Thus, I think it is reasonable to ask patients reporting mixed symptoms to characterize their urine loss. I usually have them pick a percentage (which isn’t always easy). I ask, “Is your urge incontinence 10%, 50% or 90% of your problem?” If urgency is 90% of the problem and stress incontinence is minimal, then naturally that patient’s care should be focused on the urge incontinence, and vice versa.
It becomes more problematic in the middle, with that 50/50 group. But I’m old-fashioned in that I like to treat the urge incontinence first and get that under control. Of course, in women with poor sphincter function, this distinction becomes more difficult because of the inevitable overlap of symptoms. But this is a small subset of the whole population.
DAVILA: Even if you operate on these patients to correct sphincter function, you must follow them closely. You shouldn’t be saying, “We’ll see you in 6 months.”
In addition, the cofactor of urogenital atrophy should be addressed. Atrophy can cause significant urinary urgency and nocturia symptoms, although most women may not report vaginal atrophy symptoms.4 Local estrogen cream at a low dosage can be used pre- and postoperatively without concern about systemic absorption.5
Which patients benefit from bulking agents?
SAND: We touched on the use of periurethral injections of bulking agents. How do you determine when bulking agents are appropriate?
MYERS: I use periurethral injections for demonstrated sphincter deficiency. The ideal patient has a supported bladder neck and true sphincter deficiency—for example, patients whose sphincter deficiency is caused by pelvic radiation or significant surgical scarring.
In recent years, I have loosened the guidelines slightly, in that a number of my patients are elderly women with urethral hypermobility who are not healthy enough to undergo a major operation. In these patients, I use a pessary to support the bladder neck before performing an injection, and I make sure the patient understands that she will need to use the pessary even after the injection. I have better results when there is no hypermobility.
LUBER: The concept of ISD as the sole cause of urinary incontinence is less mysterious than it at first appears. In the typical patient with a fixed poorly functioning urethra, a Qtip test will be 0 degrees at rest, and will still be 0 degrees with straining. The patient will leak readily with any kind of provocative maneuver, be it coughing or slight straining. With or without urodynamics, we know that patient’s urethra is not functioning properly. Such a patient, for me, is the ideal candidate for bulking agents.
Unfortunately, bulking agents tend to have short half-lives of around 2 years. Still, you can improve the quality of life of these patients tremendously in that time by periurethrally injecting bulking agents during a very simple office or outpatient visit.
I have had less satisfaction and success using bulking agents in patients with urethral hypermobility, although I do like Dr. Myers’ idea of correcting the hypermobility with an intravaginal support device and then using collagen to improve their urethral coaptation. That’s a nice concept.
Improvements being studied
SAND: Currently, we have 2 injectables approved by the US Food and Drug Administration: collagen and carbon-coated microspheres. Are new agents coming out? Do you expect improvements in the current agents?
DAVILA: The number of bulking agents being studied right now is huge. I think the future will bring one that can be implanted without the need for cystoscopy. A couple of trials under way use a conical urethral template for needle placement, and the injection is performed without cystoscopy. Although we’re a number of years away from having enough data to support the widespread implementation of this approach, the momentum is certainly in that direction.
The half-lives of bulking agents also are increasing. Collagen was an excellent start, but we are moving toward permanence. In addition, most of the agents being studied are simpler to inject than collagen. Biotechnology is coming to the forefront with polymers that are either temperature-sensitive or able to reconfigure themselves over time. Thus, they should serve as a nidus for collagen deposition or remain in place longer, enhancing urethral sphincteric function.
It isn’t clear which agent will take a leading role in the next few years, but a number of them have great promise. This is an exciting time in the management of stress incontinence as we move from invasive procedures such as retropubic urethropexy to minimally invasive surgery—as well as from the operating room to the office.
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