Successful approaches to common urinary problems in postmenopausal women

Introduction

Urgency incontinence

Stress incontinence

Recurrent UTI

Neurogenic (atonic) bladder

Conclusion

References

Introduction

Urological problems are common in postmenopausal women. This article will discuss some successful interventions for varieties of pathologies, including urgency incontinence (UI), stress incontinence (SI), recurrent urinary tract infections (UTIs) and neurogenic (atonic) bladder.

• Further reading: Stress urinary incontinence: management in primary care

Urinary incontinence is the involuntary leakage of urine. In a study of postmenopausal women, about 56% reported this problem at least weekly.¹ There are six different subtypes of urinary incontinence: stress incontinence (most common type in postmenopausal women), urgency incontinence, mixed incontinence combining features of the aforementioned two types, overflow incontinence, functional incontinence and lastly true incontinence usually related to a postoperative vesicovaginal or ureterovaginal fistula.

Urgency incontinence

Urgency incontinence (UI) is a common and potentially disabling condition affecting 15-30% of those aged 65 years and older.²

Therapeutic options for UI include behavioural therapy, pharmacological treatment (antimuscarinic agents, beta-3 agonist), neuromodulation and chemodenervation. Weight loss and exercise is recommended in obese patients with urgency incontinence.³

Behavioural therapy consists of a voiding diary, limiting fluid intake, avoiding caffeinated beverages, scheduled toileting every two hours during the day and urge suppression (also referred to as bladder training). When the patient feels the urge to void, she should keep still, squeeze pelvic muscles quickly five times, relaxation techniques should be attempted while the patient is trying to distract herself and wait till the urge subsides then she can go to the bathroom.⁴

Urge suppression may not be successful in frail elderly women and is difficult to implement in those with cognitive impairment. Low quality evidence showed that bladder training improved UI compared with no active treatment.³

There is some evidence that pharmacological treatment with antimuscarinic agents, eg. darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine, trospium, improved UI compared to placebo with NNT (number needed to treat) to improve symptoms ranging from six to 10 patients. They may achieve continence and improve quality of life. Side effects of antimuscarinic agents include urinary retention, dry mouth, constipation, nausea, blurred vision, tachycardia and confusion. They are contraindicated in patients with narrow angle glaucoma. Agents that do not cross the blood brain barrier, eg. trospium, are preferred in the elderly. Moderate quality evidence showed that the B3 agonist, mirabegron achieved continence and improved UI more than placebo.⁴ B3 agonists are associated with hypertension, arrhythmias.

Neuromodulation is based on the pain gate control theory published for the first time in 1965.⁵ This theory, despite its flaws, asserts that stimulation of thick myelinated fibers, eg. A-beta fibers, is able to suppress painful stimuli conveyed by smaller unmyelinated fibers, eg. C fibers.

It is postulated that neuromodulation of sacral nerves at a specific frequency can inhibit afferent nociceptive fibers from the urinary bladder and hence suppress the urgency. Modalities to treat UI include sacral neuromodulation and percutaneous tibial nerve stimulation.

Sacral neuromodulation has been approved to treat UI. After ruling out treatable causes of UI, eg. stones, interstitial cystitis, tumour, the patient receives a temporary external pulse generator connected via wire leads to S3. After one to two weeks, if the patient’s symptoms improve by >50%, a permanent stimulator is implanted in the hip area in the subcutaneous tissue. The programming of the stimulator can be adjusted to improve symptoms. Age doesn’t appear to affect efficacy of the procedure.

Percutaneous tibial nerve stimulation is an office procedure where a needle electrode is inserted 5cm above the medial malleolus for 30 minutes weekly for a total of 12 weeks. According to some studies, response rate is about 54%⁶ in patients with UI who failed antimuscarinic drug and complete recovery was maintained in 42% of those patients at one year.

Chemodenervation using intravesical injection of Botulinum toxin acts by inhibiting presynaptic release of Acetylcholine. A recent study⁷ showed that chemodenervation was superior to sacral neuromodulation in decreasing the number of daily incontinence episodes and in complete symptom resolution at six months. However, the Botulinum toxin group has higher rate of UTI compared to neuromodulation group at six months (35% versus 11%) and a greater need for self-catheterisation (8% of patients in chemodenervation group at one month, 4% at three month and 2% at six month). Intravesical injection of the toxin usually needs to be repeated every nine months.

Stress incontinence

Stress incontinence affects about 25 million women in the US. Therapeutic options include behavioural therapy, Kegel exercise, alpha agonists, eg. pseudoephedrine, midodrine, and surgery. Duloxetine, a serotonin norepinephrine uptake inhibitor (SNRI) has been approved by European regulatory authorities for treatment of stress incontinence. Onuf’s nucleus is a group of motoneurons located in the anterior horn of the sacral region and is the origin of the pudendal nerve. Pudendal nerve is involved in the control of external urethral sphincter. Onuf’s nucleus is rich in norepinephrine and serotonin receptors. A small RCT demonstrated promising results with 24% of patients on duloxetine declining their planned procedure for SI. Of note, 48% of the patients didn’t tolerate the dose of 40mg orally twice daily.⁸

Recurrent UTI

Recurrent UTI is the most common bacterial infection in postmenopausal women. At least two RCTs showed that intravaginal oestrogen reduces the incidence of UTI in this patient group by one third to three quarters.⁹ If topical application is not feasible, women can use a estradiol vaginal ring, which can be replaced every three months. Lactobacillus, taken orally¹⁰ or applied as vaginal suppositories,¹¹ showed a trend towards fewer UTI. Cranberry data regarding that indication are mixed.

Neurogenic (atonic) bladder

Neurogenic bladder is the name given to a number of urinary conditions in people who lack bladder control due to a brain, spinal cord or nerve problem. This nerve damage can be the result of diseases such as multiple sclerosis (MS), Parkinson’s disease or diabetes. It can also be caused by infection of the brain or spinal cord, heavy metal poisoning, stroke, spinal cord injury, or major pelvic surgery. People who are born with problems of the spinal cord, such as spina bifida, may also have this type of bladder problem.¹²

Nerves in the body control how the bladder stores or empties urine, and problems with these nerves cause overactive bladder (OAB), incontinence, and underactive bladder (UAB) or obstructive bladder, in which the flow of urine is blocked.¹²

A systematic review and meta-analysis found little evidence to inform best practice for management. A review of intermittent self-catheterisation regimens found that clean non-coated catheters were the most cost-effective. However, because they were designated as single-use devices, the authors recommended that a precautionary principle should be adopted and that patients should be offered a choice between hydrophilic and gel reservoir catheters.¹³

Antimuscarinics are recommended for those with spinal cord pathology and symptoms of bladder overactivity. They should also be considered in the following:

• Primary brain pathology and bladder overactivity.
• Impaired bladder storage on urodynamic testing.¹⁴

Surgery is a last resort. It is usually indicated if patients have had, or are at risk of, severe acute or chronic sequelae, or if social circumstances, spasticity or quadriplegia prevent use of continuous or intermittent bladder drainage:

• Sacral (S3 and S4) rhizotomy converts a spastic into a flaccid bladder.
• Bladder augmentation involves enlarging the bladder storage capacity using intestinal sections. It is associated with a number of complications and requires adequate risk-benefit assessment before being undertaken.
• Urinary diversion may involve an ileal conduit or ureterostomy. Cystectomy may also be recommended to prevent pyocystitis.

Conclusion

In summary, it is advisable to follow a stepwise approach in treating urinary incontinence in postmenopausal women. Behavioural therapy is initially attempted and if unsuccessful pharmacological treatment is indicated. If the patient did not control her symptoms or did develop side effects related to pharmacotherapy, other approaches as outlined above can be attempted.

Emad E. Shoukr, Assistant Professor of Medicine, Division of Geriatrics, University of North Texas, Fort Worth.

Conflict of interest: none declared.

A version of this article appeared at http://www.imedpub.com/articles/successful-approaches-to-common-urinary-problems-in-postmenopausalwomen.pdf

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References

1. Brown JS, Grady D, Ouslander JG, et al. Prevalence of urinary incontinence and associated risk factors in postmenopausal women. Heart & Estrogen/Progestin Replacement Study (HERS) Research Group. Obstet Gynecol 1999; 94: 66-70
2. Gibbs CF, Johnson TM, Ouslander JG (2007) Office management of geriatric urinary incontinence. Am J Med 2007; 120: 211-20
3. Qaseem A, Dallas P, Forciea MA, Starkey M, Denberg TD, et al. Nonsurgical management of urinary incontinence in women: a clinical practice guideline from the American College of Physicians. Ann Inter Med 2010; 161: 429-40.
4. Reuben DB, Herr KA, Pacala JT, Pollock BG, Potter JF, et al. (2005). Geriatrics at your fingertips (19th edn.). American Geriatrics Society, USA pp: 155-57
5. Melzack R, Wall PD (1965) Pain mechanisms: a new theory. Science 150.
6. Nuhoglu B, Fidan V, Ayyıldız A, et al. Stoller afferent nerve stimulation in woman with therapy resistant over active bladder; a 1-year follow up. Int Urogynecol J Pelvic Floor Dysf 2006; 17: 204-207.
7. Amundsen CL, Richter HE, Menefee SA, Komesu YM, Arya LA, et al. Onabotulinumtoxin A vs. Sacral neuromodulation on refractory urgency urinary incontinence in women: a randomized clinical trial. JAMA 2006; 316: 1366-74
8. Swift S, Morris S, McKinnie V, Freeman R, Petri E, et al. (2006) Validation of a simplified technique for using the POPQ pelvic organ prolapse classification system. Int Urogynecol J Pelvic Floor Dysfunct 2006; 17: 615-20
9. Perrotta C, Aznar M, Mejia R, Albert X, Ng CW (2008) Oestrogens for preventing recurrent urinary tract infection in postmenopausal women. Cochrane Database Syst Rev.
10. Beerepoot MA, ter Riet G, Nys S, et al. Lactobacilli vs antibiotics to prevent urinary tract infections: a randomized, double-blind, noninferiority trial in postmenopausal women. Arch Inter Med 2012; 172: 704-12
11. Stapleton AE, Au-Yeung M, Hooton TM, et al. Randomized, placebo-controlled phase 2 trial of a Lactobacillus crispatus probiotic given intravaginally for prevention of recurrent urinary tract infection. Clin Infect Dis 2011; 52: 1212-17
12. https://www.urologyhealth.org/urologic-conditions/neurogenic-bladder, Accessed 14/04/18
13. Bermingham SL, Hodgkinson S, Wright S, et al; Intermittent self catheterisation with hydrophilic, gel reservoir, and non-coated catheters: a systematic review and cost effectiveness analysis. BMJ 2013; 346
14. Urinary incontinence in neurological disease: assessment and management; NICE Clinical Guideline (August 2012)