Hormone replacement therapy: The right choice for your patient?

Surgical options for stress incontinence include periurethral injections and sling operations. The former involves injecting a bulking material (such as collagen paste) around the urethra to increase its coaptation (urethral closure). It is a simple, almost painless, outpatient procedure with minimal risks, but results vary. Several procedures may be required to achieve continence, and most patients have recurrent incontinence within 5 years.

In contrast, sling operations have a better success rate. Slings can be made from various materials including the patient’s own fascia, cadaveric fascia, animal materials such as porcine intestinal submucosa, or synthetic mesh. Most materials have good short-term results, with stress incontinence cured or significantly improved for over 90% of patients.¹⁵ Long-term success depends on the sling material used. The risks and duration of hospitalization depend on the specific materials and techniques, but most slings are inserted either as outpatient surgery or with overnight hospitalization.

Urge incontinence. For urge incontinence, pelvic floor muscle exercises are beneficial because contraction of the pelvic floor inhibits the detrusor by a reflex. This is well described in a book for lay people.¹⁶

Anticholinergic drugs are commonly used and are more effective than placebo.^{11, 17}Side effects include dry mouth, constipation, and mental status changes.

Ways to reduce side effects:

1. Sustained-release formulations of oxy-butynin (Ditropan XL) or tolterodine (Detrol LA)
2. Anticholinergics that are more selective for the bladder, such as tolterodine (Detrol)
3. Transdermal oxybutynin (Oxytrol), which decreases the first-pass liver metabolism and minimizes production of metabolites that have side effects of their own
4. Trospium chloride (Sanctura), which does not cross the blood-brain barrier and therefore has less effect on the central nervous system.¹⁸

Interestingly, magnesium supplementation (MgOH, 350 mg twice daily) was effective for urge incontinence in a placebo controlled trial.¹⁹ If conservative treatments fail, the surgical options include sacral nerve stimulation or augmentation cystoplasty. The latter has high morbidity and should be considered only as a last resort for a person with incapacitating incontinence.

Recurrent UTI. For recurrent urinary tract infections, several options are available. Cranberries contain polymeric proanthocyanidins, which inhibit the binding of Escherichia coli to uroepithelial cells. Cranberry juice or cranberry extract tablets were more effective than placebo in the few studies available, but the optimum preparation and dose are unknown.²⁰Also, since the P fimbriae on E coli bind to mannose residues on uroepithelial cells, it is expected that free mannose in the urine might competitively inhibit this binding.

Mannose is sold over the counter as a preventative for urinary tract infections. No published literature supports its use, but it appears harmless.

Another option is methenamine hippurate, which is a urinary tract antiseptic. Controlled trials to date have not proven its efficacy, but adverse events are infrequent.²¹

Antibiotics can also be used as chronic low-dose prophylaxis or intermittent self-start therapy when infection symptoms occur.²² Best for low-dose prophylaxis are antibiotics with minimal adverse effects on the fecal and vaginal flora, such as trimethoprim alone, trimethoprim/sulfamethoxazole, nitrofurantoin, cephalexin (in minimal doses), and fluoroquinolones.²³

Cardiac risk factors

Dr Leong: Mrs JC’s risk factors for heart disease include hypertension, hyperlipidemia, obesity, and family history of CHD. While hormone therapy should not be used to prevent heart disease, there are well-established treatments for hyperlipidemia including diet, exercise, and lipid lowering medications, such as the statins. She should be advised to lose weight. If healthy lifestyle changes do not control her blood pressure, antihypertensive medication would be indicated.

For prevention of osteoporosis, Mrs JC should be advised to start weight-bearing exercise and to include adequate calcium and vitamin D in her diet. Besides estrogen, bisphosphonates, raloxifene, and calcitonin are effective medication for osteoporosis treatment and prevention.

Should the patient be treated with HRT?

Dr Pees: Mrs JC’s family history of CHD does not contraindicate hormonal therapy. But neither is hormonal therapy indicated to prevent CHD. Mrs JC should be strongly urged to begin an exercise program, diet modifications, and possibly the use of statins. Studies support exercise as a significant factor in reducing the risk of CHD and, to a lesser degree, the risk of breast cancer. If, after thorough counseling with reference to WHI risk findings, Mrs JC wishes to remain on or start hormone therapy, she should start on the lowest effective dosage to relieve her vasomotor symptoms. She should also be reevaluated periodically and be kept appraised of new data as they become available.