OBGMANAGEMENT ■ OBG BY PETER K. SAND, MD; G. WILLY DAVILA, MD; KARL LUBER, MD; and DEBORAH L. MYERS, MD

Stress urinary incontinence: A closer look at nonsurgical therapies

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

e know what it is: The involuntary tried and true and brand new? To address loss of urine during activities that this question, OBG MANAGEMENT convened Wincrease intra-abdominal pressure. a panel of expert urogynecologists. Their And we know what it isn’t: Rare. We even focus was conservative therapies. know how to treat stress incontinence, since it affects women of all ages and generally can be A wide range of options attributed to urethral hypermobility and/or to preserve fertility intrinsic sphincter deficiency. But are we up- SAND: We are fortunate to have a number of to-date on all the management options, both very effective nonsurgical treatments for stress urinary incontinence (SUI). Why don’t we begin by laying out the full complement O UR PANELISTS of options? Dr. Davila, when a pre- ■ Peter K. Sand, MD, moderator of this menopausal woman presents to your center discussion, is professor of obstetrics and with SUI, what therapies do you offer if she gynecology at the Feinberg School of Medicine, is waiting to complete childbearing? And Northwestern University, Evanston, Ill. how do you counsel her? DAVILA: ■ G. Willy Davila, MD, is chairman, We first try to determine what effect department of gynecology, Cleveland Clinic the incontinence is having so we can devel- Florida, Weston, Fla. op a suitable treatment plan. For example, if the patient leaks urine with minimal exer- ■ Karl Luber, MD, is assistant clinical professor, cise, it may be more difficult to treat her division of female pelvic medicine and than a woman who leaks only with signifi- reconstructive surgery, University of California cant exertion. It also may be more difficult School of Medicine, San Diego, and director of the female continence program at Kaiser to treat SUI in a woman for whom exercise Permanente, San Diego. is very important, compared with someone who exercises sporadically. ■ Deborah L. Myers, MD, is associate professor Fortunately, with the current options, it of obstetrics and gynecology, Brown University

School of Medicine, Providence, RI. 40 OBG MANAGEMENT • September 2003 isn’t necessary to do a full urodynamic evalu- TABLE 1 ation and spend a lot of time and energy Drugs that affect assessing the patient. We take a history in stress urinary incontinence which we focus on behavioral patterns, look- WORSEN INCONTINENCE ing especially at fluid intake. A high caffeine Alpha blockers intake is particularly telling. Then we look at • Prazosin (Minipress) voiding patterns to make sure the patient is • Doxazosin (Cardura) urinating regularly. A bladder diary is typical- • Terazosin (Hytrin) ly very helpful for that—and it doesn’t need Diuretics to be a full 7-day diary; a 3-day diary should IMPROVE INCONTINENCE suffice. If the patient is going to be treated Alpha agonists nonsurgically, completion of a diary has sig- • Ephedrine nificant educational value regarding fluid • Phenylephrine intake and voiding patterns. • Phenylpropanolamine Once we have assessed behavioral pat- Mixed-effect agents terns, we do a physical exam to evaluate the • (Tofranil) (also ) Estrogens (local administration) neuromuscular integrity of the pelvis. If the patient has good pelvic tone—with minimal prolapse and the ability to perform an and other means of strengthening the pelvic effective Kegel contraction of the pelvic floor floor muscles. muscles—she should do very well with phys- In addition, a number of medications can iotherapeutic or conservative means of improve urethral resistance, and simple inter- enhancing pelvic floor strength. So behavior- ventions such as limiting fluid intake and modification strategies work very well for altering behavioral patterns are also useful. patients with mild stress incontinence. We I often will use multiple modalities. typically begin with a trial of biofeedback- Basically, I do everything I can if the patient guided or self-directed pelvic floor exercises. wants to avoid surgery because of future Patients with significant prolapse who childbearing. leak very easily don’t do as well with simple SAND: Dr. Luber, are your practice patterns conservative therapies. Examples include a different? woman whose empty-bladder stress test sug- LUBER: The emphasis on medical interven- gests severe degrees of sphincteric inconti- tions is entirely appropriate. Few things are nence with urinary leakage and patients who as satisfying as helping a patient improve cannot contract their pelvic floor muscles— without surgery, especially when she express- some women are simply unable to identify es concerns about the need for an operation. these muscles. Those are the patients we tend I believe in offering the patient a menu of to test more extensively. nonsurgical choices. Women are often badly SAND: Dr. Myers, how do you treat these informed about their options, and I like to take patients? some time to educate them once the basic eval- MYERS: A lot depends on physical exam uation is complete. Sometimes that can be dif- findings. For example, for a cystocele, a vagi- ficult, but it is extremely helpful to take 5 or 10 nal continence ring may be useful. minutes to thoroughly explain the cause of the If there is excellent support but the incontinence, using diagrams if necessary. Kegel contractions are weak, I would proba- This gives them a better understanding of the bly look to pelvic floor therapy, which nonsurgical approach. includes biofeedback, electrical stimulation, I also try to reinforce use of vaginal sup-

September 2003 • OBG MANAGEMENT 41 Stress urinary incontinence: A closer look at nonsurgical therapies

port devices such as continence rings and pes- mature women tends to become very atroph- saries, which are very helpful in both younger ic and nonresponsive. I usually steer my eld- and older women. In addition, I emphasize the erly patients with poor pelvic floor recruit- importance of pelvic muscle rehabilitation, ment and tone to biofeedback because they giving verbal instructions, coaching the are unlikely to get a response to pelvic floor patient, and recommending a physical thera- exercises done independently. pist when necessary. MYERS: I make it a point to SAND: At our center, we also offer conservative options ini- offer people a full menu of tially to all patients. As you treatment options and try to let know, many older patients have them make an independent other medical problems that decision once they have the render surgical therapy inadvis- basic information. One could able. So I proceed with the argue that it’s difficult for menu we discussed earlier. I patients to make educated favor electrical stimulation for decisions about different treat- patients who are unable to do ments, even with a small any type of Kegel squeeze. I amount of data. think it’s important Still, we talk with for the patient to get them about behav- It is possible to reduce incontinence an idea what a leva- ioral techniques episodes by 90% using biofeedback and tor contraction feels and interventional like and, hopefully, devices. electrical stimulation. learn to perform the We also discuss — Dr. Davila exercise on her own. use of alpha-adren- ergic agents (pseudoephedrine) and the tri- Rehabilitating the pelvic floor: cyclic imipramine, as well as Electrical stimulation, electrical stimulation as an alternative to physiotherapy, and moderation Kegel contractions with biofeedback. When SAND: I’m not a big fan of independent the incontinence is exercise-induced, some- pelvic floor exercises without biofeedback, as thing as simple as a tampon in the vagina can studies at Duke some years ago showed very sometimes be very effective, as Nygaard et al poor compliance, with only 10% of people demonstrated.1 staying on self-directed Kegel exercise thera- py.2 Roughly one third of those were actually Treating the doing a Valsalva maneuver instead of con- postmenopausal woman tracting their muscles—and that is destruc- SAND: What about women of advanced age, tive over time. So I discuss electrical stimula- beyond the reproductive years? How would tion as an option, as well as innervation you treat a patient over 65 if she elected not to using an electromagnetic chair. have surgery? MYERS: In our practice, if someone has an LUBER: The pelvic floor is not an area that absent Kegel squeeze or only a 1 or 2 on a people exercise on a daily basis in normal scale of 5, we will start her on electrical stim- activities, as we do our arms and legs. In ulation. Once those muscles have been edu- addition, over the course of time—perhaps in cated and strengthened, we move to biofeed- combination with the denervation associated back. If a woman already has a strong Kegel with vaginal birth—the pelvic floor of squeeze, we tend to recommend biofeedback

42 OBG MANAGEMENT • September 2003 Stress urinary incontinence: A closer look at nonsurgical therapies

first. I have not had any expe- TABLE 2 rience with the electromag- Recommended therapeutic agents netic chair. LUBER: I manage patients DRUG DOSAGE similarly. In our center, elec- STRESS INCONTINENCE trostimulation is reserved pri- Phenylpropanolamine (Dimetapp) 25-50 mg every 6 to 8 hours marily for those patients who Pseudoephedrine (Sudafed) 60 mg every 6 to 8 hours need to be “jump started”— Imipramine (Tofranil) 25-100 mg at bedtime who lack the ability to isolate Estrogen intravaginal cream 2 g twice weekly (Estrace, Premarin) and contract their pelvic floor muscles. Electrostimulation URGE INCONTINENCE seems to help. Then they go • Ditropan 2.5-5 mg 3 times a day on to more intensive biofeed- • Ditropan XL 5-15 mg daily back-assisted pelvic muscle • Oxytrol (transdermal) 3.9 mg patch twice weekly rehabilitation. (Urispas) 100-200 mg 3 or 4 times a day DAVILA: Some years ago, our (Detrol LA) 4 mg daily center compared voluntary (Levbid) 0.375 mg 2 times a day Kegel contractions with elec- Imipramine (Tofranil) 25-100 mg at bedtime trically stimulated Kegel Estrogen intravaginal cream 2 g twice weekly contractions at various fre- (Estrace, Premarin) quencies and found that vol- NOCTURIA untary Kegel contractions Desmopressin (DDAVP) 0.1-0.4 mg at bedtime are much stronger than stim- OVERFLOW INCONTINENCE ulated ones.3 Bethanechol (Urecholine) 20-100 mg every 6 hours for underactive detrusor causing LUBER: We conducted a sim- overflow incontinence ilar trial, with comparable findings.4 SAND: In the orthopedic area, people can and I published a paper describing a multi- have electrically stimulated contractions that modality approach to pelvic floor muscle reha- are maximized until they are equal in inten- bilitation using biofeedback and electrical stim- sity to voluntary contractions. Unfortunately, ulation. We showed that it is possible to reduce we can’t do that for the pelvic floor due to incontinence episodes by 90%.5 In a motivated limitations in the delivery system and the patient, that reduction can be maintained. electrodynamics of the currents being used. I can’t agree enough about the impor- LUBER: To use an analogy from psychoanaly- tance of a physiotherapist, whether that hap- sis, electrical stimulation is like a couch and pens to be a physical therapist or your nurse the physiotherapist is like the psychiatrist. or someone else who takes the time to instruct The couch doesn’t do much good without the patient on how to isolate and contract the the psychiatrist there. So we use electrical pelvic floor muscles. It really takes a team of stimulation to help patients recruit those people to address pelvic floor dysfunction, so muscles—and we use it in conjunction with that’s where we direct our focus. a physical therapist. Without the coaching SAND: Any other tips to give patients about and monitoring of the physical therapist, I pelvic floor rehabilitation? don’t think these patients are going to bene- LUBER: Yes. It’s a good idea to stress the impor- fit as much from electrostimulation. tance of moderation. If a sedentary person sud- DAVILA: A number of years ago, my colleagues denly decided to rehabilitate the muscles of her

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arms and set about doing 100 curls with 40-lb MYERS: We should start to obtain it. weights, the next day she would barely be able SAND: One of the things that concerns me to brush her teeth; her arm function would be greatly about postoperative Kegels is the fact worse than it was on day 1. And if one of our that patients don’t do them properly. If a patients decided to focus on the muscles of her woman is doing the Valsalva maneuver or pelvic floor and began with a similarly overzeal- increasing her intra-abdominal pressure ous program, she might actual- instead of contracting the lev- ly report that her stress inconti- ators, she may actually nence had worsened. So we do undermine the surgery rather need to warn patients that the than promote its effect. pelvic floor muscles can That’s the other side of using become extremely debilitated Kegel exercise therapy post- and advise them to start reha- operatively. bilitation slowly. DAVILA: But at the 6- or 8- MYERS: I agree. Otherwise week visit, you simply do an muscle fatigue develops. exam to see if she can per- SAND: Let’s talk a few form a Kegel properly. I tell moments about my patients, “We’re pelvic floor reha- I don’t see the justification for getting going to do the best bilitation follow- surgery we can do. ing surgery. Do all these patients to do pelvic floor Then you have you recommend it therapy without good data. to take care of to your patients— your repair.” That or is it only useful — Dr. Sand means avoiding as an alternative or straining and lim- prelude to surgery? iting lifting to 5 lb or so during the healing DAVILA: I think it is very important. Once an phase, doing pelvic floor exercises after 6 incontinence operation is finished, there is a weeks, and remaining careful about lifting on tendency to think the job is done. That is an a long-term basis. incorrect attitude. We see the patient at 3 If a patient cannot contract her pelvic months, 6 months, and yearly to make sure floor muscles at the postoperative visit, we she is doing her Kegels. While the impor- send her to our physiotherapist. Frequently, 1 tance of postoperative Kegel exercises and or 2 visits are enough for the patient to learn biofeedback has not been studied in depth, I to perform Kegels. think they are key to maintaining the success I do agree that if the patient is perform- of our surgical interventions. ing the Valsalva maneuver instead of con- MYERS: I agree. I think it’s a major weakness tracting her muscles, she can do more dam- of our field that we don’t promote pelvic floor age than good. But proper patient selection exercises postoperatively. After orthopedic and instruction should take care of that. procedures, physical therapy frequently is MYERS: If a patient is doing the Valsalva used, since there is an understanding that the maneuver every time I ask her to do a Kegel, muscles as well as the ligaments need to be I tell her not to do them at all. I say: “You are rehabilitated. This concept needs to be going to need additional help with this for addressed in pelvic floor reconstructive sur- the next 6 to 8 weeks. If you want to maxi- geries as well. mize your muscle strength, this is something SAND: But we have absolutely no data. that will be for your benefit.” CONTINUED

46 OBG MANAGEMENT • September 2003 Stress urinary incontinence: A closer look at nonsurgical therapies

As I said before, I think pelvic floor helping these patients maintain or improve rehabilitation is a very important compo- their pelvic floor tone. nent of incontinence treatment. Some investigators have emphasized ligament Occlusive devices: supports and fascial supports to control Effective yet poorly received incontinence, and other investigators SAND: Are occlusive devices a useful nonsurgi- emphasize muscular support. It is probably cal option? a combination of both. LUBER: A number of devices have become SAND: I have a different view. Although I available through the years but have had fairly would like to believe that sta- short half-lives on the market. bilizing the pelvic floor will I think that is because patients help protect the connective- often are hesitant to put some- tissue supports or the “imita- thing in their urethra on a tion” supports we have insti- daily basis. That may change tuted surgically, I don’t see the in the future, but in our justification for getting all patient population, it still these patients to do pelvic appears to be the rule. floor therapy without good It isn’t clear why women data demonstrating that fact. seem to be more comfortable LUBER: But I think we all with intravaginal devices than would agree that urethral occlusive simply resupport- Simply resupporting a patient’s urethra devices. I suspect it ing a patient’s ure- is unlikely to re-create the continence is because many thra is unlikely to women have had re-create the conti- mechanism that is compromised. some experience nence mechanism — Dr. Luber with tampons or that is compro- diaphragms, so a mised. pessary is not such a foreign concept as ure- For example, if we assessed urethral sup- thral occlusive devices seem to be. port in 100 parous women, 70% to 80% would MYERS: That has been our experience as have what we call hypermobility, but probably well. Patients even resist external obstructive only 15% would have stress incontinence.6 So devices. I was surprised at the poor reception there is something beyond hypermobility that the “patch” received. causes incontinence. Yet our surgical enterpris- DAVILA: We have all participated in clinical es focus exclusively on recreating urethral sup- trials of occlusive devices. In that scenario, port. One could argue that, since the sling cre- patients do pretty well, as long as they are ates support circumferentially, it is more being thoroughly monitored and followed. dynamic. Still, it does not address the neuro- When it comes to actual usage, however, muscular component. patients are not as successful as you might When an individual undergoes knee sur- expect them to be. So your comments are gery, it is almost intuitive that the muscular absolutely correct. support adjacent to the destabilized knee needs to be strengthened in addition to the surgery. Pharmacologic agents So, regardless of the absence of data on the role DAVILA: When it comes to conservative of pelvic floor rehabilitation in conjunction therapy early in the treatment process, the with surgery, I would stress the importance of type of incontinence may not be as impor-

48 OBG MANAGEMENT • September 2003 Stress urinary incontinence: A closer look at nonsurgical therapies tant as it is with surgery. The agents we are reuptake of serotonin and norepinephrine in discussing may bring about improvement in the spinal cord, it increases the activity of the women with stress or urgency symptoms. pudendal nerve, which in turn stimulates the But as you move beyond first-stage thera- urethral sphincter—thus reducing the leakage pies, you need to delve a bit of urine. Where this drug will further into the history to ultimately fit remains unclear, determine whether symptoms however. are primarily urgency-related Although the data show or stress-related in order to an improvement in SUI avoid prescribing a medica- compared with placebo, tion that may not be effective imipramine or duloxetine cer- for the patient’s type of incon- tainly doesn’t equal the effects tinence (TABLES 1 and 2). of surgical therapy or bulking SAND: That’s an important agents.8 So perhaps it will be point. What pharmacologic used for mild stress inconti- agents do you use nence or as an adjunct for stress inconti- for the patient who nence? And what Imipramine has anticholinergic continues to experi- developments do you properties, so it helps urgency symptoms ence leakage after foresee? surgical therapy. Other but also improves urethral resistance. DAVILA: I frequently alpha agonists—besides encounter the follow- — Dr. Myers pheny propanolamine ing scenario: A —are being studied as woman with stress we speak, but we do incontinence comes in for her initial visit not know whether their side effects will out- and reports that she is taking Detrol (toltero- weigh their potential benefit. If these agents dine tartrate) or Ditropan (oxybutynin chlo- pass the test, then we may have additional ride). The first thing I do is tell her that this drugs in the near future. ■ agent is not the appropriate medicine for her symptoms. Unfortunately, many clinicians REFERENCES 1. Nygaard I, DeLancey JOL, Arnsdorf L, Murphy E. Exercise and incontinence. are not aware of the differences between Obstet Gynecol. 1990;75:848-851. stress and urge incontinence. Thus, they 2. Bump RC, Hurt WG, Fantl JA, Wyman JF. Assessment of kegel pelvic muscle exercise performance after brief verbal instruction. Am J Obstet Gynecol. may prescribe the wrong medication for the 1991;165:322-327. patient. Since medications for overactive 3. Bernier F, Jenkins P, Davila GW. Does functional electrical stimulation elicit a pelvic floor muscle contraction? Presented at the American Urogynecologic Society bladder (urge incontinence) are widely Meeting in Tucson, Ariz, 1997. available, the scenario just mentioned is 4. Luber KM, Wolde-Tsadik G. The efficacy of functional electrical stimulation in treating genuine stress incontinence. A randomized clinical trial. Neurourol Urodyn. quite common. 1997;16:543-551. MYERS: 5. Davila GW, Bernier F. Multimodality pelvic physiotherapy treatment of urinary I offer patients the tricyclic antide- incontinence in adult women. Int Urogynecol J. 1995; 6:187-194. pressant imipramine, which is excellent for 6. Walters MD, Jackson GM. Urethral mobility and its relationship to stress inconti- people with incontinence symptoms. nence in women. J Reprod Med. 1990;35:777-784. 7. Norton PA, Zinner NR, Yalcin I, Bump RC. Duloxetine versus placebo in the treat- Imipramine has anticholinergic properties, ment of stress urinary incontinence. Am J Obstet Gynecol. 2002;187:40-48. so it helps urgency symptoms but also 8. Neimark M, Davila GW. New bulking agents for the treatment of ISD: the quest for permanence. Contemp Urol. 2002;3:34-48. improves urethral resistance—consequently, it can improve stress incontinence as well. DAVILA: Duloxetine is a new antidepressant The authors report no financial relationship with any companies whose that has been widely studied.7 By blocking the products are mentioned in this article.

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