Various anatomical, physiological, genetic, lifestyle and reproductive factors interact throughout a woman’s life span and contribute to pelvic floor disorders. Ageing affects pelvic floor anatomy and function, which can result in a variety of disorders, such as pelvic organ prolapse, lower urinary tract symptoms, dysfunctional bowel and bladder evacuation, and sexual dysfunction. The exact mechanisms and pathophysiological processes by which ageing affects pelvic floor and lower urinary and gastrointestinal tract anatomy and function are not always clear. In most cases, it is difficult to ascertain the exact role of ageing per se as an aetiological, predisposing or contributing factor. Other conditions associated with ageing that may co-exist, such as changes in mental status, can result in different types of pelvic floor dysfunction (e.g. functional incontinence). Pelvic organ dysfunction may be associated with significant morbidity and affect quality of life. These groups of patients often pose difficult diagnostic and therapeutic dilemmas owing to complex medical conditions and concurrent morbidities. In this chapter, we summarise the current evidence on the management of pelvic floor disorders, with emphasis on elderly women and the associations between the ageing process and these disorders. Clinicians with an understanding of the affect of ageing on the pelvic floor and lower urinary and gastrointestinal tract anatomy and function, and the complex interplay of other comorbidities, will be able to investigate, diagnose and treat appropriately there women. A holistic approach may result in substantial improvements in their quality of life.
Introduction
Various anatomical, physiological, genetic, lifestyle and reproductive factors interact throughout a woman’s life span to contribute to pelvic floor disorders (PFDs). Ageing affects pelvic floor anatomy and function, which can result in a variety of disorders, such as pelvic organ prolapse, lower urinary tract symptoms, dysfunctional bowel and bladder evacuation, and sexual dysfunction. In most cases, PFDs co-exist, making multidisciplinary assessment and treatment essential. Although age is a well-known factor affecting pelvic floor and lower urinary and gastrointestinal tract anatomy and function, the exact mechanisms and pathophysiological processes are not always clear. In most cases, it is difficult to ascertain the exact role of ageing per se as an aetiological, predisposing or contributing factor.
Although pelvic organ disorders may result in significant morbidity and can be life altering, they rarely affect woman’s overall physical health or life expectancy. The purpose of any treatment should be symptom relief and restoration of normal pelvic anatomy and function. Decisions about diagnostic and therapeutic interventions, however, should ensure that the expected anatomical, functional, and quality-of-life improvements should outweigh risks of morbidity and complications of the treatment.
Increased life expectancy, women’s awareness of pelvic floor health, disorders with associated quality of life considerations, and the development of various treatment modalities over the past few decades, are factors that have resulted in an ever-increasing demand and usage of healthcare resources in this field. The estimated demand for consultations for PFDs is anticipated to increase by 30% by the year 2030 ; women undergoing stress urinary incontinence surgery will increase by 47.2%; and those who will have surgery for pelvic organ prolapse will increase from 166,000 in 2010 to 245,970 in 2050 in the USA.
In women with frailties, multiple comorbidities, or cognitive dysfunction, the primary aim should be to optimise quality of life. Thus, decisions for treatment modalities require a thorough assessment of the woman’s condition, and a recognition that some women may be too frail to undergo interventions with surgical and anaesthetic risks.
Pelvic organ prolapse
Age, body mass index, and higher vaginal parity, are the most common risk factors for pelvic organ prolapse (POP). Studies from the Women’s Health Initiative, which included women in the USA aged between 50 and 79 years, reported a prevalence of any degree of prolapse (grades 1–3) based on examination to be 41.1%. The prevalence of cystocele was 24.6–34.3%, rectocele 12.9–18.6%, and uterine prolapse 3.8–4.2%. Among 1000 women who presented for an annual gynaecological examination, every additional 10 years of age conferred an increased risk of prolapse of 40%. A prospective cohort study of 249 women showed that, over 3 years, prolapse increased by at least 2 cm in 11% and regressed by the same amount in 3% of women, confirming that prolapse is a dynamic disease process and that not all cases of prolapse progress with time.
Pathogenesis
Epidemiological studies indicate that vaginal birth and ageing are two major risk factors for the development of POP. Pudendal nerve injury may not be related to denervation of levator ani muscles, as they are innervated by nerve roots S3–S5.
Loss of skeletal muscle volume and function occurs in virtually all striated muscles during ageing. As the striated muscles lose tone, ligamentous and connective tissue support of the pelvic organs sustain more forces conferred by intra-abdominal pressure. As the connective tissues stretch and bear these loads for long periods of time, they eventually fail, resulting in prolapse. Loss of connective tissue ‘resilience’ is believed to contribute to pelvic organ prolapse during ageing. Thus, increased collagen content by immunofluorescence most likely represents mature and newly formed immature collagen. Research into mouse models suggests that elastic fibre homeostatic networks are important in the pathogenesis of POP, as in adults and in elderly people, elastic fibres gradually become tortuous, frayed, and porous. Although no effective prevention strategy for prolapse has been identified, considerations include weight loss, reduction of heavy lifting, treatment of constipation, modification of obstetric risk factors, and pelvic floor physiotherapy.
Treatment
The surgical management of POP involves vaginal and abdominal procedures with or without use of meshes or grafts for tissue reinforcement. Use of meshes is more common in cases of severe fascial defects, where reconstruction with native tissue cannot be achieved. The age-specific rate for vaginal mesh procedures is highest in women aged 70–79 years, whereas the rates of abdominal sacrocolpopexy and minimally invasive sacrocolpopexy are highest in women aged 60–69 years. Warnings on the safety of use of synthetic mesh in transvaginal repairs, however, have recently been issued. The US Food and Drug Administration (FDA) stated that, on the basis of on updated analysis of adverse events reported to the FDA, and complications reported in the scientific literature, they identified surgical mesh for transvaginal repair of POP as an ‘area of continuing serious concern’. They identified adverse effects ranging from transient pain or dyspareunia, constipation and small mesh erosions, to larger vaginal mesh exposures or extrusions or perforations into the bladder or bowel. Shrinkage or contraction of mesh around pelvic organs, or excess tension on the mesh arms, can cause vaginal pain in some women. Vaginal surgery can potentially affect vaginal length and function, and the insertion of mesh can make the vagina less pliable and perhaps more prone to pain or dyspareunia.
Risk factors for mesh erosion include urogenital atrophy and smoking, and vaginal or topical oestrogen; smoking cessation may be helpful for affected women. Advanced uterine prolapse and lack of surgical experience are two significant predictors of failure after transvaginal mesh procedures. The American Congress of Obstetricians and Gynecologists and the American Urogynecologic Society recommends that mesh augmentation be reserved for women at high risk in whom the benefit of mesh placement outweighs the potential risks. Despite this, the rate of vaginal mesh procedures has not dramatically increased, given that the initial FDA public health notification was in 2008.
Pessaries
Before the 19th century and the advent of surgical treatments, vaginal pessaries were the gold standard for POP management. Pessaries are an inexpensive, simple, low-risk, and effective conservative treatment, and they feature in most treatment algorithms as a first-line treatment for managing POP irrespective of age or prolapse severity.
Pessaries are particularly suitable for elderly women who do not wish to have surgery. They are changed every 3–6 months depending on the type. Contraindications include non-compliance with follow up, dementia, active vaginal infection, persistent vaginal erosion or ulceration, or severe vaginal atrophy.
Immediate potential complications include pain, bleeding, urinary retention, defecatory dysfunction, and urethral mucosal prolapse. Factors include prolonged use, vaginal atrophy, advanced age and cognitive impairment.
Pessary use significantly improves prolapse and bladder symptoms. Fernando et al. evaluated prospectively the symptoms of 97 women after successful pessary fitting using baseline and 4-month questionnaires. They found a significant difference in voiding in 39 women (40%, P = 0.001); in urinary urgency in 37 (38%, P = 0.001); in urinary urgency incontinence in 28 (29%, P = 0.015); in bowel evacuation in 27 (28%, P = 0.045); in fecal urgency in 22 (23%, P = 0.018); and in fecal urgency incontinence in 19 women (20%, P = 0.027). Komesu et al., however, found little effect of pessary on bowel-related symptoms. Clemons et al. showed that age greater than 65 years and severe comorbidity were significant predictors of continued pessary use after 1 year in women with POP.
Surgery
The ideal procedure in older women would be to repair symptomatic pelvic floor defects efficiently, with rapid postoperative recovery, and to conform to the sexual activity desires of the patient.
Anterior wall defects
Surgical interventions include anterior colporrhaphy and paravaginal repair. Carey et al. compared symptomatic anterior wall prolapse repair outcomes at a mean follow up of 21 months in women aged 80 years and in younger women. They showed similar rates of symptomatic failure between the groups (6% v 5%, respectively). Recurrence of any vaginal support defect in the older group was 10%, and no mortality was reported.
Posterior wall defects
Midline colporrhaphy, with or without perineorrhaphy, should be carried out, with high anatomical success, but functional success rates may be considerably lower, irrespective of age.
Apical defects
Apical cure rates for abdominal sacrocolpopexy range from 78–100%. Abdominal sacrocolpopexy seems to have superior anatomical outcomes compared with apical prolapse repair through vaginal approach. This procedure, however, requires a laparotomy, has a longer operative time and recovery period, and higher postoperative complications compared with vaginal approaches. Similar satisfaction rates have been documented when comparing vaginal and abdominal procedures. A randomised-controlled trial showed similar perioperative complication rates and outcomes in women aged 70 years and older compared with a younger group undergoing abdominal sacrocolpopexy, but longer hospital stay in the older group (3.1 v 2.7 days). Laparoscopic sacrocolpopexy may be an option, even in older women; however this requires significant surgical skills.
The uterosacral ligament suspension, with or without culdeplasty, is an option. Vetere et al. reported on outcomes of prolapse surgery in women aged 65 years and older (mean 75 years), the majority receiving McCall’s culdeplasty (a variation of the uterosacral ligament suspension). Twelve-month follow up showed a 6% prolapse recurrence rate. Complications included no mortality, 17 out of 34 febrile, one wound infection, two transfusions, and one cardiac event.
Anatomical success rates for sacrospinous fixation range from 29–98% and 53– 96% for the ileococcygeus fixation, depending on the definition of success and the length of follow up in an unselected patient population.
Colpocleisis
In women who do not wish to preserve postoperative coital function, an obliterative surgical procedure should be considered. It is less invasive, requires shorter operative times and less anaesthesia, and has fewer surgical risks than other vaginal reconstructive procedures. Thus, colpocleisis is suitable for women of advanced age or those with significant medical comorbidities, who have either declined conservative treatment (pessary use) or had unsatisfactory results.
It is important to counsel women that intercourse is precluded, but in the properly selected individual, report of regret is low, anatomical success rates and patient satisfaction are high, and improvements in health-related quality of life are equivalent to reconstructive approaches.
Pelvic organ prolapse
Age, body mass index, and higher vaginal parity, are the most common risk factors for pelvic organ prolapse (POP). Studies from the Women’s Health Initiative, which included women in the USA aged between 50 and 79 years, reported a prevalence of any degree of prolapse (grades 1–3) based on examination to be 41.1%. The prevalence of cystocele was 24.6–34.3%, rectocele 12.9–18.6%, and uterine prolapse 3.8–4.2%. Among 1000 women who presented for an annual gynaecological examination, every additional 10 years of age conferred an increased risk of prolapse of 40%. A prospective cohort study of 249 women showed that, over 3 years, prolapse increased by at least 2 cm in 11% and regressed by the same amount in 3% of women, confirming that prolapse is a dynamic disease process and that not all cases of prolapse progress with time.
Pathogenesis
Epidemiological studies indicate that vaginal birth and ageing are two major risk factors for the development of POP. Pudendal nerve injury may not be related to denervation of levator ani muscles, as they are innervated by nerve roots S3–S5.
Loss of skeletal muscle volume and function occurs in virtually all striated muscles during ageing. As the striated muscles lose tone, ligamentous and connective tissue support of the pelvic organs sustain more forces conferred by intra-abdominal pressure. As the connective tissues stretch and bear these loads for long periods of time, they eventually fail, resulting in prolapse. Loss of connective tissue ‘resilience’ is believed to contribute to pelvic organ prolapse during ageing. Thus, increased collagen content by immunofluorescence most likely represents mature and newly formed immature collagen. Research into mouse models suggests that elastic fibre homeostatic networks are important in the pathogenesis of POP, as in adults and in elderly people, elastic fibres gradually become tortuous, frayed, and porous. Although no effective prevention strategy for prolapse has been identified, considerations include weight loss, reduction of heavy lifting, treatment of constipation, modification of obstetric risk factors, and pelvic floor physiotherapy.
Treatment
The surgical management of POP involves vaginal and abdominal procedures with or without use of meshes or grafts for tissue reinforcement. Use of meshes is more common in cases of severe fascial defects, where reconstruction with native tissue cannot be achieved. The age-specific rate for vaginal mesh procedures is highest in women aged 70–79 years, whereas the rates of abdominal sacrocolpopexy and minimally invasive sacrocolpopexy are highest in women aged 60–69 years. Warnings on the safety of use of synthetic mesh in transvaginal repairs, however, have recently been issued. The US Food and Drug Administration (FDA) stated that, on the basis of on updated analysis of adverse events reported to the FDA, and complications reported in the scientific literature, they identified surgical mesh for transvaginal repair of POP as an ‘area of continuing serious concern’. They identified adverse effects ranging from transient pain or dyspareunia, constipation and small mesh erosions, to larger vaginal mesh exposures or extrusions or perforations into the bladder or bowel. Shrinkage or contraction of mesh around pelvic organs, or excess tension on the mesh arms, can cause vaginal pain in some women. Vaginal surgery can potentially affect vaginal length and function, and the insertion of mesh can make the vagina less pliable and perhaps more prone to pain or dyspareunia.
Risk factors for mesh erosion include urogenital atrophy and smoking, and vaginal or topical oestrogen; smoking cessation may be helpful for affected women. Advanced uterine prolapse and lack of surgical experience are two significant predictors of failure after transvaginal mesh procedures. The American Congress of Obstetricians and Gynecologists and the American Urogynecologic Society recommends that mesh augmentation be reserved for women at high risk in whom the benefit of mesh placement outweighs the potential risks. Despite this, the rate of vaginal mesh procedures has not dramatically increased, given that the initial FDA public health notification was in 2008.
Pessaries
Before the 19th century and the advent of surgical treatments, vaginal pessaries were the gold standard for POP management. Pessaries are an inexpensive, simple, low-risk, and effective conservative treatment, and they feature in most treatment algorithms as a first-line treatment for managing POP irrespective of age or prolapse severity.
Pessaries are particularly suitable for elderly women who do not wish to have surgery. They are changed every 3–6 months depending on the type. Contraindications include non-compliance with follow up, dementia, active vaginal infection, persistent vaginal erosion or ulceration, or severe vaginal atrophy.
Immediate potential complications include pain, bleeding, urinary retention, defecatory dysfunction, and urethral mucosal prolapse. Factors include prolonged use, vaginal atrophy, advanced age and cognitive impairment.
Pessary use significantly improves prolapse and bladder symptoms. Fernando et al. evaluated prospectively the symptoms of 97 women after successful pessary fitting using baseline and 4-month questionnaires. They found a significant difference in voiding in 39 women (40%, P = 0.001); in urinary urgency in 37 (38%, P = 0.001); in urinary urgency incontinence in 28 (29%, P = 0.015); in bowel evacuation in 27 (28%, P = 0.045); in fecal urgency in 22 (23%, P = 0.018); and in fecal urgency incontinence in 19 women (20%, P = 0.027). Komesu et al., however, found little effect of pessary on bowel-related symptoms. Clemons et al. showed that age greater than 65 years and severe comorbidity were significant predictors of continued pessary use after 1 year in women with POP.
Surgery
The ideal procedure in older women would be to repair symptomatic pelvic floor defects efficiently, with rapid postoperative recovery, and to conform to the sexual activity desires of the patient.
Anterior wall defects
Surgical interventions include anterior colporrhaphy and paravaginal repair. Carey et al. compared symptomatic anterior wall prolapse repair outcomes at a mean follow up of 21 months in women aged 80 years and in younger women. They showed similar rates of symptomatic failure between the groups (6% v 5%, respectively). Recurrence of any vaginal support defect in the older group was 10%, and no mortality was reported.
Posterior wall defects
Midline colporrhaphy, with or without perineorrhaphy, should be carried out, with high anatomical success, but functional success rates may be considerably lower, irrespective of age.
Apical defects
Apical cure rates for abdominal sacrocolpopexy range from 78–100%. Abdominal sacrocolpopexy seems to have superior anatomical outcomes compared with apical prolapse repair through vaginal approach. This procedure, however, requires a laparotomy, has a longer operative time and recovery period, and higher postoperative complications compared with vaginal approaches. Similar satisfaction rates have been documented when comparing vaginal and abdominal procedures. A randomised-controlled trial showed similar perioperative complication rates and outcomes in women aged 70 years and older compared with a younger group undergoing abdominal sacrocolpopexy, but longer hospital stay in the older group (3.1 v 2.7 days). Laparoscopic sacrocolpopexy may be an option, even in older women; however this requires significant surgical skills.
The uterosacral ligament suspension, with or without culdeplasty, is an option. Vetere et al. reported on outcomes of prolapse surgery in women aged 65 years and older (mean 75 years), the majority receiving McCall’s culdeplasty (a variation of the uterosacral ligament suspension). Twelve-month follow up showed a 6% prolapse recurrence rate. Complications included no mortality, 17 out of 34 febrile, one wound infection, two transfusions, and one cardiac event.
Anatomical success rates for sacrospinous fixation range from 29–98% and 53– 96% for the ileococcygeus fixation, depending on the definition of success and the length of follow up in an unselected patient population.
Colpocleisis
In women who do not wish to preserve postoperative coital function, an obliterative surgical procedure should be considered. It is less invasive, requires shorter operative times and less anaesthesia, and has fewer surgical risks than other vaginal reconstructive procedures. Thus, colpocleisis is suitable for women of advanced age or those with significant medical comorbidities, who have either declined conservative treatment (pessary use) or had unsatisfactory results.
It is important to counsel women that intercourse is precluded, but in the properly selected individual, report of regret is low, anatomical success rates and patient satisfaction are high, and improvements in health-related quality of life are equivalent to reconstructive approaches.
Urinary incontinence
Urinary incontinence can result in psychosocial difficulties, including low self-esteem, sexual dysfunction, social isolation, and loneliness.
In elderly women especially, urinary incontinence may have associated medical complications, and some investigators consider it as a marker for an increased mortality rate in some cases. Many elderly women accept it as a normal part of ageing, and they do not seek help earlier than an average of 4 years.
Geriatric incontinence evaluation begins with understanding its affect on women’s quality of life and daily function. Assessment should include review of medical conditions, medication history, and examination for neurological conditions, mobility, and dexterity. Stage III-IV POP can cause obstruction at the ureterovesical junction, with voiding dysfunction, which is more likely with older age and uterus in situ . Treatment is indicated especially in cases with associated complications, such as recurrent urinary tract infections (UTI). Interventions include restoration of anatomy and, if no anatomical problem exists, voiding dysfunction and overflow incontinence require either intermittent or indwelling catheterisation. Behavioural treatments, such as prompted voiding, can be considered in selected women. In various clinical trials, symptoms improved in 33–60% of women.
The prevalence of incontinence increases with age. In a US study of women over the age of 80 years, incontinence was found in 31.7% compared with women aged 40–59 years, who had a prevalence of 17.2%. Urinary incontinence can be transient in elderly women, in women with a temporary underlying condition such as UTI or atrophic vaginitis, in women with chronic overflow (i.e. associated with outlet obstruction or poor detrusor contractility and voiding dysfunction) and in those with functional disorders (i.e. associated with factors not directly associated with the bladder).
Nocturia may affect quality of life and increase fracture risk. Nocturnal polyuria has multiple pathophysiological and medical causes in elderly women. A bladder diary can help in identifying possible causes, which may include bladder problems, fluid intake and medications. A bedside commode may reduce fracture risks.
Pathogenesis
Urological, gynaecological, and neurological disorders, and functional impairments, particularly dementia and lack of mobility, are common factors. Nursing-home residents seem to have ‘functional’ incontinence particularly associated with immobility and dementia.
Hormone replacement therapy (HRT) has been implicated as a risk factor, as increased incidence of all types of urinary incontinence has been reported at 1 year among women who were continent at baseline. Given the controversial evidence on the role of HRT on lower urinary tract symptoms and, particularly, urinary incontinence according to different studies, a decision for commencing HRT should include prior assessment for such symptoms, monitoring changes compared with baseline, and appropriate patient counselling.
Diagnosis
Apart from the standard diagnostic tests, it is important in elderly women to evaluate their ability to take part in daily activities (e.g. bathing, dressing and eating), and assess vision, muscular weakness, paralysis or poor co-ordination, tremor, numbness, and tingling sensation.
Role of urodynamics
Urodynamic investigations are commonly undertaken before surgical intervention; however, it is unclear how the test contributes to decision making on treatment options, or its predictive value on outcomes. The function of the urethra and bladder during the storage and voiding phase, and the pathophysiology of the symptoms, can be assessed. For cases of voiding dysfunction, the role of urodynamics in investigation and diagnosis is well established and results in improved outcomes. It is an objective quantitative assessment that helps practitioners in making a correct diagnosis, and hence appropriate interventions and follow up of treatment. Moreover, urodynamics testing reduces the risk of a patient undergoing unnecessary surgical procedures.
Urodynamic investigations are often used for the diagnosis of stress urinary incontinence (SUI). The ability of urodynamic urethral function tests to predict symptom severity is unclear, as is the role of some urodynamic parameters, including maximum urethral closure pressure and valsalva leak point pressure in predicting outcomes after treatment for stress urinary incontinence.
Urinary urgency incontinence
Urinary urgency incontinence (UUI) can be caused by involuntary bladder contractions or poor bladder compliance that results from loss of the viscoelastic features of the bladder. It is most commonly idiopathic; however, it is associated with advancing age, and cognitive and neurological impairment. Moreover, aetiology, pathophysiology, and rationale of different treatments in elderly people with urinary urgency incontinence, is poorly understood, making communication and appropriate counselling of these people essential.
Epidemiology
Mixed and urgency incontinence predominate in older women, whereas young and middle-aged women predominantly suffer from stress incontinence. Lower prevalence of urinary infections occur in black, Hispanic, and Asian women compared with white women.
Risk factors for urinary infection can be race (e.g. white women are more susceptible), congenital defects, and neurological abnormalities, such as Parkinson’s disease, multiple sclerosis, stroke, or herpes zoster infection, obstetric and gynaecological factors (e.g. pregnancy, childbirth, parity), effects of pelvic surgery, radiation, and pelvic organ prolapse and others such as age, diabetes, changes in mobility, UTI, cognitive impairment, menopause, and medications such as diuretics.
Treatment
Conservative
Lifestyle and behavioural modifications, such as fluid management, avoidance of bladder irritants, bladder training and timed voiding, have positive outcomes. Pelvic floor muscle exercises have a positive effect on prolapse symptoms and severity, as reported in a Cochrane analysis. Biofeedback can be used to optimise pelvic floor function. For this purpose, intravaginal devices are used, or small pad electrodes (electrocardiogram-type pads) are placed on the skin of the abdomen and anus and transmit signals to a computer, which displays visual evidence of the type, magnitude, duration and other properties of the pelvic floor muscle contractions and tone.
Pharmacotherapy
Pharmacotherapy is the mainstay of treatment for urgency and UUI, and antimuscarinic drugs are still the most widely used agents. Contraindications and side-effects caused by muscarinic receptor binding in organs other than the bladder, should be considered, particularly when treating elderly women. The effects of antimuscarinic drugs on salivary glands are responsible for the most common and bothersome side-effect of dry mouth. Other effects include constipation, blurred vision, somnolence, dizziness and cognitive impairment. The binding of muscarinic receptors in the heart may lead to cardiovascular adverse events, and QT interval prolongation has been a concern with antimuscarinic drugs. In a randomised, double-blind, placebo-controlled, crossover trial, tolterodine significantly increased heart rate compared with placebo, but darifenacin did not affect heart rate. In a study with real-life conditions (i.e. with inclusion of large numbers of participants with cardiovascular comorbidities and taking several other medications), therapeutically effective doses of solifenacin did not increase heart rate or blood pressure. Untreated, close-angle glaucoma, gastrointestinal tract obstruction (e.g. paralytic ileus, stenosing peptic ulcer and toxic megacolon) may be intensified by slowing gastrointestinal activity. Myasthenia gravis, urinary retention or outflow obstruction, are contraindications for their use. They are also secreted by the renal tubules, and may theoretically interfere with the elimination of other drugs.
Surgical treatment
In patients with refractory overactive bladder who have failed medical treatment, sacral neuromodulation is an option, as it can provide effective relief of overactive bladder symptoms and neurogenic retention. Another, less invasive treatment is percutaneous tibial nerve stimulation.
Intravesical botulinum toxin injections are an efficacious second- and third-line treatment. Repeat injections are required every 6–9 months. They seem to be safe, but have high voiding dysfunction rates.
Stress urinary incontinence
Stress urinary incontinence is caused by increased intra-abdominal pressure that exceeds the urethral pressure. Urethral hypermobility or intrinsic sphincter deficiency affect the continence mechanism.
Treatment
Conservative
Weight loss has been shown to improve SUI symptoms. Fluid modifications should be considered in patients with high volumes of fluid intake. Constipation and chronic coughing should be treated. Timed voiding may also help in controlling symptoms. Pelvic floor muscle exercises are effective conservative treatment but require compliance. Other treatments include biofeedback, use of vaginal cones, electrostimulation, and bladder neck support devices. The use of topical vaginal oestrogens may be beneficial in post-menopausal women with vaginal atrophy.
Pharmacotherapy
Duloxetine has been used in Europe but is rarely part of a treatment algorithm. No pharmacological treatment is available for SUI in the USA.
Surgery
If all conservative measures fail, surgical intervention can be considered. The number of women who have undergone SUI procedures has increased from 48,345 in 1979 to 103,467 in 2004. Further analysis by age stratification showed more than doubling of the age-adjusted rate for women aged 52 years, rising from 0.64 to 1.60 per 1000. Rates of retropubic urethral suspension procedures decreased by 0.08% per year between 1979 and 2004, whereas suburethral sling use increased by 0.01%.
Urethral bulking
Urethral bulking injection is minimally invasive, well tolerated, and efficacious, especially in the short term. It improves the urethral coaptation and restores the mucosal seal mechanism of continence. It has been used in women with isolated intrinsic sphincter deficiency, limited urethral mobility, and absence of detrusor overactivity. A broader range of women with all types of SUI have been treated.
Urethral bulking injection is most appropriate for elderly women, women who cannot undergo surgery, those who require continued anticoagulation therapy, desire non-surgical therapy for SUI, have persistent SUI after an anti-incontinence procedure, or have poor bladder emptying and may be at higher risk for voiding dysfunction. Its efficacy is only 40% or less in some studies, and these results may deteriorate with time, necessitating reinjections.
Synthetic mid-urethral slings
Synthetic mid-urethral slings are now the mainstay of treatment for women with SUI. It is a minimally invasive procedure, and the sling can be placed via a retropubic or transobturator approach.
Owing to serious complications of the use of mid-urethral slings, the FDA and American Urological Association have reconsidered the efficacy and safety of their use. In a Cochrane meta-analysis the efficacy and complications of mid-urethral slings were compared. The efficacy of retropubic slings was found to be slightly higher for objective cure rates, but no difference was found in subjective cure rates between retropubic and transobturator slings. Transobturator slings, however, have a higher incidence of transient groin pain (12%), but retropubic slings have a higher risk of bladder perforation (5.5% v 0.3%) and postoperative voiding dysfunction (7% v 4%). Novara et al., in an updated systematic review, confirmed these findings. They also found that retropubic slings have higher rates of haematoma and vaginal perforation, as well as storage lower urinary tract symptoms.
Elderly women have increased prevalence of mixed urinary incontinence and intrinsic sphincter deficiency, which could potentially pose a higher risk of adverse outcomes and lower success with mixed urinary incontinence for SUI. Thus, the use of mid-urethral slings to treat SUI in elderly women requires appropriate counselling about the lower cure rates as well as the higher risks of de-novo urgency.
Contraindications include the presence of pure detrusor overactivity and an atonic or a neurogenic bladder. Also, women who are otherwise at high risk for postoperative voiding dysfunction, and are unable or unwilling to perform self-catheterisation, may not be suitable candidates. In elderly women, and those who also have overactive bladder symptoms or evidence of voiding dysfunction concomitant with POP, a transobturator approach is preferable.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
