Clinical Review

Stress urinary incontinence: A closer look at nonsurgical therapies

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This pervasive condition has spawned a host of treatments, from conservative measures like pelvic floor rehabilitation to cutting-edge modalities such as radiofrequency therapy. In this discussion, a panel of experts compares the less invasive options and offers pearls on evaluating and counseling patients and selecting appropriate treatments.


 

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OUR PANELISTS
  • Peter K. Sand, MD, moderator of this discussion, is professor of obstetrics and gynecology at the Feinberg School of Medicine, Northwestern University, Evanston, Ill.
  • G. Willy Davila, MD, is chairman, department of gynecology, Cleveland Clinic Florida, Weston, Fla.
  • Karl Luber, MD, is assistant clinical professor, division of female pelvic medicine and reconstructive surgery, University of California School of Medicine, San Diego, and director of the female continence program at Kaiser Permanente, San Diego.
  • Deborah L. Myers, MD, is associate professor of obstetrics and gynecology, Brown University School of Medicine, Providence, RI.

We know what it is: The involuntary loss of urine during activities that increase intra-abdominal pressure. And we know what it isn’t: Rare. We even know how to treat stress incontinence, since it affects women of all ages and generally can be attributed to urethral hypermobility and/or intrinsic sphincter deficiency. But are we upto-date on all the management options, both tried and true and brand new? To address this question, OBG Management convened a panel of expert urogynecologists. Their focus was conservative therapies.

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SAND: We are fortunate to have a number of very effective nonsurgical treatments for stress urinary incontinence (SUI). Why don’t we begin by laying out the full complement of options? Dr. Davila, when a premenopausal woman presents to your center with SUI, what therapies do you offer if she is waiting to complete childbearing? And how do you counsel her?

DAVILA: We first try to determine what effect the incontinence is having so we can develop a suitable treatment plan. For example, if the patient leaks urine with minimal exercise, it may be more difficult to treat her than a woman who leaks only with significant exertion. It also may be more difficult to treat SUI in a woman for whom exercise is very important, compared with someone who exercises sporadically.

Fortunately, with the current options, it isn’t necessary to do a full urodynamic evaluation and spend a lot of time and energy assessing the patient. We take a history in which we focus on behavioral patterns, looking especially at fluid intake. A high caffeine intake is particularly telling. Then we look at voiding patterns to make sure the patient is urinating regularly. A bladder diary is typically very helpful for that—and it doesn’t need to be a full 7-day diary; a 3-day diary should suffice. If the patient is going to be treated nonsurgically, completion of a diary has significant educational value regarding fluid intake and voiding patterns.

Once we have assessed behavioral patterns, we do a physical exam to evaluate the neuromuscular integrity of the pelvis. If the patient has good pelvic tone—with minimal prolapse and the ability to perform an effective Kegel contraction of the pelvic floor muscles—she should do very well with physiotherapeutic or conservative means of enhancing pelvic floor strength. So behaviormodification strategies work very well for patients with mild stress incontinence. We typically begin with a trial of biofeedbackguided or self-directed pelvic floor exercises.

Patients with significant prolapse who leak very easily don’t do as well with simple conservative therapies. Examples include a woman whose empty-bladder stress test suggests severe degrees of sphincteric incontinence with urinary leakage and patients who cannot contract their pelvic floor muscles—some women are simply unable to identify these muscles. Those are the patients we tend to test more extensively.

SAND: Dr. Myers, how do you treat these patients?

MYERS: A lot depends on physical exam findings. For example, for a cystocele, a vaginal continence ring may be useful.

If there is excellent support but the Kegel contractions are weak, I would probably look to pelvic floor therapy, which includes biofeedback, electrical stimulation, and other means of strengthening the pelvic floor muscles.

In addition, a number of medications can improve urethral resistance, and simple interventions such as limiting fluid intake and altering behavioral patterns are also useful.

I often will use multiple modalities. Basically, I do everything I can if the patient wants to avoid surgery because of future childbearing.

SAND: Dr. Luber, are your practice patterns different?

LUBER: The emphasis on medical interventions is entirely appropriate. Few things are as satisfying as helping a patient improve without surgery, especially when she expresses concerns about the need for an operation.

I believe in offering the patient a menu of nonsurgical choices. Women are often badly informed about their options, and I like to take some time to educate them once the basic evaluation is complete. Sometimes that can be difficult, but it is extremely helpful to take 5 or 10 minutes to thoroughly explain the cause of the incontinence, using diagrams if necessary. This gives them a better understanding of the nonsurgical approach.

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