There are now three RCTs that have reported on obese women with stress, urge and mixed urinary incontinence and determined that losing 5 to 10% of body weight by exercise plus a controlled diet consistently improved continence and quality of life. She also noted that pelvic floor muscle training (PFMT) and exercises (PFME) can be done at home with written instructions or with vaginal weights or taught in an office setting throughvaginal palpation or biofeedback. But how the clinician chooses the method, home or office PFMT, depends on practicality and feasibility, as age may be a factor. Home PFMT is performed without supervision while office PFMT requires the patient make multiple visits, so there are advantages and disadvantages to these two settings. Strengthening of the pelvic floor muscle (PFM) will not necessarily always improve a patient's incontinence. There are numerous studies that have compared the efficacy of vaginal weights and/or biofeedback with PFME alone, however, very few recent studies. It is important to understand the practical implication of teaching PFMEs as many patients benefit from some type of feedback for teaching and understanding how to contract the muscle. If the patient is going to perform these at home, well-written instructions are needed and must be written at the level of the patient's comprehension. The cost of vaginal weights vary from $60 to $120. However, according to Medicare requirements, office biofeedback requires that the patient has failed PFMEs without feedback. Dr. Erickson noted that increasing PFM strength is not the only intervention as it is necessary to also teach the “knack,” an intentional PFM contraction. The patient is taught to contract the PFM before the event that caused the UI, e.g. if they leak urine when coughing, the muscle should be quickly contracted prior to the cough.
[refs: Caruso DJ, Gomez CS, Gousse AE. Medical management of stress urinary incontinence: is there a future? Curr Urol Rep. 2009 Sep;10(5):401-7.
Gameiro MO, Moreira EH, Gameiro FO, Moreno JC, Padovani CR, Amaro JL. Vaginal weight cone versus assisted pelvic floor muscle training in the treatment of female urinary incontinence. A prospective, single-blind, randomized trial. Int Urogynecol J Pelvic Floor Dysfunct. 2010 Apr;21(4):395-9.
Ranasinghe WK, Wright T, Attia J, McElduff P, Doyle T, Bartholomew M, Hurley K, Persad RA. Effects of bariatric surgery on urinary and sexual function. BJU Int. 2011 Jan;107(1):88-94
Subak LL, Richter HE, Hunskaar S. Improving urinary incontinence in overweight and obese women through modest weight loss. Obesity and urinary incontinence: epidemiology and clinical research update. J Urol. 2009 Dec;182(6 Suppl):S2-7
Subak LL, Wing R, West DS, Franklin F, Vittinghoff E, Creasman JM, Richter HE, Myers D, Burgio KL, Gorin AA, Macer J, Kusek JW, Grady D; PRIDE Investigators. Weight loss to treat urinary incontinence in overweight and obese women. N Engl J Med. 2009 Jan 29;360(5):481-90
Wing RR, Creasman JM, West DS, Richter HE, Myers D, Burgio KL, Franklin F, Gorin AA, Vittinghoff E, Macer J, Kusek JW, Subak LL; Program to Reduce Incontinence by Diet and Exercise. Improving urinary incontinence in overweight and obese women through modest weight loss. Obstet Gynecol. 2010 Aug;116(2 Pt 1):284-92
Wing RR, West DS, Grady D, Creasman JM, Richter HE, Myers D, Burgio KL, Franklin F, Gorin AA, Vittinghoff E, Macer J, Kusek JW, Subak LL; Program to Reduce Incontinence by Diet and Exercise Group. Effect of weight loss on urinary incontinence in overweight and obese women: results at 12 and 18 months. J Urol. 2010 Sep;184(3):1005-10.
Wyman, J.F., Burgio, K.L., Newman, D.K. Practical aspects of lifestyle modifications and behavioural interventions in the treatment of overactive bladder and urgency urinary incontinence. International Journal of Clinical Practice: 2009;63(8): 1177–1191.]
Dr Erikson went on to note that they are no FDA approved drugs for stress UI, however some are used off-label. The purpose of any drug for stress UI would be to stimulate the urethral alpha-adrenergic receptors. Drug categories include sympathomimetic amines. Phenylpropanolamine is no longer available because of the increased drug risks and the FDA has restricted it as an ingredient in medications. Sudafed might also increase drug risk but no formal studies. Duloxetine, a norepinephrine reuptake inhibitors was better in placebo controlled trials but the FDA application for this drug was withdrawn due to increased risks of suicidal thoughts. Duloxetine might be an option if the patient has both depression and fibromyalgia, in addition to stress UI. Imipramine improves symptoms caused by poor urethral closure pressure in uncontrolled studies, but no specific studies on this drug have been performed. If used, patients, especially elderly patients, need careful monitoring and the benefit of this drug may not outweigh its adverse events.
[refs: Cardozo L, Lange R, Voss S, Beardsworth A, Manning M, Viktrup L, Zhao YD. Short- and long-term efficacy and safety of duloxetine in women with predominant stress urinary incontinence. Curr Med Res Opin. 2010 Feb;26(2):253-61.
Knadler MP, Lobo E, Chappell J, Bergstrom R. Duloxetine: clinical pharmacokinetics and drug interactions. Clin Pharmacokinet. 2011 May 1;50(5):281-94
Vij M, Robinson D, Cardozo L. Emerging drugs for treatment of urinary incontinence. Expert Opin Emerg Drugs. 2010 Jun;15(2):299-308
Vaginal or urethral devices for stress UI are available, and tampons and incontinence pessaries may provide urethral support. These are vaginal devices that support the bladder neck to prevent stress UI. A super tampon may be equal or better than pessary for urine loss with exercise. The Atlas study (Richter, 2010) randomized women with stress UI to either an incontinence pessary or behavioral treatment program. 
Results showed no difference between the groups as combination therapy was not superior to single-modality therapy. There have been several urethral devices or inserts studies over the years. The one currently available includes the Femsoft. Their acceptance in clinical practice has been very low. It takes time to teach a patient to use the urethral insert and they only are ideal for patients with exercised induced stress UI.
The next topic present by Dr Erickson was PRMEs for pelvic organ prolapse (POP). There two RCTs comparing PFMT (home exercises) and a control (written instructions only) group diary. A pessary has been used for centuries as a conservative device to treat POP. Ideally, the patient should be able to remove and replace it and most come to be seen regularly. Women with an intravaginal device need to be on transvaginal estrogen, Adverse events of the pessary include vaginal discharge, ulceration, fistula or new onset bladder or bowel symptoms as the pessary may lift the prolapse and unmask these symptoms. Most clinicians start with a ring pessary. To insure proper fit, the clinician should sweep a finger between the pessary and the vaginal wall to insure that it will not cause trauma to the vaginal mucosa. Patients should stand, sit, and bend over to see if it becomes dislodged. Patents are asked to valsalva and void with the pessary in place prior to leaving the office. If a ring pessary does not provide support, others such as a Gellhorn may be used.
[refs: Atnip SD. Pessary use and management for pelvic organ prolapse. Obstet Gynecol Clin North Am. 2009 Sep;36(3):541-63
Braekken IH, Majida M, Engh ME, Bø K. Can pelvic floor muscle training reverse pelvic organ prolapse and reduce prolapse symptoms? An assessor-blinded, randomized, controlled trial. Am J Obstet Gynecol. 2010 Aug;203(2):170.e1-7
Hagen S, Stark D, Glazener C, Sinclair L, Ramsay I. A randomized controlled trial of pelvic floor muscle training for stages I and II pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct. 2009 Jan;20(1):45-51.
Kuncharapu I, Majeroni BA, Johnson DW. Pelvic organ prolapse. Am Fam Physician. 2010 May 1;81(9):1111-7
Richter, H.E., Burgio, K.L., Brubaker, L., Nygaard, I.E., Ye, W., Weidner, A., Bradley, C.S., Pelvic Floor Disorders Network. Continence pessary compared with behavioral therapy or combined therapy for stress incontinence: a randomized controlled trial. Obstet Gynecol. 2010; 115(3):609-17.
Shaikh, S., Ong, E.K., Glavind, K., et al. Mechanical devices for urinary incontinence in women. Cochrane Database of Syst Rev 2006;2:CD001756.]
Presented by Deborah Erickson at the Society for Urodynamics and Female Urology (SUFU) 2011 Winter Meeting - March 1 - 5, 2011 - Arizona Biltmore, Phoenix, Arizona, USA
Reported for UroToday by Diane K. Newman, RNC, MSN, CRNP, FAAN and Continence Nurse Practitioner Specialist - University of Pennsylvania Medical Center.
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