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n e w e ng l a n d j o u r na l
of
m e dic i n e
clinical practice
A 45-year-old woman reports losing urine with coughing, laughing, or sneezing since
the birth of her last baby. She has been unable to lose the 25 lb (11 kg) that she gained
after her pregnancy 6 years ago. She voids every 3 hours and reports no urinary urgency or nocturia. Her incontinence keeps her from participating in her exercise class,
and she leaks urine during sexual intercourse. Her body-mass index (BMI, the weight
in kilograms divided by the square of the height in meters) is 28, and a routine pelvic
examination is normal. How should she be evaluated and treated?
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The
n e w e ng l a n d j o u r na l
S t r ategie s a nd E v idence
Evaluation
of
m e dic i n e
1. During the past 3 months, have you leaked urine (even a small amount)?
Yes
No
Questionnaire completed
2. During the past 3 months, did you leak urine:
(Check all that apply.)
a. When you were performing some physical activity, such as coughing, sneezing, lifting, or exercise?
b. When you had the urge or the feeling that you needed to empty your bladder, but you could not get to the toilet fast enough?
c. Without physical activity and without a sense of urgency?
3. During the past 3 months, did you leak urine most often:
(Check only one.)
a. When you were performing some physical activity, such as coughing, sneezing, lifting, or exercise?
b. When you had the urge or the feeling that you needed to empty your bladder, but you could not get to the toilet fast enough?
c. Without physical activity and without a sense of urgency?
d. About equally as often with physical activity as with a sense of urgency?
Definitions of types of urinary incontinence are based on responses to question 3:
Response to Question 3
Type of Incontinence
Stress-only or stress-predominant
Urge-only or urge-predominant
Other-cause-only or other-cause-predominant
Mixed
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AUTHOR: Rogers
RETAKE
FIGURE: 1 of 3
1st
2nd
3rd
Revised
Line
4-C
SIZE
ARTIST: ts
H/T
H/Tmarch 6, 2008
n Enon
engl j med 358;10 www.nejm.org
Combo
33p9
EMail
clinical pr actice
M a nage men t
Absorptive Devices
Absorptive products such as pads play an important role in the care of women with stress incontinence. Because of their lower cost and lesser
stigma, many women use sanitary napkins or
minipads in lieu of incontinence pads; however,
the latter are more effective for patients with incontinence. In a randomized trial comparing a
variety of incontinence products, patients preferred incontinence pads to menstrual pads, although the cost of incontinence pads was greater.20 For women with large urine losses, disposable
products may be associated with fewer skin problems than nondisposable products.20 Cleaning the
urogenital area with premoistened wipes made
for adults helps to control odor; adult wipes are
larger, and more brands contain odor-reducing
and skin-care ingredients.
Behavioral and Physical Therapy
First-line treatment for stress incontinence includes pelvic floor exercises (contractions of the
pelvic floor musculature) and various behavioral
modifications. Perception of a cure is more common in women who perform pelvic floor exercises
than in those who do not.21 Although recommendations regarding the number of repetitions necessary for treatment vary widely, efficacy has been
shown with 30 to 50 daily contractions.22,23 In a
small, randomized trial, women who were trained
to perform a pelvic floor contraction in anticipation of a cough, sneeze, or laugh had less urine
loss than women who did not perform a contraction.24 Not all women are able to perform pelvic
floor exercises correctly with oral instructions.
Women can be coached on how to perform exercises during an annual pelvic bimanual examination. Women unable to identify their pelvic floor
musculature may benefit from seeing a physical
therapist trained in pelvic floor therapy. Performance of pelvic floor exercises is not recommend
ed during voiding, because frequent interruptions
of voiding may cause voiding dysfunction, and the
ability to stop the flow of urine intermittently
does not confirm that exercises are performed
correctly.
For obese or overweight women, weight loss is
likely to result in improvement in incontinence.
In a small trial, obese women who were random
ly assigned to a liquid weight-loss diet had a
significantly greater reduction in incontinence
frequency than did controls whose treatment was
delayed. A reduction of 5 to 10% in the baseline
weight resulted in an approximately 50% reduction in the frequency of incontinence.11 Other
modifications to diet and habits, including the cessation of smoking and reduction of caffeine intake, have no proven efficacy in reducing incontinence but are commonly recommended.
Medications
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The
n e w e ng l a n d j o u r na l
of
m e dic i n e
receive estrogen alone or estrogen and progesterone than among those assigned to receive placebo.27 Given these results, the initiation of hormone therapy for treatment of stress incontinence
is not indicated.
Devices
Devices that treat stress incontinence include tampons and pessaries. Pessaries are intravaginal
devices that support the pelvic organs (Fig. 2).
Incontinence pessaries have knobs that sit under
the urethra to increase urethral support. Pessaries require upkeep and need to be removed and
cleaned regularly; the risks associated with use
are minimal but include erosion of vaginal tissue
and vaginal discharge. Because pessaries come in
a variety of shapes and sizes, they must be fitted
for comfort and to optimize the relief of symp-
Types of Pessaries
COLOR FIGURE
Figure 2. Pessaries for Treating Stress Incontinence.
3
2/05/08
Incontinence pessaries have knobs that sit under the urethra to increase urethral support. In the inset, various types Draft
are shown
(clockwise
Rogers
Author
from top left): an incontinence dish with support, an incontinence dish without support, an incontinence ring with
support
and
knob,
Fig #
2
and an incontinence ring without support.
Pessary Placement
Title
ME
Solomon
KMK
DE
Artist
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Issue date
3/06/08
clinical pr actice
A
Pubic
symphysis
Burch Colposuspension
Urethra
Coopers ligament
Vagina
Bladder
Uterus
Fascial Sling
Tape
Sling
2/14/08
Rogers
3
Surgical Treatment Options
ME
DE
Artist
Solomon
KMK
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The
n e w e ng l a n d j o u r na l
A r e a s of Uncer ta in t y
Definition of Cure
Reported cure rates associated with surgical treatment of stress incontinence by means of Burch
colposuspension, suburethral sling, tension-free
vaginal tape, or transobturator tape range widely,
from 30% to 100%.34 This wide variation relates
in part to the use of varying definitions of cure.
Traditionally, cure for stress incontinence was
defined as no loss of urine on either urodynamic
or pad testing and was determined by the treat-
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of
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clinical pr actice
already been approved. The potential risks associated with this process are evidenced by the experience with the ProteGen sling, which was
widely implanted in women before clinical trials
were conducted. Subsequent reports showed erosion of the sling into vaginal tissue in up to 30%
of women after 5 months of use, and it was ultimately removed from the market.44 An additional
concern related to the 510(k) device-approval process is that the reporting of adverse events and
complications is voluntary and probably underrepresents the true incidence. Until peer-reviewed
comparative data are available, caution is warrant
ed in the adoption of new devices, and patients
should be informed that the data available to guide
the use of many new techniques are limited.
Guidel ine s
The International Continence Society, the American Urogynecologic Society, and the Society of
Gynecological Surgeons issued a statement standardizing terminology related to pelvic floor disorders, including urinary incontinence, and outlined the recommended assessment; the current
review is generally consistent with these recommendations.18 The American College of Obstetricians and Gynecologists has published practice
guidelines for the care of women with urinary
incontinence, although not stress incontinence
specifically.45 In 1997, the American Urological
Association published recommendations for surgical management of stress incontinence,46 but
these antedate recent randomized trials of surgical interventions.
C onclusions
a nd R ec om mendat ions
The loss of urine while coughing, sneezing, or engaging in physical activity, as reported by the patient in the vignette, is characteristic of stress
incontinence. I would perform a physical examination, including a cough stress test, and urinalysis and assessment of post-void residual volume
of urine. Assuming the urinalysis results and the
residual volumes are normal, I would instruct the
patient in behavioral changes and pelvic-floor exercises. Specifically, I would ask the patient to
complete a voiding diary, which I would review
with her to assess whether she is drinking excessive amounts of fluids and to evaluate her voiding
habits. During the physical examination, I would
make sure that she knows how to perform pelvic
floor exercises and instruct her to work toward
performing 30 to 50 such exercises daily. Weight
loss may reduce her incontinence symptoms and
should be encouraged. For times when she is
physically active, an incontinence pessary may be
helpful. I would also discuss surgical treatment
as an alternative to behavioral or device therapies.
I would explain that surgical treatment would
probably result in improved quality of life and
sexual function and would be expected to decrease
considerably, but not completely eliminate, all
symptoms of incontinence.
Dr. Rogers reports receiving lecture fees for serving as a course
director at a symposium at an annual meeting of the American
Urogynecologic Society; consulting fees and research support
from Pfizer; and consulting fees from Novartis Pharmaceuticals.
No other potential conflict of interest relevant to this article was
reported.
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