Running head: STRESS INCONTINENCE

Stress Incontinence Tara Stephen Midwives College of Utah

STRESS INCONTINENCE Abstract Many women suffer from stress urinary incontinence, generally caused from a weakening of the

muscles that control urine flow or that suspend the urinary bladder. There are multiple treatment options available to these women including lifestyle changes, pelvic floor exercises, herbal and homeopathic remedies, and medical modalities. It is important to have a complete diagnosis before beginning treatment, and all treatment should begin with the least interventive methods.

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The standardization subcommittee of the International Continence Society defines female stress urinary incontinence (SUI) as the complaint of involuntary leakage of urine on effort or exertion, or on sneezing or coughing (Moore, Serels, & Davila, 2008). SUI appears to affect at least 25% of women between the ages of 30 and 60 years (Moore et al., 2008). Slack, Jackson, & Wein list the classifications of urinary incontinence as (2008): Extraurethral o Fistula (vesico-, uretero, urethrovaginal) o Ectopic urethra Urethral o Functional Due to physical disability Due to lack of awareness or concern o Postvoid dribbling Urethral diverticulum Vaginal pooling of blood o Outlet underactivity Genuine stress urinary incontinence Lack of urethral support Hypermobility, deficient hammock Intrinsic sphincter deficiency Neurological disease/injury Fibrosis Urethral instability o Bladder overactivity Involuntary contractions Neurological disease/injury Bladder outlet obstruction Afferent activation (including inflammation/infection) Idiopathic Decreased compliance Neurological disease/injury Fibrosis Idiopathic Combination of the above o Overflow incontinence

Stress urinary incontinence falls under the Outlet Underactivity category, but there are many factors that may contribute to its development. Most SUI is due to a weakening of the pelvic floor muscles. As these muscles lose tone, the abdominal and pelvic organs begin to

STRESS INCONTINENCE prolapse, causing a slack in the mid-urethra, leading to dysfunction of the rhabdosphincter,

which is critical for maintaining continence (Jankowski, Pruchnic, Wagner, & Chancellor, 2008). One of the most common causalities of SUI is pregnancy. The enlarged uterus and fetus exert pressure on the bladder and urethra as the pregnancy progresses. This pressure stretches and can weaken the pelvic floor and damage nerves. Typically once the pregnancy has ended the SUI will resolve. However, SUI associated with pregnancy is a predictor for postpartum incontinence, as well as a risk factor for continued stress incontinence five years after delivery (Slack et al., 2008). There is also growing evidence that not only the pregnancy, but also the mode of delivery is predisposing women to SUI. Cesarean delivery offers the least correlation with SUI, followed by vaginal and forceps deliveries (Slack et al., 2008). Birth weights higher than 4 kg (8 lbs 13 oz) have also been associated with increased SUI (Slack et al., 2008), as has higher parity (Incontinence, 2011). Along these same lines, obesity has also been shown to increase the occurrence of SUI. The effects of obesity are similar to those of pregnancy and include increased pressure to the urinary tract and organs causing chronic strain, stretching, and weakening of the pelvic floor muscles and nerves (Slack et al., 2008). An abdominal mass may cause the same physiological changes and also contribute to SUI (Frye, 2010). Other factors that may be an issue in SUI are smoking and chronic lung disease, due to the repeated increased internal pressure created during coughing, and anorexia nervosa or hyperemesis gravidarum, again due to the increased internal pressure created during vomiting. Menopause has also been shown to be associated with a higher incidence of SUI. It has been theorized that the low estrogen level in menopause is the causative factor. However, hormone replacement therapy has failed to improve symptoms (Slack et al., 2008).

STRESS INCONTINENCE Finally, a change in the make-up of the abdominal cavity, such as occurs with hysterectomy, has also been associated with SUI (Frye, 2010).

There are many treatments for SUI, but before treatment can begin, it is important that an accurate diagnosis is made. Diagnosis of any urinary incontinence should begin with a detailed health history. It should also include a urodynamic assessment and evaluation of all symptoms (Slack et al., 2008). Once a diagnosis of SIU has been made, treatment should begin conservatively. Lifestyle changes are the first step in treating SIU. Strides should be made in improving overall health. Weight reduction, smoking cessation, and eliminating caffeine are important steps in improving general health and are helpful in reducing the symptoms of SUI. It is also important to receive treatment for chronic cough or any other exacerbating conditions such as constipation (Slack et al., 2008). Secondly, exercises to improve the tone of the pelvic floor muscles must be incorporated. Studies have shown that these pelvic floor exercises, also known as Kegels, are not only beneficial, but also curative in up to 73% of women (Nygaard, Kreder, Lepic, Fountain, & Rhomberg, 1996) (Dinc, Beji, & Yalcin, 2008) (Neumann, Grimmer, Deenadayalan, 2006). Combining pelvic floor exercises with adjunctive therapies may provide up to 97% improvement in symptoms (Neumann et al., 2006). Using weighted cones may help improve the efficacy of the pelvic floor exercises, at least during the learning period (Riley, 2012). There is further evidence that squatting exercises are also effective in improving the symptoms of SUI (Contursi, 2011). It was believed for a long time that as SUI is most often due to a structural issue, herbal and homeopathic remedies would not be beneficial. However, there is some evidence now to the

STRESS INCONTINENCE contrary. Horsetail may help with connective tissue integrity, thereby increasing the tone of the pelvic floor. Plantain and marshmallow have also been suggested in SUI treatment. Beneficial homeopathic remedies may include Causticum and Sepia (Urinary Incontinence, n.d.). There are many medical modalities of treatment for SUI including pessaries, urethral inserts, medications, intravaginal electrical stimulation and pelvic floor physiotherapy, periurethral injections, regeneration of sphincter, extracorporeal magnetic innervation (ExMI), and various surgeries. Pessaries are ring-shaped devices that are fitted and placed in the vagina to provide support (Stress Incontinence, 2010). They may be effective in treating SUI due to organ prolapse, however, most patients found them undesirable (Thys, Roovers, Geomini, & Bongers, 2012). Urethral inserts are disposable devices inserted into the urethra (Stress Incontinence,

2010). The inserts act as a plug to prevent leakage, much like a tampon. They are generally only used to prevent incontinence during an activity, but could be worn at any time in the day. They are not meant to be worn 24 hours a day, however. Again, for a long time medications were not considered beneficial in treating SUI as the etiology is structural. However, studies have shown that serotonin and norepinephrine increase the tone of the urinary rhabdosphincter, thereby preventing urinary leakage (Yashiro, Thor, & Burgard, 2010). Serotonin and norepinephrine reuptake inhibitors have been used successfully to treat SUI (Kielb, 2005). Mariappan, Ballantyne, NDow, & Alhasso showed that the drug duloxetine is beneficial in treating SUI (2005). It is unclear, however, if the benefits shown are sustainable. The drug venlafaxine has also been shown to have clinical efficacy in treating SUI (Erdinc et al., 2009). Alternative treatments for increasing serotonin levels are also beneficial in

STRESS INCONTINENCE treating SUI. L-tryptophan, ginkgo biloba, kava, St. Johns Wort, sceletium, and licorice have all been shown to increase serotonin levels (Natural Alternative to Serotonin Reuptake Inhibitors, 2011) (Contursi, 2011). Exercise has also long been known to increase levels of serotonin and elevate mood. Another treatment method for SUI is intravaginal electrical stimulation. During this treatment, electrical current of frequencies below 12 Hz stimulate the pudendal nerve, which may inhibit the detrusor muscle and reduce involuntary contractions (Amaro, J. L., Oliveira Gameiro, & Padovani, 2005). Electrical stimulation also works passively in making the subject more conscious of their perineal muscles. This method has been shown to be effective in

treating SUI and may be more desirable to patients than some more invasive methods (Amaro et al., 2003). In periurethral injections, bulking agents such as collagen are used to bulk up the tissue surrounding the urethral sphincter (Incontinence, 2011). This bulk exerts more pressure on the urethra, making it easier to keep closed (Stress Incontinence, 2010). The main benefit of this procedure is that it is done in an outpatient setting under local anesthesia. The drawback to this procedure is that it may have limited effectiveness and may need to be repeated multiple times. The success rate has been listed as 10 30% cure (Incontinence, 2011). Sakamoto, Sharma, & Wheeler, found that periurethral collagen injections appear to be beneficial (2007). Regeneration of sphincter is currently one of the more innovative treatments in SUI. In studies involving regeneration of sphincter it was found that transplanted muscle and/or stem cells may have the ability to undergo self-renewal and multipotent differentiation, leading to sphincter regeneration, (Jankowski et al., 2008).

STRESS INCONTINENCE Extracorporeal Magnetic Innervation (ExMI) is a noninvasive, effective, and painless treatment for SUI. During treatment, the patient sits on a chair with a pulsing magnetic field generator in the seat. The generator produces a rapidly changing magnetic field, and

consequently an electric current within the field. This current is then induced into the tissue that is adjacent to the magnetic field. The tissues within the human body do not all have the same properties for conducting electricity. Nerves, as the bodys means of conducting electric currents, are the most sensitive tissues to this electrical depolarization. Consequently, the fluctuating magnetic field will cause a propagating impulse in a motor nerve, releasing neurotransmitters at the motor end plates. This in turn provokes muscle contraction thereby toning the pelvic floor muscles (Galloway, et al., 1999). Not only has this approach been shown have a success rate of over 77% at three months, but it also has the added benefits of being completely noninvasive, not even requiring the patient to undress (Dilmen, Perk, Soyupek, Tkel, & Ekinci, 2008) (Galloway, et al., 1999). It has also been shown to have continued benefits until the first year after treatment, with the effects gradually decreasing at the second year after treatment (Dilmen et al., 2008). There are many surgical methods used in treating SUI. Although many of the methods show great success, other treatment options should be considered and utilized before choosing surgery due to the potential side effects of the procedures. The Urology Care Foundation lists the potential side of effects of surgically treating SUI as bleeding, infection, pain, urinary retention or voiding difficulties, de novo urgency, pelvic organ prolapse, and failure of surgery to fix leakage, (Incontinence, 2011). On the plus side, the risk of erosion of the material into the tissues is now very small since they began using a monofilament polypropylene knitted mesh as the tape rather than cadaverous or autologus tissue (Incontinence, 2011) (Slack et al., 2008).

STRESS INCONTINENCE One method of surgical intervention is retropubic colposuspension. In this method, abdominal surgery is performed in which the vaginal or periurethral tissues are fastened to the

pubic bone. The long-term results for this surgery are positive, however this is major abdominal surgery, which carriers a greater risk and longer recovery time (Incontinence, 2011). This procedure can be performed laparoscopically, although the results have not been typically as good as with the open surgery (Incontinence, 2011). Sling surgical methods have mostly replaced the retropubic colposuspension unless abdominal surgery is needed for another reason. The sling techniques include the retropubic, transobturator, and single incision methods (Moore et al., 2008). In the retropubic (RP) technique, tension-free vaginal tape (TVT) made of the monofilament polypropylene knitted mesh is introduced with a needle vaginally and guided behind the pubic bone. It then exits suprapubically. The tape then provides mid-urethral support. This procedure is performed as an outpatient surgery under local anesthetic. There is potential for significant complications with this procedure. Complications include urinary retention, pain, de novo urge symptoms, and rare but serious complications such as bladder or bowel perforation or injuries to the urethra, major vessels, or nerves. These complications are due to the blind passage of the needle through the RP space. This method is successful however, with an 85% cure rate at 56 months following treatment (Moore et al., 2008). The transobturator (TO) method uses the same TVT as the RP method to provide midurethral support. However the procedure differs from the RP method. In this procedure, needles are introduced through the groin via the obturator foramen. The needles remain below the endopelvic fascia and do not enter the RP space or abdominal cavity thereby introducing less risk. Additionally, the TO sling lies in a position similar to that of the pubourethral ligament. As

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it is in a more natural support position, it is theorized that there will be less voiding dysfunction or obstruction as compared to the RP slings. Studies have shown the cure rates to be between 85 and 95% (Moore et al., 2008). Additionally, there seem to be fewer complications as compared with RP. There has been some groin pain associated with this surgery, sometimes even longterm pain, however, the incidence of pain seems to be much less with the outside-in approach as opposed to an inside-out approach (Moore et al., 2008). Finally there is the single-incision mini sling method of surgical treatment for SUI, which came on the market in 2007. In this technique, a mini-sling made of the TVT is used. The TVT is either U-shaped to mimic the TO tape position, or V-shaped to mimic the RP tape position. A metal trocar attached to the ends of the mesh pass the tape either through the RP space or the obturator fascia and muscle. The trocar enters and exits through the same incision, reducing surgical damage and risk. The short term results of this method are not as good as those of the RP or TO method and are reported at 69 83%. As this technique is newer than the others, there is limited data about the long-term efficacy of the procedure (Moore et al., 2008). There are many treatment options for SUI available to the more than 25% of women who suffer with this malady. Lifestyle changes, pelvic floor exercises, and herbal and homeopathic remedies should always be among the first course of action when treating SUI. If these changes are ineffective or less effective than desired, medical options including pessaries, urethral inserts, medications, intravaginal electrical stimulation and pelvic floor physiotherapy, periurethral injections, regeneration of sphincter, extracorporeal magnetic innervation (ExMI), and various surgeries.

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STRESS INCONTINENCE Dinc, A., Beji, N. K., & Yalcin, O. (2008). Effect of pelvic floor muscle exercises in the treatment of urinary incontinence during pregnancy and the postpartum period. International Urogynecology Journal, 20(10), 1223-1231.

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Erdinc, A., Gurates, B., Celik, H., Polat, A., Kumru, S., & Simsek, M. (2009). The efficacy of venlafaxine in the treatment of women with stress urinary incontinence [Abstract]. Archives of Gynecology and Obstetrics, 279(3), 343-348. Frye, A., (2010). Healing passage: A midwifes guide to the care and repair of the tissues involved in birth. Portland, Oregon: Labrys Press. Galloway, N. T. M., El-Galley, R. E. S., Sand, P. K., Appell, R. A., Russell, H. W., & Carlan, S. J. 1999. Extracorporeal magnetic innervation therapy for stress urinary incontinence. Urology, 53(6), 1108-1111. Jankowski, R., Pruchnic, R., Wagner, D., & Chancellor, M. B. (2008). Regenerative therapy for stress urinary incontinence [Abstract]. Tzu Chi Medical Journal, 20(3), 169-176. Kielb, S. J. (2005). Stress incontinence: Alternatives to surgery. International Journal of Fertility and Womens Medicine, 50(1), 24-29. Mariappan, P., Ballantyne, Z., NDow, J. M., & Alhasso, A. A. (2005). Serotonin and noradrenaline reuptake inhibitors (SNRI) for stress urinary incontinence in adults [Abstract]. Cochrane Database Syst Rev, 20(3), CD004742. Moore, R. D., Serels, S. R., & Davila, G. W. (2008). Minimally invasive treatment for female stress urinary incontinence. Obstetrical Gynecology, 3(2), 257-272. Neumann, P. B., Grimmer, K. A., Deenadayalan, Y. (2006). Pelvic floor muscle training and adjunctive therapies for the treatment of stress urinary incontinence in women: A systematic review. BMC Womens Health, 6(11), 1-28.

STRESS INCONTINENCE Nygaard, I. E., Kreder, K. J., Lepic, M. M., Fountain, K. A., & Rhomberg, A. T. (1996).

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Efficacy of pelvic floor muscle exercises in women with stress, urge, and mixed urinary incontinence [Abstract]. American Journal of Obstetrics and Gynecology, 174(1), 120125. Riley, J. (2012). Urinary incontinenceFemale. Conditions & Procedures InBrief. Retrieved from: http://web.ebscohost.com/chc/detail?sid=d8798d80-1df1-4539-80418f246c0c1bce%40sessionmgr111&vid=5&hid=118&bdata=JnNpdGU9Y2hjLWxpdmU %3d#db=cmh&AN=HL11481 Sakamoto, K., Sharma, S., & Wheeler, J. S. (2007). Long-term subjective continence status and use of alternative treatments by women with stress urinary incontinence after collagen injection therapy [Abstract]. World Journal of Urology, 25(4), 431-433. Slack, A., Jackson, S., & Wein, A. (2008). Fast facts: Bladder disorders. Oxon, United Kingdom: Health Press Limited. Thorp, J. M., Stephenson, H., Jones, H., & Cooper, G. (1994). Pelvic floor (Kegel) exercises A pilot study in nulliparous women. The International Urogynecology Journal, 5, 86-89. Thys, S. D., Roovers, J. P., Geomini, P. M., & Bongers, M. Y. (2012). Do patients prefer a pessary or surgery as primary treatment for pelvic organ prolapse [Abstract]. Gynecologic and Obstetric Investigation, 74, 6-12. Varney, H., Kriebs, J. M., & Gegor, C. L. (2004). Varneys Midwifery: Fourth Edition. Sudbury, MA: Jones and Bartlett Publishers. Yashiro, K., Thor, K. B., & Burgard, E. C. (2010). Properties of urethral rhabdosphinceter motoneurons and their regulation by noradrenaline. The Journal of Physiology, 588, 4951-4967. doi:10.1113/jphysiol.2010.197319