Stress urinary incontinence and overactive bladder syndrome: current options and new targets for management

In the United States, office visits for women seeking treatment for urinary incontinence more than doubled between 1994 and 2000, from 1845 per 100 000 women. This review article addresses treatment options for 2 common types of incontinence in women: stress urinary incontinence (SUI) and detrusor overactivity (DO), commonly referred to as urge urinary incontinence (UUI). In the past, those with SUI typically faced limited treatment options, such as Kegel exercises, pessaries, or major surgery (Burch or Marshall-Marchetti-Krantz operations). However, treatment options for women also included anticholinergic medications, behavioral therapy, and implantable neuromodulation. In recent years, more options have become available. For women with SUI, a variety of minimally invasive synthetic midurethral sling approaches (eg, retropubic, transobturator, and single incision) and office-based procedures (eg, periurethral injection of bulking agents and radiofrequency collagen denaturation [Renessa?; Novasys Medical]) are now offered. More outpatient options will hopefully be available soon, including an inflatable, free-floating balloon to act as a shock absorber, and injection of muscle-derived stem cells into the periurethral tissue. Women with UUI now have targeted options, such as posterior tibial nerve stimulation (PTNS) and intravesical injections of onabotulinumtoxinA (Botox?; Allergan, Inc.), in addition to nonoral systemic medications.     

56例中年女性尿失禁患者的尿流动力学分析

目的 研究中年女性(35～55岁)尿失禁患者的尿流动力学变化,提高相应诊治水平.方法 对56例尿失禁的中年女性患者进行尿流动力学研究,并与正常对照组(17例)比较.结果 56例患者中压力性(SUI)尿失禁患者为33例(58.93％)(SUI组)、急迫性(UUI)尿失禁患者为9例(16.07％)(UUI组)、混合性(SUI/UUI)尿失禁患者为14例(25.00％)(SUI/UUI组).SUI组患者最大尿流率(Qmax)(27.72±5.21)ml/s高于正常对照组(20.45±7.15)ml/s,差异有统计学意义(P＜0.05);UUI组的膀胱初感容量(FS)、正常排尿感觉(ND)、强烈排尿感觉(SD)、急迫排尿感觉(UD)与正常对照组[(135.65±42.73)ml与(132.70±40.65)ml、(166.24±51.42)ml与(160.70±50.44)ml、(315.75±42.34)ml与(320.75±42.34)ml、(320.24±45.03)ml与(335.75±51.98)ml]比较差异均有统计学意义(P均＜0.05);SUI组及SUI/UUI组患者测得Valsalva漏尿点压力(ALPP)[(62.29±25.40)cm H2O与(88.30±28.54)cm H2O]比较差异有统计学意义(t=13.041,P＜0.05);SUI组患者的最大尿流率时逼尿肌压(Pdet-Qmax)、最大尿道压(MUP)及最大尿道闭合压(MUCP)明显低于正常对照组[(24.29±6.24)cm H2O与(34.45±8.20)cm H2O、(68.20±18.27)cm H2O与(87.14±17.26)cm H2O、(74.24±35.75)cm H2O与(90.66±30.10)cm H2O]差异均有统计学意义(P均＜0.05).结论 中年女性尿失禁患者具有较大患者群体,其分类较为复杂,尿流动力学检查对于明确其诊断及选择正确治疗方法,提高疗效具有重要指导意义.     

Treatments for stress urinary incontinence

Stress urinary incontinence (SUI) is a common problem among women, particularly after childbearing. While it is not in itself life-threatening, it inevitably impairs quality of life, causing embarrassment and even social isolation--this is often both the reason that people with SUI seek medical help and the method of measuring the success of treatment. A range of treatment and management options is available for dealing with this distressing condition.     

Emerging pharmacologic approaches for the treatment of lower urinary tract disorders

Lower urinary tract disorders include disorders affecting continence (stress urinary incontinence, urge urinary incontinence, and benign prostatic hyperplasia) and male erectile dysfunction. Although none of these conditions are fatal, they affect overall quality of life. Throughout modern medicine the treatment of these conditions was limited to psychological counseling or surgical intervention. In recent years, research defining the physiological mechanisms of continence and male sexual function has aided in the pharmacologic design of approaches to these conditions. These agents can act both centrally or on the peripheral genitourinary smooth muscle to alleviate disease symptoms. Incontinence is primarily treated with agents that act directly on the bladder smooth muscle such as muscarinic antagonists. However, afferent blockade to attenuate the spinalbulbospinal reflex pathway including mixed norepinephrine/serotonin reuptake inhibitors may provide a key breakthrough. Erectile dysfunction treatment has been revolutionized via the discovery of the nitric oxide pathway and phosphodiesterase 5 inhibitors. New peripheral targets as well as centrally acting agents represent potential emerging therapies. In this review, the pharmacologic basis of treatment of these disorders is discussed with special emphasis on emerging new therapeutics.     

Stress urinary incontinence in active elderly women

Urinary incontinence in the elderly is a significant health problem fraught with isolation, depression, and an increased risk of institutionalization and medical complications. Stress urinary incontinence (SUI), the complaint of involuntary loss of urine during effort or exertion or during sneezing or coughing, is the most common type of urinary incontinence. SUI can seriously degrade the quality of life for many active seniors, and has become an economic challenge for society. With the rapid increase in the active elderly worldwide, SUI is becoming a significant global problem. However, since only a fraction of women with SUI have consulted a physician, the clinical extent and public health impact of SUI are probably underestimated. The mounting social, medical, and economic problem of SUI in active elderly women as a rapidly growing segment of the population worldwide is reviewed. We evaluate the age-related changes of the lower urinary tract, examine risk factors, and suggest different treatment options shown to be effective in reducing SUI in this population.     

Managing stress urinary incontinence -- a primary care issue

Stress urinary incontinence (SUI) is a common condition in women, caused by anatomical problems related to factors such as age, parity, menopause and obesity. Depending on the clinical findings and on the severity of symptoms, SUI can be managed with conservative methods including pelvic floor exercises, vaginal cones and general lifestyle modification advice; or, it can be treated surgically with procedures such as Burch colposuspension, vaginal slings or tension-free tapes and injection of bulking agents alongside the urethra. SUI is greatly underdiagnosed, because many women are reluctant to consult their doctors about their condition. Department of Health guidelines are placing greater emphasis on primary care management of the condition and Primary Care Trusts (PCTs) to provide consistent, integrated continence care services. The availability of new, non-invasive treatment options, such as duloxetine, are likely to have a positive impact on the future of SUI management.     

Geriatric urinary incontinence.

Urinary incontinence (UI) is now recognized as a prevalent, physically and emotionally disruptive, and costly health problem in the geriatric population. Because incontinence may be a manifestation of a subacute or reversible process within or outside of the lower urinary tract, and because effective treatment is available, it is important for primary care physicians to identify and appropriately assess incontinence in their geriatric patients. The initial evaluation of an incontinent geriatric patients. The initial evaluation of an incontinent geriatric patient includes a targeted history and physical examination, urinalysis, and simple tests of lower urinary tract function. Potentially reversible conditions that may be causing or contributing to the incontinence, such as delirium and urinary tract infection (UTI), should be identified and managed. Patients who may benefit from further testing, including urologic or gynecologic examination and/or complex urodynamic tests, should be identified and referred. Several therapeutic modalities can be used to treat geriatric UI. Behavioral therapies are noninvasive and effective, both in functional community-dwelling geriatric patients and in functionally impaired nursing home residents. Behavioral therapies include bladder training, pelvic muscle exercises, biofeedback, scheduled toileting, habit training, and prompted voiding. Pharmacologic therapy is often used in conjunction with behavioral therapy. For stress incontinence, alpha-adrenergic drugs are used and can be combined with topical or oral estrogen therapy in women. For urge incontinence, pharmacologic treatment involves drugs with anticholinergic and direct bladder muscle relaxant properties. Pharmacologic therapy for overflow incontinence is generally not effective on a long-term basis. Surgical treatment is indicated when a pathologic lesion such as a tumor is diagnosed, or when anatomic obstruction is believed to be the cause of the patient's symptoms. Surgical treatment of stress incontinence can be highly effective in properly selected women. Nonspecific, supportive treatments are also important in managing geriatric UI. Education for patients and caregivers is critical for the success of most therapies. Environmental manipulations and the appropriate use of toilet substitutes are especially important in frail, functionally impaired patients. Highly absorbent adult undergarments are helpful for managing many patients, but should not be used as the initial response to incontinence, and are best used in conjunction with more specific treatment whenever possible. Chronic indwelling catheterization should only be used to manage incontinence when it is associated with clinically significant urinary retention, skin conditions that cannot heal because of incontinence, or severe illness that makes the catheter the most comfortable method of management.(ABSTRACT TRUNCATED AT 400 WORDS)     

Cross-sectional imaging following surgical interventions for stress urinary incontinence in females

Stress urinary incontinence (SUI) is a condition in which the weakness of the pelvic floor muscles causes unintentional loss of urine. For patients who are unable to achieve symptomatic improvement from lifestyle modification and pharmacotherapy, surgical placement of the pelvic slings or the use of urethral bulking agents has been shown to provide tremendous symptomatic improvement. Learning to recognize the pelvic slings and to identify their complications on imaging is invaluable; however, this is challenging because of the change in the local anatomy after surgical placement of the sling. In this paper, we present CT and MR imaging to demonstrate the surgical and non-surgical treatments of female SUI and their complications. Through this pictorial essay, our goal is to familiarize radiologists with recognizing the various forms of treatment for SUIs, the relevant pelvic anatomy, and complications that may occur secondary to the surgical placement of the pelvic slings.     

Management of ST-segment elevation myocardial infarction in EDs

Emergency department (ED) physicians are critical in the accurate diagnosis, efficient management, and treatment of patients with ST-segment elevation myocardial infarction. The initial reperfusion strategy involves the choice between mechanical reperfusion using primary percutaneous coronary intervention and pharmacologic treatment with fibrinolytics. The benefits of these approaches are time dependent, and practices vary according to institutional resources and local guidelines. Nevertheless, the need for early intervention and the use of certain therapies are well recognized. Therefore, ED physicians must be aware of all treatment options available, including the use of adjunctive therapies. Initial treatment should include beta-blockers, aspirin (or clopidogrel if aspirin is contraindicated), nitroglycerin, and analgesia, regardless of reperfusion strategy. Clopidogrel is now approved as an adjunctive therapy for patients undergoing fibrinolysis as their reperfusion therapy. Both unfractionated heparin and low-molecular-weight heparin are feasible adjunctives in patients with ST-segment elevation myocardial infarction undergoing reperfusion therapy. In addition, multiple new antithrombin agents are being investigated. The choice adjunctive treatments should be based on specific patient populations and on the initial reperfusion strategy.     

盆底肌肉功能锻炼治疗女性轻中度压力性尿失禁的临床研究

目的观察盆底肌肉功能锻炼治疗女性轻、中度压力性尿失禁(SUI)的临床疗效,为寻找合适的治疗方法提供理论参考。方法将107例轻、中度SUI患者随机分为治疗组和对照组。对照组采用常规药物治疗,治疗组采用盆底肌肉功能锻炼治疗。连续治疗12周后评价临床疗效,观察治疗前后两组患者尿动力学指标的变化。结果 (1)两组患者的最大尿流率、平均尿流率与治疗前比较显著下降(P0.05)。两组患者的排尿时间、功能性尿道长、最大尿道关闭压与治疗前比较显著上升(P0.05),且治疗组与对照组比较均有显著性差异(P0.05);(2)治疗组临床疗效总有效率为92.2%,显著高于对照组(P0.05)。结论盆底肌肉功能锻炼是轻、中度女性SUI患者的首选治疗方法 ,值得临床推广应用。     

Chirurgie de l’incontinence urinaire à l’effort chez la femme obèse

Obesity is an established risk factor for SUI. Among overweight women, a weight loss program improves urinary incontinence with a reduction in the frequency of self-reported urinary incontinence episodes and may be suggested as a first-line therapy. Success rates after TVT are similar among obese patients and normal-weight patients, and TVT is the prime procedure to treat SUI in obese patients. Obesity does not appear as a risk factor for intra- and postoperative complications.     

Relationship between health promotion lifestyle profiles and patient outcomes of biofeedback therapy for urinary incontinence

Computerized EMG biofeedback therapy is a conservative treatment option for patients with urge incontinence, frequency, and certain types of stress urinary incontinence. Patient motivation to follow through with treatment and home exercise program is an important factor for successful therapy. The Health Promotion Lifestyle Profile (HPLP) II measures the frequency of health-promoting behaviors. A preliminary study of 45 patients suggested the HPLP II is a valid and reliable predictor of patient motivation. Further research is needed to ascertain if the tool may serve to predict patients' commitment to biofeedback and subsequent success with therapy. Effective screening of patients can also reduce overuse of services and ensure appropriate use of percapitated dollars.     

Interstitial cystitis/painful bladder syndrome

Interstitial cystitis (IC) is a chronic, painful bladder syndrome primarily found in women. Although the direct cause(s) of IC are unknown, several theories exist. Common symptoms include urinary urgency, frequency, and pain. Treatment options include behavioral therapies, use of pharmacologic agents, and surgery. Patients benefit from prompt diagnosis and initiation of treatments. Important clinical features of IC in women including the pathology, common symptoms, and recommended evaluation and management strategies are reviewed.     

女性压力性尿失禁生酮饮食治疗临床路径

压力性尿失禁(SUI)限制了女性日常活动,严重影响女性生活质量,对患者造成巨大的心理负担.流行病学调查证实,向心性肥胖是SUI的高危因素.目前,一系列的研究数据表明,基础腹内压的增高是肥胖导致尿失禁的重要病理生理过程,对肥胖的有效管理将有利于控制基础腹内压,进而有利于尿失禁的治疗.减重是治疗肥胖女性SUI的一线治疗措施...     

Pediatric voiding dysfunction: current evaluation and management

Voiding dysfunction and urinary incontinence in children is common. Both are associated with significant effects on quality of life and comorbidities, including urinary tract infections (UTIs) and constipation. A thorough history, physical examination, and non-invasive evaluation are essential in determining the etiology. Interventions, such as behavioral therapy/biofeedback and pharmacologic therapies, are primary treatments. Prevalence rates, current evaluation, and management techniques are discussed in this article.     

The importance of screening,assessing, and managing urinary incontinence in primary care

PURPOSE: To present evidence that routine screening for urinary incontinence is justified because it is a clinically relevant and prevalent disorder that responds to treatment, resulting in improved outcomes for many patients managed by the nurse practitioner (NP). DATA SOURCE: Selected scientific literature. CONCLUSIONS: The prevalence of urinary incontinence and success of treatment options justify routine screening, individualized assessment, and treatment. IMPLICATIONS FOR PRACTICE: Routine screening for urinary incontinence by NPs is uncommon. Based on the relative risk, the potential success of treatment and improved quality-of-life outcomes after treatment, NPs should regularly screen and assess for incontinence.     

Interventions to facilitate smoking cessation

Tobacco use, primarily cigarette smoking, is the leading cause of preventable morbidity and mortality in the United States, and nearly one third of those who try a cigarette become addicted to nicotine. Family physicians, who see most of these patients in their offices every year, have an important opportunity to decrease smoking rates with office-based interventions. The U.S. Public Health Service recommends that primary care physicians use the five A's (Ask, Advise, Assess, Assist, and Arrange) model when treating patients with nicotine addiction. Physicians can improve screening and increase cessation rates by asking patients about tobacco use at every office visit. Behavior modification can improve long-term smoking cessation success; even brief (five minutes or less) advice on smoking cessation during an office visit can increase cessation rates. The effectiveness of nonpharmacologic treatments generally is lower; therefore, pharmacotherapy is recommended for smokers who are willing to attempt cessation, unless medical contraindications exist. The pharmacologic agents approved by the U.S. Food and Drug Administration for treatment of tobacco dependence include bupropion (a non-nicotine therapy) and nicotine replacement therapies in the form of a gum, patch, nasal spray, inhaler, and lozenge. These agents have similar long-term success rates.     

Diagnosis and management of migraine headaches

Migraine headaches afflict approximately 6% of men and 18% of women in the United States, and cost billions of dollars each year in lost productivity, absenteeism, and direct medical expendi tures. Despite its prevalence and the availability of therapeutic op tions, many patients do not seek treatment, and among those who do, a significant portion are misdiagnosed. Correct diagnosis can be made by identifying the historic and physical examination finding that distinguish primary headache disorders from secondary head ache disorders, as well as the key clinical features that distinguis migraine headaches from other types. Once diagnosis is made, im proper or inadequate management of headache pain, related symp toms such as nausea, and the possible aggravating side-effects of pharmacologic therapies represent further obstacles to effective ther apy. Dissatisfaction with migraine therapy on the basis of these factors is common. Among abortive therapy options there are de livery methods available which may avoid aggravating symptom such as nausea. Recommended pharmacologic agents include non steroidal anti-inflammatory drugs, intranasal butorphanol, ergota mine and its derivatives, and the triptans. Indications for prophylac tic in addition to abortive therapy include the occurrence o headaches that require abortive therapy more than twice a week, tha do not respond well to abortive therapy, and which are particularly severe. Research is ongoing in the pathophysiology of migraines evaluation of nonpharmacologic treatment modalities, assessment of new drug therapies, and validation of headache guidelines.     

Patient selection and education for use of the CapSure (Re/Stor) continence shield

Stress urinary incontinence affects millions of women. Many treatment options are available, ranging from behavioral or nonsurgical therapies to surgical intervention. The clinical findings of a multicenter trial using the CapSure (Re/Stor) continence shield to evaluate the safety and efficacy of this device for treating women with stress urinary incontinence are reported here. Additionally, the role of patient education and selection is discussed.