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Current treatments for patients with stress urinary incontinence

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Stress urinary incontinence (SUI) has been defined as the complaint of involuntary leakage of urine on effort, exertion, sneezing or coughing (Abrams et al, 2002). It becomes known as urodynamically proven stress incontinence (USI) when filling cystometry (a test of bladder function) shows a rise in intra-abdominal pressure, without a detrusor muscle (bladder muscle) contraction, causing urine loss via the urethra.

Abstract

VOL: 100, ISSUE: 02, PAGE NO: 50

Jeanette Haslam, MPhil, GradDip(Phys), MCS, SRP, is senior visiting fellow, University of East London

 

Stress urinary incontinence (SUI) has been defined as the complaint of involuntary leakage of urine on effort, exertion, sneezing or coughing (Abrams et al, 2002). It becomes known as urodynamically proven stress incontinence (USI) when filling cystometry (a test of bladder function) shows a rise in intra-abdominal pressure, without a detrusor muscle (bladder muscle) contraction, causing urine loss via the urethra.

Prevalence of SUI
The absolute prevalence of stress urinary incontinence is difficult to determine because studies have used different definitions, measures, study designs and sampling procedures. Also, there is a scarcity of well-validated measures (Perry, 2002). However, it has been found that urinary incontinence is two to three times more prevalent in women than men (Monga, 2002). SUI is estimated to affect about four million women in the UK, with a prevalence rate of 20-30 per cent. However, only 7-12 per cent perceive it to be a problem (McGrother et al, 2001). The Continence Foundation (2000) has estimated that the cost of incontinence in the UK in 1998 was more than 423m a year. Causes of incontinence
Pregnancy and childbirth are acknowledged to be major factors for SUI. Obesity, smoking and the menopause have also been implicated (Monga, 2002). Chronic cough, smoking, constipation, lifting and pelvic surgery have also been associated with SUI (Bump & Norton, 1998). Damage to the muscle, fascia and/or nerve supply to the pelvic floor results in bladder neck hypermobility, decreased pelvic floor muscle activity and/or diminished urethral sphincter function - all of these factors can contribute to SUI. Health promotion strategies are contributing to the awareness of continence.

Assessment
Much has been written about the appropriate verbal and physical assessment of a person presenting with urinary incontinence (Laycock, 2002). Assessment is a prerequisite before any therapeutic intervention, and informed consent is essential before any examination or therapy. All patients should complete a frequency volume chart (a record of volumes and frequency of fluid intake and urinary output) that must be evaluated and discussed. Anyone presenting with irritative bladder symptoms must have a urinalysis to detect abnormal deposits in their urine that may be contributing to continence problems.

Conservative management of stress urinary incontinence
Pelvic floor muscle (PFM) exercises have underpinned the conservative management of SUI since Kegel popularised them in the 1940s (Kegel, 1948). More recently other holistic methods of PFM-activation involving the whole abdomino-pelvic cavity muscles have been advocated (Haslam, 2003). Different methods of rehabilitation of the PFMs aim to improve: - Strength; - Power; - Endurance; - Functionality. The rehabilitative process may include the use of self-vaginal assessment, vaginal cones, neuromuscular electrical stimulation (NMES), pressure and/or electromyogram (EMG) biofeedback, or other facilitation techniques. It is also accepted that women should be taught how to use a PFM contraction to increase intra-urethral pressure whenever they are at risk of urinary leakage (Miller et al, 1998). Motivation is essential for patient adherence. This requires negotiation, goal-setting and agreement on when PFM exercise should be practised (Chiarelli, 2002). The effectiveness of the therapeutic intervention may also depend on the knowledge and expertise of the therapist. It has been recommended that PFM training should last for 15-20 weeks to achieve an effect before any more invasive treatment (Royal College of Obstetricians and Gynaecologists (RCOG) 42nd Study Group on Incontinence in Women, 2002). After this time the patient should be referred for surgical review. This may be as a day patient or for an overnight stay and could involve tension-free vaginal tape surgery, or major surgery such as colposuspension procedure.

Devices for stress urinary incontinence
Various transvaginal devices have also been designed for use in the treatment of SUI, but as they are relatively expensive, many women do not use them daily but only for particular occasions. Transurethral devices are effective but are associated with discomfort, migration of the device, and high morbidity including haematuria and urinary tract infections (Anders, 2002). Also, many older women are embarrassed and do not like to use any devices that involve touching their own genitalia (Prashar et al, 2000). Women frequently use absorbent pads and are often continually anxious that they may have an offensive odour. This contributes to a decrease in quality of life, with some women reducing social and sexual relationships due to their urinary incontinence (Norton et al, 1988).

Drug therapy for stress urinary incontinence
Drug therapy has been used in the treatment of SUI. In the past, phenylpropanolamine or oestrogen therapy were prescribed for the treatment of SUI. Phenylpropanolamine has been withdrawn due to the risk of haemorrhagic stroke and there is a lack of conclusive evidence for the use of oestrogen therapy. However, duloxetine (a selective serotonin and noradrenaline reuptake inhibitor) should be available for the treatment of stress incontinence in the UK next year. It is necessary to understand the neurophysiology of the urethral sphincter to appreciate how duloxetine works (Box 1). A study by Norton et al (2002) demonstrated in a double-blind, randomised, placebo-controlled study over a 12-week period (n=553) that duloxetine was effective and safe to be prescribed for the treatment of SUI. Its effectiveness was dependent on dose - the study used 20-80mg daily. Although few women had their incontinence eliminated completely, they did have a decrease in frequency of episodes. Many women had a measurable improvement in their quality of life. The drug was generally well tolerated, although there were between nine and 15 per cent discontinuation rates (the higher the dosage, the higher the rate of adverse events). The most common adverse event was nausea.

Nurse prescribing and the management of SUI
The present list of prescription-only medicines for independent nurse prescribing includes those for the treatment of minor injuries and ailments such as constipation and haemorrhoids. However, no medicines are currently available in the Nurse Prescribers’ Formulary for the treatment of detrusor overactivity and SUI. Supplementary prescribing allows nurses to prescribe medicines to patients. Also, specialist continence nurses can at present supply medication, such as anticholinergic medication, antibiotics and oestrogen cream, within the auspices of their group protocol. Nurses require appropriate training in pharmacology, diagnostic skills and the ability to make clinical decisions before being able to prescribe and supply medicines.

Conclusion
Working on the principle that medicine is continually striving to advance and that specialist nurses and physiotherapists are increasingly taking on junior doctors’ roles, perhaps in the future specialist nurses and physiotherapists working in continence care will be able to prescribe appropriate medicines for patients. All health professionals concerned with continence care should be knowledgeable about current research so that patients receive accurate information on possible treatments, and so that health professionals can communicate effectively with one another. A new generation of drugs opens opportunities for the treatment of SUI, not necessarily in isolation but with other well-tried therapies. There will always be patients for which surgery is still appropriate, from the minimally invasive procedures such as vaginal tapes to major surgery such as colposuspension. However, medicines offer more weapons for the armoury in the battle against urinary incontinence.

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