Stress Urinary Incontinence in Women: Diagnosis and Medical Management

Mark Deutchman, MDMedical Writer: Meghan Wulster-Radcliffe, PhD

Disclosures
In This Article

Treatment

If the history and physical exam identify an underlying cause such as urinary tract infection or fecal impaction, the patient should be treated accordingly and followed up to determine whether symptoms have resolved. If medications result in intolerable side effects, substitutions can be made or dosages reduced, if possible. A trial of topical estrogen may be of benefit for younger postpartum women or for peri- and postmenopausal women who may be estrogen deficient.

After underlying causes are ruled out or treated, most women with incontinence will have symptoms suggesting the stress or the mixed type. Management falls into these general categories:

  • Behavioral

  • Mechanical

  • Pharmacologic

  • Surgical

Behavioral therapy includes bladder retraining and biofeedback, particularly for those with overactive bladder. Pelvic floor muscle exercises (Kegel exercises) are used to rehabilitate and strengthen the pelvic floor muscles and promote urine storage. Compliance is often poor, but results have been favorable for motivated patients who receive proper clinical training and assessment and who repeat contractions several times a day for at least 3 months.[18,19] Patients must be properly instructed in Kegel exercises. Some patients incorrectly perform a "bearing down" effort, which will actually make their SUI worse. Perhaps the most effective way to instruct a woman in the proper performance of pelvic floor exercise is during the physical examination. The examiner's fingers are placed within the vagina and the patient is asked to squeeze the pelvic muscles around them as if trying to hold back urine or stool. This squeeze should be held for about 10 seconds, then released for 10 seconds. The woman should be asked to perform the same type of squeeze at home 10 times in a row, 3 to 4 times per day. Patient instructions for performing Kegel exercises are available for download from the American Academy of Family Physicians (AAFP) at http://familydoctor.org/handouts/642.html.[20]

Nonsurgical mechanical treatments include pessaries to elevate the vesico-urethral angle, urethral occlusive devices, and use of weighted vaginal cones to provide sensory feedback during pelvic floor muscle exercise. Although these devices have demonstrated efficacy and tolerability in clinical studies, patient acceptance has not been sufficient for commercial success. The lack of acceptance has been associated with difficulties in inserting and removing these devices, physical discomfort, and cost.[19]

Anticholinergics and alpha-adrenergics have been suggested for off-label treatment of SUI ( Table 5 ). An anticholinergic effect on the smooth muscle of the urethra has not been documented, however. In addition, alpha-adrenergic agents such as pseudoephedrine and tricyclic agents such as imipramine do not constitute effective treatment for most SUI patients.[21]

An understanding of the physiology of bladder filling, emptying, and control under stress suggests that unlike anticholinergics, selective inhibition of serotonin and norepinephrine reuptake can help control SUI.[22] This physiology is illustrated in Figures 1 and 2.

The physiology of bladder filling and of the guarding reflex.

The physiology of bladder emptying.

Recently, a new selective serotonin and norepinephrine reuptake inhibitor, duloxetine, has demonstrated efficacy in phase 2 and phase 3 trials[23,24,25,26] and has been approved throughout the European Union for the treatment of SUI. As of November 2005, duloxetine has not been approved for use in the treatment of SUI in the United States. The mechanism of action of this new agent is presumed to be via Onuf's nucleus in the sacral spinal cord.[24] Pudendal motor neurons located in Onuf's nucleus regulate the urethral striated muscle sphincter, and Onuf's nucleus has a high density of norepinephrine and serotonin receptors. Norephinephrine and serotonin stimulate these neurons, causing an increase in the strength of urethral sphincter contractions. Duloxetine blocks the reuptake of norepinephrine and serotonin, increasing pudendal nerve activity and sphincter muscle tone.[27]

In an integrated analysis of 4 randomized, controlled, clinical trials including 1913 women with SUI, duloxetine significantly decreased the median incontinence episode frequency by 51.5%, compared with a 33.3% reduction in the placebo group.[28] Among the patients taking duloxetine, those with more severe symptoms experienced greater benefit. The main adverse event, which led to a discontinuation rate of 5% among 958 patients taking the 40- to 80-mg dose, was nausea; the placebo discontinuation rate among 955 patients was 0.3%.[29]

If behavioral and pharmacologic treatments fail, surgical therapy is possible.[30] Some of the most common surgical options are listed in Table 6 .

Despite its frequency and potential significant impact on quality of life, patients often under-report SUI. They may be embarrassed, they may consider incontinence a normal part of aging, they may fear surgery, or they may not know about medical management options.[31] For these reasons, it is important for physicians to inquire about incontinence. A downloadable patient information resource is available from AAFP at http://familydoctor.org/healthfacts/189/.[32]

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