Raised intra-abdominal pressure
Urethral sphincter incompetence
Decreased or absent urethral pressure transmission
Bladder neck hypermobility
Parity
Vaginal (particularly instrumental) delivery
Physical trauma to pelvic floor
History of sexual abuse/violence, in particular if pelvic floor/sphincteric tone has damage
Bladder over distension
Congenital abnormalities
Collagen deficiency
Estrogen deficiency and menopause
13.5.1 What Are the Psychosexual Implications of Incontinence?
13.5.1.1 Sexual Dissatisfaction
Sexual dysfunction is a common complaint among women suffering from urinary incontinence [18]. Among women who seek medical help for urinary incontinence, 25–64 % report problems associated with sexual function, including decreased sexual desire, anorgasmia, and dyspareunia [15, 19]. Of women suffering from urinary incontinence, 46 % said their symptoms negatively impacted on their sexual function, thus reducing the frequency of sexual intercourse [20]. Symptoms reported included dyspareunia, leaking during coitus, embarrassment, and depression [21]. In addition, this study revealed that women suffering from urge incontinence experienced greater difficulties with sexual incontinence than women with stress incontinence. Of 201 women attending a UK clinic with urinary incontinence, 38 % reported avoiding sexual intercourse due to their condition, because they appraised this phenomenon as a negative stimulus in their sexual relationship [22].
The prevalence of coital incontinence can vary from 10 to 27 % in the total population [23]. Decreased frequency of sexual activity can also be the consequence of fear of leakage, wearing pads during the night, or feeling unattractive. In a systematic review on the prevalence of sexual impairment in women with urinary incontinence and the prevalence of urinary leakage during sexual activity, incontinence was shown to have a negative effect on sexual function in a large subset of the population. Population prevalence was noted to be 2 %, whereas prevalence in clinical samples reached 10–56 %. Studies of impairment in sexual function were more varied and methodologically heterogeneous with reported prevalences from 0.6 to 64 % of women [24]. This broad range of prevalences is a reflection of poor reporting in the literature. Only a few studies report on this topic, and those that do have very broad inclusion criteria, allowing heterogeneous samples to be compared. This means that this broad figure is the reflection of inadequacies in reporting the data.
13.5.1.2 Sexual Partner Relationship
The relationships of couples can be significantly affected by urinary incontinence. In a study on the impact of female urinary incontinence on partner relationships, 38 % of women and 32 % of men reported that the female partner’s incontinence impacted negatively on their relationship. Furthermore, 20 % of women and 17 % of men reported reduced intimacy, affection, and physical proximity [25]. There has been only 1 study that has looked specifically at divorce as an issue relating to incontinence. When asked, several women said that they felt that their incontinence had been a factor in their marriage breakdown and subsequent divorce; others feared that without a cure for their incontinence, their marriage might be in jeopardy [26]. This shows that suffering from incontinence has a very high cost in psychosocial terms.
13.6 Specific Diagnostic Aspects
13.6.1 Which Diagnostics Would You Always Use in SUI and Which Are Optional?
13.6.1.1 History Taking
Diagnosis of UI starts with a clinical interview. This interview should at least contain:
When in your patient’s life did the UI start?
How did the UI progress or change over time?
Which situations trigger the UI? This may already give clues to what type of UI your patient has.
Questions about voiding habits: frequency during day and night, painfulness, feeling of obstruction, use of abdominal pressure, and voiding position.
How did your patient cope with her UI until now? This helps you to understand the way she views the complaint and about the way she copes with it. Is there shame about the UI, embarrassment, or fear for being smelled or wetting her clothes in public spaces?
How does the UI interfere with her social and sexual life? This gives you an idea about the way she experiences the burden of incontinence for her social and sexual functioning.
13.6.1.2 Basic Investigations
Midstream Urine (MSU) Sample
Urinary tract infection (UTI) may cause or exacerbate lower urinary tract symptoms, such as dysuria and frequency, urgency, and urinary incontinence; therefore, an MSU sample, or dipstick urinalysis, must be taken from all women presenting with urinary symptoms.
Bladder Diary
A bladder diary completed over a minimum of 3 days covering variations in usual activities, such as both working and leisure days, is a useful tool in the initial assessment of women with UI. While a clinical interview may provide information on the voiding habits of a patient, the impression of symptom severity obtained is largely subjective and to some extent retrospective. There is a tendency for patients to exaggerate their urinary symptoms when giving a history [27], and their recall of incontinent episodes may not be reliable. The frequency volume chart (urinary or bladder diary) provides an objective assessment of a patient’s fluid input and urine output.
Urodynamic Testing
The term “urodynamic studies” (UDS) was defined by the International Continence Society (ICS) in 1988 as to “involve the assessment of the function and dysfunction of the urinary tract by any appropriate method” [28].
Urodynamic testing is an examination that assesses how the bladder and urethra are performing their job of storing and releasing urine. A typical urodynamic test takes about 30 min to perform. It involves the use of a small catheter used to fill the bladder and record measurements. This examination is not mandatory prior to conservative therapy, although it should be performed prior to any decision on surgical management, or in the evaluation of complex patients, or those with previous failed continence surgery.
13.6.1.3 Assessment of Quality of Life
Disease-Specific Quality of Life Questionnaires
To improve the sensitivity of quality of life (QoL) questionnaires, disease-specific tools have been developed to assess particular medical conditions more accurately and in greater detail. The questions are designed to focus on key aspects associated with lower urinary tract symptoms, while scoring is performed so that clinically important changes can be detected. There are several Grade A recommended disease-specific QoL questionnaires that can be used in women with lower urinary tract dysfunction (Table 13.2) [1, 29–34].
Table 13.2
Disease-specific quality of life questionnaires
King’s Health Questionnaire: now known as ICIQ-LUTs QoL [1] |
Bristol Female LUT symptoms questionnaire (BFLUTS): now known as ICIQ-FLUTS [29] |
Urogenital Distress Inventory (UDI) [30] |
Urogenital Distress Inventory-6 (UDI-6) [31] |
ICIQ-UI Short Form [32] |
Incontinence Impact Questionnaire (IIQ) [33] |
I-QoL (urinary incontinence-specific QoL instrument) [34] |
13.6.1.4 Assessment of Sexual Function
Up to 64 % of sexually active women attending a urogynecology clinic suffer from female sexual disorder (FSD) [19]. Although sexual dysfunction is so prevalent, a recent survey of members of the American [35] and British [36] Urogynecologic Society reported that only a minority of doctors screen all patients for FSD, citing lack of time, uncertainty about therapeutic options, and older age of the patient as potential reasons for failing to address sexual complaints as part of routine history. Seventy-six percent found training for FSD unsatisfactory [34].
Although it is obvious that an optimal clinical interview also contains questions about sexual functioning, after which a patient may be referred to a psychosexual counselor if agreed by the patient. However, as mentioned previously, since many gynecologists do not routinely address these issues in their interviews, it is important to ensure that basic screening for sexual dysfunction is carried out. Therefore, it is “strategic” to detect abnormalities in sexual function in all urogynecological patients by using a validated questionnaire.
Two Grade A recommended questionnaires that may be used are:
- 1.
Female Sexual Function Index [37]: The Female Sexual Function Index (FSFI) is a comprehensive 19-item tool that assesses 6 domains of sexual function: desire, arousal, lubrication, orgasm, satisfaction, and pain.
- 2.
Golombok Rust Inventory of Sexual Satisfaction [38]: The Golombok Rust Inventory of Sexual Satisfaction (GRISS) is a short 28-item questionnaire for assessing the existence and severity of sexual problems. The female version of the GRISS produces a total score as well as subscales of infrequency, avoidance, anorgasmia, noncommunication, non-sensuality, and vaginismus. The GRISS is used by sexual dysfunction clinics and relationship counselors to monitor the state of their patient’s sexual function. It has also been used in clinical trials of new treatment approaches and pharmacological products designed for treatment of sexual dysfunction. It is particularly useful in identifying the extent of any change in sexual function as a result of therapy.
13.6.2 Red Flag Symptoms
The following are red flag symptoms:
Microscopic hematuria in women aged 50 years and older
Visible hematuria
Recurrent or persisting UTI associated with hematuria in women aged 40 years and older
Suspected malignant mass arising from the urinary tract
13.6.3 Consideration for Early Referral to a Specialist Service
These are the indications for early referral to a specialist:
Persisting bladder or urethral pain
Clinically benign pelvic masses
Associated fecal incontinence
Suspected neurological disease
Symptoms of voiding difficulty
Suspected urogenital fistulae
Previous continence surgery
Previous pelvic cancer surgery
Previous pelvic radiation therapy
13.6.4 Most Common Diagnoses Arising from the Diagnostic Process
These are the most common diagnoses we encounter:
Urine dipstick may reveal a urinary tract infection.
Hematuria may reveal a bladder infection or a bladder malignancy.
A bladder diary may reveal excessive fluid intake, wrong kind of fluids, such as caffeine, fizzy pop, etc.
Urodynamic study may reveal detrusor overactivity and/or voiding dysfunction. Also other incidental findings may be found, such as urethral or bladder diverticulum and urinary reflux.
13.7 Specific Therapeutic Aspects
13.7.1 Which Therapeutics Would You Always Use in SUI and Which Are Optional?
13.7.1.1 Conservative Management
Conservative treatment of USI should be considered in all women presenting with urodynamic stress incontinence and particularly in those women who have not yet completed their family or are unfit for surgery. Conservative management includes:
- 1.
- 2.
Pelvic floor muscle rehabilitation remains the first-line conservative measure, with cure rates varying between 21 and 84 % [21, 42, 43]. Evidence would suggest that pelvic floor muscle training (PFMT) is more effective if patients are given a structured program [44], particularly with supervision [45].
- 3.
Pessaries. These devices are believed to work by augmenting urethral closure during increased intra-abdominal pressure and thus increasing urethral resistance [46]. The main benefit of using continence pessaries is the avoidance of morbidity and rarely mortality associated with surgical therapies.
- 4.
Medical treatment:
- (a)
Duloxetine hydrochloride, a dual serotonin and norepinephrine reuptake inhibitor (SNRI), has been available since 2004. Current evidence would suggest that women with moderate-to-severe SUI can be improved while taking duloxetine 40 mg twice per day. Animal studies have implicated serotonin and norepinephrine in the neural control of lower urinary tract function. In cats, serotonergic agonists suppress parasympathetic activity and enhance sympathetic and somatic activity [47, 48], effects that promote urine storage by relaxing the bladder and increasing outlet resistance. Duloxetine, which is a balanced and potent inhibitor of serotonin and norepinephrine reuptake, has been demonstrated to increase bladder capacity and striated urethral sphincter activity through central actions in the spinal cord in the cat [49]. The ability of duloxetine to stimulate pudendal motor neurons and increase striated urethral sphincter contractility is thought to be the basis for its efficacy in women with SUI [50]. Nausea is the most frequently reported adverse event of duloxetine hydrochloride.
- (b)
There is no evidence for the use of systemic estrogen therapy in SUI, although vaginal use may benefit women with urogenital atrophy [51].
- (a)
13.7.1.2 Surgical Management
When offering a surgical procedure, it is important to discuss with the woman the risks and benefits of the different treatment options for SUI, using simple language, avoiding jargon, and supplementing the discussion with patient information leaflets. Although a detailed review of the available surgical options is beyond the scope of this chapter, available options are:
Synthetic mid-urethral tape
Open/laparoscopic colposuspension
Autologous rectus fascial sling
Periurethral bulking agents
13.7.2 To Whom Would You Refer in Case of SUI and Why?
13.7.2.1 Psychosexual Counseling
Incontinent women may be burdened with anxieties and feelings of embarrassment and shame, and they live in constant fear that others will discover their condition. Women’s sexual function and relationships with their partners may be significantly affected by their incontinence, thus augmenting their feelings of low self-confidence. Furthermore, major depression has been shown to be more common in incontinent women, adding to the cycle of low self-esteem, increased social withdrawal, and, ultimately, a reduction in quality of life.
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