Management of urinary incontinence in women
BMJ 2000; 321 doi: https://doi.org/10.1136/bmj.321.7272.1326 (Published 25 November 2000) Cite this as: BMJ 2000;321:1326
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In their otherwise interesting review of urinary incontinence in
women1, Thakar and Stanton state that patients with chronic urinary
incontinence, particularly the elderly, maybe easier to manage with a
permanent indwelling catheter. As one of the 'geriatric giants' described
by Isaacs in 19922, urinary incontinence is a major problem in older
patients with a prevalence of 1 in 5-10 in women over 65, rising to 2 in 3
in nursing home residents3. These patients deserve the same attention and
assessment as their younger counterparts, even if they have medical
conditions that preclude appropriate surgical treatment, or cognitive
impairment that prevents them from complying with pelvic floor exercises
or bladder retraining.
Simple measures can often significantly improve symptoms. These might
include switching to decaffeinated tea or coffee, excluding urinary tract
infections or causes of polyuria such as diabetes mellitus or
hypercalcaemia, a review of medication including diuretic use and those
that predispose to urinary retention, and practical measures to ensure
that those with physical disabilities have easy access to toileting
facilities. Cognitively impaired patients may benefit from timed, prompted
voiding. Liaison with the continence nurse advisor may help with the
provision of aids that make management of continence acceptable to carers.
Long-term urinary catheterisation causes inevitable bacteriuria which
is difficult to eradicate, with a resultant increase in pyelonephritis,
bacteraemia, and sepsis. It is an invasive procedure with an appreciable
morbidity and mortality4, a fact which should be taken into consideration
prior to usage in a frail elderly patient. In addition, in a condition
with such a high prevalence, widespread use of long-term urinary catheters
for incontinence has significant cost implications, with the cost of
medical consequences of catheterisation outweighing the savings in
continence devices5.
Long-term urinary catheterisation should be only considered in women
with urinary retention for whom intermittent self-catheterisation is not
appropriate, and as a last resort in patients in patients with excoriated
skin or pressure sores in whom other measures have failed.
Virginia Aylett, Olwyn Lynch
Specialist Registrars
Department of Medicine for the Elderly,
St James's University Hospital,
Beckett Street,
Leeds LS7 9TF
References:
1.Thakar R, Stanton S. Management of urinary incontinence in
women.BMJ 2000; 321: 1326-31.
2.Isaacs B.Incontinence.In The Challenge of Geriatric
Medicine.Oxford: Oxford University Press, 1992: 101-22.
3.Good practice in continence services. London: Department of Health,
2000.
4.Platt R, Polk BF, Murdock B et al. Mortality associated with
nosocomial urinary-tract infection. N Engl J Med 1982; 307: 637-42.
5.Ouslander JG, Kane RL. The costs of urinary incontinence in nursing
homes. Med Care 1984; 22: 69-79.
Competing interests: No competing interests
Editor - We are pleased to see a clinical review article on the
management of urinary incontinence in the BMJ (1), the subject of which we
feel should receive more publicity. We would however wish to make some
comments about the article.
We do not agree that conservative treatment is only indicated for patients
who are unfit for or refuse surgery but rather that this modality of
treatment should almost always be considered as first line therapy.
Our major concern is that there is not a balanced description of the
relative risks and complications of the surgical interventions described
which we feel to be important in a review article. This is particularly
obvious in table two which refers to recurrent stress incontinence as a
complication specific to laparoscopic colposuspension but not the other
procedures. Surely any operation, which does not have a 100% cure rate for
genuine stress incontinence has this as a potential complication.
With regards to the comments on laparoscopic colposuspension, we are sure
that the authors are aware that there is currently in progress an MRC-
funded study comparing laparoscopic versus open colposuspension which we
are sure will properly evaluate the two procedures because previous
articles have not compared like with like.
The two randomised studies on laparoscopic colposuspension reported in the
paper would suggest that this is the end of the story. The first study (2)
was very early on in the learning curve of that author and may well
represent the learning curve referred to by the authors.
The paper referred to by Su et al (3) was not strictly randomised as
patient choice was allowed for. In addition some of the laparoscopic group
also under went an open hysterectomy after the laparoscopic
colposuspension was complete. More importantly, the paper states that the
aims were to insert at least two sutures on each side of the bladder neck
in both the open and laparoscopic group. The authors state that in most
cases in the laparoscopic group they were unable to insert more than one
suture on each side due to insufficient dissection. This has not been our
experience in performing laparoscopic colposuspensions and indeed if we
were able to insert only one suture we would consider this an indication
to proceed to a laparotomy. There has been a recent paper (4), which has
compared one and two sutures for laparoscopic colposuspension, and there
were significant differences in cure rates.
Having explained some of the potential complications of other procedures
it seems strange that there is no mention of complications with TVT
procedure. There have been reported mortalities, tape erosions and bladder
injuries and we feel that these have not been adequately reported in this
article.
We commend the BMJ for commissioning an article on this under-publicised
subject but would welcome a broader debate upon the relative merits of the
different surgical approaches.
References
1. Thakar R, Stanton. Management of urinary incontinence in women.
BMJ 2000; 321: 1326-1331.
2. Burton G. A five year prospective randomised urodynamic study
comparing open and laparoscopic colposuspension. Neurourol Urodyn 1999;
18: 295-296.
3. Su TH, Wang KG, Hsu CY, Wei HJ, Hong BK. Prospective comparison of
laparoscopic and traditional colposuspensions in the treatment of genuine
stress incontinence. Acta Obstet Gynecol Scand 1997; 76: 576-582.
4. Persson J, Wolner-Hanssen. Laparoscopic Burch Colposuspension for
Stress Urinary Incontinence: A Randomized Comparison of One or Two Sutures
on Each side of the Urethra. Obstet Gynecol 2000;95(1):151-155.
Alfred Cutner MD MRCOG
Consultant Gynaecologist
Urogynaecology Unit,
The United Elizabeth Garrett Anderson Hospital and Hospital for Women,
Soho.
John Osborne FRCOG
Consultant Gynaecologist
Urogynaecology Unit,
The United Elizabeth Garrett Anderson Hospital and Hospital for Women,
Soho.
Competing interests: No competing interests
The paper by Thakar and Stanton[1] is a starting point for examining
evidence on treatment of urinary incontinence in women. Articles were
obtained by MEDLINE search (1966-2000) with subsequent hand searching of
citations, aided by personal experience. However, even a search limited
to MEDLINE would have identified more articles than are cited in the
review, and the authors do not say how they selected articles to use.
Because of the restricted search method, the conclusions that the authors
draw may be misleading. It is of concern that robust evidence, such as
that provided by systematic reviews using meta-analysis based on
randomised controlled trials, was not included.
Systematic reviews do exist in this area. The Cochrane Incontinence
Group has now published 14 systematic reviews in the Cochrane Library[2],
six of which are directly relevant to the review by Thakar and Stanton.
These are reviews on absorbent products, anterior vaginal repair, bladder
training, prompted voiding, suburethral sling operations, and vaginal
cones. In addition, less rigorous systematic reviews have also been
published and not used, for example on surgery[3] and physical
treatment[4].
Further, in a meta-analysis confined to randomised controlled trials,
colposuspension, which is generally considered to be the ‘gold standard’
for surgical management of genuine stress urinary incontinence, was
clearly shown, to be more effective than anterior repair, which is the
traditional operation[5]. Yet the latter is not mentioned in the review.
Clinical reviews are an important source of information for
practitioners. They should be based on the best information available[6].
Yours sincerely
Adrian Grant
June Cody
Cathryn Glazener
Jean Hay-Smith
Peter Herbison
Mela Lapitan
Katherine Moore
Don Wilson
The Editors of the Cochrane Incontinence Group
1. Thakar R, Stanton S. Management of urinary incontinence in women.
BMJ 2000;321:1326–31.
2. The Cochrane Incontinence Review Group, The Cochrane Library, Update
Software, Oxford (2000).
3. Black NA, Downs H. The effectiveness of surgery for stress incontinence
in women: a systematic review. Br.J.Urol. 1996;78:497–510.
4. Berghmans LCM, Hendriks HJM, Bo K, Hay-Smith EJ, de Bie RA, van
Waalwijk van Doorn ESC. Conservative treatment of stress urinary
incontinence in women: a systematic review of randomized clinical trials.
Br.J.Urol. 1998;82:181–91.
5. Glazener CM, Cooper K. Anterior vaginal repair for urinary
incontinence in women (Cochrane Review). In: The Cochrane Library,Update
Software, Oxford 2000, Issue 1.
6. Mulrow CD. Rationale for systematic reviews. BMJ 1994;309:597–9.
On behalf of the Editors of the Cochrane Incontinence Group
Competing interests: No competing interests
Dear Sir - I read the article on "Management of Urinary Incontinence
in Women" (p1326 of the BMJ 25th.November 2000) with interest,
particularly to see what had changed since I
retired in 1982. On the whole little had changed but two forms of
treatment I had found useful were not mentioned.
The first is intense Faradic stimulation of the pelvic floor muscles
under general anaesthesia using an electrode applied to the perineum.
This was followed by bladder
drill for a day or two on the ward and to be continued after discharge.
(This manoeuvre reminds me of the dramatic effect of Faradism on a sports
injury of the quadriceps
which converts a floppy muscle immediately to one as hard as a rock and
enables one to go out play that day).
The second is the use of bladder distension under general anaesthesia
for urge incontinence. The bladder was distended with saline till it was
palpable abdominally to
the size of a 14 to 16 week pregnancy. This, too, was followed by bladder
drill on the ward.
All these cases were followed up routinely at three months with a
high success rate. I admit that maybe the success may have been less
dramatic after a longer follow
up although all the ladies were invited to return for a repeat if
necessary: few did.
In the description of the nylon sling operation I presume the tape
ends, brought out through the skin, were united in front of the skin,
although the article does not say
so. I used nylon tape in this way but united the tapes in front of the
rectus muscles but behind the rectus sheath. (I did not unite them in
front of the sheath
remembering the unacceptable incidence of fistula formation when the round
ligaments were united in front of the sheath with non-absorbable sutures
in the course of
ventrosuspension - then a common operation). I read a paper on the Nylon
Sling operation to the North England Obstetrical and Gynaecological
Society on 16 th.
February, 1968. I described 10 operations, all with at least one previous
operation for stress incontinence with a follow-up period of between nine
months and two years.
Eight operations were successful and there were two failures - one
following a later umbilical repair operation by a general surgeon who was
unaware of the sling.
T.F.Redman,TD,FRCS(Ed),FRCOG
5 MAYO CLOSE,
LEEDS, LS8 2PX.
Competing interests: No competing interests
Re: Catheterisation in the Elderly: Not the 'Easy' Option
As a community nurse working in Australia,my role involves caring
for many elderly women who require continence advice.I find the article
distressing for my clients who are referred to as helpless in continence
advice, and should be given a catheter.I never give up educating all my
clients equally with conservative management with the involvement of their
local GP
I feel if all incontinent people were given correct conservative
education, surgeons would be out of work.This is even more correct when i
realise one of our leading teaching hospitals does not have a Continence
Advisor.This is an area that still requires more research and
education.
Competing interests: No competing interests