Stress Incontinence: Not Stressing Over Leakage Part 1

I wanted to write about stress incontinence because I am sure I'm not the only one who has seen recent commercials featuring Katherine Heigl (of Grey's Anatomy fame) about Poise pads for bladder leakage. Understandably, the commercials are informational enough, but the purpose is to sell women their product.

The management of urinary leakage, both non-surgical and surgical options, exceeds over $12 billion dollars in the United States (Hartigan et al., 2019), so convincing women to purchase Poise pads makes sense as a continued business model. And considering the rate that stress incontinence is reported by women ages 15 to 39 years old at 41% (Hartigan et al., 2019), it's a type of business model that can span for years, with no end in sight. At least, that's what people may think if they do not have all the facts.

I tend to see a lot of patients with stress incontinence as their chief complaint, and during their initial evaluations with me, I spend a lot of time educating them about it because there is a lot of misinformation out there. Sometimes my patients believe urinary leakage is a natural progression as they age. Other times, my patients believe that this is something they'll have to live with for the rest of their lives.

When people hear the word incontinence, they tend to think there's only one type of incontinence. But there isn't! The different types of incontinence are: urge, stress, mixed, and functional.

• Urge: increased urge to use the bathroom, increased frequency (having to void more than once every 2-4 hours), leaking urine on the way to the bathroom, increased urge when arriving at home.

• Stress: Intra-abdominal pressure mismanagement. Increased pressure from laughing, coughing, sneezing, exercising, jumping, or lifting, and the pelvic floor muscles do not provide closure of the urethra, resulting in urinary leakage.

• Functional: Leakage because obstacles are in the way or the bathroom is too far away

• Mixed: urge and stress incontinence combined

There's so much regarding this topic that even the amount I have read on and written about below is not near the full entity of knowledge for stress incontinence. That's why I am always studying and reading what I can.

Role of pelvic floor in lower urinary tract infection (Chermansky & Moalli, 2015)

Continence is maintained through urethral closure and support. Urethral closure is created by the endopelvic fascia, the arcus tendineus fascia pelvis (ATFP), and a portion of the levator ani muscles.

Pelvic organs are elevated through the closure of the urogenital hiatus due to the pubococcygeus compressing the vagina, urethra, and rectum towards the pubic bone. This allows your pelvic floor to maintain closure even through times of increased intra-abdominal pressure. The connective tissue in the pelvic floor is able to function with minimal tension due to the levator ani muscles. If these muscles are damaged, then the connective tissue takes up more of the support which may cause them to stretch. This can lead to urethral hypermobility and stress incontinence for some.

Two theories as to why stress incontinence happens are the hammock theory and the integral theory:

Hammock theory was proposed by DeLancey and Ashton-Miller. They theorized that the pubocervical fascia creates a backboard at the bladder neck for urethral compression during times when there is increased intra-abdominal pressure. As well, it is theorized by DeLancey that the "connection between the pubocervical fascia and levator ani muscles" allows the bladder neck to be elevated when there is active contraction from the levator ani muscles. If the muscles and fascia are injured, it can lead to stress incontinence.

The integral theory was proposed by Petros and Ulmsten, which "the vaginal wall, the pubourethral ligaments, and the pubococcygeus muscle interact together to orchestrate the various muscle movements involved in bladder neck opening and closing." If the vaginal wall is too lax, then the urethra won't be held against the pubourethral ligaments for urethral closure, leading to stress incontinence.

Another component of this theory is that the vaginal walls function to "prevent urgency and urge urinary incontinence by supporting hypothesized stretch receptors located within the bladder neck and proximal urethra."

Conservative Treatments

There are a few options for treatment of stress incontinence. Providers may prescribe medication for it. Pelvic health physical therapy is another treatment that I will discuss more in-depth in another post.

Medication

Oxybutynin is a common medication providers prescribe to patients to treat "overactive bladder, such as frequent or urgent urinary incontinence (urine, leakage), and increased nighttime urination" (drugs.com). This medication helps to "reduce muscle spasms of the bladder and urinary tract" (drugs.com).

As with any medication, there are potential side effects that may occur. The more serious side effects that, if they occur, should have a patient stopping their medication and calling their doctor:

• severe stomach pain or constipation

• hallucinations, agitation, confusion, or somnolence (drowsiness, strong urge to sleep)

• blurred vision, tunnel vision, eye pain, or seeing halos around lights

• little or no urination

• painful or difficult urination

• dehydration - dizziness, confusion, feeling very thirsty, or less urination

The common side effects for this medication are:

• dizziness, drowsiness

• headache

• dry mouth

• diarrhea, constipation

There may be interactions with other medications, supplements, or vitamins, so inform your provider of everything you are taking.

While this medication would be helpful if someone had urge incontinence or overactive bladder, it may not necessarily be for someone with stress incontinence. This is because that type of incontinence deals more with intra-abdominal pressure mismanagement against urethral closure, which this medication does not address.

Another medication option that I have seen patients get prescribed is Solifenacin/Vesicare. It is also used to treat overactive bladder symptoms, including frequent urination, sudden urgency, and urine leakage (incontinence). The way this medication works is by relaxing the bladder muscles, which lets the bladder hold more urine.

Side effects for solifenacin include:

• blurred vision

• dry mouth, dry eyes

• painful urination

• constipation, or

• heat stroke: decreased sweating, dry skin, dizziness, tiredness, nausea, feeling hot

Surgical management of urinary stress incontinence - Where are we now? (Dwyer & Karmakar, 2018)

There are surgical managements utilized for stress incontinence. The most common surgery is the mid-urethral sling (MUS) since it was introduced in the late 1990s, accounting for at least 80% of stress incontinence surgeries performed.

MUS are classified into three different groupings depending on both when the procedure was created and by the anatomical positioning of the sling.

Retropubic: mid-urethral placement inserted vaginally behind the pubic symphysis. There are two suprapubic incisions with the procedure.

Transobturator sling: mid-urethral tape is placed via the obturator foramina. This procedure has an outside-in approach and an inside-out approach.

Single incision mini-slings that are placed mid-urethral and attached to the obturator fascia and muscle, but no exit incisions.

2017 global data from commercial companies revealed that:

• 43% of MUS that were performed used the retropubic approach

• 45% transobturator sling

• 12% single incision mini-slings

How effective are MUS procedures?

Many meta-analyses and subsequent RCTs have shown no significant difference in subjective and objective cure rates for stress incontinence between the retropubic or transobturator approaches.

When it came to the results of reoperation after undergoing a mid-urethral sling procedure, about 10% of women needed another operation to repair the sling.

Rates of reoperation per procedure:

• 6% pubovaginal slings

• 6% retropublic mid-urethral tape

• 6% Burch colposuspension

• 9% transobturator tape

• 44% urethral injection therapy

Significant predictors for MUS failure were noted:

• BMI > 25

• Mixed incontinence

• Previous continence surgery

• Intrinsic sphincter deficiency

• Diabetes mellitus

Another procedure that is commonly utilized are urethral bulking agents. "The bulking agents to date have had a reasonable short-term effectiveness but repeated reinjections have been necessary to maintain continence."

From a pelvic health physical therapist point of view, these procedures have a risk of failing years down the road because nothing was done to fix the original problem, which is the intra-abdominal pressure mismanagement and how the pelvic floor muscles respond to said pressure. This is something that pelvic health physical therapists can educate their patients on and treat them.

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References

Chermansky, C. J., & Moalli, P. A. (2016). Role of pelvic floor in lower urinary tract function. Autonomic neuroscience : basic & clinical, 200, 43–48. https://doi.org/10.1016/j.autneu.2015.06.003

Dwyer, P. L., & Karmakar, D. (2019). Surgical management of urinary stress incontinence - Where are we now?. Best practice & research. Clinical obstetrics & gynaecology, 54, 31–40. https://doi.org/10.1016/j.bpobgyn.2018.10.003

Hartigan, et al, Journal of Women's Health Physical Therapy: October/December 2019 - Volume 43 - Issue 4 - p 160-170 

Oxybutynin: Uses, dosage & side effects. Drugs.com. (n.d.). https://www.drugs.com/oxybutynin.html

Solifenacin: Uses, dosage, side effects, warnings. Drugs.com. (n.d.-b). https://www.drugs.com/solifenacin.html