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Female stress urinary incontinence: an evidence-based, case study approach.

Over half of all women are affected by urinary Incontinence at some point during their lives. Due to patients' embarrassment and health care providers' reluctance to discuss this sensitive subject, many women may go untreated, and in turn, suffer with disruptive symptoms and co-morbid complications associated with urinary incontinence. This article highlights a literature review of the evaluation and management of female stress urinary incontinence using a corresponding case study example. Increasing awareness and implementing evidence-based, nonsurgical treatment options are essential components of high-quality care for women with stress urinary incontinence. Urologic nurses and other health care professionals are in an ideal position to evaluate and identify strategies for the treatment of female stress urinary incontinence.

Key Words: Stress urinary incontinence, pessary, pelvic floor physical therapy (PFMT), estrogen.

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Urinary incontinence (UI) is a common medical problem that affects numerous women throughout the United States. Nearly 50% of women suffer from some form of UI during their lifetime, which can have a significant impact on a woman's quality of life (Melville, Katon, Delaney, & Newton, 2005). Social, psychosocial, physical and sexual health can all be compromised for incontinent women. UI can result in a disruption of social relationships (Dugan et al., 2000), and women with UI are shown to have higher rates of depression and social isolation than those without UI (Fultz & Herzog, 2001). Psychological distress can occur because of the embarrassment, anxiety, or de creased self-esteem associated with the incontinent episodes (Dugan et al., 2001). In severe cases of UI, hospitalization may occur as a result of skin ulcers, infection, or falls (Magon, Kalra, Malik, & Chauhan, 2011). Lastly, UI may also contribute to sexual dysfunction due to urinary leakage with intercourse (Barber, Dowsett, Mullen, & Viktrup, 2005).

Not only does this common medical problem cause personal difficulty for the female patient, it is also quite costly to the American health care system. The estimated annual cost per patient is $750, which includes routine care items for incontinence, such as peripads and laundry (Subak et al., 2008). This personal cost translates into a societal cost of $12 billion to $20 billion annually when including medical treatment, nursing home admissions, and complications associated with UI (Chong, Khan, & Anger, 2011; Subak et al., 2008).

The prevalence of UI and its significant impact on women's lives is substantial. The consequences of UI are numerous and can affect patients' health and quality of life on many levels. It is imperative that health care providers become knowledgeable on the evaluation of female UI so they may better serve their patient population. In addition, increasing provider awareness on the non-surgical, evidence-based treatment options existing for stress UI will significantly improve the quality of life for many suffering women (Melville et al., 2005).

Case Study

A hypothetical case was developed based on the authors' experience and clinical expertise.

Initial Presentation
   A 47-year-old para 3 Caucasian,
   mildly obese female
   presents to her health care
   provider with a complaint of
   urinary leakage. She describes
   progressively worsening
   UI for the past seven
   years. She indicates she has
   experienced UI occurring
   with forceful coughing and
   sneezing for several years;
   however, in the past year, she
   has had a number of respiratory
   infections that have
   exacerbated the condition.
   She is now wearing minipads
   on a daily basis. The patient
   has also noticed a worsening
   in her incontinence symptoms
   and vaginal dryness as
   she has progressed into
   perimenopause. She indicates
   that urinary leakage
   will occur daily with coughing,
   sneezing, straining, and
   occasional changes in position.
   The patient denies urinary
   urgency unless she has
   a very full bladder. She voids
   every three to four hours and
   experiences nocturia one
   time nightly. She ingests four
   to five sources of caffeine per
   day and smokes 10 cigarettes
   per day. Her medical history
   includes depression, hypertension,
   and asthma. The
   patient's current medications
   are fluoxetine (Prozac[R]) 40
   mg, hydrochlorothiazide (Microzide[R])
   25 mg, albuterol
   (ProAiim) two puffs, and low-dose
   aspirin (Ecotrin[R]) 81
   mg. Her past surgical history
   includes a Cesarean section
   x1, appendectomy, and total
   vaginal hysterectomy.


Types of UI

Prior to developing a treatment plan for the patient, the health care provider must identify the type of UI the patient is experiencing. The three most common types of UI include stress, urge, and mixed UI (Abrams et al., 2009). Two other less common types include overflow UI and functional UI. Stress UI is commonly defined as "the complaint of involuntary leakage of urine on effort or exertion such as sneezing, laughing, or coughing" (Abrams et al., 2009, p. 1769). The amount of urine lost is small and occurs as a result of any action that increases intra-abdominal pressure.

Pathophysiology and Risk Factors

Female stress UI occurs as a result of two different anatomic problems that can affect the lower urinary tract: a hypermobile urethra or an intrinsic sphincter defect (ISD). The most common cause of female stress UI is a hypermobile urethra (Newman & Wein, 2009). This occurs due to a disruption in the endopelvic fascia and the levator ani muscles, resulting in loss of support of the bladder neck and proximal urethra (Yoshimura et al., 2007). When there is an increase in abdominal pressure, the urethra has no "backboard" to compress against because of the disruption of the endopelvic fascia; therefore, intra-abdominal pressure exceeds urethral pressure, and involuntary loss of urine occurs (Newman & Wein, 2009).

The second cause of female stress UI is an ISD. This occurs when the urethral sphincter does not close properly due to a weakening of the striated muscles around the bladder neck and is often referred to as a "pipe-stem" urethra because the urethral vesical junction is often immobile (Ghoniem, Elgamasy, Elsergany, & Kapoor, 2002). This results in the inability to create a urethral pressure gradient that is equal or greater than the bladder pressure, and the involuntary loss of urine occurs. Both a hypermobile urethra and an ISD may occur independently or in conjunction with one another (Kayigil, Iftekhar, & Metin, 1999). Causes of stress UI as a result of either a hypermobile urethra or ISD are multifactorial and may include age, Caucasian race, obesity, pregnancy, childbirth, menopause, prior pelvic surgery, and chronic cough (Derpapas et al., 2012; Graham & Mallett, 2001; Hannestad, Rortveit, Daltveit, & Hunskaar, 2003; Newman & Wein, 2009; Press, Klein, Kaczorowski, Liston, & von Dadelszen, 2007; Townsend, Curhan, Resnick, & Grodstein, 2010; Wesnes, Hunskaar, Bo, & Rortveit, 2009).
   The patient has multiple risk
   factors that put her at an increased
   possibility for developing
   stress UI. These
   include age, Caucasian race,
   mild obesity, perimenopausal
   status, prior obstetrical
   history (para 3), surgical history
   of a hysterectomy, and
   smoking/chronic cough.


Evaluation of Female Stress UI

A thorough history and physical examination must be performed by the health care provider prior to determining the most appropriate treatment plan for the patient. Initial evaluation can be performed through a history, physical examination, and some minimally invasive testing.

History

There are multiple types and causes of UI; therefore, a thorough history is essential to achieve an accurate diagnosis. Over half of the patients suffering from UI never seek medical treatment (Teunissen & Lagro-Janssen, 2004). For this reason, it is necessary for the health care provider to directly inquire about UI focusing on patients' bladder patterns and the presence of leakage. The patient should keep a three-day voiding diary to provide a more accurate written record of fluid intake, fluid output, and the occurrence of urinary leakage. Information regarding patients' prior surgeries, childbirths, medical illnesses, and current medications should also be collected. Any transient causes of UI should be identified through patients' history using the TOILETED pneumonic (Dowling-Castronovo & Specht, 2009).

Physical Examination

The initial evaluation should begin with a physical examination including abdominal, neurological, and pelvic assessments. Cognitive function and mobility should also be assessed to rule out functional incontinence. During the abdominal examination, the health care provider should identify any masses, tenderness, herniation, or previous scarring (DuBeau, 2011). The neurologic examination should include assessment of reflexes (anal wink and bulbocavernosus reflex) and perineal sensation (DuBeau, 2011). A pelvic examination should be performed examining the external genitalia for birth trauma. Pelvic floor muscle (levator ani) strength should be assessed by having the patient perform a pelvic floor muscle contraction "Kegel" exercise (Herbuck, 2008). Pelvic organ prolapse (POP) should be identified and documented if present (Persu, Chappie, Cauni, Gutue, & Geavlete, 2011). Lastly, a speculum examination will identify atrophic changes and vaginal dryness, which may be contributing to the patient's symptoms (Newman & Wein, 2009).

Laboratory Studies

On initial examination, it is prudent to collect a clean-catch midstream urine sample for both a urinalysis and a urine culture to rule out the presence of bacteriuria or pyuria, which are generally suggestive of a urinary tract infection (Newman & Wein, 2009). Additional evaluation is warranted if hematuria or glucosuria are identified because they may be precursors for other morbidities, such as bladder carcinoma or diabetes mellitus (Newman & Wein, 2009). Currently, there is no recommendation for serum testing for the evaluation of stress UI.

Radiological Imaging

Imaging is not routinely utilized for the evaluation of female stress UI. A lateral cystourethrography will identify hypermobility or fixation of the urethra, and three-dimensional ultrasound will evaluate the urethral sphincter. However, due to the cost and the complexity of these procedures, it is typically only warranted in evaluating more complex urinary dysfunction, such as a diverticulum or fistula (Fantl et al., 1996; Unger, Weinstein, & Pretorius, 2011).

Specialized Tests

Provocative stress test. The provocative stress test is a minimally invasive, inexpensive test. It should be performed on all women who complain of stress UI symptoms for the health care provider to visualize urinary leakage from the urethra (Jelovsek & Reddy, 2012). This test is conducted when the patient has a full bladder. The patient is asked to Valsalva or cough in both the supine and standing positions. Instantaneous urinary leakage is indicative of stress UI, while delayed, sustained urinary leakage suggests urge UI (Jelovsek & Reddy, 2012).

Cotton swab test. A measurement of urethral hypermobility is obtained by the cotton swab test (Knarr, Schnatz, Whitehurst, & Long, 2010). This test is performed by placing a sterile, lubricated cotton swab into the urethra at the level of the urethrovesical junction. The patient is asked to cough, and the angle between the stem of the cotton swab and the floor is subjectively measured by the health care provider. A change in the angle of greater than 30 degrees indicates a hypermobile urethra, therefore suggesting deficiency in urethral support (Newman & Wein, 2009). If the angle is less than 30 degrees, the urethra is considered fixed, and this suggests the UI is likely a result of ISD (Newman & Wein, 2009). Historically, urethral hypermobility was measured by the cotton swab test; however, this has become less common due to poor test-retest and interobserver reliability (Jelovsek & Reddy, 2012).

Post-void residual volume. A postvoid residual (PVR) urine volume, measured by urethral catheterization or ultrasound, should be assessed within 10 to 20 minutes after voiding to identify urinary retention (Newman & Wein, 2009). A PVR between 50 to 100 ml is considered adequate emptying, while any volume greater than 200 ml is considered inadequate and should be investigated further for bladder outlet obstruction or neurological disorders (DuBeau, 2011; Newman & Wein, 2009).

Cystometric evaluation. If a diagnosis has not been established following the completion of a history, physical examination, and initial minimally invasive testing, cystometric testing may be considered. Uncomplicated stress UI can be diagnosed most easily with simple cystometry. During this procedure, the bladder is retrograde filled with sterile water using a catheter attached to an open barrel 60 ml syringe, which is held at the level of the bladder. The patient notifies the provider of their first sensation of bladder filling, their first sensation of urinary urgency, and their maximum bladder capacity. If the meniscus in the syringe rises, it is suggestive of a bladder contraction, and this is diagnostic of detrusor overactivity. It is important to note that if the meniscus of water in the syringe is static, this would indicate no detrusor overactivity. When the patient reaches capacity in the absence of a bladder contraction, the catheter is removed, and the provocative stress test is performed. Unlike complex cystometry, this study examines only bladder pressure and does not measure abdominal or detrusor pressure (Newman & Wein, 2009).

Complex multichannel cystometry (urodynamics) is more invasive, expensive, and timely than simple cystometry. Complex multichannel cystometry is capable of capturing bladder, abdominal, and detrusor pressures that are necessary for the diagnosis of more complicated urinary disorders. Health care providers must ensure that the benefits of the test outweigh the risks prior to ordering it (Ward et al., 2008).

When testing for stress UI using complex urodynamics, a Valsalva leak point pressure is expected to be greater than 100 cm [H.sub.2]0 if a patient has a hypermobile urethra (Colli, Arribani, Goka, Parazzini, & Wein, 2003). If stress UI is caused by an ISD, complex urodynamics testing is expected to reveal a Valsalva leak point pressure less than 60 cm [H.sub.2]0 (Colli et al., 2003). Valsalva leak point pressures with intermediate values between 60 cm to 100 cm [H.sub.2]0 are likely stress UI cases that possess both an element of ISD and hypermobile urethra (Lane & Shah, 2000).
   Physical examination of the
   patient was performed revealing
   normal external genitalia.
   The vagina was parous in
   appearance with vaginal
   rugation and minimal atrophic
   changes. There was some
   mild relaxation of the anterior
   vaginal wall consistent with a
   Grade 1 (Persu et al., 2011)
   cystocele. A cotton swab test
   was performed showing a
   hypermobile urethra with an
   excursion of greater than 45
   degrees with Valsalva maneuver.
   Post-void residual was 35
   ml following a voided volume
   of 350 ml. Her urinalysis was
   negative for leukocyte esterase,
   hematuria, or glucosuria.
   The urine culture was negative
   for bacterial growth.

   Due to the patient's clinical
   history of straightforward,
   stress-predominant UI, she
   was evaluated using simple
   cystometry rather than complex
   cystometry (urodynamics).
   The patient experienced
   a first sensation of bladder
   filling at 30 ml, a first urge at
   160 ml, strong urge at 240
   ml, and bladder capacity at
   300 ml. During the filling
   phase, no detrusor overactivity
   was identified. The 300
   ml of water remained in the
   patient's bladder, and the
   catheter was removed. While
   supine on the examination
   table, the patient was encouraged
   to cough and a small
   amount of prompt urinary
   leakage was noted without
   temporal delay. She was then
   placed in the erect position
   and put through several
   maneuvers, including jumping
   and coughing. Prompt
   urinary leakage was noted
   without temporal delay for
   both maneuvers. The patient
   was diagnosed with stress UI
   with urethral hypermobility.
   There was no evidence of
   detrusor overactivity.

   The patient is interested in
   definitive treatment for her
   UI, beginning with the least
   invasive, non-surgical options.
   If these methods are
   unsuccessful, then she would
   consider surgical correction
   of her stress UI. Non-surgical
   options include pelvic floor
   muscle training (PFMT), local
   and systemic estrogens and
   pessary placement. All of
   these modalities are relatively
   inexpensive, do not compromise
   future surgical management
   and can be initiated by
   her health care provider.


Evidence-Based Non-Surgical Treatments for Female Stress UI

Treatment based on best evidence is the standard. Rutledge and Grant (2002) explain that evidence-based practice (EBP) is "care that integrates best scientific evidence with clinical expertise, knowledge of pathophysiology, knowledge of psychosocial issues, and decision-making preferences of patients" (p. 1). This process allows health care providers to utilize the best available evidence to guide clinical practice.

Lifestyle and Behavioral Therapy

Lifestyle and behavioral management strategies are the easiest, least expensive, non-surgical treatments for stress UI. These include dietary changes with the avoidance of caffeine and alcohol, fluid restriction of up to two liters per day, timed voiding to prevent the bladder from reaching its capacity, medication adjustments for possible urinary side effects (diuretics), weight loss, and smoking cessation (DuBeau, 2012).

Due to the "common sense" nature of the treatment methods, little research was identified in a recent search of the Cochrane Review or the Joanna Briggs Institute databases. For example, a recent Cochrane Review titled "Lifestyle Interventions for the Treatment of Urinary Incontinence in Adults (Protocol)" was initiated but later withdrawn for an unknown reason (Imamura, Williams, Wells, & McGrother, 2010). An earlier Cochrane Review investigated timed voiding for the management of UI in adults (Ostaszkiewicz, Johnston, & Roe, 2004). Two trials including 298 participants were examined. The review concluded that reduction of UI was greater in the intervention group; however, findings were not statistically significant, and the quality of the studies were poor due to the use of multiple interventions and poor blinding technique. Therefore, no conclusion supported by empirical data could be drawn for or against timed voiding (Ostaszkiewicz et al., 2004).

Weight loss is the most widely supported lifestyle modification for the reduction of stress UI that was identified in the literature. Subak, Richter, and Hunskaar (2009) found with each five-unit increase in body mass index (BMI) there was a 20% to 70% increase in UI risk. Caffeine consumption has also been shown to affect UI if the intake is greater than 204 mg/day; however, there was no distinction between the type of incontinence (stress, urge, or mixed) (Gleason, Richter, Redded, Burgio, & Markland, 2013).
   The patient is committed to
   improving her stress UI with
   as little intervention as possible.
   She is eager to try and
   decrease her caffeine consumption
   to one cup of coffee
   per day, decrease her
   smoking to three cigarettes
   per day, and attempt to lose
   15 pounds. If she is not successful
   with these lifestyle
   modifications, an additional
   option would be to alter her
   diuretic hypertension medication
   to another class of
   antihypertensive drug.


Pelvic Floor Muscle Training (PFMT)

Conservative treatment with pelvic floor muscle training (PFMT) should be offered to all women as first-line management and is effective for both stress and urge UI (Newman & Wein, 2013). It has been shown that brief verbal instruction on PFM contractions is adequate in 78% of women (Henderson, Wang, Egger, Masters, & Nygaard, 2013).

In 2010, a Cochrane Systematic Review of PFMT versus no treatment, or inactive control treatments for UI was performed. Fourteen randomized or quasirandomized trials including 836 women (435 PFMT, 401 controls) were examined in the review. One arm of each trial included PFMT, while other arms studied included no treatment, placebo, sham, or another type of inactive control treatment. Women were diagnosed with UI (all types stress, urge, and mixed - grouped together) based on symptoms, signs, or urodynamics testing. Results confirm that women treated with PFMT were more likely than non-PFMT groups to report improved or cured UI. Women who performed PFMT also reported fewer incontinence episodes per day and a better quality of life. Lastly, there was a greater improvement in symptoms for stress versus urge UI (Dumoulin & Hay-Smith, 2010).

A more recent study (Kocaoz, Eroglu, & Sivaaslioglu, 2013) examined 102 women and the role of PFMT in the pregnancy and postpartum periods and its effect on stress UI. In this study, stress UI was significantly reduced for women in the intervention group at 28 and 32 weeks gestation and 12 weeks postpartum compared to subjects in the control group (Kocaoz et al., 2013).

For a woman to be successful at PFMT, she must be contracting the correct pelvic muscles. Verbal and written instruction alone may not be sufficient in helping women identify the right muscle group and how to contract it properly. The health care professional may use manual, digital feedback to feel the muscle contraction during vaginal examination, while biofeedback uses an electronic device to measure the muscle pressure. PFMT using manual, digital feedback instruction is usually given during one office visit. On the contrary, PFMT using biofeedback instruction is performed over several repeat office visits.

In 2011, a Cochrane Systematic Review examined digital feedback versus biofeedback to augment PFMT for female UI. Twenty-four trials with 1,583 women were examined; women included in these studies were diagnosed with UI based on symptoms, signs, or urodynamics testing. All trials examined were randomized or quasi-randomized with two arms of the trial, including PFMT, and one arm including verbal feedback or device-mediated feedback. Women who received biofeedback were significantly more likely to report their UI was improved or cured compared to those who received PFMT alone (RR = 0.75, 95%, CI = 0.66 to 0.86). However, many trials were at risk for bias because the biofeedback arm had more contact with health care professionals than the non-biofeedback arm. In addition, there was a large amount of variation in the biofeedback regimens (Herderschee, Hay-Smith, Herbison, Roovers, & Heineman, 2011).

The patient was seen by her health care provider for a three-month follow up. She reported decreasing her caffeine consumption to two cups of coffee per day and was smoking three to four cigarettes per day. She noted a small decrease in her urinary leakage since her smoker's cough has improved. At this point, the patient does not wish to undergo surgical correction of her stress UI and requests further minimally invasive treatment options to improve upon her current continence status.

The health care provider verbally reviewed PFMT and also provided manual, digital feedback instruction. The patient was encouraged to see a pelvic floor physical therapist for additional training with biofeedback. If this modality proves unsuccessful, further non-surgical treatments for stress UI can be considered.

Pharmacologic Therapy

Pharmacologic therapy is an additional non-surgical treatment for stress UI that may be considered. Estrogens, alphaadrenergic agonists, and some antidepressants have been examined for the treatment of stress UI. However, there is no currently available FDA-approved pharmacologic therapy for stress UI (Abed & Rogers, 2008; Smith & Wein, 2011).

Estrogen. The peak prevalence of stress UI coincides with the time that an average woman reaches natural menopause (Cody, Richardson, Moehrer, Hextall, & Glazener, 2010). As women reach perimenopause and menopause, their estrogen levels decrease. Estrogen receptors exist throughout the lower urinary tract, and the decreasing estrogen levels result in a weakening of the tissue in the urethra and vagina (DuBeau, 2012). This anatomical weakening may therefore contribute to female stress UI. Supplemental oral (systemic) and local intravaginal (local) estrogen preparations have been studied to identify the effects on UI.

A Cochrane Systematic Review of estrogen therapy for UI in post-menopausal women included 33 studies of 19,313 incontinent women in which 9417 received estrogen therapy (Cody et al., 2010). Randomized controlled trials and quasi-randomized studies, which included estrogen in at least one arm of the trial in postmenopausal women with symptomatic or urodynamic diagnoses of UI (stress, urge, and/or mixed), were included. The trials used varying combinations of estrogen, dose, duration of treatment, and length of follow up. Results suggest that local estrogen therapy may improve or cure UI (type of UI not specified) (RR = 0.74, 95%, CI = 0.64 to 0.68). No long-term effects were examined; however, several short-term side effects were identified, including vaginal bleeding, breast tenderness, or nausea (Cody et al., 2010).

Systemic administration of estrogen or estrogen/progesterone has been shown to result in worse UI than placebo (RR = 1.32, 95% CI = 1.17 to 1.48; RR = 1.11, 95% CI = 1.04 to 1.18), respectively (Cody et al., 2010), which is consistent with data from the Heart and Estrogen/Progestin Replacement Study (HERS) (Grady et al., 2001). Identified long-term effects of systemic estrogen therapy and the association with endometrial cancer, breast cancer, cardiovascular disease, and stroke further discourage its use (Cody et al., 2010).

Due to the current evidence regarding topical versus systemic estrogen, the patient was started on intra-vaginal estrogen cream. She was instructed to insert 0.5 gm at bedtime two times weekly to improve upon her complaints of vaginal dryness, and although not FDA-approved for the treatment of stress UI, her health care provider was hopeful that a secondary effect of improved stress UI would also occur.

Antidepressants. Antidepressants are believed to decrease bladder contractility and increase urethral resistance, resulting in improved UI; however, the exact mechanism is unknown (Cannon & Chancellor, 2003; Rovner & Wein, 2004). While this class of medications may improve mild symptoms of stress UI, it is not curative (Norton, 2002), and no antidepressant drugs are currently approved by the United States Federal Drug Administration (FDA) for treatment of stress UI.

A Cochrane Systematic Review of serotonin and noradrenaline reuptake inhibitors (SNRI) for female stress UI was performed in 2009. Ten trials involving 3,944 women with stress or mixed UI were identified. All trials examined were randomized or quasi-randomized controlled trials where at least one arm involved an SNRI. The treatment duration varied between three to 12 weeks. Results suggest that duloxetine was significantly better than placebo in improving participants' subjective quality of life (95% CI 3.84 to 6.68). However, objective cure of pad tests and 24-hour pad weight did not support the benefit of duloxetine over placebo. One trial suggested duloxetine was superior to PFMT. Although some side effects, especially nausea, were reported with duloxetine, subjects reported they were acceptable and did not cause discontinuation of the medication. No trials were available for inclusion in the review that support the sustainability of the benefits of duloxetine (Mariappan, Alhasso, Grant, & N'Dow, 2009). Duloxetine is not FDA-approved in the United States due to adverse events, including liver toxicity and suicidal ideations (Verghese & Latthe, 2013).

Alpha-adrenergic agonist. Alpha-adrenergic agonist drugs, such as norepinephrine and midodrine, have also been examined for the treatment of stress UI. They are not FDA-approved for treatment. Alpha-adrenergic receptors are present in both the bladder neck and the proximal urethra, and produce smooth muscle contraction when they are stimulated (Cannon & Chancellor, 2003). This results in an increase in maximal urethral pressure and maximal urethral closure pressure (Smith & Wein, 2011). Because of this physiologic response, alpha-agonists may help the bladder neck to contract more strongly, and therefore, have been studied for the nonsurgical management of stress UI.

A Cochrane Systematic Review of alpha-adrenergic drugs for treatment of female stress UI included 22 randomized and quasi-experimental studies, 11 of which were cross-over trials (Alhasso, Glazner, Pickard, & N'Dow, 2010). The trials included 1,099 women, of which 673 received an alpha-adrenergic drug (e.g., phenylpropanolamine (Accutrim[R]), midodrine (ProAmatine[R]), norepinephrine (Levophed[R]), clenbuterol (Broncodil[R]), terbutaline (Bricanyl[R]) or diphenylpyraline (Eskornade[R]). Results suggest that the alphaadrenergic agonist drugs studied were better than placebo in reducing both objective (e.g., pad changes, incontinent episodes) and subjective symptoms of female stress UI; however, there was not enough evidence to evaluate higher versus lower dose adrenergic drugs (Alhasso et al., 2010). Moreover, in two of the involved trials, adrenergic agonists were shown to improve stress UI more than PFMT. Although these trials demonstrated improvement in female UI, one quarter of the women experienced adverse effects, such as anxiety, insomnia, hypertension, arrhythmias, and stroke (Alhasso et al., 2010). For this reason, adrenergic agonists are not commonly used for the treatment of stress UI.

Pessary

Pessaries are a common, nonsurgical treatment for women with stress UI that date back to Egyptian times (Edwards, 1970). This device is placed intravaginally and is used to extrinsically support the bladder neck and urethra (Lipp, Shaw, & Glavind, 2011). The most common types of pessaries are the incontinence dish or incontinence ring. These incontinence pessaries differ from other pessaries because they have a knob on the ring or dish pessary, which is placed behind the symphysis at the level of the urethrovesical junction to provide additional support to the urethra (Keyock & Newman, 2011). These modalities are most frequently utilized by women whose stress UI is episodic in nature (i.e., exercise-induced), by women who are not surgical candidates due to co-morbidities, or by women who have not completed childbearing. Maintenance for the pessary may be performed by the patient; this includes weekly removal and cleaning of the device (with soap and water) prior to reinsertion (Bash, 2000). The patient should return for evaluation every six weeks to three months or sooner if she has any complications, including urinary or bowel retention, pelvic pain, vaginal bleeding, or leukorrhea (McIntosh, 2005). Incontinence pessaries are helpful for some women, but only about 50% of patients who try a pessary will continue to use it for two years or beyond (Abed & Rogers, 2008).

Pessaries have shown a similar reduction rate in stress UI symptoms when compared to PFMT. A Cochrane Systematic Review of mechanical devices, including pessaries and tampons, for management of UI was conducted in 2011. This evidence-based review consisted of seven randomized or quasi-randomized studies involving 732 women who had symptoms, signs, or urodynamically diagnosed UI (primarily stress UI). Results suggest that use of a mechanical device may be better than no treatment, but the evidence was inconclusive (Lipp et al., 2011). More recently, Kenton et al. (2012) performed the ATLAS trial, which identified there was no statistical significant difference in the reduction of stress UI between pessary use versus PFMT.
   The patient returned for a
   six-month follow-up visit and
   reported she was doing very
   well with lifestyle changes.
   She had lost 12 pounds, quit
   smoking, and had decreased
   her caffeine to two cups of
   coffee per day. She had completed
   a course of PFMT and
   biofeedback training. These
   modalities improved her daily
   leakage with coughing and
   change in position; however,
   she was still leaking urine
   regularly during her aerobic
   exercise class.

   When presented with the possible
   surgical and non-surgical
   treatment options, the
   patient chose to try an incontinence
   pessary. She was fitted
   for a 1.5-inch incontinence
   ring pessary without
   difficulty. Additionally, she
   was to continue intra-vaginal
   estrogen cream two times
   weekly. The patient chose to
   intermittently insert the
   incontinence pessary prior to
   exercise class or if she had a
   severe cold. She was educated
   on self-care and was
   instructed to phone the office
   with leukorrhea, vaginal
   bleeding, or pain.

   The patient was seen for a
   six-week follow-up visit and
   reported she was happy with
   the current management of
   her stress UI. She continued
   her lifestyle modifications,
   practiced her PFMT regularly,
   and utilized the incontinence
   ring pessary for her
   aerobics class. The patient
   was very pleased that with
   these minimally invasive,
   inexpensive therapies, she
   was able to successfully
   manage her stress UI. At this
   time, she was not interested
   in a referral for surgical correction
   of her stress UI.


Recommendations

* Identification of the type and underlying cause of UI is essential to provide the appropriate treatment options.

* The primary therapeutic options for UI should be treatments that are minimally invasive, with the fewest reported complications.

* Behavioral therapies should be utilized as first-line management for UI (Newman & Wein, 2013).

* Conservative treatment with PFMT should be offered for stress UI (Dumoulin & HaySmith, 2010).

* Pelvic floor muscle training should be performed with digital or electronic biofeedback for improved symptom control (Herderschee et ah, 2011).

* Systemic estrogen should not be utilized for the treatment of stress UI (Cody et al., 2010).

* Vaginal estrogen, if indicated, may be utilized for treatment of vaginal dryness in peri- or post-menopausal women (Cody et ah, 2010); however, it is not U.S. FDA-approved for treatment of stress UI.

* There are no U.S. FDA-approved pharmacologic therapies for stress UI (Abed & Rogers, 2008).

* Vaginal pessaries may be offered for conservative management of stress UI because they have been found to be better than no treatment and similar in terms of success to PFMT (Lipp et al., 2011).

Conclusion

Many options exist for the treatment of female stress UI. Conservative approaches are effective, and there is little associated risk; therefore, they should be offered as first-line treatments. If conservative treatments are unsuccessful, surgical procedures are available to offer patients who experience continued stress UI.

References

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Knarr, J., Musil, C., Warner, C., Kless, J.R., & Long, J. (2014). Female stress urinary incontinence: An evidence-based, case study approach. Urologic Nursing, 34(3), 143-151. doi:10.7257/1053-816X.2014.34.3.143

Jamie Knarr, DNP, MSN, RN, is a Urogynecotogy Nurse Practitioner, Reading Health System, Reading, PA.

Carol Musil, PhD, RN, FA AN, is a Professor, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH.

Camille Warner, PhD, is an Assistant Professor, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH.

Jack R. Kless, PhD, CRNA, is an Interim Director of Anesthesia Nursing, Cleveland Clinic, Cleveland, OH, and was an Assistant Professor, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, at the time this article was written.

Jaime Long, MD, is a Urogynecologist, Reading Health System, Reading, PA.
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Title Annotation:Advanced Clinical Practice
Author:Knarr, Jamie; Musil, Carol; Warner, Camille; Kless, Jack R.; Long, Jaime
Publication:Urologic Nursing
Article Type:Report
Geographic Code:1USA
Date:May 1, 2014
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