Evaluation and Patient Selection

As with any patient undergoing evaluation for urinary incontinence, the patient's general medical history should be reviewed, especially the incontinence history, previous incontinence therapies, and current incontinence symptoms. In addition to a pelvic examination, urinalysis and/or urine culture should be used to check for infection to ensure that an injectable agent will not be implanted in the setting of an active infection. Urodynamics or a supine stress test may be used to confirm the diagnosis of SUI and significant ISD. Cystoscopy may be performed before and certainly at the time of the injection procedure to inspect the urethra for pathologic conditions such as stricture, ure-thral diverticulum, or poor mucosal closure and tissue integrity.

Patients with SUI and normal detrusor function are ideal candidates for injectable bulking agents. The presence of significant ISD was originally the primary indication for the use of injectable bulking agents in patients with SUI. However, varying degrees of ISD do coexist or are transiently introduced with hypermobility and, thus, injectable bulking agents have been successfully used in patients with hypermobility to improve the ISD component of their incontinence. Furthermore, women who would require regional or general anesthesia for their SUI treatment, but are poor operative risks (i.e., use of hypocoagulable med-ications),should be offered injectable bulking agents under a local anesthetic as a viable option for treating their condition.

Detrusor overactivity may be present or unrecognized in many patients with confirmed SUI. Although injectable bulking agents are indicated primarily for SUI, many patients with mixed signs and symptoms of SUI and overactive bladder notice improvement in their overactive bladder condition as a result of improving the SUI condition. These findings are tempered by reports of de novo or worsening overactive bladder conditions in studies using injectable bulking agents. However, these cases typically represent under-recognized and previously unmanaged coexisting overactive bladder conditions.

When using Contigen, a sensitivity skin test should be administered 30 days before the treatment to detect hypersensitivity to bovine collagen. Testing involves injecting 0.1 mL of bovine collagen intradermally in the inner aspect of the forearm. The patient is instructed to report any redness or swelling at the test site for 30 days.

A relative contraindication to injectable therapy is severe vaginal tissue atrophy as evident by mucosal prolapse and urethral caruncles. It is generally recommended that hormonal deficiency resulting in vaginal atrophy be treated with topical estrogens for several months before injection therapy to improve urethral compliance, tissue manipulation, and acceptance of the bulking agent, as well as the ability of the periurethral tissue to retain the injectable bulking agent long-term. Absolute contraindications to therapy with injectable bulking agents include significant urethral pathology such as a urethral diverticulum, an untreated urinary tract infection, and known hypersensi-tivity to injectable bulking agents, such as Contigen.

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