Collaborative for Education on Urinary Incontinence and Women's Health (ceUIwh)

Clinical Consult

Each month, questions with a common theme will be selected and answered comprehensively by one of our Steering Committee members. Previously answered questions will be archived each month for your reference. If you wish to submit a question, click here.

This Month's Question:

What are the pros and cons of the different treatment options for stress urinary incontinence?

Response by Mikel L. Gray, PhD, CCCN, CUNP, posted 11/24/2004

Several treatment options, both surgical and nonsurgical, are available for stress urinary incontinence (SUI). Nonsurgical methods include behavioral modifications, medication, and medical devices. Generally, these treatments are first-line therapies. Surgery is an option for severe SUI that is associated with significant pelvic organ prolapse or that has proved to be resistant to other treatment, provided the patient is a good candidate for surgery. Risks, benefits, and patient preference should be considered when choosing any treatment option.

Behavioral modifications include pelvic floor muscle training, bladder training, and lifestyle changes, all of which are noninvasive and health-promoting tactics. Bladder training and record-keeping with a 3-day bladder diary are important in order to assess baseline urinary frequency and pattern—activities associated with urine leakage—and treatment progress.^1,2 Modifications of fluid intake and voiding habits are often required.

In conjunction with pelvic floor muscle exercises or bladder training, it is important to make lifestyle alterations, such as changes to diet, fluid intake, medications, or high-impact exercise. For instance, a patient should avoid over-consumption of water and products containing caffeine because caffeine increases urine production.³ When feasible, alterations in medication regimens may alleviate SUI. For example, diuretics, alpha-adrenergic blockers, and angiotensin-converting enzyme inhibitors may contribute to incontinence severity; and, therefore, selection of alternative agents may relieve or alleviate urine loss.

Pelvic floor muscle training, which involves performing Kegel exercises, is designed to teach and enhance pelvic muscle function and alleviate urinary leakage.⁴ Muscle training begins by helping the patient to identify and isolate the correct muscles; the clinician may initiate education during a vaginal examination by asking the patient to contract the pelvic muscles surrounding the vaginal vault. Muscle training should be based on the principles of exercise physiology and include daily exercise sessions with a graded muscle training program that enhances maximum contraction strength and endurance. Once a patient can properly identify, contract, and relax the pelvic floor muscles, she is taught to practice “the Knack,” which is the intentional contraction of the external urethral sphincter just prior to stress-related urine loss.⁵ Advantages of pelvic floor muscle training include increased urethral resistance and a reported 62% reduction in frequency of incontinence episodes.⁶ Adherence to muscle training is a significant challenge for many patients; however, an audiocassette tape used in combination with a structured exercise program has been shown to enhance patient compliance.⁷

Weighted vaginal cones provide an alternative to pelvic floor muscle training. They are retained in the vagina, which requires contraction of the pelvic floor muscles. Vaginal cones may be retained for 15 minutes twice a day.⁸

Medications also may be used to treat urinary incontinence, either alone or in combination with pelvic floor muscle training. However, none of the drugs currently prescribed are approved specifically for SUI. Estrogen, either in suppository, vaginal ring, or cream form, can be placed in the vagina to reverse the effects of declining estrogen levels during menopause.⁹ Although estrogen therapy has been shown to significantly increase maximum urethral closure pressure, it has not been shown to significantly decrease urine loss when administered as monotherapy.

Ephedrine and pseudoephedrine are alpha-adrenergic agonists that increase the tone of smooth muscle within the urethra and bladder neck. They are sometimes used off-label for the treatment of SUI. However, they exert a limited effect on the magnitude of urine loss during periods of physical exertion, and they are associated with significant adverse side effects including exacerbation of hypertension and tachycardia. Imipramine, a tricyclic antidepressant, combines alpha-adrenergic and anticholinergic properties and is sometimes prescribed off-label for the management of SUI or mixed urinary incontinence.¹⁰ However, it also has significant side effects, including not only the same side effects typically associated with alpha-adrenergic agonists and anticholinergic agents, but also alterations in short-term memory.

Duloxetine is an investigational agent that has been shown in clinical trials to be effective for the treatment of SUI.¹¹ A balanced dual serotonin norepinephrine reuptake inhibitor, duloxetine increases the concentrations of serotonin and norepinephrine at the presynaptic neuron in Onuf's nucleus of the sacral spinal cord.¹²

In one study of patients who have SUI, duloxetine was shown to reduce incontinence-episode frequency by about 50%, compared with 27% for the placebo group. The drug also produced an 11% increase in quality of life, compared with 6.8% for the placebo group. Nausea, which tended to be mild to moderate and transient, was the most common side effect and reason for discontinuation (6.4%) but usually resolved after 1 week to 1 month.¹³

Medical devices used for the management of SUI include intravaginal support devices and disposable intraurethral inserts. Certain types of pessaries may alleviate UI by applying gentle pressure against the vaginal wall and to the nearby urethra. However, a pessary must be fitted by a clinician and cared for properly; additionally, routine removal and cleaning is necessary to prevent vaginal infections or erosion. Urethral inserts are compact disposable devices that are inserted into the urethra. A small balloon tip is inflated with a gentle push to temporarily block anticipated urine leakage, such as the type that happens during sports or exercise.

If a patient's nonsurgical treatments are unsuccessful or if she wishes to pursue surgery, she should be referred to a urologist, gynecologist, or urogynecologist for further evaluation and treatment. The specialist may recommend a surgical procedure to manage SUI. A suburethral bulking agent, such as GAX collagen or silicone beads, may be injected under the urethral mucosa under endoscopic guidance. Suburethral injections are frequently effective, but durability is limited, and most patients require re-injection within 3 years.¹⁴

Open or laparoscopic surgical procedures are designed to restore support to the bladder base and proximal urethra or enhance coaptation of the urethral lumen. Risks include those associated with spinal or general anesthesia, infection, and bleeding. An abdominal approach called a colposuspension is effective in correcting SUI, particularly among women with descent of the bladder base and hypermobility of the urethra.¹⁵ A suburethral sling procedure may be performed partly through the abdomen or vagina. This procedure, which has many variations, uses a strip of natural or synthetic material to provide support for the proximal urethra while enhancing coaptation of the sphincter mechanism. Simplifications of the sling techniques have led to the development of less invasive methods, such as the tension-free vaginal tape (TVT) procedure.¹⁶ A synthetic mesh ribbon-like strip is surgically inserted through the vagina to provide support at the middle of the urethra. The TVT procedure has gained popularity because it is minimally invasive and can be performed under local anesthesia, with same-day or next-day discharge.¹⁷

In conclusion, improvement in patient quality of life is the measure of success for management of SUI. Treatment can be initiated only after a thorough evaluation of the problem and its cause. A detailed medical history should be taken, and a bladder record should be completed, followed by a physical examination, pelvic floor muscle assessment, and urinalysis.¹⁸ Nonsurgical management with behavioral modifications, medication, and medical devices may provide benefit with less significant risks and costs than surgical intervention.

References

Frewen WK. Bladder training in general practice. Practitioner. 1982;226:1847-1849.
Wyman JF. Managing urinary incontinence with bladder training: a case study. J ET Nurs. 1993;20:121-126.
Gray M. Caffeine and urinary continence. J Wound Ostomy Continence Nurs. 2001;28:66-69.
Sampselle CM. Behavioral intervention: the first-line treatment for women with urinary incontinence. Curr Urol Rep. 2003;4:356-361.
Miller J, Kasper C, Sampselle C. Review of muscle physiology with application to pelvic muscle exercise. Urol Nurs. 1994;14:92-97.
Dougherty M, Bishop K, Mooney R, Gimotty P, Williams B. Graded pelvic muscle exercise. Effect on stress urinary incontinence. J Reprod Med. 1993;38:684-691.
Gallo ML, Staskin DR. Cues to action: pelvic floor muscle exercise compliance in women with stress urinary incontinence. Neurourol Urodyn. 1997;16:167-177.
Wilson PD, Borland M. Vaginal cones for the treatment of genuine stress incontinence. Aust N Z J Obstet Gynaecol. 1990;30:157-160.
Elia G, Bergman A. Estrogen effects on the urethra: beneficial effects in women with genuine stress incontinence. Obstet Gynecol Surv. 1993;48:509-517.
Sullivan J, Abrams P. Pharmacological management of incontinence. Eur Urol. 1999;36(suppl 1):89-95.
Norton PA, Zinner NR, Yalcin I, Bump RC; Duloxetine Urinary Incontinence Study Group. Duloxetine versus placebo in the treatment of stress urinary incontinence. Am J Obstet Gynecol. 2002;187:40-48.
Jost W, Marsalek P. Duloxetine: mechanism of action at the lower urinary tract and Onuf's nucleus. Clin Auton Res. 2004;14:220-227.
Dmochowski RR, Miklos JR, Norton PA, Zinner NR, Yalcin I, Bump RC; Duloxetine Urinary Incontinence Study Group. Duloxetine versus placebo for the treatment of North American women with stress urinary incontinence. J Urol. 2003;170(4 pt 1):1259-1263.
Lightner DJ. Review of the available urethral bulking agents. Curr Opin Urol. 2002;12:333-338.
Drouin J, Tessier J, Bertrand PE, Schick E. Burch colposuspension: long-term results and review of published reports. Urology. 1999;54:808-814.
Jeffry L, Deval B, Birsan A, Soriano D, Darai E. Objective and subjective cure rates after tension-free vaginal tape for treatment of urinary incontinence. Urology. 2001;58:702-706.
Ulmsten U, Johnson P, Rezapour M. A three-year follow up of tension free vaginal tape for surgical treatment of female stress urinary incontinence. Br J Obstet Gynaecol. 1999;106:345-350.
Newman DK. Therapeutic strategies for managing stress urinary incontinence in women. Am J Nurs Pract. May 2004(suppl):23-32.