EDUCATION & DEBATE BMJ: first published as 10.1136/bmj.303.6815.1453 on 7 December 1991. Downloaded from Regular Review Urinary incontinence in women: have we anything new to offer? Linda Cardozo Quality of life has become a major issue for the 1990s, not its social on the * Genuine stress incontinence (urethral sphincter only because of impact individual incompetence) and society but also because of its political implica- * Detrusor instability (hyperreflexia) tions. Urinary incontinence is one of the medical * Retention with overflow conditions which severely adversely affect quality of * Fistulae-vesicovaginal, ureterovaginal, urethro- life, and yet in the United Kingdom little attention has vaginal, complex been focused on this problem. In the United States, * Congenital abnormalities-for example, epispa- however, the National Institutes of Health have dias, ectopic ureter, spina bifida occulta acknowledged that urinary incontinence is not only * Urethral diverticulum abnormal and antisocial but also extremely expensive. * Temporary-for example, urinary tract infection, loss of mobility, faecal impaction The conclusions of a consensus conference held at * Functional the National Institutes of Health (box 1) in 1988 are just as pertinent in the United Kingdom as in the BOx 2-Common causes ofurinary incontinence United States, even though, numerically, the problem is smaller in the United Kingdom. Certainly, it is true prolapse alone, and assessment was basically clinical that more attention is being given to this neglected with occasional micturition cystography to evaluate the disability. A recent MORI poll estimated that at least posterior urethrovesical angle. Most women in whom three and a half million, and possibly as many as 10 surgery was considered appropriate were treated with million, British people have urinary incontinence.2 Its an anterior colporrhaphy. But because of its poor long prevalence increases with age, and it is commoner in term results and lack of alternatives both women and women than men at all ages. These figures are similar doctors became disenchanted with the treatment, and to those quoted previously. In a large survey Thomas an unfortunate attitude of acceptance subsequently et al showed that at least a third of women aged over 35 developed. Only with the advent of urodynamichttp://www.bmj.com/ are incontinent twice each month or more.' studies, some 20 years ago, did the outlook for women Before the 1970s the aetiology of urinary inconti- with urinary incontinence improve considerably. nence was poorly understood, and its classification was Stress incontinence is a symptom, or a sign, but not vague. Stress incontinence was thought to be due to a diagnosis. It is the most common symptom of dysfunction ofthe lower urinary tract in women, which rarely occurs alone4 and may have various causes. * Urinary incontinence is common among older Unfortunately, the correlation between clinical diag- Americans and is epidemic in nursing homes nosis and urodynamic diagnosis is poor, and as the on 26 September 2021 by guest. Protected copyright. * Urinary incontinence costs Americans more than treatment for the various conditions with which stress $10 bn/year * Urinary incontinence is not part of normal aging, incontinence is associated is completely different it is but age related changes predispose to its occurrence important to ensure an accurate diagnosis.5 * Urinary incontinence leads to stigmatisation and Box 2 shows the common causes of urinary inconti- social isolation nence. About 85-90% of cases of urinary incontinence * Of the 10 million Americans with urinary incontin- in women are due to genuine stress incontinence or ence, more than half have had no evaluation or detrusor instability, and as these are both common treatment problems it is not unusual for them to coexist. * Most urinary incontinence can be cured or improved * Every person with urinary incontinence is entitled Genuine stress incontinence to evaluation and consideration for treatment * Most health care professionals ignore urinary Genuine stress incontinence (urethral sphincter incontinence and do not provide adequate diag- incompetence) is the commonest cause of urinary nosis and treatment incontinence and is associated with congenital weak- * Inadequate staffing of nursing homes prohibits ness, pregnancy, vaginal deliveries, and the meno- proper treatment and contributes to neglect of pause and may be exacerbated by previous surgery for residents incontinence. Women usually describe stress inconti- * Medical and nursing educations neglect urinary nence with or without frequency, urgency, urge King's College Hospital, of a curriculum for incontinence; development incontinence, or prolapse. Stress incontinence may be London SE5 9RS urinary incontinence is urgently needed shown on clinical examination, but this only verifies Linda Cardozo, MD, * A major research initiative is required to improve consultant obstetrician and assessment and treatment for urinary incontinence the patient's history and does not diagnose the cause of gynaecologist the incontinence. Usually the diagnosis of genuine BOX 1 -Summary of conclusions of consensus conference on incont- stress incontinence is made by exclusion. It is defined BMJ7 1991;303:1453-7 inence, National Institutes ofHealth, 1988 as the involuntary urethral loss of urine when the BMJ VOLUME 303 7 DECEMBER 1991 1453 intravesical pressure exceeds the maximum urethral pressure without detrusor activity. Thus if cystometry Conservative treatment shows normal findings and stress incontinence is Kegel exercises observed the diagnosis is of genuine stress inconti- Faradism Interferential therapy nence (fig 1). Videocystourethrography may help diagnosis in difficult cases. Perineometry BMJ: first published as 10.1136/bmj.303.6815.1453 on 7 December 1991. Downloaded from Treatment for genuine stress incontinence may be Tampons conservative or surgical. Box 3 shows the conventional Mechanical devices Oestrogens forms of treatment. Conservative treatment is indi- cated when the incontinence is mild, when the patient a Adrenergic agonists is unfit for or declines surgery, and for women who Surgical treatment have not yet completed their families. Nowadays it Vaginal -Anterior colporrhaphy may be useful when the patient is on a long hospital -Urethrocliesis waiting list for surgical correction. However, it is Abdominal -Marshall-Marchetti-Krantz operation unusual for anything more than mild genuine stress -Burch colposuspension incontinence to be completely cured by these conserva- Combined -Sling tive measures, and most women eventually require -Endoscopically guided bladder neck suspension (for example, Stamey, Raz) surgery. This is unfortunate as there is an increasing Other -Neo-urethra demand for less interventionist treatment. A recent -Artificial sphincter national survey of physiotherapeutic practice in -Urinary diversion England identified an urgent need for data on efficacy, as physiotherapists are treating many women with Box 3 -Conventional treatmentfor genuine stress incontinence stress incontinence in a rather haphazard way.6 Two fairly new aids for strengthening the pelvic floor combined treatment should be considered in managing muscles, cones and maximum electrical stimulation, postmenopausal women with mild genuine stress have been devised by Plevnik.7R incontinence. Weighted vaginal cones are currently sold as a set of Surgery for genuine stress incontinence aims at five, all of the same shape and size but of increasing elevating the bladder neck and proximal urethra to an weight (range 20-90 g). When inserted into the vagina intra-abdominal position; at supporting the bladder a cone stimulates the pelvic floor to contract to prevent neck and aligning it to the posterosuperior aspect ofthe it from falling out and this provides "vaginal weight pubic symphysis; and, in some cases, at increasing training." A 60% to 70% improvement rate has been outflow resistance. Undoubtedly, the results of supra- reported with this technique,9 and a recent study pubic operations such as the Burch colposuspension or showed that cones are as effective as more conventional Marshall-Marchetti-Krantz operation are better than pelvic floor re-educative treatment (interferential those for the traditional anterior colporrhaphy with therapy) and that their use requires less supervision. 10 bladder neck buttress,'5 and a cure rate of 80-90% is Maximum electrical stimulation can be carried out generally reported. There is no "best" operation, and with a home device which utilises a vaginal electrode the procedure often needs to be tailored to suit the through which a variable current is passed. The individual woman. The most popular operations, woman can adjust the strength of the stimulus and is however, are colposuspension (retropubic urethro- instructed to use the device for 20 minutes daily for one pexy) and endoscopically guided bladder neck suspen- month, initially. Maximum electrical stimulation has sions (for example, Stamey or Raz procedures). Colpo- been used in managing both genuine stress inconti- suspension is a more major procedure with a higher http://www.bmj.com/ nence and detrusor instability, and, although it is incidence of side effects and complications but seems widely used in Yugoslavia8 and Scandinavia," it has not to produce a longer lasting cure for more women.'6 yet gained popularity elsewhere. Women who have undergone multiple previous A recently reported palliative measure is