Almost always a treatment option exists for women with urinary incontinence

Almost one in five women in general population, and nearly 3 out of 4 women living in nursing homes suffer from urinary incontinence, but only 1 in 4 women seek treatment for this issue which has profound effect on quality of life.

Wide range of therapies are available and almost there is some treatment option for all women suffering from this issue says a review of therapies published online in JAMA.

Stress urinary incontinence is the commonest problem in women and often caused by weak pelvic muscles because of physical changes from pregnancy, childbirth, and menopause. 

Urge incontinence does not have a specific cause, it is often termed as ‘overactive bladder’ and the leakage follows a strong urge to urinated. It is associated with other medical disorders like diabetes, Alzheimer’s disease, Parkinson’s disease, multiple sclerosis, or stroke.

The two types of incontinence sometimes coexist.

Women are mostly shy of discussing this problem with the healthcare provider and continue coping with the problem instead of seeking treatment and cure.

The physician should initiate the treatment with understanding the women’s goal for seeking the consultation, how it’s affecting her quality of life, and any previous treatment. A concomitant physical examination should follow to rule out pelvic organ prolapse, cancer or neurological disease.

Urinary Tract Infection and hematuria should also be ruled out.

The therapy should begin with advising about pelvic muscle exercise and life style modifications. If the patient is obese she should be advised to reduce weight, adequate hydration, limiting the caffeine intake and timed voiding at regular intervals to reduce the urgency of episodes.

For stress urinary incontinence, options include estrogen vaginal cream, transurethral and periurethral injection techniques bulking procedures. Common agents used for bulking are autologous fat, glutaraldehyde cross-linked bovine collagen, calcium hydroxylapatite, pyrolytic carbon-coated beads, polydimethylsiloxane, and ethylene vinyl alcohol copolymer.

Botox and stem cell therapy may be useful in some cases.

Urethral inserts are also in use, along with pessary or stiff vaginal ring to support prolapsed bladder or vagina.

Other surgical options include bladder neck suspension, mid-urethral sling, and Transobturator vaginal tape (TVT-O) is widely used for stress incontinence in women.

For treating the urge incontinence, medications are prescribed to relax the bladder and that includes Antimuscarinics, Tricyclic antidepressants and Beta-3 agonists.

Botox (onabotulinumtoxinA) and electric nerve stimulation are the other options.

Non-ablative vaginal Er:YAG laser (VEL) has been reported to improve SUI in small pilot studies. Large randomized studies are needed to compare its efficacy with other treatments and evaluate the duration of therapeutic effects.

Urinary incontinence is a common problem of aging, and physicians should initiate the conversation about it, as women are too embarrassed to talk about it. Treatment should be initiated by life style modification, medicines and surgery if conservative measures fails.

Abstract

ACOG and AUGS issues recommendations for management of mesh and graft complications in gynecologic surgery.

Courtesy: Sanders firm 

The American College of Obstetricians and Gynecologists (ACOG) and the American Urogynecologic Society (AUGS) have jointly developed a committee opinion of the management of mesh and graft complications in gynecologic surgery.

The document provides surgeons with guidance for managing complications after mesh surgery. It also stresses the importance of good clinical history and detailed physical examination.

Knowledge of exact location of the mesh/graft is a must, and case notes/operative notes from the index procedure are best in providing the necessary information.

Diagnostic testing includes cystoscopy, proctoscopy, colonoscopy, or radiologic imaging.

The procedures most commonly associated with mesh complications are Midurethral Sling, Abdominal sacral colpopexy and transvaginal mesh.

The recommendations by American College of Obstetricians and Gynecologists and the American Urogynecologic Society includes the following:

• Short-term voiding dysfunction after placement of a synthetic midurethral sling is common and, if improving, can be managed expectantly for up to 6 weeks. However, retention (inability to empty the bladder) or small-volume voids with large postvoid bladder residual volume should receive earlier intervention.
• Long-term voiding dysfunction (typically 3 months or longer) after a midurethral sling placement are managed by referral to a clinician with appropriate training and experience, such as a female pelvic medicine and reconstructive surgery specialist.     
• Asymptomatic exposures of monofilament macroporous meshes can be managed expectantly in the hope that spontaneous reepithelialization can occur.
• A trial of vaginal estrogen can be attempted for small (eg, less than 0.5-cm) mesh exposures, if not successful primary reclosure is advised.
• Persistent vaginal bleeding, vaginal discharge, or recurrent urinary tract infections (UTIs) after mesh placement should prompt an examination and possible further evaluation for exposure or erosion.
• Pelvic pain (including dyspareunia), possibly related to nonexposed mesh, is complex, may not respond to mesh removal, and should prompt referral to a clinician with appropriate training and experience, such as a female pelvic medicine and reconstructive surgery specialist.
• Mesh removal surgery should not be performed unless there is a specific therapeutic indication.

The full text of committee opinion of the management of mesh and graft complications in gynecologic surgery can be accessed here.