Urinary Incontinence

On today’s episode, we visit with Dr. Kyle Wohlrab, who is an associate professor and urogynecologist at Brown University / Women and Infants Hospital of Rhode Island. He takes us through the basics of urinary incontinence.

Urinary incontinence is quite common: almost 1/3 of women in their lifetime. The Women’s Preventive Services Initiative even recommends annual standardized incontinence screening for women annually.

The mechanisms of incontinence include:
Stress - leakage with Valsalva (sneeze/laugh/cough/activity). Generally in small volumes.
Urge - aka overactive bladder; spasms or overactivity of bladder detrusor muscle that can prompt large volume leakage.
Mixed - a combination of the above; often one of the above types is “predominant.”

We review in the podcast many of the most important parts of a history and workup, but the most important aspect are the patient’s goals with respect to incontinence. This also will guide our therapy. Childbirth, obesity, and activities involving heavy weight bearing are some common risk factors.

One of the tests that can easily be performed, but many have limited experience with, is a simple cystometrogram. Essentially, one backfills the bladder. If during filling, one sees a rise in the meniscus, this is suggestive of detrusor overactivity. After filling with 200-300cc,, one can do a filled cough stress test to evaluate for stress incontinence.

Treatments vary by type of incontinence, but can be broken down into three categories for each type:
Stress - pelvic floor PT, vaginal inserts, and surgical therapy — midurethral sling, Burch urethropexy, urethral bulking.
Urge - pelvic floor PT and behavioral modification, medial therapies, and surgical therapies — neurostimulators.

For medical therapies for urge incontinence, antimuscarinic therapy is generally first line. Oxybutynin and trospium are the most commonly used medications in this class. Recall that antimuscarinic drugs have the “slow down” side effects of dry mouth/dry eyes, constipation, abdominal pain, and sedation. Newer medications in this class can have fewer side effects but can have difficulty with insurance coverage. Trospium is the newest medication that also doesn’t cross the blood-brain barrier, limiting neurologic side effects — especially useful in the elderly!

Beta agonists are another option for medical therapy with mirabegron. Rather than acting on muscarinic receptors, these act on beta agonists. These thus should be avoided in patients with uncontrolled hypertension.

When should someone refer to urogynecology? Dr. Wohlrab’s advice is to refer once someone has failed a line of therapy, or when patients begin looking for surgical therapy. Especially after listening today, we hope you’re comfortable with this workup and treatment!

Further reading from the OBG Project:
Urinary Incontinence – How to Make the Diagnosis in Your Office and When to Refer
Treating Urinary Incontinence Without Surgery: Options and Pearls
Prolapse and Stress Incontinence: Burch Procedure vs Midurethral Sling
Surgery for Urinary Incontinence – When the Sling’s the Thing