Female Voiding Dysfunction and Urinary Incontinence Amanda Vo, MD, Stephanie J. Kielb, MD* KEYWORDS Overactive bladder (OAB) Urge urinary incontinence (UUI) Stress urinary incontinence (SUI) Vesicovaginal fistula (VVF) Ureterovaginal fistula (UVF) KEY POINTS Urinary continence relies on coordination of the autonomic and somatic nervous systems, in addition to normal lower urinary tract support and sphincter function. Overactive bladder may be treated in a stepwise fashion with behavioral therapies, phar- macologic management, and procedural options. Stress urinary incontinence is most effectively treated with minimally invasive surgical techniques that reinforce urethral support. Urogenital fistulas, although more common in developing countries than in the United States, are extremely distressful to patients and repair often requires larger reconstructive surgery. NORMAL URINARY CONTINENCE AND VOIDING The lower urinary tract (LUT) has 2 main functions, low-pressure storage of urine, then consciously controlled, coordinated emptying. This involves coordination of the auto- nomic and somatic nervous systems. Coordination occurs at the pontine micturition center and the cerebral cortex provides inhibition. Disease states affecting the cortex such as stroke or Parkinson’s disease can, therefore, cause of loss of inhibition, with urinary urgency, frequency, and at times urge incontinence. Neurologic disease below the pontine micturition center can cause a variety of LUT complications, including co- ordination issues which may put upper tract (renal) function at risk; the details of such conditions are complex and are not discussed further in this review. Disclosures: The authors have no disclosures to report. Department of Urology, Northwestern University Feinberg School of Medicine, 303 East Chi- cago Avenue, Tarry 16-703, Chicago, IL 60611, USA * Corresponding author. E-mail address: [email protected] Med Clin N Am 102 (2018) 313–324 https://doi.org/10.1016/j.mcna.2017.10.006 medical.theclinics.com 0025-7125/18/ª 2017 Elsevier Inc. All rights reserved. Downloaded for Roopa Ram ([email protected]) at University of Arkansas for Medical Services from ClinicalKey.com by Elsevier on February 05, 2019. For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved. 314 Vo & Kielb Urinary continence depends on normal LUT support as well as normal sphincter function, both internal and external. The involuntary internal sphincter at the bladder neck may be affected by previous surgery. The external sphincter in the distal urethra is controlled by voluntary muscle contraction, normally ensuring continence if the in- ternal sphincter is compromised. Continence is achieved when the urethra maintains a pressure greater than the bladder pressure. Pelvic floor musculature is responsible for supporting the bladder neck and proximal urethra. Weakened support of these structures may result in stress urinary incontinence (SUI).1 As the bladder fills, the “guarding reflex” inhibits the parasympathetic nervous system and activates the sympathetic nervous system, reducing detrusor tone and increasing sphincter tone. When capacity is reached, sensory nerves detect detrusor distension and signal the spinal cord to suppress the guarding reflex. The voiding reflex can then be activated, which stimulates the parasympathetic nervous system and in- hibits the sympathetic nervous system, thereby leading to bladder contraction and sphincter relaxation. The voiding reflex is usually under voluntary control by the central nervous system, but if the central nervous system is unable to suppress the voiding re- flex, involuntary voiding occurs when the bladder becomes full (“reflex voiding”).2 Lower Urinary Health Across the Lifespan in Women LUT symptoms (LUTS) in childhood may be predictive of overactive bladder (OAB) in adults. Risk factors for LUTS in children include obesity, holding of urine, and consti- pation. The prevalence of LUTS increases with age, particularly in the reproductive years. Pregnancy and vaginal delivery stretch pelvic muscles, which can affect inner- vation and connective tissue support of the bladder and urethra.3 As menopause is reached, the rate of LUTS and urinary incontinence increases. The onset of symptoms may be attributable to age. Hormones may also play a role, but there is limited understanding of this mechanism. Fifty percent of women over the age of 65 in the community have urinary incontinence, and rates increase to more than 70% for those in long-term care facilities.4 Urodynamics Urodynamics (UDS) is the dynamic study of the transport, storage, and emptying of urine. UDS include various tests, such as postvoid residual (the amount of urine in the bladder after urination), uroflowmetry (measuring flow rate over time), cystometry (measuring bladder pressure and volume), videourodynamics (simultaneous fluoros- copy), and urethral function tests (measuring outlet competence).5 The clinical usefulness of UDS is not well-defined, but lends valuable information in the appropriate setting. According to the American Urological Association, UDS are useful in the following situations: to identify factors contributing to LUT dysfunction and assess their relevance; to predict the consequences of LUT dysfunction on the upper tracts; to predict the consequences and outcomes of therapeutic intervention; to confirm and/or understand the effects of interventional techniques; and to investi- gate the reasons for failure of a treatment.5 Because performing UDS is not without risks (ie, risk of infection with catheter place- ment, risk of radiation with fluoroscopy), clinicians often contemplate whether the infor- mation potentially gained from UDS outweighs the risks. In uncomplicated cases, physicians may choose conservative treatment before performing invasive testing. OVERACTIVE BLADDER OAB is a clinical diagnosis defined by the International Continence Society as the presence of “urinary urgency, usually accompanied by frequency and nocturia, with Downloaded for Roopa Ram ([email protected]) at University of Arkansas for Medical Services from ClinicalKey.com by Elsevier on February 05, 2019. For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved. Female Voiding Dysfunction 315 or without urgency urinary incontinence (UUI), in the absence of a urinary tract infec- tion (UTI) or other obvious pathology.”6 Although OAB is usually idiopathic, it is asso- ciated with bladder inflammation, chronic bladder outlet obstruction, pregnancy, vaginal childbirth, postmenopausal status, obesity, and older age.7 Notably, OAB is more prevalent in women (12.8%) than in men (10.8%).8 Neurologic disease such as stroke, Parkinson’s disease, transverse myelitis, and cord injuries may also mani- fest with OAB-like symptoms. Epidemiology and Impact The incidence of OAB varies by the definition used, but in population-based studies, rates range from 9% to 47%. OAB increases steadily with age, and is more common in the frail elderly, with rates as high as 9 times as great in patients aged 65 to 74 compared with those aged 18 to 24.9–11 OAB has been shown to have a negative impact on quality of life and can result in increased morbidity and mortality. Symptoms can be highly bothersome to patients, negatively affecting sleep, work productivity, and overall health-related quality of life.9,12 Women with symptoms of OAB report frequent awakening at night to void, leading to poor sleep quality and feelings of fatigue.13 Additionally, symptoms of OAB can lead to anxiety, depression, and social isolation for fear of urinary incontinence.14 Consequences are even greater in the elderly population given their increased chronic comorbidities.15 One-fourth of falls occur at night and more than one-half of these are related to toilet visits.16 A common and serious repercussion of falls is hip fractures, which can lead to postoperative cardiac complications, urinary tract infec- tions, pressure ulcers, and pneumonia.17 In-hospital mortality after a hip fracture in the elderly reaches almost 5%, and all-cause mortality within 3 months is 5 to 8 times greater in this population compared with controls.18 In the long term, hip fractures also negatively affect patients’ functional status, ability to complete activities of daily living, and overall health-related quality of life.19 In addition to individual impact, consequences of OAB can be seen within society. The economic consequences of OAB are significant, with annual costs estimated to be more than $12 billion annually in the United States. This figure includes direct costs related to treating OAB, the treatment of associated conditions as described previ- ously, and the indirect costs from loss of productivity. On average, approximately $410 is spent for each female patient with OAB.20 A study by Coyne and colleagues12 found that patients with OAB were more likely to be unemployed compared with those without symptoms (9.0% compared with 7.7%), and those with OAB were also more likely to change jobs and retire early. Of patients who were employed, 26% reported always worrying about interrupting work with frequent trips to the bathroom. Initial Evaluation: Patient History, Symptoms, and Physical Examination A diagnosis of OAB is given when urinary frequency (daytime and nighttime) and urgency, with urgency incontinence (OAB-wet) or without urgency incontinence (OAB-dry) is self-reported as bothersome. Urgency is defined