Aust. N.Z.J. Obstet. Gynaec. (1979) 19: 42
Seven Years Experience in the Evaluation and Management of Patients With Urge Incontinence of Urine John R. Fliegnerl and Peter P. Glenning2
Royal Women’s Hospital and Department of Obstetrics and Gynaecdogy University of Melbourne
Summary: In 1970 the authors established a specific clinic at the Royal Women’s Hospital in an attempt to evaluate the causes of urinary incontinence, to improve the follow-up of patients treated for this complaint, and to determine areas where treatment was deficient. Of 258 patients seen in the clinic so far 80 (31 %) were considered to have had stress incontinence, 84 (33%) urgency, and 82 (32%) both symptoms. Incontinence of urine with exertion was common in patients with urgency and furthermore, the Bonney test of urethral elevation was of no value in distinguishing stress from urge incontinence. Therapy with Probanthine 15 mg t.d.s. and Tofranil 25 mg t.d.s. was effective in 127 patients (90%) in whom urgency was the sole or dominant complaint.
Although urinary incontinence is an uncommon problem in the male it is one of the commonest urological complaints in the female. The clinical significance of incontinence and the necessity for its correction is based on the frequency, the amount of urine lost, and whether or not it causes social embarrassment. The preliminary results of treatment and follow-up of patients with stress urinary incontinence seen in a clinic established by the authors at the Royal Women’s Hospital in 1970 have been published (Glenning and Fliegner, 1976). However, it soon became apparent that the condition of urge incontinence was poorly understood, often confused with stress incontinence, and poorly 1. First Assistant. 2. Gynaecologist.
treated. The current study was undertaken in an attempt to evaluate the problem of urge incontinence with particular reference to pitfalls in diagnosis and the current status of treatment. PATIENTS AND METHODS
Since its inception, 258 patients have been seen in the special urinary incontinence clinic at the Royal Women’s Hospital. Each patient was assessed by at least one of the authors, who then analysed the degree of stress o r urge incontinence, and suggested an appropriate form of treatment. The perfect symptomatology of a patient with stress incontinence would include such features as the absence of frequency or nocturia, being always continent when lying down, and a transient loss of urine with a rise in intra-abdominal pressure after the bladder is emptied.
43
J. R. FLIEGNER AND P. P. GLENNING
Table 1. Aetiology of Urgency 1. Psychosomatic disorder-over
90% (Frewen, 1972).
2. Diseases of bladder and urethra - cystitis and urethritis (“trigonitis”) - calculi - urinary tuberculosis - diverticulae; Huhner’s ulcer - papilloma and carcinoma of bladder. 3. Polyuria - excessive fluid intake - cold environment - pregnancy - diabetes; impaired renal function - cardiac disease and diuretics - insomnia.
4. Mechanical factors - extrinsic pressure kraurosis vulvae urethral stricture.
Patients with urge incontinence have a low capacity bladder (< 300 ml), and the key symptoms include frequency, precipitancy, nocturia, eneuresis, dysuria, emotional lability, and in severe cases involuntary voiding which is often precipitated by cold, running water and anxiety. Once the patient gets the desire to micturate the bladder must be emptied immediately, and control is lost unless she is able to reach the toilet in time. The patient often states that she is wet all the time and because of her predicament may become a social outcast. Of the 258 patients seen in the clinic 80 (31%) were considered to have had stress incontinence, 84 (33%) urgency, and 82 (32%) both urge and stress. It was in the latter group that diagnostic confusion often occurred. In patients in whom urgency was the dominant complaint, there was often a strong jet of urine expelled on straining, and involuntary voiding could occur even after the patient ceased straining. As previously reported (Glenning and Fliegner, 1976) the Bonney’s test of urethral elevation is considered to be of no value in distinguishing stress from urge incontinence, since it may be positive in either condition. Similar observations have been reported by Moolgoaker et al. (1972). Special Investigations (a) Microscopy and culture of urine. This test was performed in every patient, but it was rare for the specimen to show infection, even when urgency was the sole or major complaint. Indeed, only 4 of 84 patients (4%) with a mixture of stress and urgency had a urinary tract infection. (b) Intravenous pyelography, cystoscopy and bladder capacity were routinely performed to exclude abnormalities of the bladder and urethra as listed in table 1. However, in patients with
urgency the only constant finding was a reduced bladder capacity (150-350 ml), confirming our previous report that urge incontinence is usually
a psychosomatic disorder. (c) Micturating cysto-urethrogram. Cysto-urethrography is no longer carried out on patients referred to the clinic with urinary incontinence. Although Hodgkinson (1970) and Frewen (1972) state that cysto-urethrography is an invaluable aid in the conclusive diagnosis of stress incontinence we do not consider that it is of benefit in distinguishing urge from stress, or that it is of assistance in deciding the correct surgical approach in a particular patient. (d) U r o - d y m i c studies. We are now evaluating intravesical and intra-urethral pressure profiles. Here again, reports in the literature are conflicting. Enhorning (1964), Griffiths (1973) and Beck (1976) stress the importance of a positive urethral closing pressure in maintaining normal continence. However, Edwards and Malvern (1974), and Stanton (1977) feel that urethral pressure profiles are of limited value, and offer little guidance as to whether the urethral sphincter mechanism functions normally. The only practical application is in the assessment of whether or not an organic narrowing of the urethra is present where difficulty in voiding exists. TREATMENT
Urge incontinence is essentially a psychosomatic disorder, and its treatment must be orientated with this mind. Over the past 7 years the clinic has used different combinations of anti-spasmodics and antidepressants, but has found the ideal combination tQ be probantheline bromide (Probanthine) 15 mg t.d.s. and imipramine (Tofranil) 25 mg t.d.s. Satisfactory results were achieved in 90% of patients in whom urge was the sole or major complaint (table 2). The only side effects have been transient dryness in the mouth and tiredness, but rarely has it been necessary to reduce the dosage of the drugs because of this If the condition is refractory, an additional Table 2. Results of Drug Therapy in 127 Patients with Urge Incontinence as their Sole or Major Complaint
Results
No. of Drug
26
3
11 15
1 2
+ + + +
62
35 3
+ +
patients
Buscopan and Valium Librium and Probanthine Probanthine Probanthine and Tofranil
Septrin and Tofranil
13
Cure
P < 0.001
Improved
= 54%
Failure
12
11
6=64% 6=53%
4 7
21 = 90% 4=54%
6
6
44
AUST. AND N.Z.
JOURNAL OF
dose of Tofranil and Probanthine may be required at night. Urinary analgesics and antibiotics may be required in the occasional patient in whom infection is present. Dilatation of the urethra and cystodistension is not performed as a routine, but is reserved for those patients in whom there is an obstructive element, or where the response to medical treatment is refractory. It cannot be overstressed that the most important aspect in treating urgency is the building u p of the patient’s confidence, both in herself and in her ability to overcome her urinary disturbance. Emotional problems are discussed and alleviated, and other causes of polyuria such as excessive tea drinking, diuretics, and diabetes are evaluated. Treatment with Probanthine and Tofranil is generally long term, but is varied according to circumstances and may be ceased during remission. Patients are reviewed regularly at intervals of 6 weeks to 3 months. We have been encouraged by the response to the above treatment, and only exceptionally was the response unsatisfactory and admission to hospital necessary. DISCUSSION
A study of 258 patients referred with urinary incontinence to a special clinic at the Royal Women’s Hospital, Melbourne, has shown that urge incontinence due to bladder detrusor instability is as common as stress incontinence. The quoted incidence of urgency in incontinent females differs widely in literature reports from 25 % (Green, 1975); 30% (Frewen, 1972); 60% (Jeffcoate, 1975) and 75% (Robertson, 1976). The two conditions are often confused, and in a third of patients both are present simultaneously to varying degrees. A history of incontinence associated with coughing or sneezing is as frequent with the urge variety as it is with stress incontinence. This is especially so in the severe cases. As stated in a previous report (Glenning and Fliegner, 1976) from this clinic, it cannot be stressed too strongly that a major problem in the successful treatment of stress incontinence is making the correct diagnosis. Urge incontinence is one of the commonest psychosomatic conditions in gynaecology, and its treatment must be oriented with this in mind. Combined therapy with propantheline (Probanthine) 45-60 mg/day and imipramine (Tofranil) 75-100 mg/day produces very satisfactory results. Propantheline opposes the action of acetylcholine and acts at the postganglionic cholingeric nerve endings to reduce bladder motility and increase its
OBSTETRICS AND GYNAECOLOGY
capacity. Imipramine is a tricyclic antidepressant drug, structurally related to the phenothiazines. It also has anticholinergic effects and potentiates sympathomimetic drugs by preventing the active re-uptake of noradrenaline into cellular stores, and by sensitizing the alpha-adrenergic receptors of the bladder neck and urethra to sympathetic motor innervation. It is also of value in the treatment of eneuresis. The treatment of urge incontinence demands perseverance and sympathy. Any urinary tract infection should be investigated and treated appropriately, although this was present in only 5% of women presenting with urge incontinence. Again, aggravating factors such as obesity, chronic cough and excessive fluid intake must be eliminated. In patients with refractory and long standing urgency, admission to hospital and bladder reeducation may be necessary. Cystodistension and urethral dilatation may be of value where the bladder capacity is less than 300 ml, or where there is evidence of bladder trabeculation at cystoscopy. Pelvic floor exercises designed to strengthen the pelvic floor and perineal muscles are of little, if any, value in the management of either stress or urge urinary incontinence. Acknowledgements We are indebted to the members of the staff of the Royal Women’s Hospital for allowing us to see and review their patients.
References Beck, R. P., Arnusch, R. N., and King, R. N. (1976), Amer. J . Obstet. Gynec., 125: 593. Beck, R. P., and Maughan, G. B. (1964), Amer. J . Obstet. Gynec., 89: 746. Bonney, V. (1923), J . Obsret. Gynaec. Brit. Emp., 30: 358. Edwards, L., and Malvern, J. (1974), Brit. J . Urol., 46: 325. Enhorning, G., Miller, E., and Hinman, F. (1964), Surg. Gynec. Obstet., 118: 507. Frewen, W. H. (1972), 1. Obstet. Gynaec. Brit. Cwlth, 79: 77. Glenning, P., and Fliegner, J. (1976), Aust. N.Z. 1. Obstet. Gynaec., 16: 177. Green, T. H. (1975), Arner. 1. Obstet. Gynec., 122: 368. Griffiths, D. (1973), Brit. J . Urol., 45: 497. Hodgkinson, C. P. (1970), Amer. J . Obstet. Gynec., 108: 1141
JeffcoLe, T. N. A., and Roberts, H. (1952), 1. Obstet. Gynaec. Brit. Emp., 59: 685. Jeffcoate. T . N. A. (1975). Princides of Gvnaecolow, -. 4th Edn, Butterworths; London. Moolgaoker, A. S., Ardran, G. M., et al. (1972), J . Obstet. Gynaec. Brit. Cwlth, 69: 389. Robertson, J. R. (1976), Clin. Obstet.’Gynec., 19: 315. Stanton, S. L. (1977), Female Urinary Incontinence, LloydLuke, London, p. 37.
Seven Years Experience in the Evaluation and Management of Patients With Urge Incontinence of Urine John R. Fliegnerl and Peter P. Glenning2
Royal Women’s Hospital and Department of Obstetrics and Gynaecdogy University of Melbourne
Summary: In 1970 the authors established a specific clinic at the Royal Women’s Hospital in an attempt to evaluate the causes of urinary incontinence, to improve the follow-up of patients treated for this complaint, and to determine areas where treatment was deficient. Of 258 patients seen in the clinic so far 80 (31 %) were considered to have had stress incontinence, 84 (33%) urgency, and 82 (32%) both symptoms. Incontinence of urine with exertion was common in patients with urgency and furthermore, the Bonney test of urethral elevation was of no value in distinguishing stress from urge incontinence. Therapy with Probanthine 15 mg t.d.s. and Tofranil 25 mg t.d.s. was effective in 127 patients (90%) in whom urgency was the sole or dominant complaint.
Although urinary incontinence is an uncommon problem in the male it is one of the commonest urological complaints in the female. The clinical significance of incontinence and the necessity for its correction is based on the frequency, the amount of urine lost, and whether or not it causes social embarrassment. The preliminary results of treatment and follow-up of patients with stress urinary incontinence seen in a clinic established by the authors at the Royal Women’s Hospital in 1970 have been published (Glenning and Fliegner, 1976). However, it soon became apparent that the condition of urge incontinence was poorly understood, often confused with stress incontinence, and poorly 1. First Assistant. 2. Gynaecologist.
treated. The current study was undertaken in an attempt to evaluate the problem of urge incontinence with particular reference to pitfalls in diagnosis and the current status of treatment. PATIENTS AND METHODS
Since its inception, 258 patients have been seen in the special urinary incontinence clinic at the Royal Women’s Hospital. Each patient was assessed by at least one of the authors, who then analysed the degree of stress o r urge incontinence, and suggested an appropriate form of treatment. The perfect symptomatology of a patient with stress incontinence would include such features as the absence of frequency or nocturia, being always continent when lying down, and a transient loss of urine with a rise in intra-abdominal pressure after the bladder is emptied.
43
J. R. FLIEGNER AND P. P. GLENNING
Table 1. Aetiology of Urgency 1. Psychosomatic disorder-over
90% (Frewen, 1972).
2. Diseases of bladder and urethra - cystitis and urethritis (“trigonitis”) - calculi - urinary tuberculosis - diverticulae; Huhner’s ulcer - papilloma and carcinoma of bladder. 3. Polyuria - excessive fluid intake - cold environment - pregnancy - diabetes; impaired renal function - cardiac disease and diuretics - insomnia.
4. Mechanical factors - extrinsic pressure kraurosis vulvae urethral stricture.
Patients with urge incontinence have a low capacity bladder (< 300 ml), and the key symptoms include frequency, precipitancy, nocturia, eneuresis, dysuria, emotional lability, and in severe cases involuntary voiding which is often precipitated by cold, running water and anxiety. Once the patient gets the desire to micturate the bladder must be emptied immediately, and control is lost unless she is able to reach the toilet in time. The patient often states that she is wet all the time and because of her predicament may become a social outcast. Of the 258 patients seen in the clinic 80 (31%) were considered to have had stress incontinence, 84 (33%) urgency, and 82 (32%) both urge and stress. It was in the latter group that diagnostic confusion often occurred. In patients in whom urgency was the dominant complaint, there was often a strong jet of urine expelled on straining, and involuntary voiding could occur even after the patient ceased straining. As previously reported (Glenning and Fliegner, 1976) the Bonney’s test of urethral elevation is considered to be of no value in distinguishing stress from urge incontinence, since it may be positive in either condition. Similar observations have been reported by Moolgoaker et al. (1972). Special Investigations (a) Microscopy and culture of urine. This test was performed in every patient, but it was rare for the specimen to show infection, even when urgency was the sole or major complaint. Indeed, only 4 of 84 patients (4%) with a mixture of stress and urgency had a urinary tract infection. (b) Intravenous pyelography, cystoscopy and bladder capacity were routinely performed to exclude abnormalities of the bladder and urethra as listed in table 1. However, in patients with
urgency the only constant finding was a reduced bladder capacity (150-350 ml), confirming our previous report that urge incontinence is usually
a psychosomatic disorder. (c) Micturating cysto-urethrogram. Cysto-urethrography is no longer carried out on patients referred to the clinic with urinary incontinence. Although Hodgkinson (1970) and Frewen (1972) state that cysto-urethrography is an invaluable aid in the conclusive diagnosis of stress incontinence we do not consider that it is of benefit in distinguishing urge from stress, or that it is of assistance in deciding the correct surgical approach in a particular patient. (d) U r o - d y m i c studies. We are now evaluating intravesical and intra-urethral pressure profiles. Here again, reports in the literature are conflicting. Enhorning (1964), Griffiths (1973) and Beck (1976) stress the importance of a positive urethral closing pressure in maintaining normal continence. However, Edwards and Malvern (1974), and Stanton (1977) feel that urethral pressure profiles are of limited value, and offer little guidance as to whether the urethral sphincter mechanism functions normally. The only practical application is in the assessment of whether or not an organic narrowing of the urethra is present where difficulty in voiding exists. TREATMENT
Urge incontinence is essentially a psychosomatic disorder, and its treatment must be orientated with this mind. Over the past 7 years the clinic has used different combinations of anti-spasmodics and antidepressants, but has found the ideal combination tQ be probantheline bromide (Probanthine) 15 mg t.d.s. and imipramine (Tofranil) 25 mg t.d.s. Satisfactory results were achieved in 90% of patients in whom urge was the sole or major complaint (table 2). The only side effects have been transient dryness in the mouth and tiredness, but rarely has it been necessary to reduce the dosage of the drugs because of this If the condition is refractory, an additional Table 2. Results of Drug Therapy in 127 Patients with Urge Incontinence as their Sole or Major Complaint
Results
No. of Drug
26
3
11 15
1 2
+ + + +
62
35 3
+ +
patients
Buscopan and Valium Librium and Probanthine Probanthine Probanthine and Tofranil
Septrin and Tofranil
13
Cure
P < 0.001
Improved
= 54%
Failure
12
11
6=64% 6=53%
4 7
21 = 90% 4=54%
6
6
44
AUST. AND N.Z.
JOURNAL OF
dose of Tofranil and Probanthine may be required at night. Urinary analgesics and antibiotics may be required in the occasional patient in whom infection is present. Dilatation of the urethra and cystodistension is not performed as a routine, but is reserved for those patients in whom there is an obstructive element, or where the response to medical treatment is refractory. It cannot be overstressed that the most important aspect in treating urgency is the building u p of the patient’s confidence, both in herself and in her ability to overcome her urinary disturbance. Emotional problems are discussed and alleviated, and other causes of polyuria such as excessive tea drinking, diuretics, and diabetes are evaluated. Treatment with Probanthine and Tofranil is generally long term, but is varied according to circumstances and may be ceased during remission. Patients are reviewed regularly at intervals of 6 weeks to 3 months. We have been encouraged by the response to the above treatment, and only exceptionally was the response unsatisfactory and admission to hospital necessary. DISCUSSION
A study of 258 patients referred with urinary incontinence to a special clinic at the Royal Women’s Hospital, Melbourne, has shown that urge incontinence due to bladder detrusor instability is as common as stress incontinence. The quoted incidence of urgency in incontinent females differs widely in literature reports from 25 % (Green, 1975); 30% (Frewen, 1972); 60% (Jeffcoate, 1975) and 75% (Robertson, 1976). The two conditions are often confused, and in a third of patients both are present simultaneously to varying degrees. A history of incontinence associated with coughing or sneezing is as frequent with the urge variety as it is with stress incontinence. This is especially so in the severe cases. As stated in a previous report (Glenning and Fliegner, 1976) from this clinic, it cannot be stressed too strongly that a major problem in the successful treatment of stress incontinence is making the correct diagnosis. Urge incontinence is one of the commonest psychosomatic conditions in gynaecology, and its treatment must be oriented with this in mind. Combined therapy with propantheline (Probanthine) 45-60 mg/day and imipramine (Tofranil) 75-100 mg/day produces very satisfactory results. Propantheline opposes the action of acetylcholine and acts at the postganglionic cholingeric nerve endings to reduce bladder motility and increase its
OBSTETRICS AND GYNAECOLOGY
capacity. Imipramine is a tricyclic antidepressant drug, structurally related to the phenothiazines. It also has anticholinergic effects and potentiates sympathomimetic drugs by preventing the active re-uptake of noradrenaline into cellular stores, and by sensitizing the alpha-adrenergic receptors of the bladder neck and urethra to sympathetic motor innervation. It is also of value in the treatment of eneuresis. The treatment of urge incontinence demands perseverance and sympathy. Any urinary tract infection should be investigated and treated appropriately, although this was present in only 5% of women presenting with urge incontinence. Again, aggravating factors such as obesity, chronic cough and excessive fluid intake must be eliminated. In patients with refractory and long standing urgency, admission to hospital and bladder reeducation may be necessary. Cystodistension and urethral dilatation may be of value where the bladder capacity is less than 300 ml, or where there is evidence of bladder trabeculation at cystoscopy. Pelvic floor exercises designed to strengthen the pelvic floor and perineal muscles are of little, if any, value in the management of either stress or urge urinary incontinence. Acknowledgements We are indebted to the members of the staff of the Royal Women’s Hospital for allowing us to see and review their patients.
References Beck, R. P., Arnusch, R. N., and King, R. N. (1976), Amer. J . Obstet. Gynec., 125: 593. Beck, R. P., and Maughan, G. B. (1964), Amer. J . Obstet. Gynec., 89: 746. Bonney, V. (1923), J . Obsret. Gynaec. Brit. Emp., 30: 358. Edwards, L., and Malvern, J. (1974), Brit. J . Urol., 46: 325. Enhorning, G., Miller, E., and Hinman, F. (1964), Surg. Gynec. Obstet., 118: 507. Frewen, W. H. (1972), 1. Obstet. Gynaec. Brit. Cwlth, 79: 77. Glenning, P., and Fliegner, J. (1976), Aust. N.Z. 1. Obstet. Gynaec., 16: 177. Green, T. H. (1975), Arner. 1. Obstet. Gynec., 122: 368. Griffiths, D. (1973), Brit. J . Urol., 45: 497. Hodgkinson, C. P. (1970), Amer. J . Obstet. Gynec., 108: 1141
JeffcoLe, T. N. A., and Roberts, H. (1952), 1. Obstet. Gynaec. Brit. Emp., 59: 685. Jeffcoate. T . N. A. (1975). Princides of Gvnaecolow, -. 4th Edn, Butterworths; London. Moolgaoker, A. S., Ardran, G. M., et al. (1972), J . Obstet. Gynaec. Brit. Cwlth, 69: 389. Robertson, J. R. (1976), Clin. Obstet.’Gynec., 19: 315. Stanton, S. L. (1977), Female Urinary Incontinence, LloydLuke, London, p. 37.
