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 • Imipramine (Tofranil) (also anticholinergic) 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 antidepressant 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.