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Treatment of Stress Urinary Incontinence in Women: A Medical and Surgical Review.

Urinary incontinence (UI) is defined by the International Continence Society (ICS) as "the complaint of involuntary loss of urine" (Haylen et al., 2010, p. 5). Urinary incontinence occurs in both men and women, although it is twice as common in women (Buckley & Lapitan, 2010). The International Consultation on Incontinence reviewed 36 general population studies and determined that in most studies, 25% to 45% of women report some degree of UI, while 9% to 39% of those over age 60 years report it as a daily occurrence (Buckley & Lapitan, 2010). However, the prevalence of UI is difficult to determine because patients are often reluctant to report due to factors such as embarrassment and the belief that it is an inevitable part of the aging process (Bardsley, 2016; Zilinskas, 2018).

In women, subtypes of UI are generally classified as stress, urge, or mixed (see Table 1) (Milsom et al., 2013). Stress urinary incontinence (SUI) is the most common form and will be the main focus of this article. According to Reynolds, Dmochowski, and Penson (2011), half of women with UI report SUI as their sole or primary symptom. The ICS defines SUI as the "complaint of involuntary loss of urine on effort or physical exertion (e.g., sporting activities) or on sneezing or coughing" (Haylen et al., 2010, p. 5). According to Milsom and colleagues (2009), young and middle-aged women are more likely to report SUI, while older women generally report urge and mixed incontinence. Research reveals that pregnancy increases the risk of developing SUI. Having a vaginal delivery is associated with a two-fold risk of developing SUI when compared to those who have had a cesarean section (31% vs. 15%) (Stothers & Friedman, 2011; Tahtinen et al., 2016). Additional risk factors for SUI include obesity, diabetes mellitus, genetic factors, hormones, medications, and smoking (Stothers & Friedman, 2011).

UI has the potential to negatively impact a woman's quality of life. Results of a systematic review performed by Seshan and Muliira (2014) concluded that any form of UI can affect a woman's physical, mental, and sexual health, as well as her social well-being. Many women with UI have feelings of shame, avoid sexual intimacy, abandon work, avoid physical activities, and limit fluid intake for fear of accidental urination. Lack of self-confidence and feeling unattractive were also reported and often led to alienation (Seshan & Muliira, 2014).

Pathogenesis of Stress Urinary Incontinence

The female pelvic floor consists of muscles and connective tissue that span the underneath of the pelvis, leaving openings for the anus, urethra, and vagina (Min et al., 2017). The ability of the urethra to remain closed during periods of rest and increased intra-abdominal pressure depend on the proper support of these structures, as well as a functioning urethral sphincter mechanism (Koelbl et al., 2013). The proximal portion of the urethra is supported by the external urethral sphincter, which is a sleeve of striated muscle located posterior to the pubic bone. A tendinous connection attaches the external urethral sphincter to the levator ani muscle. This allows for closure of the urethral lumen upon increased pressure and maintains urinary continence (Koelbl et al., 2013). Also aiding in continence is the levator ani, coccygeus muscles, and endopelvic fascia, which resemble a sling at the base of the pelvis (Donovan & Terrell, 2018; Koelbl et al., 2013).

SUI is categorized as either urethral hypermobility or intrinsic sphincter deficiency (ISD). A stressful maneuver, such as coughing or sneezing, is associated with an increase in intraabdominal pressure of 150 cm H2O and a displacement of the proximal urethra by approximately 10 mm downwards. Upon increased pressure, the stretch resistance (or stiffness of the pelvic floor structures) compresses the proximal urethra against the supportive structure, aiding in its closure (Ashton-Miller, Howard, & DeLancey, 2001). Damage to the endopelvic fascia, or levator ani muscle or its nerves would cause the supportive structures and bladder neck to become less stiff, resulting in urethral hypermobility. According to the ICS, ISD is the result of a weakened urethra, resulting in low urethral closure pressure and low valsalva leak point pressures (Koelbl et al., 2013).

Assessment and Diagnosis

Research reveals that approximately 3% of healthcare providers question their patients about incontinence, and an estimated 25% to 50% of patients seek treatment for UI (Wiers & Keilman, 2017). It is important that healthcare providers begin to focus on the prevention, diagnosis, and treatment of UI due to its prevalence among women and negative impact on quality of life. The clinical assessment of UI should begin with a thorough problem-focused history, including symptoms, time of onset, and frequency (Abrams et al., 2013). Standardized questions and validated questionnaires are useful in identifying those with UI symptoms and determining the type of incontinence, its severity, and the impact on quality of life. A standardized question such as, "Do you sometimes leak urine when you cough or sneeze or when you exert yourself, such as when lifting a heavy object?" may be used to assess for SUI (Staskin et al., 2013). The ICS recommends the use of objective measures, such as a bladder diary, and subjective measures, including patient-reported outcomes, for both the initial measurement of symptoms and assessment of therapy impact (Staskin et al., 2013).

A comprehensive assessment has been identified as the most valuable means of diagnosing SUI and includes the surgical and obstetric history, review of medical conditions, list of medications, social history, family history, and physical examination (Staskin et al., 2013). During the physical examination, the examiner should focus strongly on the abdominal, pelvic, and neurological assessment. For the evaluation of a patient with the complaint of SUI, a cough stress test is the recommended diagnostic tool. In the lithotomy position, the visualization of urine loss in sync with a forceful cough confirms SUI diagnosis (Guralnick, Fritel, Tarcan, Espuna-Pons, & Rosier, 2018). Urodynamic studies are extensions to the basic examination and are recommended in those with recurrent or complicated incontinence involving pain, hematuria, recurrent infections, pelvic irradiation, significant voiding symptoms, radical pelvic surgery, or suspected fistula (Abrams et al., 2013; Bent & McBride, 2018).

Treatment

A stepwise approach is recommended for the treatment of SUI, beginning with conservative measures and progressing to more invasive treatments to meet the patient's desired quality of life (Zilinskas, 2017). Conservative medical treatment often involves behavior and lifestyle changes, pelvic floor muscle training (PFMT), and intravaginal support devices. Minimally invasive treatment, such as the injection of urethral bulking agents, may also be used. Surgical interventions for SUI include colposuspension and the use of midurethral slings.

Lifestyle Modifications

According to the National Institute for Health and Care Excellence (NICE) (2013) clinical guidelines, initial therapy for SUI includes conservative management and patient education. Lifestyle modifications for SUI often include exercise, weight loss, dietary management, and smoking cessation (Imamura, Williams, Wells, & McGrother, 2015; NICE, 2013; Tso & Lee, 2018). Overweight (body mass index [BMI] = 25.0 to 30.0 kg/[m.sup.2]) and obesity (BMI greater than 30.0 kg/[m.sup.2]) are associated with SUI, including more frequent episodes of UI due to an increase in intraabdominal pressure and stress on the pelvic floor (Fuselier, Hanberry, Lovin, & Gomelsky, 2018). Each 5-unit BMI increase is associated with a 20% to 70% increase in UI risk (Subak, Richter, & Hunskaar, 2009). Dietary management for the treatment of SUI is aimed at a reduction in weight. Weakness in the pelvic floor and increased intra-abdominal pressure due to excess weight is a risk factor for incontinence (de Vries & Heesakkers, 2017; Pair & Sommerall, 2018).

Pelvic Floor Muscle Training

Pelvic floor exercises are considered first-line treatment for SUI. PFMT reduces SUI by strengthening the pelvic floor muscles, most importantly the levator ani muscle, and improving the support of the urethra, vagina, and rectum (Pair & Somerall, 2018; Tso & Lee, 2018). A Cochrane review comparing PFMT to no treatment found that women were more likely to report fewer episodes of leakage per day and better quality of life when treated with PFMT (Dumoulin, Cacciari, & Hay-Smith, 2018). According to Moore and colleagues (2013), the objective of PFMT for the prevention of SUI is to improve the timing of pelvic floor muscle contraction, the strength and stiffness of the pelvic floor structures, and function of the urethral sphincter. Forms of PFMT may include pelvic floor muscle contractions and the use of assistive devices, such as vaginal cones, pelvic floor biofeedback, or electrical stimulation.

Pelvic floor muscle contractions. Programs targeting the pelvic floor muscles are often taught by a healthcare provider and focus on repetitious, voluntary contractions of the pelvic floor muscles for the treatment of SUI (Guevara, 2018). A pelvic floor muscle contraction, also known as a Kegel exercise, is the voluntary isolation of the pubococcygeus (PC) muscles. To aid in identifying the PC muscles, providers may insert one gloved finger into the vagina and ask the patient to contract the pevlic muscles you would use to stop the flow of urine while keeping the anus and legs relaxed (Pair & Somerall, 2018). Although no gold standard exists for the assessment of pelvic floor muscle function, digital palpation is clinically useful (Guevara, 2018). The Perfect Scheme and Brink scales, among others, may be used in clinical practice to assess pelvic floor muscle strength (Guevara, 2018).

Vaginal cones. Vaginal cones are weighted devices, ranging from 20 to 100 grams, that women insert into the vagina to induce muscle contraction and retrain the pelvic floor (Bent & McBride, 2018). Over time, the weight of the cone is increased until it can be held in place without slipping out of the vaginal orifice. Vaginal cones are not recommended for women with pelvic organ prolapse because it is possible the cone is being held in place by the prolapsed bladder and not the strength of the pelvic muscle contraction (McIntosh, Anderson, & Reekie, 2015). A Cochrane review supports the use of vaginal weighted cones and found their use to be superior to no treatment in women with SUI (Herbison & Dean, 2013).

Pelvic floor biofeedback. Pelvic floor biofeedback provides a structured approach to learning how to isolate and contract the pelvic floor muscles. This adjunct to PFMT allows for visual or auditory feedback via the use of a probe or surface electrode. When the patient performs a voluntary contraction, a probe placed in the vagina or an electrode placed on the perineum alerts the patient when she has contracted the correct muscles, including information regarding contraction strength and duration (McIntosh et al., 2015).

Electrical stimulation. Electrical stimulation is used for treatment in SUI patients as a form of passive pelvic floor muscle contraction. A portable unit provides an electrical charge to the pelvic nerves via a vaginal probe or conducting pads which results in contraction of the pelvic floor muscles (Bent & McBride, 2018). A recent study found that electrical stimulation may also aid in restoring the tensile strength and stability of pelvic floor muscles by the induction of collagen deposition (Min et al., 2017). However, too few studies are available to provide evidence-based guidance on its use (Stewart, Berghmans, Bp, & Glazener, 2017).

Intravaginal Support Devices

Intravaginal support devices are a conservative option for the treatment of SUI. The most common type of support device is known as a pessary. A pessary, often made of silicone, is a device that is placed high within the vagina and acts to support the bladder neck and restore proper urethral positioning. Each pessary is unique and can come in a multitude of shapes and sizes; therefore, each must be fitted by a trained professional (Zilinskas, 2017). The shape of the device works to promote continence by compressing the urethra against the pelvic bone as intra-abdominal pressure rises (McIntosh et al., 2015). Patients are taught how to effectively remove and reinsert the pessary for cleaning and vaginal intercourse. Vaginal infection and ulceration of the mucosa are risks associated with the use of a pessary device, and follow up with a medical professional is recommended every 6 to 12 months for proper fit and a vaginal inspection (McIntosh et al., 2015; Zilinskas, 2017). To prevent atrophy and ulceration of the vaginal mucosa in postmenopausal women, a vaginal hormone replacement is advised (Zilinkas, 2017). For patients who are unable to manage the care of a pessary, such as difficulty with self-insertion, pessary care may be provided at 1- to 3-month intervals.

Pharmacologic Treatment

The U.S. Food and Drug Administration (FDA) (2018b) does not include the use of medications for the treatment of SUI. Medications such as systemic and localized estrogen, duloxetine, botulinum toxin, and alpha adrenergic agonists have been used in off-label treatment of SUI. Research has found drug therapy to show weak evidence and multiple adverse effects (Andersson et al., 2013). The American College of Physicians and American Urological Association do not recommend the use of systemic pharmacological therapy for the treatment of SUI (Hersh & Salzman, 2013; Kobashi et al., 2017).

Laser Therapy

The two types of laser therapy for the treatment of SUI include the vaginal erbium ER:YAG laser (VEL) and C[O.sub.2] laser. Laser therapy provides support to pelvic floor structures due to its thermogenic effect on collagen, which is the induction of neoangiogenesis within target tissues (Capobianco et al., 2018). The procedure is a painless, minimally invasive process that only takes a few minutes to complete. Three sessions are completed over one month, and the benefits can last up to 6 months (Capobianco et al., 2018; Pergialiotis, Prodromiodou, Perrea, & Domumouchtsis, 2017). However, the use of laser therapy for UI has not been approved by the FDA, and therefore, many insurance companies and third party payers do not cover the cost (Gambacciani & Palacios, 2017; FDA, 2018a). The long-term safety and efficacy of laser therapy requires further study.

Urethral Bulking Agents

According to the International Urogynecological Association (IUGA) (2013), SUI symptoms are reported as improved or in some cases cured in 60% to 70% of women who have received urethral bulking. Urethral bulking agents (UBAs) are recommended in the management of SUI by the American Urological Association, American Urogynecology Society, and NICE, especially for patients who prefer a non-invasive approach, those who are not fit for anesthesia, and in older adults. Bulking agents are placed in the office setting under local anesthesia. The injectable agent is placed under the urethral mucosa via a rigid cystoscope. This technique allows for closure of the bladder neck and proximal urethra during periods of increased intra-abdominal pressure (Bent & McBride, 2018). Injectable agents currently approved by the FDA for use in SUI treatment include polydimethylsiloxane (silicone, Macroplastique[R]), spherical particles of calcium hydroxylapatite (CaHA) in a gel carrier (Coaptite[R]), and carbon-coated zirconium beads (Durasphere[R]) (see Table 2). Although UBAs are often an effective alternative to surgery, their cost-effectiveness is reduced by the need for reinjection due to the degradation of injected material. Reinjection is required every 6 to 12 months (de Vries & Heesakkers, 2017). In a recent Cochrane review that assessed the effects of periurethral and transurethral injection therapy in women with SUI, injection therapy was found to be inferior to open surgery at 12 months follow up and is not recommended as an alternative therapy in women who are fit for other surgical procedures (Kirchin et al., 2017).

Surgical Treatment of SUI

There are multiple procedures and techniques available for those who have failed to achieve urinary continence with conservative measures. These procedures may be performed as open, laparoscopic, or robot-assisted, and use a suture-only method to restore the anatomy by repositioning the bladder neck and stabilizing the urethra. The first surgical approach used to treat SUI was colposuspension of the bladder neck (de Vries & Heesakkers, 2017). Marshall-Marchetti-Krantz (MMK) and Burch colposuspension are two of the most studied retropubic procedures. The MMK method places a set of permanent sutures on each side of the urethra, collecting both vaginal and urethral tissue, which are fixated to the fibrocartilage of the symphysis pubis (Bent & McBride, 2018). However, the MMK procedure places patients at risk for osteitis pubis, and a modified approach known as Burch colposuspension became the standard open retropubic colposuspension procedure (de Vries & Heesakkers, 2017; Lapitan, Cody, & Mashayekhi, 2017). In Burch colposuspension, the paravaginal fascia is attached to Cooper's ligament to avoid the complication of osteitis pubis (de Vries & Heeksakkers, 2017).

A recent Cochrane review found open retropubic colposuspension to be an effective longterm treatment option for SUI. The overall continence rate was estimated at 85% to 90% within the first year of treatment, and declined slightly to 70% after a 5-year follow up (Lapitan et al.,

2017) . Although the mid-urethral sling has largely replaced the retropubic colposuspension, the American Urological Association continues to recommend its use for SUI, specifically in those who are undergoing a concomitant abdominal-pelvic procedure or who do not wish to use mesh (Kobashi et al., 2017).

Mid-Urethral Slings

The earliest sling procedures date back to over 100 years ago. With many improvements, there are now a number of sling procedures available. Today, the most common type of surgery used to treat SUI is the mid-urethral sling. The mid-urethral sling procedure involves no sutures and is considered less invasive than colposuspension. It is used to improve continence with the placement of a sling, most commonly formed with artificial mesh or autologous material, under the proximal urethra and bladder neck (Bent & McBride, 2018). Currently, the retropubic and transobturator approach are the most frequently used techniques. Short-term analyses have found the effectiveness of retropubic and transobturator mid-urethral sling to be equivalent (Kobashi et al., 2017).

Retropubic mid-urethral sling. The retropubic mid-urethral sling approach uses tension-free vaginal tape (TVT), which is inserted either top-down or bottom-up. According to Ford, Rogerson, Cody, and Ogah (2017), the bottom-up retropubic mid-urethral sling approach is considered more effective compared to the top-down approach. The bottom-up retropubic approach is accomplished by creating a small incision under the urethra, guiding the sling behind the pubic bone and out through two supra-pubic incisions (Bent & McBride, 2018). Adverse events associated with the use of TVT include unintended puncture of retropubic, intra-abdominal viscera or neurovascular structures, as well as postoperative hematoma. Bladder perforation is the most common complication (Dmochoski et al., 2013).

Transobturator mid-urethral sling. The transobturator tape (TOT) sling procedure was designed to decrease the risk associated with the retropubic sling. The transobturator sling is placed either inside-out, through the obturator membrane via a vaginal incision and guided out in the genitocrural fold, or outside-in, as it is placed through the genitocrural fold and exits via the vaginal incision (Capobiano et al., 2018). Research evidence has yet to suggest the use of the inside-out versus outside-in approach for the transobturator mid-urethral sling (Ford et al., 2017). Adverse events continue to be associated with the transobturator sling procedure. According to Dmochowski and colleagues (2013), intraoperative complications, such as injury to the bladder, viscera, and vessels, have been reported, as well as chronic conditions, including de novo urgency and sling erosion.

Single-sling incision. To reduce some complications associated with mid-urethral slings, the single-incision - or mini-sling approach has recently become popular (Nambiar, Cody, Jeffery, & Aluko, 2017). This next generation sling was designed to cause fewer side effects compared to standard slings due to their shortened length and minimal tissue penetration. A recent Cochrane review found evidence suggesting less postoperative pain associated with single-incision slings; however, more trials are needed to assess their comparison to mid-urethral slings (Nambiar et al., 2017).

Conclusion

SUI is an embarrassing condition that is widely underreported. It has negative impacts on a woman's social well-being and overall health. SUI can be easily diagnosed and treated through open patient-provider communication and screening measures. The management of SUI includes conservative and surgical options. Conservative options, including behavioral therapy and pelvic floor muscle training, have long been the cornerstone of treatment. Surgical management is indicated once conservative measures have failed. At this time, pharmacological treatment is very limited. As the population continues to age, further research and treatment guidelines are needed to improve treatment selection and outcomes for individuals with SUI.

doi:10.7257/1053816X.2019.39.1.29

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Kristin Sanders, BSN, RN, is a Registered Nurse, Baptist Medical Center Downtown Jacksonville, FL.
Table 1.

Forms of Urinary Incontinence

Types of UI    Description

Stress         The involuntary loss of urine upon
               effort, physical exertion, coughing, or
               sneezing.

Urge           The involuntary loss of urine which is
               associated with urgency.

Mixed          The combination of both stress and urge
               UI.

Table 2.

FDA-Approved Urethral Bulking Agents

Urethral Bulking    Material                 Adverse Effects
Agent

Durasphere[R]       Carbon-coated            Local lymphatic and
                    zirconium oxide beads    peri-urethral
                    suspended in a           dislocation of carbon
                    polysaccharide carrier   beads; urethral
                    gel.                     prolapse.

Macroplastique[R]   Polydimethylsiloxane     Excessive foreign body
                    (silicone) particles     granulomas.
                    suspended in a
                    bioexcretable carrier
                    hydrogel of
                    polyvinylpyrolidone.

Coaptite [R]        Spherical particles of   Additional injections
                    calcium-                 required due to
                    hydroxylaptite in an     product absorption;
                    aqueous gel carrier.     urethral prolapse.
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Title Annotation:General Clinical Practice
Author:Sanders, Kristin
Publication:Urologic Nursing
Article Type:Report
Date:Jan 1, 2019
Words:5131
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