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Home , Stress incontinence, Urinary incontinence, Urodynamic testing

J Am Board Fam Pract: first published as 10.3122/jabfm.5.3.289 on 1 May 1992. Downloaded from The Evaluation And Treatment Of In Women: A Primary Care Approach

Mark D. Walters, M.D., andJanet P. Realini, M.D.

Abslrtlet: llIIcllgroutul: Urinary incon1inence, the involun1ary loss of urine severe enough to have adverse social or hygleoic consequences, is a major clinical problem and a significant cause of disability and dependency. At least 10 million adults in the US suft'er &om urinary incontinence, including III eBdmated 15 to 30 percent of community-dwelling older persons. In spite of its high rate of occurrence, fewer than one-half of women with regular urinary incontinence seek medical help for their problem, either because of embarrassment or the perception that their symptoms are normal. Metbods: MEDUNE files were sea.rched from 1970 to 1990 using the key words "incontinence," "prevalence," and "diagnosis" and for specitlc nonsurgical treatments. Only articles pertaining to adult women were chosen. ReSlllts tmtl CtmelflSlmIs: Urinary incontinence frequently can be diagnosed accurately by family physicians using basic tests in the office. Many women experience improvement of incontinence with properly employed behavioral and pharmacologic therapy. Other women bendlt &om referral for specialized evaluation and consideration for surgical therapy. (J Am Board Pam Prac:t 1992; 5:289-301.)

Urinary incontinence is a common problem sionalleaking with , laugh, or sneeze; more among women - and one that often goes un­ frequent symptoms of are addressed in primary care. Defined as the in­ found in about 2 percent.6-8 Twenty percent to 40 voluntary loss of urine severe enough to have percent of middle-aged and community-dwelling adverse social or hygienic consequences, urinary elderly women have incontinenceS-II; the rate is incontinence affects at least 10 million US adults even higher among institutionalized elderly.I2,13 at an estimated annual cost of $10.3 billion} In spite of its high rate, urinary incontinence is

While incontinence as such is not life threaten­ underrecognized and undertreated. Surveys of http://www.jabfm.org/ ing, it affects quality of life by causing psychologi­ community-dwelling women suggest that fewer cal distress and social disruption. Urinary incon­ than one-half of women with regular urinary in­ tinence is associated with anxiety, , and continence seek medical help for their problem, sexual dysfunction2-4; patients suffer embarrass­ either because of embarrassment or the percep­ ment and often limit their excursions outside the tion that their symptoms are normal.lo,n home, their social interactions, and their sexual While much literature addresses evaluation and activities.s treatment of incontinence by urologists and gyne­ on 29 September 2021 by guest. Protected copyright. The rate of urinary incontinence among cologists, little guidance is designed specifically women of all ages is high, but estimates of the for the family physician. In fact, many women magnitude of the problem vary widely with differ­ experience considerable improvement of in­ ent definitions of disease, different populations continence with properly employed nonsurgical studied, and different survey methods. Up to one­ therapy - therapy appropriate to primary care. half of young nulliparous women report occa- Other women benefit from referral for special­ ized evaluation and consideration for surgical therapy. Thus, it is important that family physi­ Submitted, revised, 2 January 1992. cians detect urinary incontinence and be able to From the Department of Obstetrics and Gynecology, Univer­ evaluate, treat, and refer patients appropriately. sity MacDonald Hospital for Women, Cleveland, OH, and the Department of Family Practice, The University of Texas Health The purpose of this review is to offer a practical Science Center at San Antonio. Address reprint requests to Mark approach to the evaluation and treatment of D. Walters, M.D., Department of Obstetrics and Gynecology, women with urinary incontinence in the primary University MacDonald Hospital for Women, 2074 Abington Road, Oeveland, OH 44106. care setting. Adequate evaluation of many women

Urinary Incontinence in Women 289 J Am Board Fam Pract: first published as 10.3122/jabfm.5.3.289 on 1 May 1992. Downloaded from with urinary incontinence can be accomplished in Bladder-filling disorders are usually due to un­ an office setting, using history, physical examina­ inhibited, involuntary detrusor contractions. In tion, ane a few simple tests. These tools allow the the absence of a known neurologic abnormality, physician to formulate a presumptive diagnosis of this detrusor overactivity is called detrusor insta­ the type of incontinence, so that appropriate con­ bility (DI). Detrusor overactivity caused by a dis­ servative treatment can be instituted. In addition, turbance of neurologic control is termed detrusor conditions that require specialized evaluation can hyperreflexia. IS Mixed incontinence refers to in­ be identified. continence with features of more than one type­ usually GSI and DI. ~ of Incontinence Ouerfluw incontinence is defined as any involun­ Among women complaining of urinary inconti­ tary loss of urine associated with overdistention of nence, the differential diagnosis includes genito­ the bladder. IS This diagnosis is usually associated urinary and nongenitourinary conditions (Table with mellitus or other neurologic dis­ 1). Genitourinary disorders include problems of eases. The terms "voiding difficulty" or "voiding bladder filling and storage, as well as extraurethral dysfunction" refer to problems with emptying the disorders, such as and congenital abnor­ bladder, including , urethral ob­ malities. Nongenitourinary conditions are those struction, and poor detrusor function. Voiding in which function of the lower urinary tract is difficulty is frequently associated with overflow intact, but other factors, such as immobility or incontinence. severe cognitive impairment, result in urinary in­ The relative likelihood of each cause of incon­ continence.l In addition, some women who com­ tinence varies with the age and health status of plain of wetness or leaking have other causes for the individual. Among ambulatory, adult inconti­ their symptoms; vaginal discharge, for example, nent women, the most common condition is can mimic urinary incontinence. 14 GSI, which represents 50 to 70 percent of Genuine stress incontinence (GSI) is defined by cases. 16-l8 DI and mixed forms account for 20 to the International Continence Society as the in­ 40 percent of incontinence cases. 16 Among non­ voluntary loss of urine occurring when, in the institutionalized elderly incontinent women absence of a detrusor contraction, the intravesical evaluated in referral centers, GSI is found less pressure exceeds the maximum urethral pres­ frequently (30 to 46 percent), and detrusor over­ sure.IS The mechanism ofthis condition is incom­ activity and mixed disorders are more common, http://www.jabfm.org/ petence of the bladder neck and , resulting occurring in 29 to 61 percent of cases. 13, 19,20 In­ mainly from an abnormal descent and mobility of continence in institutionalized elderly women is these structures with increases in intraabdominal more likely to be due to detrusor overactivity (38 pressure or from an intrinsic dysfunction of the to 61 percent); GSI is found in only 16 to 21 urethral sphincteric mechanism. percent.2l,22 on 29 September 2021 by guest. Protected copyright. Evaluation Urinary incontinence can be a symptom of which

Genitourinary Causes Nongenitourinary Causes patients complain, a sign demonstrated on exami­ nation, or a amdition (i.e., diagnosis) that can be Filling or !torage disorders Neurologic Genuine sttess incontinence Cognitive confirmed by definitive studies. 'When a woman Detrusor instability (idiopathic) Functional complains of urinary incontinence, appropriate Detrusorh~flena Mood evaluation includes exploring the nature of her (neurogenic) Environment Mixed types Phannacologic symptoms and looking for physical findings. The Metabolic history and are the two most Fistula important steps in the evaluation. A preliminary Vesical diagnosis can be made with simple office tests and Ureteral Urethral laboratory tests, allowing for therapy to be insti­ Congenital tuted. 'When the patient does not improve, when Ectopic neurologic disease or other complex conditions Epispadias are present, or when the possibility of surgery is

290 JABFP May-June 1992 Vol. 5 No.3 J Am Board Fam Pract: first published as 10.3122/jabfm.5.3.289 on 1 May 1992. Downloaded from entertained, definitive, specialized studies are Thorough medical, neurological, surgical, gy­ necessary. necologic, and obstetric histories are important. Dia­ betes, , , vitamin B12 defi­ History ciency, , and lumbar disc disease are One should elicit a description of the complaint, examples of illnesses that can cause incontinence. including its duration and frequency. A clear Cough can worsen previously mild stress inconti­ understanding of the severity of the problem or nence symptoms. Chronic severe constipation is disability and its effect on quality of life should be associated with a number of urinary problems, sought. Table 2 lists questions that are helpful in including voiding difficulties, urgency, stress in­ evaluating incontinence in women. The first continence, and increased bladder capacity.23 question is designed to elicit the symptom of Prior surgery, such as hysterectomy, vaginal repair, stress incontinence, i.e., urine loss with events and retropubic surgery, can affect urinary function. that increase intraabdominal pressure. The symp­ A complete list of the patient's medications will tom of stress incontinence is usually (but not al­ help to reveal whether individual drugs might ways) associated with the diagnosis of GSI. Ques­ influence the function of the bladder or urethra, tions 2 through 9 help elicit the symptoms that leading to urinary incontinence or voiding diffi­ are associated with DI. The symptom of urge culties. Types of drugs that commonly affect incontinence is present if the patient answers lower urinary tract function are shown in Table 3. question 3 affinnatively. Frequency (questions 4 Especially in the elderly, reducing a drug dosage and 5), bed-wetting (question 6), leaking with or eliminating an offending drug can resolve uri­ intercourse (question 8), and a sense of urgency nary problems. Diuretic use can, if not induce (questions 2 and 7) are all associated with the incontinence, worsen the condition.24 condition of DI. Questions 9 and 10 help to de­ Patient histories regarding the frequency and fine the severity of the problem. Questions 11 severity of urinary symptoms are less accurate and through 13 screen for urinary tract and reliable than are urinary diaries.25 Diaries require neoplasia, and questions 14 through 17 are de­ the patient to record the daily volume and fre­ signed to elicit symptoms of voiding dysfunction. quency of fluid· intake and voiding, as well as episodes of incontinence and associated events, such as cough or urgency. Diaries are usually kept 'lWt1e 2. Qlladou ... die I'+UuIdoa o,.-ae VrIMrf Iaeoalilleace. for 1 to 7 days and are useful to·corroborate or http://www.jabfm.org/ 1. Do you leak urine when you cough, sneeze, or laugh? modify the working diagnosis, especially when 2. Do you ever have such an uncomfurtably strong need to symptoms are confusing or uncertain. In addition, urinate that if you don't reach the toilet you will leak? review of diaries can detect excessive fluid intake 3. If "yes" to No.2, do you ever leak befure you reach the toilet? or situations for which scheduled voiding could 4. How many times during the day do you urinate? help control symptoms. 5. How many times do you void during the night after on 29 September 2021 by guest. Protected copyright. going to bed? PIIysbl~ 6. Have you wet the bed in the past year? Every incontinent woman should have a general 7. Do you develop an urgent need to urinate when you are physical and lower extremity neurologic nervous, under stress, or in a hurry? examma- 8. Do you ever leak during or after ? 'Mie 3.11ed1a1d.a 'I1uIt CD Afted Lower Urt.rJ 'INct JIacdo& 9. Do you find it necessary to wear a pad because of your leaking? Type of Medication Lower Urinary ThIct Effects 10. How often do you leak? Diuretic , frequency, urgency 11. Have you had bladder, urine, or Iddney infectioos? Urinary retention, ovedlow 12. Are you troubled by pain or discomfurt when you incontinence urinate? Psychotropic 13. Have you had blood in your urine? Antidepressant Anticholinergic actions, sedation 14. Do you find it hard to begin urinating? Antipsychotic Anticholinergic actions, sedation 15. Do you have a slow urinary stream? Sedative-hypnotic Sedation, muscle reluation 16. Do you have to strain to pass your urine? u-Adrenergic blocker Stress incontinence 17. After you urinate, do you have dribbling or a feeling that u-Adrenergic agonist Urinary retention your bladder is still full? ~Adrenergicagonist Urinary retention

Urinary Incontinence in Women 291 J Am Board Fam Pract: first published as 10.3122/jabfm.5.3.289 on 1 May 1992. Downloaded from tion, and the is of primary ous Imtative symptoms, such as , fre­ importance. Vaginal discharge, because it can quency, urgency, incontinence, and voiding diffi­ mimic incontinence, should be detected and culty.30,31 In these cases, treatment of the infection treated. of the and implies will usually eradicate the symptoms. Bacteriuria changes in the urethra, bladder, and periurethral can be an incidental finding, however, because it tissues that result from deficiency. The is frequently asymptomatic, especially in the eld­ presence and severity of , rectocele, en­ erly.32 It seems reasonable to prescribe appropri­ terocele, and uterovaginal prolapse are noted. A ate antibiotics for bacteriuric incontinent patients bimanual examination is done to rule out coexist­ and to reevaluate in several weeks. Patients with ent gynecologic disorders, which can occur in up hematuria or with recurrent or persistent urinary to two-thirds of patients.26 With the rectal exami­ tract should undergo appropriate nation the physician further evaluates for pelvic evaluation and urologic consultation. Diabetes disease and for , the latter of which should be ruled out in patients with polyuria fre­ can be associated with voiding difficulties and quency, , voiding difficulties, or chronic incontinence in elderly women.27 Urinary incon­ . Tests of renal function, tinence has been shown to improve or resolve urine cytology, and radiographic procedures are after the removal of fecal impactions in institu­ necessary only for specific medical and urologic tionalized geriatric patients.28 indications. Urinary incontinence can be the presenting The office evaluation of incontinence should symptom of early neurologic disease. The physi­ involve some assessment of voiding, detrusor cian performs the general and lower extremity function during filling, and competency of the neurologic examination to evaluate general cog­ urethral sphincteric mechanism. During the as­ nitive function and sensory and motor functions sessment, one should try to determine specifically of sacral segments 2 to 4, which contain the the circumstances leading to the involuntary loss important neurons controlling micturition and to of urine. If possible, such circumstances should be look for signs of a myelopathy (spasticity, hyper­ reproduced and directly observed and evaluated. reflexia, weakness). To test motor function, the This series of tests is most easily initiated with the patient extends and flexes the hip, knee, and ankle patient's bladder comfortably full. In the supine and inverts and everts the foot. The strength and position, direct observation of the external ure­ tone of the external anal sphincter are estimated thral meatus with coughing (stress test) is done. http://www.jabfm.org/ digitally. The patellar, ankle, and plantar reflex Urine leaking in spurts during or immediately responses are tested. Sensory function along the after the cough is the physical finding, or sign, of sacral dermatomes is tested by using light touch stress incontinence. If no leaking is observed su­ and pinprick on the perineum and around the pine, then the test should be repeated in the thigh and foot. standing position. Prolonged loss of urine, leak­ Two reflexes can help in the examination of ing 5 to 10 seconds after coughing, or no urine on 29 September 2021 by guest. Protected copyright. sacral reflex activity. In the anal reflex, stroking loss with provocation indicates that GSI is un­ the skin adjacent to the anus causes reflex contrac­ likely, and other causes of incontinence, usually tion of the external anal sphincter muscle. The detrusor instability, might be present. After this bulbocavernous reflex involves contraction of the stress test, the patient is allowed to void as nor­ bulbocavernous and ischiocavernous muscles in mally as possible in private, noting the amount of response to tapping or squeezing the clitoris. Un­ time to void. The urine is collected in a container fortunately, these reflexes can be difficult to eval­ attached inside the toilet and the voided volume is uate clinically and are not always present, even in recorded. The patient then returns to the exami­ neurologically intact women.29 nation room, and the volume of residual urine is measured. This measurement is most directly and O~Tes18 accurately done with "in and out" transurethral Few laboratory tests are necessary for the evalua­ catheterization. Ifa clean urine sample has not yet tion of incontinence. A clean midstream or cathe­ been obtained for analySis and culture, it can be terized urine sample is obtained for urinalysis and obtained at this time. Less invasive techniques culture. Patients with acute cystitis can have vari- used to estimate bladder volume include bladder

292 JABFP May-June 1992 Vol. 5 No.3 J Am Board Fam Pract: first published as 10.3122/jabfm.5.3.289 on 1 May 1992. Downloaded from

palpation (by bimanual examination) and ultra­ Urinary Incontinence in Women sonography.33 Bladder palpation has been re­ ported to be adequate for gross estimation of retained urine in the elderly,27 but, compared with catheterization, it is relatively insensitive for de­ tecting volumes of residual urine. 34 These simple office exercises yield much infor­ mation about lower urinary tract ftmction. The average urine flow rate, calculated by dividing the volume voided by the number of seconds to void, should be more than 10 to 15 mUsec. Bladder capacity is estimated by noting the sum of the volume voided and residual urine volume. Nor­ mal values for bladder capacity range from 300 mL35 to 750 mL.36 Postvoiding residual urine volumes should be less than 100 mL. 37,38 Because isolated instances of elevated residual urine volume might not be of significance,37 the test should be repeated when abnormally high values are obtained.

M""'ng the DItIgnosis The findings of a careful history and physical examination predict the actual incontinence diag­ nosis with reasonable accuracy. Women who have Figure 1. A1goritbmic maluatlon of urinary incontlaence the symptom of stress incontinence as their only in women. ERT =estrogen repJacement~ GSI • complaint have a 70 to 90 percent chance of hav­ genuine stress incontinence, DI = detrusor insIIIbiJity. ing GSI confirmed on diagnostic . 16-18,20,39-44 Ten percent to 30 percent of erly individuals.27,48 The initial goal should be to such patients will be found to have 01 (alone or be diligent in seeking out and treating all transient

coexistent with genuine stress incontinence). causes of urinary incontinence and voiding diffi­ http://www.jabfm.org/ Sensory urgency, urge incontinence, diurnal and culty (fable 4).48 Complex causes of incontinence nocturnal frequency, and bed-wetting have all are identified early, and consultation and special­ been associated with 01.17,40,45-47 The more of ized tests are obtained. Patients are then catego­ these abnormal urinary symptoms the patient has, rized as probable GSI, probable 01, or mixed GSI the greater the chance that she has 01.47 The and OI. For GSI and 01, appropriate behavioral physical findings of abnormal neurologic exami­ or medical therapy can be given, and a substantial on 29 September 2021 by guest. Protected copyright. nation20 and cystocele 16 have been associated with percentage of patients can be expected to re- detrusor hyperreflexia and GSI, respectively. Symptoms of voiding difficulty (i.e., hesitancy, poor stream, postvoiding fullness, or dribbling), low urine flow rate, high bladder capacity, or high Delirium residual urine volume suggest voiding dysftmc­ Restricted mobility tion. When any of these findings is present, Drugs urodynamic testing is required to determine the Urinary retention cause and the mechanism (obstructive versus non­ Urinary infection obstructive) of the voiding dysftmction. Fecal impaction Based on the clinical evaluation, the family Spinal cord compressioo physician can formulate a presumptive diagnosis Polyuria and initiate treatment, using the algorithm in Fig­ *Modified and lmed with permission by Ous\ander JG. Diagnostic ure 1 as a guide. Similar guidelines for evaluating evaluation of geriatric urinary incontinence. Clin Geriatt Med incontinence have been used with success in eld- 1986; 2:715.

Urinary Incontinence in Women 293 J Am Board Fam Pract: first published as 10.3122/jabfm.5.3.289 on 1 May 1992. Downloaded from spond. Even patients with mixed incontinence been consistently reported for the various ure­ have responded to various forms of conservative thral suspension procedures. Because some therapy in about 60 percent of the cases.49 women improve with nonsurgical treatments, The family physician must recognize that, even however, all women with GSI should have a trial under the most typical clinical situations, the di­ of conservative therapy before corrective surgery agnosis of incontinence based only on office is offered. Furthermore, some patients do not evaluation has limited accuracy. This diagnostic desire surgery, are poor surgical candidates, or inaccuracy is acceptable if medical or behavioral have urinary incontinence that is not so severe as treatment (as opposed to surgery) is used, because to justify major surgery. the morbidity and cost of these treatments are low Four main types of conservative treatment are and because the ramifications of no cure of incon­ effective for some women with stress inconti­ tinence (continued incontinence) are not severe. nence: exercises, bladder retraining, 'When surgical treatment of stress incontinence is pharmacologic therapy, and mechanical devices. considered, urodynamic testing is recommended Other nOvel types of nonsurgical therapy exist, to confirm the diagnosis. such as functional electrical stimulation, but these 'Whenever objective clinical findings do not should be prescribed only after a definitive diag­ correlate with or reproduce the patient's symp­ nosis is made. toms, urodynamic testing is indicated for diagno­ sis. Trials of therapy must be followed up periodi­ Physiotherll/1J cally to evaluate response. If the patient fails to Physiotherapy is an important first-line method improve, then appropriate consultation is indi­ for both prophylaxis and treatment of urinary and cated. Consultation with a gynecologist or urolo­ . Pelvic floor exercises were in­ gist should also be considered for complex cases troduced by Kegel in 1948 to restore tone to that might require urodynamic testing, surgical perineal muscles after delivery and to treat stress treatment, or both. Examples of these situations urinary incontinence.50,51 Modem studies, using are presented in Table 5. objective measures for diagnosis and outcome, consistently report improvement in 50 to 75 per­ 'ireatment cent of cases. 52-57 Pr'fIsIImetl Gatliu SIras ~ In a typical treatment program, patients are

Surgery is clearly the most effective treatment for instructed to tighten the vaginal muscles and http://www.jabfm.org/ GSI. Cure rates of more than 80 percent have those muscles that interrupt , to hold this tension for 5 to 10 seconds, then to release. TIIbIe 5. ~ fa WIdda CoMuI1IIdoa for 1M IIftIIIIdoa .... This exercise should be done 10 to 20 times in 'lftaaeat ofUrt.ry ~ Would Ie IDdIaded each session, and the session repeated up to every Histoty hour during the day. with a finger Neurologic disease inserted intravaginally or with a perineometer can Surgery to treat urinary incontinence on 29 September 2021 by guest. Protected copyright. Pelvic malignancy aid the patient in evaluating progress. Active physiotherapy programs are performed for 2 to 6 Physical examination and office evaluation weeks, after which daily maintenance exercises Persistent urinary tract infection after treatment are done, ideally for life. Improvement is more Hematuria Abnonnal neurologic examination likely to occur in younger women and in those Difficulty passing urethral with less severe disease. 57 In general, the success Signs of voiding difficulty or retention of pelvic floor exercises in treating stress inconti­ Absent bladder sensation with filling Large bladder capacity nence depends on the instructor's enthusiasm and High postvoiding residual urine volwne knowledge and on the patient's motivation and Small bladder capacity interest. Fistula Weighted vaginal cones can be used to enhance Urethral diverticula Failure to improve after treatment of incontinence based on the response of pelvic floor exercises. This prod­ clinical evaluation uct, marketed under the name Femina TM, is a set Whenever objective clinical findings do not correlate with or , of five lead-filled plastic conical devices ranging in reproduce the patient's symptoms or concerns weight from 20 g to 70 g. 'When inserted into the

294 JABFP May-June 1992 Vol. 5 No.3 J Am Board Fam Pract: first published as 10.3122/jabfm.5.3.289 on 1 May 1992. Downloaded from vagina, they provide a simple and practical aid for after estrogen therapy.70,71 No improvf:ment in identifying and exercising pelvic floor muscles, urinary symptoms was found after treatment with thereby improving pelvic floor strength and progestin.72 symptoms of stress incontinence in some women. A trial of estrogen therapy for estrogen­ In addition, increasing the cone weights creates deficient women with GSI should be given in the biofeedback. to the patient on her progress. Sev­ absence of contraindications. The proper dosage eral studies have shown that stress incontinence is and route of administration of estrogen have not improved in approximately two-thirds of patients, been established but probably are those that re­ some of whom could avoid surgery. 58,59 verse atrophic uroepithelial changes. Patients can be prescribed conjugated in doses of PharmtJCokJgic Therapy - Estrogen 0.625 mg/d (or a comparable estrogenic prepara­ The vagina and urethra have similar epithelial tion and dosage). The route of administration can linings as a result of their common embryologic be oral, vaginal, or dermal. The dosage is then origin. Urinary cytologic changes are similar to titrated to achieve maximum estrogenic responses those of the vagina during the , in the vaginal (and urethral) epithelilUn with during , and after .60,61 minimal side effects. Phenylpropanolamine can High-affinity estrogen receptors are present in be used in combination with estrogen for additive surgically removed urethral tissue and pubococ­ effects.73 -75 Related issues of estrogen replace­ cygeal muscle in women.62,63 ment therapy, such as concurrent use of proges­ Hypoestrogenemia results in cytologic changes tins and assessment of risk, are beyond the scope of the urethra similar to those found in the vagina. of this article. These changes can be at least partially responsible for the sensory symptoms and decreased resis­ PharmacokJgic Therapy - Nonh01"l1lO1JlJl tance to urinary infection frequendy found after The bladder neck and proximal urethra in women menopause. Age- and estrogen-induced changes contain predominantly a-adrenoreceptors. Stimu­ in the urethral and periurethral muscle and in lation of these receptors produces smooth muscle the collagen of the endopelvic can allow contraction in i~lated tissue preparations and an for the development and progression of lower increase in bladder oudet resistance.76 Drugs used urethral resistance, urethral detachment, and pel­ for the treatment of GSI are shown in Table 6. 64

vic prolapse. Many investigators have shown that treat­ http://www.jabfm.org/ Estrogen treatment results in mucosal cyto­ ment of patients with stress incontinence with logic changes in the urethra, similar to those of a-adrenergic stimulating drugs improves symp­ the vagina, with changes toward more intermedi­ toms in some patients, probably by increasing ate and superficial cells and fewer transitional urethral closure pressure. The drugs that have cells.65 The cytologic changes of urethral mucosa, been studied include ephedrine, phenylephrine, which occur in response to estrogen, can lead to midodrine, norfenefrine, and phenylpropanola­ an improved "mucosal seal effect," thereby in­ mine. Ephedrine is a noncatecholamine sympa­ on 29 September 2021 by guest. Protected copyright. creasing urethral resistance and lessening symp­ thomimetic agent that owes part of its peripheral toms of urgency and frequency. Estrogenized cy­ action to the release of noradrenalin, which also tologic changes in the urethral mucosa also directly stimulates a- and ~-adrenergic receptors. correlate with improvement in symptoms ofstress In a 14-week, double-blind crossover study that incontinence.65 compared the effects of norephedrine chloride Numerous studies have addressed the efficacy with placebo, Ek and co-workers77 showed reduc­ of estrogen in treating lower urinary tract symp­ tion of urinary leakage with the drug in 12 of 22 toms in postmenopausal women. Subjective im­ patients. Diokno and Taub78 reported good to provement or cure of stress incontinence has been excellent results in 71 percent of patients with reported in 20 to 71 percent ofwomen.66-70 Simi­ GSI treated with ephedrine sulfate. lar results have been found using various estro­ Phenylpropanolamine hydrochloride (PPA) gen preparations, whether orally or vaginally. shares the pharmacologic properties of ephedrine Fewer symptoms of urgency or frequency and and is approximately equal in peripheral potency fewer voiding difficulties also have been observed while causing less central stimulation. Several

Urinary Incontinence in Women 295 J Am Board Fam Pract: first published as 10.3122/jabfm.5.3.289 on 1 May 1992. Downloaded from

Classification of Drug Name of Drug Minimum and Maxitnum Dosage Potential Side Effects Honnone Estrogen Oral: 0.3-1.25 mg every day Increased risk of endometrial cyclically or continuously carcinoma (unless opposed Vaginal: 2-4 g every day then with cyclic progestin). weekly for maintenance irregular vaginal bleeding a-SyTnpathonrimetic hydrochloride 15 mg twice a day to 30 mg Drowsiness. dry mouth. 4 times a day hypertension Phenylpropanolanrine 50 mg every day to 75 mg Drowsiness, dry mouth. hydrochloride twice a day hypertension Tricyclic antidepressant Inripranrine hydrochloride 25 mg every day to 75 mg Anticholinergic effects, twice a day orthostatic hypotension, hepatic dysfunction, mania; monoanrine oxidase inhibitors prohibited; cardiovascular effects (especially in the elderly) Propranolol hydrochloride 10 mg twice a day to 40 mg Fatigue. lethargy. cardiovascular 3 times a day effects placebo-controlled studies have evaluated PPA in treatment with imipramine. These investigators the treatment of women with genuine stress in­ reported an increase in functional urethral length continence. Using the dose of 50 mg twice daily, and maximal urethral pressure after a daily dose of improvement was noted in 60 to 70 percent of 75 mg of imipramine. patients, mainly in those with lesser severity of Theoretically, j3-adrenergic blocking agents disease.79•8o Modest increases in maximum ure­ might be expected to potentiate an a-adrenergic thral pressure were noted, but these increases did effect, thereby increasing resistance in the ure­ not correlate with either serum concentration or thra. Gleason, et al.84 reported success in treating subjective response. stress-incontinent patients with the j3-adrenergic PPA is a component of numerous prescription blocking agent propranolol in oral doses of 10 mg and over-the-counter medications marketed for four times daily. Although such treatment has the treatment of nasal and sinus congestion and been suggested as an alternative drug therapy for

appetite suppression. Pharmacologic studies of patients with sphincteric incompetence and hy­ http://www.jabfm.org/ PPA in these doses reported few clinically signifi­ pertension, few ifany reports of such efficacy have cant effects resulting from drug treatment.81 appeared. Other reports have noted no significant Nevertheless, reports of serious complications, changes in urethral profile measurements in nor­ including , stroke, and death, with over­ mal women after j3-adrenergic blockade. the-counter preparations containing PPA suggest that these drugs be used with care in incontinent Mechanical Devices individuals. 82 Mechanical devices, such as , can be used on 29 September 2021 by guest. Protected copyright. In general, effects of a-adrenergic drugs are to alleviate symptoms of pelvic relaxation (with or most notable in patients with mild to moderate without urinary incontinence) or for patients with symptoms but generally do not sufficiently im­ urinary incontinence who have not responded to prove severe symptoms of stress incontinence to other therapies or who are medically unfit for offer an alternative to surgical treatment. In addi­ surgical treatment. These devices also can be ap­ tion, the beneficial effects immediately reverse propriate for women with intermittent urinary with cessation of the drug, making it a poor choice incontinence, such as during upper respiratory for long-term treatment of stress incontinence. tract infections or with exercise. Imipramine hydrochloride, an antidepressant Bhatia and co-workers85 noted that placement with a-adrenergic agonist and anticholinergic ef­ of a vaginal Smith-Hodge in women who fects, appears to improve symptoms in some have stress urinary incontinence resulted in con­ women with stress urinary incontinence. Gilja, et sistent and significant increases in functional ure­ al. 83 had a 71 percent cure rate in 21 women after thrallength and urethral closure pressure under

296 JABFP May-June 1992 Vol. 5 No.3 J Am Board Fam Pract: first published as 10.3122/jabfm.5.3.289 on 1 May 1992. Downloaded from stressful conditions when compared with prepes­ the treatment ofD!. Many treatment variations sary'studies. Clinically, 10 of 12 patients became exist, and acceptable rates of cure have been continent, probably by stabilizing the urethra and demonstrated with timed voiding,87-89 bio­ urethrovesical junction to proper pressure trans­ feedback, 90 hypnotherapy,91 and .92 mission and by actively increasing urethral resis­ These interventions can reflect adaptive behav­ tance to escape of urine under stressful condi­ ioral changes,93 or they can help the patient re­ tions. Simultaneous voiding urethrocystometry gain cortical inhibitory control over lower uri­ and instrumented uroflowmetry demonstrated nary tract function. 94 absence of obstruction to free flow of urine when In a typical bladder retraining program, 89 the voiding with the pessary in place. Unfortunately, patient is asked to void on schedule every 30 to 60 pessaries are unacceptable to many women be­ minutes based on her baseline daytime voiding cause they remain in the vagina for long periods interval. The patient is instructed to "go to the of time, can interfere with sexual intercourse, and toilet and empty her bladder as completely as she can result in vaginitis. can" at the scheduled time, regardless of her de­ In another study using vaginal diaphragm sire to void. H urgency occurs prior to the as­ rings, 4 of 10 women with genuine stress inconti­ signed voiding time, she is instructed to suppress nence experienced clinical improvement in the the urge as long as possible, using reluation and amount of urine lost during pad tests, number of distraction techniques. The patient is encouraged leaking episodes per week, and overall subjective not to void off schedule; however, if the urgency assessment of response.86 Urodynamic findings cannot be controlled, and the patient perceives were essentially unchanged when the women that an incontinent episode is imminent, she is were wearing the diaphragm rings, although mild not prohibited from voiding. No fluid modifica­ restrictions in urethral mobility were noted as tions are used. Patients are asked to keep daily measured by the Q-TIp TIl test. voiding diaries, which are assessed at weekly of­ fice visits for approximately 6 weeks. Voiding in­ PlwfnlfetlDBIrWMW JruItIbIllly tervals are progressively increased by 30- to 60- Bladder Retraining minute intervals if the patient shows a decrease in Educational and bladder-retraining techniques the number of incontinent episodes and tolerates have been shown to be highly successful in the schedule without interruption. The goal of http://www.jabfm.org/

Classification of Drug Name of Drug Minimwn and Moimwn Dosage Potential Side Effects Anticholinergic PropantheJine bromide 15 mg twice a day to 60 mg Anticholinergic effects (dry 3 times a day mouth, blurred viIion, drowsineII, CODIdpatioo) Musculotropic re1uant chloride 2.S mg twice a day to S mg Anticholinergic effects

(antispasmodic) 4 times a day on 29 September 2021 by guest. Protected copyright. Dicyclomine hydrochloride 10 mg twice a day to 40 mg Anticholinergic effects 4 times a day Flavoute hydrochloride 100 mg twice a day to 200 mg Anticholinergic effects 4 times a day Calcium channel blocker Nifedipine 10 mgtwice a day to 120 mg Edema, hypo1mIaion, per day flushing, dim""", DlIIJIeI, 1erolidine hydrochloride U.S to 2S mg twice a day abdominal pain, rub, walmess, palpitatiODS Tricyclic antidepressant Imipramine hydrochloride 2S mg nery day to 7S mg Anticholinergic effects, twice a day orthostatic hypoteDlion, hepatic dysfimc:tion, mania; monoamine alidue inhibitors prohibited; c:ardimucular effects (especially ~ the elderly) *Modified and used with permission by Bent AE. Etiology and management of detrusOr instability and mixed inCOlltineace. 0bItet Gynecol elin North Am 1989; 16:853-68.

Urinary Incontinence in Women 297 J Am Board Fam Pract: first published as 10.3122/jabfm.5.3.289 on 1 May 1992. Downloaded from the program is to void at 3-hour intervals and to tage of both anticholinergic and a-adrenergic­ eliminate incontinence. stim1,llating properties.

Phar71UlCoiogic Therapy Conclusion Many drugs have been tried and studied for the Urinary incontinence is a common health prob­ medical therapy of DI. Table 7 shows the most lem in women that often goes unrecognized and commonly used drugs, their dosages, and some of untreated. Family physicians should inquire about their important side effects. 95 There is overlap this problem in their patients and, when present, among the categories listed; for example, all the should initiate a basic evaluation using the guide­ drugs except estrogen and nifedipine have anti­ lines in this paper. At least one-half ofincontinent cholinergic properties. Oxybutynin and flavoxate women can be treated successfully with behav­ have local anesthetic properties, as well as anti­ ioral and pharmacologic methods. Women who spasmodic and anticholinergic properties. Each of do not improve after office evaluation and non­ the drugs listed appears to be effective, at least for surgical treatment can then receive appropriate some patients. A placebo, however, is often found consultation and specialized evaluation. to be effective as well, so individual patient re­ sponses should be interpreted with caution. Phar­ macologic therapy should be used in conjunction with a bladder-retraining program whenever References 1. Consensus conference. Urinary incontinence in possible. adults.JAMA 1989; 261:2685-90. Side effects of these medications often limit 2. Macaulay AJ, Stem RS, Holmes OM, Stanton SL. their usefulness, especially in older women. Initial Micturition and the mind: psychological factors in dosages for elderly patients should be low; physi­ the etiology and treattnent of urinal)' symptoms in cians should observe for effects on other medi­ women. Br MedJ 1987; 294:540-3. cal problems and for interactions with other 3. Walters MD, Taylor S, Schoenfeld LS. Psychosexual study of women with detrusor instability. Obstet medications. Gynecoll990; 75:22-6. Estrogen treatment has been shown to reduce 4. Hilton P. Urinal)' incontinence during sexual inter­ urgency and frequency, but not incontinence, in course: a common, but rarely volunteered, symptom. women with DI.71 Although there are few data Br J Obstet Gynaeco11988; 95:377-81. 5. WymanJF, Harkins Sw, Choi SC, Taylor JR, Fand

to support its use for DI without GSI, a trial http://www.jabfm.org/ JA Psychosocial impact of urinary incontinence in of estrogen is reasonable for eligible estrogen­ women. ObstetGynecol1987; 70:378-81. deficient women. 6. Wolin LH. Stress incontinence in young, healthy nulliparous female subjects.J Uro11969; 101:545-9. PtwImIetl Mbtetl DI tIIUl GSJ 7. Crist T, Shingleton HM, Koch GG. Stress inconti­ When the clinical evaluation suggests the pres­ nence and the nulliparous patient. Obstet Gynecol ence of both GSI and DI, a presumptive diagnosis 1972; 40:13-7.

8. Thomas TM, Plymat KR, Blannin J, Meade Tw. on 29 September 2021 by guest. Protected copyright. of mixed incontinence is made. Urodynamic Prevalence of urinary incontinence. Br Med J 1980; evaluation can help to clarify the contribution of 281: 1243-5. each disorder to the patient's symptoms and 9. Diolmo AC, Brock BM, Brown MB, Herzog AR. should be accomplished prior to consideration of Prevalence of urinary incontinence and other uro­ surgery. Conservative therapy can be aimed at logical symptoms in the noninstitutionalized elderly. J Uro11986; 136:1022-5. either disorder or at both. In general, the compo­ 10. Holst K, Wilson PD. The prevalence of female uri­ nent believed to be chiefly responsible for the nary incontinence and reasons for not seeking treat­ patient's symptoms is treated first. The nonsurgi­ ment.NZMedJ 1988; 101:756-8. cal treatments for DI and GSI can be selected 11. Yarnell Jw. St Leger AS. The prevalence, severity and combined on an individualized basis. Be­ and factors associated with urinary incontinence in a cause estrogen replacement can be beneficial random sample of the elderly. Age Aging 1979; 8:81-5. in both DI and GSI, it probably should be 12. Ouslander JG, Kane RL, Abrass lB. Urinary inconti­ prescribed unless contraindicated. Ifdrug therapy nence in elderly nursing home patients. JAMA 1982; is considered, imipramine can offer the advan- 248:1194-8.

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Urinary Incontinence in Women 301