Stress Urinary Incontinence: An Overview of Diagnosis and Treatment Options
By Herbruck, Lianne F
Giving birth is known to create risk for various degrees of urinary incontinence (UI) at any time after the birth. Environmental and genetic factors predispose many women to pelvic floor disorders. When a woman determines she is incontinent and has approached her provider, she will need an accurate, proper diagnosis and then consider a selected course of treatment. It is imperative that she is informed of all choices so she can choose the treatment with which she is most comfortable, fits her lifestyle, and will improve her quality of life. Key Words: Urinary incontinence, conservative treatment, pelvic floor exercises, Kegel exercises, surgical treatment, tension-free vaginal tape.
Patients and caregivers alike often do not address embarrassing topics during the routine physical examination and history (Kelleher, 2003). The education of patients and an emerging awareness of the need to ask “embarrassing” questions may well be one of the greatest health care and nursing advances over the past decade (Kelleher, 2003). Provider awareness of identifying factors that predispose women to increased risk of urinary incontinence (UI), particularly stress urinary incontinence (SUI) after childbirth, could prove to be significant in helping to alleviate symptoms associated with SUI before they are life-altering (Peeker & Peeker, 2003). The ability to “diagnose” women who may be at risk for SUI by virtue of their presenting risk factors may improve levels of primary treatment, and therefore, many women could begin to engage in preventative measures that reduce their risk for acquiring SUI and its related symptoms.
Diagnosis
UI is common during the antenatal and postpartum periods. Risk factors for UI three months postpartum include higher pre-pregnancy body mass index (BMI), parity, UI during pregnancy, smoking, longer duration of breastfeeding, use of forceps, and vaginal delivery (compared with cesarean delivery). SUI is the type of UI most often associated with the process of pregnancy and birth.
History
The majority of women presenting with symptoms of SUI can be diagnosed and managed conservatively in the primary care setting without referral to a specialist (Culligan & Heit, 2000; Kelleher, 2003; Pantazis & Freeman, 2006; Peeker & Peeker, 2003). Because UI causes are varied, accurate diagnosis requires a detailed history and physical examination (McCool & Durain, 2004; Rovner & Wein, 2004). The health care provider then acts as detective by using clues, along with the symptomology of the woman, to attain adequate diagnosis and treatment. Initial investigation of UI must assess and identify the type, pattern, and severity of incontinence (Culligan & Heit, 2000; Lingam, 2001; Pantazis & Freeman, 2006).
Urinary (or bladder) diaries are excellent tools for assessing the type and severity of UI in the individual (Bernier & Sims, 2009; Culligan & Heit, 2000; Tincello, Williams, Joshi, Assassa, & Abrams, 2007). A study by Tincello et al. (2007) suggests that urinary diaries are best completed over a 3-day time frame, as opposed to the traditional 7-day regimen, to eliminate diary “fatigue” or “despair.” This shorter diary regimen could increase accuracy of symptom reporting, which may improve diagnosis of specific UI type in the individual. It is extremely important for the provider to assess the “bother” of the UI to the client and its effect on her quality of life. The subjective assessment of the impact of UI on the patient’s lifestyle and individual needs are paramount in determining an acceptable course of treatment (Pantazis & Freeman, 2006; Peeker & Peeker, 2003). For example, in a woman who has a desire for future childbearing, surgical correction of SUI is contraindicated until she has completed her family.
A thorough history is important to rule out confounding medical complications, including congestive heart failure, constipation, fluid intake, urinary tract infection (UTI) history, voiding difficulty, prior UI treatments, abdominal surgery, diabetes mellitus, stroke, chronic lung disease, cognitive impairment, drug therapies, pelvic organ prolapse (POP), fecal incontinence, and any medications that may influence UI (Culligan & Heit, 2000; Kelleher, 2003; Pantazis & Freeman, 2006; Wallace & Hooper, 2006; Ward, 2003). Assessment of relevant gynecological history is also important (see Table 1) and should include gravity, parity, number and difficulty of vaginal deliveries (instrument assisted and spontaneous), cesarean section (CS) deliveries, previous hysterectomy, vaginal or bladder surgery, and estrogen status (Culligan & Heit, 2000; Kelleher, 2003).
Physical Examination and Evaluation
Physical assessment of anterior vaginal relaxation (cystocele), as well as urethral detachment and mobility, is critical. Positive urethral hypermobility is suggestive of SUI (Lingam, 2001). Vaginal discharge can mimic UI, especially in obese patients, and use of phenazopyridine (Pyridium(R)) may be necessary to determine if leakage is actually urine (Culligan & Heit, 2000). A midstream urine sample should be sent for culture to rule out infection (Lingam, 2001), and treatment of any present UTI is necessary because UTIs can mimic signs of UI.
Levator ani (LA) muscle function should be evaluated by performance of Kegel exercises (see Figure 1). Women should be able to hold this pelvic floor contraction for 5 to 10 seconds. Women who are unable to hold the contraction may need further evaluation by a specialist. The newly postpartum woman, however, may simply need time to work the muscles of the perineum and should be strongly encouraged to do so, with a follow up in 6 months. If she is still incontinent at that time, she may need a referral. The provider should also observe for signs indicating a potential for increased intra-abdominal pressure issues, including obesity, chronic cough, or abdomino-pelvic mass (Farkas & Radley, 2002).
Widely used clinical measures of pelvic floor dysfunction (PFD) include the pelvic organ prolapse quantification system (POP-Q), the cotton-tipped swab urethral test, and urodynamic testing. These investigational tools measure pelvic support, and urethral mobility and function, and are used to guide therapy for patients with PFD (Trowbridge, Wei, Fenner, Ashton-Miller, & DeLancey, 2007).
The POP-Q was instituted for providers to accurately define the extent of POP (see Figure 2). Using the hymen as a fixed reference point, specific sites are defined in the anterior, posterior, and apical vaginal compartments and measured separately. These measurements are then categorized into an ordinal staging system. The POP-Q staging system has been validated and demonstrates good inter- and intraobserver reliability, and is easily taught to providers (Adam & Duong, 2006; Brolmann, 2004). POP-Q staging adequately addresses the extent of prolapse; however, assumptions about which organ is behind each bulge should be made with caution, and every bulge requires a complete and careful physical pelvic evaluation (Adam & Duong, 2006).
The Q-Tip(R) test is a simple diagnostic tool that assess for hypermobility of the urethrovesical junction, which is common in women (Bernier & Sims, 2009). To perform the QTip test, a sterile, well-lubricated cotton-tipped swab is placed in to the urethra. The patient is then asked to perform a bowel movement or Valsalva strain. Movement of the Q-Tip of more than 30-degrees in the horizontal plane with straining is indicative of urethral hypermobility of the urethrovcesical junction (see Figure 3).
Referral to a specialist may be necessary due to clinical findings, including recurrent UTI, voiding difficulties and bladder pain, failed conservative therapy, POP, and associated gynecological pathology (Kelleher, 2003). Women who demonstrate leakage in the supine position shortly after voiding may be at an increased risk of intrinsic sphincter deficiency, which may preclude conservative treatment measures (Culligan & Heit, 2000).
Role of Urodynamics
Urodynamics is used to help determine precise causes of UI in individual patients (see Table 2). It has been found that SUI symptoms tend to correlate poorly with urodynamic results, so urodynamic evaluation is an excellent diagnostic tool that can help to identify urinary outflow symptom causes. Urodynamic studies in patients with UI also provide greater detail of the lower urinary tract function when deciding course of treatment, possible reasons for failure of prior treatment, or help predicting the outcome of a proposed treatment (Rovner & Wein, 2004). Urodynamic studies are used in cases to prove urethral relaxation in the absence of detrusor activity (Lingam, 2001).
The 2nd International Consultation on Incontinence (ICI) in 2001 provided a review by a panel of experts regarding the performance, indications, and utility of urodynamic investigations. The ICI recommended that the investigation of incontinence symptoms via urodynamic studies in women should be performed when there is suspected voiding difficulty or neuropathy, if nonsurgical or surgical therapy has failed, or when invasive or surgical treatments are being considered (Rovner & Wein, 2004). When urodynamic evaluation is necessary, it should include assessment of bladder pressure, rate of urine flow and post-void residual urine volume determination, and filling cystometry (Carroll, 2009; McCool & Durain, 2004; Rovner & Wein, 2004; Ward, 2003). Non-Surgical Treatment of SUI
In childbearing women, the most common UI complaint is SUI. Conservative treatment for SUI can benefit women and should be offered to patients as a first option (Lingam, 2001). Conservative treatments are especially beneficial in the immediate postpartum period or in women who desire future childbearing (Kelleher, 2003; Peeker & Peeker, 2003). A key factor when beginning treatment may be linked to defining when this physiology becomes pathology. The woman’s subjective impression of her own continence status is critical to this determination (Peeker & Peeker, 2003). Surgical correction is the last step when all others have failed (Wallace & Hooper, 2006).
It is theorized that SUI may actually be a normal physiological state immediately postpartum, and some have suggested that it might be best to let the UI “run its course” in the initial postpartum period, reserving treatments for women who are still incontinent 6 month postpartum (Woldringh, van den Wijngaart, Albers- Heitner, Lycklama a Nijeholt, & Lagro-Janssen, 2007). Engaging earnestly in performance of postpartum pelvic floor exercises (PFEs) may help resolve this physiological state more quickly.
Early interventions include weight loss because a 5% to 10% drop in body weight can improve UI symptoms (Pantazis & Freeman, 2006). Noting the normal physiological drop in weight post-delivery, this initial weight loss may have a great impact on resolving SUI symptoms in the postpartum period. Other conservative measures include PFEs, biofeedback, vaginal cones, electrical stimulation units, and pessaries. Cessation of smoking, restricting fluid intake to 1.5 to 2L per day, and reducing caffeine and alcohol are first steps as well.
If conservative measures fail, use of duloxetine (Cymbalta(R)), which is a selective reuptake inhibitor of serotonin and norepinephrine, may be tried. This drug ultimately may act by stimulating the pudendal nerve, which can improve urethral sphincter closure (Pantazis & Freeman, 2006). If there is no notable improvement, urodynamic studies may be undertaken to confirm presence and type of UI.
Conservative treatments, such as PFEs, may take time to produce results; therefore, support of women during this time is critical (Wallace & Hooper, 2006). When treatments have started, support and encouragement with an optimistic outlook are essential to improving patient compliance with treatments. Reduction in patient compliance and a decrease in motivation to continue PFEs or other conservative measures contribute to poor long-term results (Morkved, Bo, Schei, & Salvesen, 2003; Pantazis & Freeman, 2006; Rovner & Wein, 2004; Sasso, 2006; Wallace & Hooper, 2006). Patients need to understand that they must assume responsibility for their own health outcomes, but being followed by a supportive and sympathetic practitioner can improve patient compliance (Pantazis & Freeman, 2006).
Tampons and Pads
In the absence of other measures, primary treatment is often directed at managing urinary leakage and its effects on clothing, skin, and personal odors. Subak et al. (2006) found nearly three- fourths of women reported purchasing and using pads and/or tampons to control urinary leakage issues. Pads are used simply to absorb urine leakage and protect the clothing. Often a first line of self- treatment, vaginal tampons are simply used as a space-occupying devices that can decrease leakage during periods of increased abdominal pressure, such as when playing sports (Kelleher, 2003, Pantazis & Freeman, 2006; Sasso, 2006). The pressure exerted by the tampon on the urethra is sometimes enough to keep adequate urethral close pressure during these activities, but tampons are not recommended as an adequate or appropriate treatment.
Kegel/Pelvic Floor Exercises
Rehabilitation of the PF muscles is the common goal of treatments, such as Kegel exercises or PFEs. Seventy percent of muscles of the PF are slow-twitch muscle fibers, which assist in muscle endurance with generation of slow and sustained, but lessintense, contractions. The remaining 30% are fast-twitch muscle fibers, which contribute to urethral closure by their contribution of quick and forceful contractions during sudden increases of intra- abdominal pressure (Rovner & Wein, 2004). These muscles are used routinely during urination, though many women are unaware of them (Saunders, 2004). PFEs involve deliberate contraction and relaxation of the pubococcygeous muscle and serve to increase resting tension, contractile force, and recruitment speed of the voluntary sphincter component of the pelvic diaphragm (see Figure 1) (Culligan & Heit, 2000; Saunders, 2004).
Regularly exercising the PF muscles prevents UI in about 1 in 6 women during pregnancy, and in 1 in 8 women after pregnancy. Long- term data are lacking, and further study is indicated to determine long-term effects of PFEs on UI (Salvesen & Morkved, 2004; Wallace & Hooper, 2006). Reports of the success of PFEs and UI range from 30% to 90% (Bernier & Sims, 2009). Further, Sampselle et al. (1998) found that PFEs resulted in a decrease in SUI in both late pregnancy and postpartum.
Up to 38% of motivated patients who follow an exercise regimen provided only as a patient handout for at least three months will experience cure of pure SUI (Culligan & Heit, 2000). However, verbal instructions alone are often insufficient for proper PFE performance. Best results are obtained by intensive, supervised training, where the patient learns proper techniques to increase the strength of PF muscles (Pantazis & Freeman, 2006; Peeker & Peeker, 2003; Wallace & Hooper, 2006; Woldringh et al., 2007). It is best if patients obtain an initial digital assessment by a trained clinical professional to be certain they are using the proper muscles during exercises (Peeker & Peeker, 2003). This does incur cost, which may proclude some women from obtaining adequate first-line measures, such as PFEs, to reduce their SUI symptoms (Kelleher, 2003, Pantazis & Freeman, 2006; Peeker & Peeker, 2003). PFEs need to be performed frequently and must be performed at a certain intensity (Culligan, Blackwell, Murphy, Ziegler, & Heit, 2005; Morkved et al., 2003; Peeker & Peeker, 2003).
Detectable PF muscle hypertrophy and notable SUI improvement may take up to 8 weeks (Pantazis & Freeman, 2006). This can lead to frustration in women who may be expecting more rapid results. However, when performed diligently, Kegel exercises strengthen the pubococcygeal muscle, help resolve SUI, and decrease urgency and frequency (Bernier & Sims, 2009; Zdanuk, 2004). PFEs with or without biofeedback can improve all aspects of functional pelvic muscle control (Sasso, 2006).
Again, although PFEs have been shown to significantly reduce the frequency of UI episodes, long-term data are lacking, and further studies are needed (Wallace & Hooper, 2006). For example, an investigation regarding intensive PFE training both before and after the first vaginal birth and its potential effect on UI protection in the long term is needed. Subsequent pregnancies were not found to be as influential on PFD as the first pregnancy (Altman et al., 2006).
Biofeedback
Biofeedback, when utilized in conjunction with a PFE regimen, is a non-surgical and costeffective method that can decrease or eliminate the embarrassing manifestations associated with UI (Bernier & Sims, 2009; Wetzel, 2004). Through the use of vaginal or anal sensors, biofeedback provides the patient with a visual of contraction strength and activity. This helps women identify and isolate the proper muscles to contract, as well as determine the adequate contraction strength of those muscles to attain greatest benefits (Bernier & Sims, 2009; Rovner & Wein, 2004).
Function of the LA muscle should be evaluated during performance of a Kegel contraction. Weak or absent LA contraction may indicate the need for biofeedback with a PF physical therapist (Culligan & Heit, 2000). PF reeducation with biofeedback helps patients learn to reuse PF musculature and can eliminate UI in 54% to 77% of patients who use it (Bernier & Sims, 2009). Biofeedback can enhance women’s ability to exercise various muscles of the pelvic floor, thereby strengthening them and preventing urinary leakage (Wetzel, 2004).
Vaginal Cones and the Colpexin(TM) Sphere
Vaginal cones are pre-weighted devices of varying weights that are held by the vaginal musculature and are thought to help improve PF tone through active and sustained muscle contraction (Rovner & Wein, 2004). The improvement in tone is directly related to the weight of the cone. The heavier the vaginal cone the woman is able to retain during training, the greater the improvement in vaginal muscle tone, and ultimately, SUI (Culligan & Heit, 2000; Peeker & Peeker, 2003).
Much like the vaginal cones, the Colpexin(TM) Sphere is an intravaginal device that provides support for the PF musculature. It consists of a polycarbonate sphere with attached string. The Colpexin Sphere has the ability to elevate prolapse defects, thereby facilitating proper performance of PFEs (Sasso, 2006). Counseling is necessary, similar to that with PFEs, for the patient to learn to contract the proper muscles (Sasso, 2006). A study by Lukban, Aguirre, Davila, and Sand (2006) evaluated 39 (27 completed the study) women suffering from POP who used the Colpexin Sphere throughout the day and night. PF function was assessed at initial visit, and after 5, 12, and 16 weeks of use. The women also completed bladder diaries on three consecutive days before each study visit. After the final evaluation, 75% of the women with UI prior to the start of the study had improvement in UI symptoms.
Appropriate candidates for the Colpexin Sphere would be women who prefer a conservative approach to their UI and POP management and who are motivated to perform regular PFEs to rehabilitate their PF muscles (Sasso, 2006). The Colpexin Sphere enhances the effects of established conservative therapy by actively facilitating performance of PFEs (Sasso, 2006). Electrical Stimulation Units
Electrical stimulation units (ESUs) can be used to inhibit the micturition reflex and contract PF muscles. The fast motor units of the paraurethral PF muscles are thought to provide most of the urethral closing force (Rovner & Wein, 2004). Using a vaginal or anal probe, ESUs provide an artificial electrical stimulation of the PF to stimulate these nerves and produce a contraction of the LA muscles (Culligan & Heit, 2000; Peeker & Peeker, 2003). It has been theorized that low-level electrical currents might stimulate re- innervation of the PF, or that it might produce or effect a change in the ratio of slow-tofast- twitch muscle fibers.
A study by Sand et al. (1995) found that twice-daily electrical stimulation decreased involuntary urine leakage and concluded that ESUs may be an effective and feasible treatment. They also speculated that up to 75% of women with surgical referrals may not need surgery after treatment with ESUs, as patients may be free enough from their symptoms post-treatment. ESU treatment is less costly than surgical intervention. However, ESU treatment is a time- consuming procedure, and because PFEs have been shown to be equally effective, the cost issue alone may prevent women from considering its use (Sand et al., 1995).
When PFE treatment is a viable option, it may be the better first- line treatment choice. However, if women prefer an option other than surgery but are unable to effectively perform PFEs, ESUs may be a less-invasive first-line option for them (Peeker & Peeker, 2003). To date, there have been no comparative studies of the 3 modalities – PFEs, ESUs, and vaginal cones – or their concurrent use. More studies are needed to determine the usefulness of ESU treatment, although it is a treatment modality that has been used for close to three decades (Peeker & Peeker, 2003).
Pessaries
Vaginal pessaries have been used for centuries to treat POP, UI, and PFD. Traditional use of the pessary was to improve POP in the absence of surgery. Pessaries have the potential to reduce, and even reverse, the degree of POP after one year of management, and their use is associated with significant improvement in urinary and defecatory symptoms (Fernando, Thakar, Sultan, Shah, & Jones, 2006; McIntosh, 2005; Rovner & Wein, 2004). Although they can be used in the primary care setting, pessaries are not often used as first- line treatment options because many providers and patients view them as inconvenient (Fernando et al., 2006; McIntosh, 2005). Nurses are ideal instructors for patients presenting pessary use for reduction of their PFD and UI symptoms because they often are the first contact patients have in a clinic and can adequately educate proper use and benefits of the pessary (Bernier & Sims, 2009; Herbruck, 2009).
Certain types of vaginal pessaries can reduce SUI by supporting the bladder neck at the urogenital angle. Pessaries also can be fitted with an incontinence ring. Women with pre-existing UI and POP are more likely to consistently use the device if the pessary selected alleviates symptoms associated with their UI as well (Bernier & Sims, 2009; Herbruck, 2009; McIntosh, 2005). When pessaries are used specifically to correct prolapse, they may unmask occult SUI (Vimplis & Hooper, 2005). Pessaries may also uncover latent SUI in patients awaiting surgical correction of other urogenital issues, which may be a helpful finding for the post- surgical recovery plan (McIntosh, 2005).
A trained professional in the clinical setting must properly fit pessaries. A properly fitted pessary can prevent urine loss during vigorous coughing in a standing position with a full bladder (Culligan & Heit, 2000; McCool & Durain, 2004; McIntosh, 2005). Pessaries can be used to treat women who are poor surgical candidates, as a temporary measure for women awaiting surgery, or for women who anticipate further childbearing (Fernando et al., 2006, McIntosh, 2005). Older patients tend to choose a pessary over surgical correction (Brolmann, 2004; McIntosh, 2005). Women who use pessaries should be able to remove the device to clean it, and they should visit their care provider regularly for vaginal inspection of irritation or infection (Bernier & Sims, 2009; Herbruck, 2009).
Common complaints with pessary use include discharge and odor. Some women also may experience pelvic pain, bleeding, UI development, and failure of the pessary to be retained or hold the prolapse (McIntosh, 2005). Fernando et al. (2006) found that prior hysterectomy and increased parity were found to be significantly associated with failure of women to retain a pessary. Follow-up care is necessary to ensure appropriate use, to minimize the associated complications, and to reinforce patient education, all of which are vital for success (McIntosh, 2005). Pessaries are a safe, effective treatment for SUI and a conservative measure that should be available to all women seeking an alternative to surgical management (McIntosh, 2005).
Estrogen
Reduction of estrogen after menopause causes significant atrophic changes in the genital tract, which can lead to itching, burning, dryness, and dyspareunia. Co-existent symptoms include urinary frequency, urgency, UI, and recurrent urinary tract infections (Kim & Chancellor, 2006; Steinauer et al., 2005). Previously, hormone replacement therapy (HRT) was credited with many benefits well beyond its indications for symptomatic relief of hot flashes, night sweats, and vaginal dryness. Improvement of UI was one of the well- known benefits of HRT in urology practice (Kim & Chancellor, 2006).
The role of estrogen as an effective therapy for UI in women is debatable and has produced mixed findings, both beneficial and harmful (Kelleher, 2003; Romanzi, 2002; Kim & Chancellor, 2006). The lower urinary tract shares a common embryologic origin with the genital tract and the urogenital sinus, and estrogen and progesterone receptors are present in the vaginal epithelium, urethra, and bladder trigone, making it reasonable to assume that localized estrogen replacement therapy could be a possible treatment for SUI (Bernier & Sims, 2009; Culligan & Heit, 2000; Rovner & Wein, 2004). However, studies have not supported the general use of estrogen to improve symptoms of SUI (Chancellor, 2000).
There is evidence that local application of estrogen may benefit women with sensory urgency from atrophic genital changes. Theories suggest that vascular and loose connective tissue begin to replace collagen, which results in poor urethral support. This, combined with higher pressures in the bladder and a weaker supportive urethral architecture, may promote incontinence (Steinauer et al., 2005).
Local estrogen application may affect the genital tissues by improving cellular maturation of the urethra, increasing urethral blood flow and engorgement of the periurethral blood supply, improving urethral closure pressure and length, and increasing mucosal thickness in postmenopausal women (Culligan & Heit, 2000; Kelleher, 2003; Steinauer et al., 2005). Localized estrogen has the potential to increase circulation in the urogential area, thereby improving functioning of the lower urogential system. It can be given as a localized estrogen cream or an estradiol-impregnated vaginal ring (Bernier & Sims, 2009; Culligan & Heit, 2000; Lowdermilk, 2004; Rovner & Wein, 2004). Estrogen in the form of a topical cream or vaginal ring may help older women with vaginal atrophy and symptoms of overactive bladder. This has proven more effective than systemic estrogen when there are atrophic vaginal changes (Moore, 2001; Pantazis & Freeman, 2006).
Recently, however, studies have shown effects of estrogen on UI that are to the contrary. The Women’s Health Initiative (WHI) and the Nurses Health Study have both shown that the use of estrogen plus progestin or estrogen alone may actually contribute to increases in UI (Steinauer et al., 2005). Although estrogenic compounds show a positive effect on pelvic organ support, they have a negative relation to urethral function and UI (Romanzi, 2002). Within 4 months of starting hormone therapy, women showed 50% higher odds of urge urinary incontinence (UUI), and 70% higher odds of SUI, with the increased risk persisting for the duration of oral hormone use (Steinauer et al., 2005).
Using the WHI’s multicenter double-blind, placebo-controlled, randomized clinical trials of menopausal hormone therapy, Hendrix et al. (2005) reviewed 23,296 post-menopausal women (aged 50 to 79 years) enrolled in the study between 1993 and 1998. All women’s UI symptoms were known at baseline and at one year. Using data from this cohort, they found that menopausal hormone therapy increased the incidence of all types of UI at one year among women who were continent at baseline, with the risk for SUI the highest. Conjugated equine estrogen (CEE) alone and CEE plus medroxyprogesterone acetate (MPA) increased the risk of UI among continent women and worsened the characteristics of UI among symptomatic women after one year. The study recommended that CEE with or without MPA should not be prescribed for the prevention or relief of UI (Hendrix et al., 2005).
HRT has long been used to improve various post-menopausal symptoms. In the National Institutes of Health (NIH) women’s heart study, it has been shown that HRT increases the risk of stroke. This would, in itself, bring its use into question for UI therapy (Kim & Chancellor, 2006; U.S, Department of Health and Human Services, National Institutes of Health [NIH], 2008).
Other Pharmacological Measures
Sometimes pharmacological methods are used when conservative or behavioral methods alone do not work, but providers often offer them as the first-line of treatment. Medications for UI treatment are diagnosis specific (Bernier & Sims, 2009). Most of the drugs used to treat incontinence are intended for treatment of UUI or overactive bladder symptoms and include anticholinergic agents such as oxybutynin (Ditropan(R)) and tolterodine (Detrol(R)), and tricylic antidepressants such as amitriptyline (Elavil(R)) and imipramine (Tofranil(R)). In 2004, duloxetine (Cymbalta(R), Yentreve(R)), was approved in Europe for treatment of SUI. It is also prescribed for treatment of depression, anxiety, and diabetic neuropathy. Duloxetine, which increases urethral resistance, is a serotonin reuptake inhibitor that can help treat SUI by stimulating the pudendal nerve via the sacral cord motor nucleus. This action enhances the closure of the external urethral sphincter (Rovner & Wein, 2004). Maximal effect usually takes place after 4 weeks of treatment (Wallace & Hooper, 2006). When combined with PFEs, it is shown to be significantly better than placebo treatment (Pantazis & Freeman, 2006). Nausea is a side effect, but this is often self- limiting and ceases after one month in 80% of women (Pantazis & Freeman, 2006; Wallace & Hooper, 2006).
Injectable Agents
Bulking agents can be injected via a minimally invasive procedure to increase the size of the tissue surrounding the urethra, which promotes more effective urethral closure. Bulking agents, such as autologous fat, bovine collagen, silicone, and dextranomer/ hyaluronic acid (Dx/HA), are injected at the bladder neck just under the urothelium or in the periurethral space (Culligan & Heit, 2000; Pantazis & Freeman, 2006; Wallace & Hooper, 2006). Autologous fat and collagen have very low long-term success rates, and subsequent injections have a higher failure rate. Silicone has a higher success rate both short term (68% to 75%) and long term (48% to 72%) (Bombieri & Freeman, 2003).
Patients who may be well suited for this treatment modality include older adults who are not good surgical candidates and who do not desire or cannot use more conservative measures, such as a pessary (Kelleher, 2003; Pantazis & Freeman, 2006; Wallace & Hooper, 2006). Although these procedures can be performed in the office, they commonly require multiple treatment sessions to achieve cure because short-term cure rates are low (Bombieri & Freeman, 2003; Culligan & Heit, 2000; Kelleher, 2003; Pantazis & Freeman, 2006; Wallace & Hooper, 2006). Bulking agents may be used to provide temporary relief for women until surgery can be performed, or they may be a shortterm solution for women who must postpone surgical correction until childbearing is completed (Wallace & Hooper, 2006). Further studies on short and long-term results are needed as newer bulking agents become available.
Surgery
When conservative therapies and other less-invasive measures fail, surgery is often the treatment of choice for women with SUI, providing they have completed their childbearing (Waetjen et al., 2003). Eleven percent of women will require surgery for PFDs in their lifetime (Bradley, Zimmerman, & Nygaard, 2007; Farkas & Radley, 2002; Handa et al., 2003; Lukacz, Lawrence, Contreras, Nager, & Luber, 2006). Caucasian women have a surgical rate for SUI that is nearly five times that of African-American women. African- American women report greater use of routine care (such as pads) and would be willing to pay more for relief (Waetjen et al., 2003).
Surgical treatment of SUI in women strives to improve urethral resistance to prevent urine leakage while preserving voluntary and complete bladder emptying (Rovner & Wein, 2004). Surgical correction results of SUI vary, and complications, including post-surgical SUI recurrence, voiding difficulties, de novo detrusor instability, surgical failure, fistula, and POP, can occur (Bombieri & Freeman, 2003; McCool & Durain, 2004; Rovner & Wein, 2004; Ward, 2003). De novo UI is a type of UUI often revealed after SUI surgery that may be a result from the surgery itself or from an existing, but asymptomatic, urgency component that is unmasked after treatment of SUI (Peeker & Peeker, 2003).
Bladder neck surgery alone places women at risk for voiding difficulties, including overactive bladder, bladder injury, bleeding, and posterior vaginal wall collapse, and these voiding difficulties may become permanent in someone who complains of hesitancy, straining to void, or incomplete emptying prior to surgery (Kelleher, 2003; Ward, 2003). Vaginal delivery is contraindicated after surgical intervention for SUI (Wallace & Hooper, 2006).
It is inadvisable to perform SUI surgery without thorough urodynamic evaluation (Ward, 2003). A full understanding of the type of UI being “cured” and what underlying UI may be unmasked are critical factors. Secondary repairs are more complex and place women at further risk for complications (Rovner & Wein, 2004; Ward, 2003). Prior to choosing the type of surgery to be performed, women must be examined for coexisting medical factors, such as POP, gynecological pathology, signs of urogenital atrophy, and other confounding factors that present in concordance with SUI (obesity, increased age, desire for children). These factors may increase the risk of complications and poor surgical outcomes (Bombieri & Freeman, 2003). Confounding factors can help define optimal surgical techniques to obtain the best outcomes for the patient. Between the years 1988 and 1998, incontinence surgeries increased by 45%, and in 1998, 68% of surgeries for SUI were done concordant with another pelvic surgery, such as POP procedure or hysterectomy, with an average hospital stay of 2.8 days (Waetjen et al., 2003).
The Burch colposuspension is often referred to as the “gold standard” of SUI surgical treatments (Harding & Thorpe, 2008; Pantazis & Freeman, 2006). This procedure strives to treat SUI by elevating the bladder neck and the urethra in a retropubic position and restoring the urethrovesical junction (Pantazis & Freeman, 2006; Rovner & Wein, 2004). Although the gold standard, its disadvantage is that the urethra is not fully supported, which may result in angulation of the vagina, increasing further risks of developing retrocele, enterocele, or vault proplase (in 30% of women) (Bombieri & Freeman, 2003; Pantazis & Freeman, 2006; Ward & Hilton, 2008). Eighty-five percent of women are still continent one year after colposuspension, and 82% are still continent at the 5- year mark. Long-term studies beyond 5 years have shown success rates between 70% to 90% (Bombieri & Freeman, 2003).
Sling procedures involve placement of material (autologous fascia, vaginal wall tissue, xenograft tissues, and synthetic materials) beneath the urethra to elevate it and increase urethral compression (Harding & Thorpe, 2008). This procedure is often used for intrinsic sphincter deficiency, a severe form of SUI (Bernier & Sims, 2009; Rovner & Wein, 2004).
The tension-free vaginal tape (TVT) procedure, introduced in the 1990s, is a minimally invasive, suburethral sling, and it is the most common treatment of SUI in women. It has been proven to be as effective as open colposuspension (Bombieri & Freeman, 2003; Deffieux et al., 2007; Harding & Thorpe, 2008; Laurikainen et al., 2007; Ward & Hilton, 2008). With placement at the mid-urethra, TVT may provide relief of SUI by reducing urethral mobility or producing a kink in the urethra during increases in intra-abdominal pressure (Rovner & Wein, 2004).
TVT procedures have been shown to cause less postoperative morbidity while achieving long-term success rates greater then 86% (Bombieri & Freeman, 2003; Culligan & Heit, 2000; Deffieux et al., 2007; Laurikainen et al., 2007; Ward & Hilton, 2008). TVT is associated with less pain, shorter operative time, fewer postoperative complications, and a quicker recovery (Kelleher, 2003; Pantazis & Freeman, 2006; Rovner & Wein, 2004; Wallace & Hooper, 2006). Complications include injury to pelvic organs, bowel or bladder perforations, obturator nerve injury, and tape erosion (longterm) (Bombieri & Freeman, 2003; Harding & Thorpe, 2008; Laurikainen et al., 2007, Rovner & Wein, 2004). Five and 6-year follow up studies have confirmed persistence of good results with TVT, including improvement in quality of life (Deffieux et al., 2007; Ward & Hilton, 2008).
One potentially negative aspect of the success and decreased morbidity associated with the minimally invasive TVT surgical procedure may be that physicians will recommend the TVT procedure as firstline treatment before trying less expensive and often equally beneficial conservative treatment options for treatment of SUI (Kelleher, 2003).
Conclusion
By using known risk factors for PFD and SUI in women, specifically for nerve damage during delivery (such as babies with large birth-weight and prolonged second-stage labor), providers can have “red flags” to determine which patients may be at heightened risk of SUI development. Providers can then focus on these women with more intensive follow up and may begin early training for PF muscles as a preventative measure (Peeker & Peeker, 2003).
It is imperative to obtain an accurate diagnosis of the UI type before discussing treatment options. Then, it is necessary to provide each patient with the choices that are best suited for treatment of her specific UI. Time should be allowed for questions so the patient can make the best decision. Conservative measures are often all that are needed, provided that the patient understands how to utilize or perform measures correctly. A lack of the basic understanding of the natural mechanisms involved in PFD, UI, and their implications has impeded progress in finding the most adequate SUI treatment (see Table 3). The challenge is to assist patients in finding the treatment option most acceptable to them and that offers the greatest improvement in their quality of life. Providers need to be especially sensitive to and aware of the needs of women with SUI who still desire future childbearing. Subak et al. (2006) found that women with UI perceive substantial benefits simply from a reduction in the number of UI episodes, and the majority of women with UI are willing to pay for UI treatments. According to the study, women indicated a willingness to pay $40 a month for 50% improvement, and over $70 a month for a cure of UI (Subak et al., 2006). The women’s willingness to pay for improvement exceeded routine care costs by 3 to 7 times, suggesting that effective UI treatment, not simply symptom management, may be beneficial economically as well as to the overall quality of life of UI sufferers.
Every woman’s experience with childbirth and its sequela, including possible development of SUI and PFD, is individual. Each woman will have a tolerance level that is different from the next, and each will have a preference regarding best treatment options (see Figure 4). As providers address individual urinary issues and their appropriate treatments successfully, the quality of life for the childbearing woman suffering from SUI will be drastically improved.
Urologic Nursing Editorial Board Statements of Disclosure
Christine Bradway, PhD, RN, disclosed that she is on the Consulting Board for Boehringer Ingelheim Pharmaceuticals, Inc.
Kaye K. Gaines, MS, ARNP, CUNP, disclosed that she is on the Speakers’ Bureau for Pfizer, Inc., and Novartis Oncology.
Susanne A. Quallich, ANP,BC, NP-C, CUNP, disclosed that she is on the Consultants’ Bureau for Coloplast.
All other Urologic Nursing Editorial Board members reported no actual or potential conflict of interest in relation to this continuing nursing education article.
Figure 1.
Proper Performance of Kegel Exercises for Pelvic Floor Muscle Training
Kegel exercises are performed to strengthen the muscles of the PF to help increase support of the bladder and urethra. They also can be used postpartum to facilitate circulation to the perineum, which promotes faster healing and increases PF muscle tone.
Have the woman contract the muscles in the perineum/pelvic floor as if she is trying to prevent passage of intestinal gas. (The old adage of “stopping the flow of urine” can actually encourage urine retention and cause dysfunction of the micturition reflex.)
She should feel the muscles draw upward and inward.
She should avoid straining or bearing-down motions while performing the contractions. (This can be avoided by exhaling gently with an open mouth as she contracts the muscles.)
Contractions should be intense, but should not involve abdomen, thighs, or buttocks.
The woman should be able to hold this contraction for 5 to 10 seconds, but may need to work up to that.
The woman should rest for 10 seconds between contractions.
Kegels should be performed at least 10 times, 3 times a day, or from 30 to 80 times a day.
Sources: Bernier & Sims (2009); Culligan & Heit (2000); Herbruck (2009); Varney et al. (2004); Zdanuk (2004).
Figure 2.
Pelvic Organ Prolapse Quantification (POP-Q) System
Stage 0 No prolapse (the apex can descend as far as 2 cm relative to the total vaginal length).
Stage 1 The most distal portion of the prolapse descends to a point greater than 1 cm above the hymen.
Stage 2 Maximal extent of the prolapse is within 1 cm of the hymen (outside or inside the vagina).
Stage 3 Prolapse extends more than 1 cm beyond the hymen but no more than within 2 cm of the total vaginal length.
Stage 4 Complete eversion, or extension to within 2 cm of the total vaginal length.
The majority of women presenting with symptoms of SUI can be diagnosed and managed conservatively in the primary care setting without referral to a specialist.
Regularly exercising the PF muscles prevents UI in about 1 in 6 women during pregnancy, and in 1 in 8 women after pregnancy.
Figure 4.
Characteristics of the “Perfect” Therapy for Stress Urinary Incontinence
* 100% Effective
* Durable
* Permanent, if desired
* Reversible, if desired
* Simple, quick, and easy for the patient to perform
* Easy for the provider to implement
* Minimally invasive
* Applicable to all types of SUI
* Effective for all types of SUI
* Low complication risk
* Low morbidity
* Quick recovery, if applicable
* Inexpensive for the patient and health care system overall
* Widely available
* Does not affect childbearing capacity
Source: Adapted from Rovner & Wein (2004).
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Lianne F. Herbruck, MSN, RN, CNM, is a Certified Nurse Midwife, Cleveland, OH.
Note: Objectives and CNE Evaluation Form appear on page 199.
Note: The author reported no actual or potential conflict of interest in relation to this continuing nursing education article.
Copyright Anthony J. Jannetti, Inc. Jun 2008
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