Urinary and Fecal Incontinence (eBook)

Contents 6
List of Contributors 10
Part I Epidemiologic and Health Costs of Incontinence 16
Chapter 1 Epidemiology of Urinary Incontinence 18
1.1 Definitions 19
1.2 Epidemiology of Nocturnal Enuresis 19
1.3 Epidemiology of Urinary Incontinence in Women 20
1.4 Epidemiology of Urinary Incontinence in Men 24
References 25
Chapter 2 Epidemiology of Faecal Incontinence: A Review of Population-Based Studies 28
2.1 Introduction 29
2.2 Prevalence 30
2.3 Associated Factors 35
2.4 Conclusions 36
References 37
Chapter 3 Economic Costs of Urinary Incontinence in Germany 40
3.1 Prevalence and Social Importance 41
3.2 From a Medical to an Economic Approach 42
3.3 Direct Costs 42
3.4 Indirect Costs 43
3.5 Economic Impact in Germany 44
3.6 From Treating to Healing 45
References 46
Chapter 4 Perception of Incontinence in and by Society 48
4.1 Background 49
4.2 Incontinence Citations in PubMed 49
4.3 Available Therapeutic Tools 50
4.4 Incontinence Knowledge in Traditional Health Care 51
References 54
Part II Pelvic Anatomy, Physiology and Etiology of Incontinence 56
Chapter 5 The Rodent Animal Model to Explain Stress Urinary Incontinence 58
5.1 Introduction 59
5.2 Part I 60
5.2.1 Experimental Set-up 60
5.2.2 Statistical Analyses 60
5.2.3 Functional Evaluation 61
5.2.4 Histological Evaluation 62
5.2.5 RT-PCR 68
5.3 Part II 69
5.3.1 Experimental Set-up 69
5.3.2 Statistical Analysis 70
5.3.3 Functional Evaluation 71
5.3.4 Histological Evaluation 72
5.4 Discussion 90
References 99
Chapter 6 Birth Trauma and Incontinence 103
6.1 Morphological Canges of the Continence Controlling System of Urethra and Anus Caused by Pregnancy and Delivery 104
6.2 Birth Trauma and Prevalence Incontinence 106
6.3 Risk factors for the Development of Urinary and Anal Incontinence 107
6.4 Summary 107
References 108
Chapter 7 Neurogenic Urinary Incontinence 111
7.1 Introduction and Aims 112
7.2 Pathophysiology of Neurogenic Urinary Incontinence 112
7.3 Therapeutic Options for Neurogenic Urinary Incontinence 114
7.4 Conclusions 117
Chapter 8 Fecal Incontinence After Rectal and Perianal Surgery 118
8.1 Introduction 119
8.2 At-risk Procedures 119
8.3 Procedure-specific Risks 120
8.4 High-risk Procedures 128
8.5 Etiology of Postoperative Incontinence 128
8.6 High-risk Patient Groups 129
8.7 Decreasing the Risk of Fecal Incontinence Following Rectal and Perianal Surgery 130
8.8 Outcomes Data 130
8.9 Conclusion 131
References 131
Part III Diagnostic Methods to Detect Incontinence 135
Chapter 9 Evaluation of Anorectal and Pelvic Floor Muscle Function 136
9.1 Anatomical Background 137
9.2 Functional Parameters and Evaluation Techniques 137
9.3 Outcome Measures and Clinical Relevance 143
9.4 Indications 149
9.5 Conclusion 150
References 150
Chapter 10 Imaging of the Pelvic Floor – Videoproctography and Dynamic MRI of the Pelvic Floor 152
10.1 Introduction 153
10.2 Technical Necessities to Perform Defecography 153
10.3 Radiation Dose of Defecography 154
10.4 Standards of Evaluation 154
10.5 Information from a Correctly Performed Defecography 155
10.6 Technical Necessities to Perform a Dynamic MRI of the Pelvic Floor 157
10.7 How to Perform Dynamic MRI 157
10.8 Indication for Dynamic MRI 158
10.9 Costs of Conventional Defecography and Dynamic MRI 158
10.10 Discussion 160
10.11 Conclusion 167
References 167
Chapter 11 Diagnostic Methods to Detect Female Urinary Incontinence 170
11.1 Assessment of Genuine Stress Incontinence 172
11.2 Basic Investigations 172
11.3 Urodynamics 173
11.4 Electromyography 177
11.5 Ultrasound 177
11.6 Conclusion 179
References 180
Part IV Conservative Therapy of Incontinence 183
Chapter 12 Pharmacological Treatment of Urinary Incontinence 184
12.1 Medical Treatment of Bladder Overactivity 186
12.2 Anticholinergic Drugs 186
12.3 Drugs with Mixed Anticholinergic Action 186
12.4 Drugs with Antimuscarinic Action 189
12.5 Drugs Acting on Membrane Channels 190
12.6 a-Adrenoceptor Antagonists and ß-Adrenoceptor Agonists 191
12.7 Antidepressants 191
12.8 Afferent Nerve Inhibitors 191
12.9 Drugs Used for Treatment of Stress Incontinence 192
12.10 Hormonal Treatment of Urinary Incontinence 193
12.11 Conclusion 194
References 194
Chapter 13 Medical,Behavioural and Minimally Invasive Therapy – A Urologist’s View 196
13.1 Introduction 197
13.2 Nervous Control of Micturition 197
13.3 Treatment of Incontinence 198
13.4 Economics of Conservative Therapy 209
References 211
Chapter 14 Medical and Behavioral Treatment of Fecal Incontinence 214
14.1 Introduction 215
14.2 Education and Medical Management 215
14.3 Biofeedback 218
14.4 Summary and Conclusions 223
References 224
Part V Operative Therapy of Urinary Incontinence 227
Chapter 15 Innovative and Minimally Invasive Treatment of Stress Urinary Incontinence 228
15.1 Introduction 229
15.2 Tension-free Vaginal Tape (TVT) – Operation 229
15.3 Other Tension-free Suburethral Slings for Treatment of Stress Urinary Incontinence 233
15.4 Conclusion 242
References 242
Chapter 16 Abdominal,Vaginal or Laparoscopic Approach for Urinary Incontinence? 246
16.1 Kelly Plication 247
16.2 Anterior Colporrhaphy With and Without Kelly Plication 248
16.3 Needle Suspension 252
16.4 Different Colposuspension Techniques 253
16.5 Comparison Between Anterior Colporrhaphy and Colposuspension 254
16.6 Tension-Free Tape 256
16.7 Comparison of Colposuspension and TVT 258
16.8 Endoscopic Colposuspension 259
16.9 Comparison of Endoscopic Burch and TVT 260
References 262
Chapter 17 Diagnostic and Surgical Management of Stress Urinary Incontinence 266
17.1 Introduction 267
17.2 Types of Urinary Incontinence 267
17.3 Female Stress Urinary Incontinence 267
17.4 Male Urinary Stress Incontinence 267
17.5 Evaluation of Urinary Incontinence 267
17.6 Possible Approaches 268
17.7 Patient History: Analysis and Examination 269
17.8 Data Gathering Prior to the Office Examination 269
17.9 Office Examination 269
17.10 Urethral Bulking Agents (Injectables) 270
17.11 Successfully Introduced Bulking with the CE Mark 270
17.12 FDA-approved Bulking Agents 272
17.13 Tissue-engineered Stem Cells for Bulking: Dream or Reality? 273
17.14 Tension-Free Vaginal Tapes 274
17.15 Comparison of Two Major Tapes 276
17.16 New Materials:The Resorbable Sling 276
17.17 Transobturatoric Tension-Free Tapes 277
17.18 Retropubic Suspensions 277
17.19 Artificial Urethral Sphincter 278
17.20 What to Do When All the Efforts Did Not Result in a Continent Patient? 278
17.21 After a Tension-Free Sling Did Not Bring the Desired Success 279
17.22 The Sling with Tension 279
17.23 Urinary Stress Incontinence in Men 279
17.24 Conclusion 281
References 282
Chapter 18 The Artificial Urinary Sphincter 286
18.1 Introduction 287
18.2 History of the Artificial Sphincter 287
18.3 Indications and Patient Selection 288
18.4 Pre- and Postoperative Patient Preparation 288
18.5 Surgical Technique 289
18.6 Activation/Deactivation and Function 291
18.7 Results 291
18.8 Conclusion 292
References 293
Part VI Operative Therapy of Fecal Incontinence 295
Chapter 19 Sphincteroplasty 296
19.1 Introduction 297
19.2 Diagnostic Evaluation 297
19.3 Operative Technique 299
19.4 Functional Results 300
References 301
Chapter 20 Dynamic Graciloplasty 304
20.1 Introduction 305
20.2 Indications 305
20.3 Technique 305
20.4 Stimulation of the Gracilis Muscle 307
20.5 Results 308
20.6 Complications 309
20.7 Discussion 309
20.8 Conclusion 310
References 310
Chapter 21 The Artificial Bowel Sphincter in the Treatment of Severe Fecal Incontinence in Adults 312
21.1 Background 313
21.2 Description of the Acticon ABS Artificial Bowel Sphincter 313
21.3 Functioning of the Acticon ABS Artificial Bowel Sphincter 315
21.4 Implantation Technique – Perioperative Care 315
21.5 Recommendations for Follow-up of Patients with Implants 317
21.6 Recently Published Results 319
21.7 Indications and Contraindications 322
21.8 Conclusion 323
References 323
Chapter 22 Innovations in Fecal Incontinence: Sacral Nerve Stimulation 326
22.1 Methods and Patient Selection 327
22.2 Patients 329
22.3 Results 332
22.4 Discussion 334
References 337
Chapter 23 Stoma Surgery 340
23.1 Introduction 341
23.2 Preparation 342
23.3 Technical Aspects of Stoma Surgery 343
23.4 Postoperative Complications 346
23.5 Summary 346
References 346
Part VII Postoperative Care of Patients After Pelvic Operations 349
Chapter 24 Postoperative Management After Surgery for Incontinence and Prolapse 350
24.1 Introduction 351
24.2 Immediate Postoperative Phase 351
24.3 Immediate Postoperative Care 351
Chapter 25 Postoperative Management of Urinary Incontinence After Urologic Surgery 354
25.1 Introduction 355
25.2 Incontinence After Radical Prostatectomy 355
25.3 Incontinence After Female Incontinence Surgery 365
25.4 Conclusion 367
References 368
Chapter 26 Incontinence Treatment after Rectal or Perianal Surgery 372
26.1 Introduction 373
26.2 Etiology 373
26.3 Perianal or Rectal Surgical Procedures Associated with Fecal Incontinence 374
26.4 Conservative Treatment 375
26.5 Surgical Treatment of Fecal Incontinence 376
26.6 Sacral Nerve Stimulation 379
References 381
Part VIII Quality of Life and Long-term Results After Incontinence Treatment 384
Chapter 27 Quality of Life with Urinary and Fecal Incontinence 386
27.1 Introduction 387
27.2 Incontinence and Health-related Quality of Life 387
27.3 Instruments 389
27.4 Summary 397
References 397
Chapter 28 Long-term Results After Surgery for Urinary Incontinence 400
28.1 Anterior Colporrhaphy 401
28.3 Needle Suspension 403
28.4 Colposuspension Techniques 405
28.5 Tension-free Vaginal Tape 407
28.6 Discussion 409
References 409
Chapter 29 Long-term Results of Surgery for Stress Urinary Incontinence – A Urologist’s View 412
29.1 Background 413
29.2 Mechanism of Urinary Continence 413
29.3 Treatment for Stress Urinary Incontinence 413
29.4 Summary 416
References 416
Chapter 30 Long-term Results After Fecal Incontinence Surgery 418
30.1 Introduction 419
30.2 Study Inclusion Criteria 419
30.3 General Study Weaknesses 420
30.4 Presentation of the Study Results 421
30.5 Overlapping Sphincteroplasty 422
30.6 Postanal Repair 422
30.7 Preanal Repair (Anterior Levatorplasty and Sphincteroplasty) 427
30.8 Total Pelvic Floor Repair 427
30.9 Dynamic Graciloplasty 430
30.10 Artificial Bowel Sphincter 430
30.11 Sacral Nerve Stimulation 435
30.12 Quality of Life 435
30.13 Conclusion 438
References 439
Chapter 31 Quality of Life with a Permanent Colostomy 444
31.1 Introduction 445
31.2 Preoperative Expectations 446
31.3 QoL Instruments 447
31.4 Individual Factors Influencing QoL in Patients with a Stoma 448
31.5 Conclusion 452
References 452
Part IX How Can We Improve the Treatment of Incontinence? 455
Chapter 32 Is Urinary or Fecal Incontinence a Preventable Event? 456
32.1 General Consideration 457
32.2 Incidence of Urinary and Fecal Incontinence 457
32.3 Factors That Might Influence Continence During Pregnancy and Delivery 459
32.4 Primary Prevention of Urinary and Fecal Incontinence 460
32.5 Secondary Prevention of Urinary and Fecal Incontinence 462
32.6 Tertiary Prevention of Urinary Fecal Incontinence 466
32.7 The Role of Cesarean Section 466
References 468
Chapter 33 Concept of the Pelvic Floor as a Unit: the Case for Multidisciplinary Pelvic Floor Centers 472
33.1 Introduction 473
33.2 Background 473
33.3 Anatomic and Functional Correlates 474
33.4 Anatomic Defects 475
33.5 Obstetrical Correlates 475
33.6 The Pelvic Floor Team 476
33.7 Patient Flow 476
33.8 Educational Programs 478
33.9 Summary 479
References 479
Part X On Asymmetry in Sphincters 482
Chapter 34 Functional Asymmetry of Pelvic Floor Innervation and Its Potential Role in the Pathogenesis of Fecal and Urinary Incontinence Report from the EU-sponsored Research Project OASIS (On A 484
34.1 Assessment of Pelvic Floor Innervation by Conventional Neurophysiological Techniques 485
34.2 The Project OASIS 489
34.3 First Results of the OASIS Technique to Study Healthy,Continent Subjects 495
References 503
Subject Index 506

1 Epidemiology of Urinary Incontinence by Steinar Hunskaar (p. 4-5)

The understanding of epidemiology – the study of the distribution and determinants of disease – is critical in the search for the risk and protective factors that lead to primary or secondary disease prevention.This chapter reviews some of the knowledge of the epidemiology of urinary incontinence (UI). The review uses only a fraction of the high-quality, population-based studies available. More comprehensive reviews have been published (Hampel et al. 1997, Thom 1998, Hunskaar et al. 2000, 2002).

1.1 Definitions
Studies of disease frequency should rely on a very specific definition of the condition under investigation. The lack of unifying definitions for UI is a fundamental problem in assessing and comparing the findings in different studies. The International Continence Society (ICS) previously defined "urinary incontinence" as "a condition where involuntary loss of urine is a social or hygienic problem and is objectively demonstrable." From 2002 the definition reads "The complaint of any involuntary leakage of urine." The old definition was not achievable outside clinical settings. It added a subjective aspect ("problem") and therefore confounded the analyses of prevalence and risk factors. The new definition is well suited for epidemiological studies, but not appropriate for defining a patient. It should therefore be combined with validated instruments for type, severity, and QoL, in addition to investigations, for the clinical setting.

"Prevalence" is defined as the probability of being incontinent within a defined population and at a defined point in time. The concept is important for establishing the distribution of the condition in the population and for projecting the need for health and medical services."Incidence" is defined as the probability of developing the condition under study during a defined time period. Incidence is usually reported for 1-, 2-, or 5-year time intervals. Epidemiological surveys must often take a pragmatic approach and therefore define "incontinence type" based on the symptoms alone. The classification can be made either by researchers or by the respondent’s confirmation of a typical description. Clinical assessment allows for more differentiation of subtypes, but is difficult to perform on a large-scale basis. Severity of incontinence is another important factor for the estimate of prevalence. "Severity" can be defined by factors such as frequency, amount, and subjective bother (Sandvik et al. 2000).

1.2 Epidemiology of Nocturnal Enuresis

Most epidemiological studies link primary and secondary enuresis together and may include both monosymptomatic and polysymptomatic cases. Also, enuresis is defined in different ways, and in many papers there is no frequency defined at all. The best studies are longitudinal cohort studies, but many are cross-sectional (Krantz et al. 1994). In some cultures, parents are more complacent about bedwetting than in others and do not regard it as a problem requiring attention.

Nocturnal enuresis is caused by relative nocturnal polyuria and/or nocturnal bladder overactivity combined with lack of arousal at the time when the bladder needs to be emptied. These factors have a different weight in different enuretic children. The pathophysiology is thus a mixed mechanism, which explains difficulties encountered when trying to define enuresis in a consistent way. Stringent epidemiological studies would need to evaluate nocturnal urine production, nocturnal bladder activity, sleep and arousal in each of the probands. Needless to say, there is no large populationbased study using such diagnostic evaluation.

1.2.1 Survey Studies

Prevalence of nocturnal enuresis at age 7 years is significant since many children start school then, meaning more exposure to the environment and thus a greater awareness of the problem.At this age, the prevalence of nocturnal enuresis seems to be between 7% and 9% (Spee-van der Wekke et al. 1998,Hunskaar et al. 2002). In the early ages, the prevalence in boys is reported to be higher than in girls by a 2 : 1 ratio in Western countries. In studies from other countries, the figures are more similar in boys and girls,but there is always a predominance of boys. It seems that the sex difference diminishes with age and becomes less obvious among older children. In a French study (Lottmann 1999), the severity and consequences of enuresis were reported: 66% had more than one wet night per month,37% more than one wet night per week, and 22% wet the bed every night. Regarding consequences, 42% were "bothered a lot" while 15% were "not bothered at all" by their enuresis. In contrast, 92% of the mothers declared that the enuresis had no significant effect on family life or the child’s behavior at school. Fourteen percent of mothers punished their child and only 13% intended to seek treatment for their child. Even if there are some ethnic and cultural differences in the prevalence of enuresis, with higher rates generally reported from Eastern countries, there is nonetheless a remarkable similarity of prevalence rates of nocturnal enuresis in populations from all parts of the world. Steinar Hunskaar