding diary is an important tool to assess for drinking habits, voiding volumes, frequency of void, daytime and nighttime urinary output, and episodes of incontinence. Diaries should be 3 days in length. 12 The physical portion should include BMI, a pelvic exam, and an objective demonstration of SUI with a full bladder. Helpful exams to elicit SUI are the cough test or Valsalva maneuver. The genitourinary exam should also assess for peri-urethral cysts, urethral hypermobility, and prolapse. Post void residual (PVR) assessment and urinalysis (UA) to evaluate for UTI or microhematuria should also be included in an initial evaluation. Routine urine culture is not necessary unless there are symptoms to suggest UTI or a positive dipstick. In most cases, a thorough history and physical exam are sufficient to diagnose the subtype of incontinence. 13,14 Additional evaluation may be considered in the diagnosis of UI in situations where the initial assessment does not provide a diagnosis, or those with abnormal urinalysis, elevated PVR, failure of prior anti-incontinence surgery, or high-grade pelvic organ prolapse (POP). Cystoscopy and/or urodynamic testing (UDS) should not be performed in an otherwise standard patient. It may be appropriate to perform cystoscopy in patients with concern for lower urinary tract abnormalities. Patients with a history of anti-incontinence surgeries, mismatch between subjective and objective measures, significant voiding dysfunction, elevated PVR, MUI with a substantial urgency component, or neurogenic lower urinary tract dysfunction may undergo UDS. 14 Other forms of UI which should be mentioned for completeness’ sake but will not be reviewed in depth in this article include overflow incontinence, continuous incontinence, and insensible incontinence. UUI treatment Once a proper history and physical have been performed andOAB/UUI has been identified, patients should be educated about the normal physiology of voiding. Treatment goals for OAB/UUI should be discussed with the patient and aimed at improving patient quality of life. It is important that treatment outcomes should be addressed up front as this has been shown to improve adherence. 15 According to the AUA/SUFU guidelines on treatment for non-neurogenic OAB, first-line treatment is behavioral therapy. 16,17 Behavioral therapies pose no risk to patients and should be offered to all as they have been shown to improve UI outcomes compared to no treatment. 18 Possible interventions include bladder training, fluid intake modification, pelvic floor muscle training (PFMT), and biofeedback. Patients should be advised to reduce intake of bladder irritants such as caffeine, alcohol, acidic/citrus liquids, and artificial sweeteners. Bladder training is intended to help patients increase the interval between voiding as well as increase bladder capacity. Patients can perform timed voiding and utilize techniques like Kegels to suppress urgency. Second-line treatments involve pharmacologic therapy of the bladder. 16,17 There are two drug classes: anticholinergic and ß3-agonist medications. Anticholinergics (also known as antimuscarinics) block the muscarinic receptors in the bladder which facilitate the voiding phase of urination by contracting the detrusor smooth muscle. ß3-agonists target the storage phase by enhancing relaxation of detrusor smooth muscle. Currently there are eight approved medications on the market in the United States, Table 1. 19,20 A systematic review of anticholinergics has found them to be comparably efficacious and safe, but with varying side-effect profiles. 21 Common side-effects include dry mouth, dry/itchy eyes, constipation, blurred vision, dyspepsia, and impaired cognitive function. Extended-release formulations can offer a more favorable side-effect profile as there is less risk of dry mouth compared to their immediate- release counterpart. 22 Anticholinergic medications are contraindicated in patients who have previously Denisenko ET AL. 28