Initial management of stress urinary incontinence: pelvic floor muscle training and duloxetine

Stress urinary incontinence (SUI) is common among women of all ages and can have a negative impact on quality of life (QoL). Often, women refrain from seeking treatment due to the fear that surgery might be the only option, or that no other treatments exist. SUI symptoms can often be treated with simple measures such as pelvic floor muscle training (PFMT), weight loss, devices, etc. However, PFMT has low compliance rates, and few continue long term. More recently, another treatment option has been introduced, i.e. the relatively balanced serotonin and noradrenaline reuptake inhibitor (SNRI) duloxetine. PFMT and/or SNRI are recommended as a first-line therapy for the initial management of SUI in women in the guidelines of the third International Consultation on Incontinence. SNRI have received a grade A recommendation. As PFMT and duloxetine target different areas (i.e. pelvic floor muscle and distal urethral sphincter/rhabdosphincter, respectively), combined therapy might provide additional benefit. A recent study comparing the effect of combined treatment with no active treatment found that combination therapy was significantly better for all outcomes, including frequency of SUI episodes, pad use, improvements in QoL and global impression of improvement scores. The data suggest that combination therapy might provide another treatment option for SUI symptoms in women.     

Measuring outcomes of importance to women with stress urinary incontinence

Objective  To provide evidence on outcomes of importance to women who have stress urinary incontinence (SUI). The secondary aim was to identify additional outcomes that ought to be collected in future primary studies or in systematic reviews of the literature.
Design  Questionnaire survey of a cohort of women with SUI.
Setting  UK.
Sample  A total of 188 women with SUI.
Methods  Areas of importance to women who suffer from SUI were assessed using a patient generated index (PGI). In addition to the PGI, the questionnaire included the King's Health Questionnaire (KHQ) and the EuroQol-5D (EQ-5D).
Main outcome measures  PGI, EQ-5D and the KHQ.
Results  In total, 38 different areas were reported by respondents on the PGI. PGI and EQ-5D scores were positively correlated and significant. Correlations between the seven domains of the KHQ and PGI were all negative, but only two were statistically significant: personal relationships and severity measures.
Conclusions  The PGI succeeded in capturing a diverse range of outcomes of importance to women suffering with SUI. Given the limited correlation between the KHQ domains and the PGI and, in addition, that the areas mentioned in the PGI were not found to map well to the EQ-5D, the PGI in this instance may be capturing concerns of women who suffer from SUI, which are not captured by quality-of-life measures such as the EQ-5D.     

盆底功能性磁刺激治疗压力性尿失禁50例分析

目的探讨功能性磁刺激(functional m agnetic stimu lation,FMS)治疗女性压力性尿失禁的临床效果。方法 2008年1月至2009年6月在辽宁省人民医院对50例压力性尿失禁(stress urinary incontinence,SUI)患者应用FMS进行治疗,年龄(52.1±9.8)岁,产次(1.7±0.5)次。根据治疗前后主观和客观临床参数进行评价,随访3、6、12个月。结果治疗结束后患者生活质量评分平均增加9.34,1h尿垫试验平均漏尿量减少4.65g,3d漏尿次数平均减少5.46次,尿动力学检查初始排尿欲膀胱容量和最大漏尿点压力分别平均增加14.58mL和17.85cmH2O,差异具有统计学意义(P<0.01)。治疗结束后78%患者不再漏尿,16%患者症状得到改善。随诊3、6、12个月,治愈患者中分别有56.41%、79.49%、94.87%症状复发。结论 FMS是治疗SUI的一种安全、简便、无痛、非侵入性的方法,临床效果显著,但疗效维持时间较短。     

压力性尿失禁患者盆底电刺激治疗临床分析

目的探讨盆底电刺激疗法治疗压力性尿失禁的治疗方案及疗效。方法12名压力性尿失禁患者随机进入前瞻性研究，应用Stimogyn BIO 2001型生物反馈＋盆底电刺激治疗仪进行治疗，选择适应治疗方案，随访观察治疗效果。结果12名患者中有4人治疗2～3次即明显有效，剩余8名患者接受8～24次治疗，6名患者治愈，2名患者症状改善，所有患者对治疗效果满意。结论生物反馈及盆底电刺激疗法能够有效治疗压力性尿失禁，应强调个体化的治疗原则及患者主动参与治疗。     

Burden of stress urinary incontinence for community-dwelling women

OBJECTIVE: The purpose of this study was to better understand the subjective bothersomeness of stress urinary incontinence symptoms and their impact on the quality of life of community-dwelling women. STUDY DESIGN: We conducted a mail survey of 605 women in the United States who reported symptoms of stress urinary incontinence. RESULTS: More than three fourths of the respondents reported their symptoms to be bothersome, with approximately 29% reporting their symptoms to be moderately to extremely bothersome. The odds of moderate-to-extreme bother decreased with age and increased with symptom severity. Concerns about social embarrassment were evident. CONCLUSION: Stress urinary incontinence symptoms can impose a significant burden on the women who have them. The results reinforce the need for health care professionals to be proactive in questioning and educating patients about this common lower urinary tract symptom.     

Duloxetine in women awaiting surgery

Stress urinary incontinence (SUI) is a common condition affecting millions of women worldwide. It has a significant impact on the quality of life (psychosocial, social and economic well-being) of sufferers and their families. Until recently, treatment options for SUI were limited to conservative treatments such as pelvic floor muscle training, which usually has a poor compliance over time, or surgical procedures that carry the risk of complications and are mainly an option for more severely affected women. Duloxetine, a potent and relatively balanced serotonin and noradrenaline reuptake inhibitor, has been evaluated in phase II and phase III clinical trials and was found to be efficacious and safe in the treatment of women with moderate to severe SUI symptoms. Even in a subgroup of women with severe SUI awaiting surgery, with or without the presence of intrinsic sphincter deficiency, duloxetine was found to be effective. In addition, a good correlation was found between efficacy outcome measures and ratings of global impression scores. Women begin to perceive themselves as being better with treatment when their incontinence episodes frequency (IEF) decreases by 46% or their Incontinence Quality of Life (I-QOL) score improves by 6.3 points. The improvements in IEF and I-QOL obtained with duloxetine were well above these threshold levels, whereas these with placebo were not. All duloxetine responses were observed within 2 weeks. Overall, duloxetine is an effective treatment for a wide variety of women presenting with SUI symptoms. It has been approved in Europe for the treatment of women with moderate to severe SUI symptoms and is now available in many European countries.     

The effect of previous treatment experience and incontinence severity on the placebo response of stress urinary incontinence

OBJECTIVE: The placebo response associated with stress urinary incontinence (SUI) is sizeable but poorly understood. The aim of this study was to examine the relationship between previous treatment experience and baseline urinary incontinence severity with placebo response. STUDY DESIGN: Nine hundred twenty-one women ages 24 to 83 years received placebo in 4 12-week randomized trials evaluating duloxetine for SUI in 16 countries in Africa, Australia, Europe, and North and South America. Incontinence episode frequency (IEF) was calculated before and after randomization with entries from subject-completed real-time diaries. At baseline, subjects reported on their experience with previous continence surgery and with current pelvic floor muscle training (PFMT) with standardized questions. Analyses included Pearson correlations and the Wilcoxon two-sample test, and were based on intent-to-treat principles. RESULTS: The placebo group averaged 17 IEF per week at baseline. Fifty-five percent of placebo-treated subjects averaged >or=14 IEF/wk, 11.8% had previous continence surgery, and 16.5% currently performed PFMT. The overall median decrease in IEF with placebo was 33%, but ranged from 11% to 57% for individual countries. The placebo response was lower in women with more severe SUI (29.6% vs 36.4%, P=.07), in those who had previous continence surgery (25.0% vs 33.3%, P=.26), and for those using PFMT (23.6% vs 33.3%, P=.02). There was a significant positive correlation (rho=.44; P <.0001) between the placebo response within a country and that country's use rate for PFMT. CONCLUSION: Treatment naivete and less severe incontinence are associated with an increased placebo response in clinical trials for stress urinary incontinence, although this difference was statistically significant only for PFMT.     

阴道单切口可调节无张力尿道中段悬吊术治疗压力性尿失禁近期疗效评价

目的 了解阴道单切口可调节无张力尿道中段悬吊术(Adjustable Single-Incision Sling,ASISAjust(R))治疗压力性尿失禁的疗效.方法 回顾性分析2012年10月至2012年12月因压力性尿失禁在北京大学人民医院接受ASIS Ajust(C)手术治疗的患者10例,采用治愈率、手术并发症及尿失禁生活质量问卷(incontinence quality of life,I-QOL)、泌尿生殖道症状调查表(urogenital distress inventory,UDI-6)评价疗效.结果 ASIS Ajust(R)术后6个月客观及主观治愈率100％,术后4d1例尿潴留,2例排尿困难,无吊带侵蚀;术后I-QOL评分较术前显著提高(P＜0.05),UDI-6评分较术前显著降低(P＜0.05).结论 ASISAjust(C)治疗压力性尿失禁操作简便,安全有效,能显著改善患者生活质量.     

Surgical treatment of stress urinary incontinence in women

Stress urinary incontinence is a common problem with 13.6% of women requiring surgery for it in their lifetime. Surgical treatments either create suburethral support or augment urethral closure. Colposuspensions and autologous rectus fascial slings are effective first-line surgical options. The use of midurethral tapes is currently suspended due to concerns with chronic pelvic and vaginal pain.     

Individual and group pelvic floor muscle training versus no treatment in female stress urinary incontinence: a randomized controlled pilot study

Objective

To compare the effects of pelvic floor muscle training (PFMT) performed during group treatment sessions (GT) and individual treatment sessions (IT) to a control group (CG) of women with stress urinary incontinence (SUI).

Hypothesis

The group treatment sessions would have better effects compared to individual treatment sessions.

Study design

This randomized controlled pilot study included women aged over 18 years, who complained of urinary leakage on stress and who had not undergone physical therapy for SUI before. Forty-nine women were randomly allocated to the PFMT in group treatment session (GT) (n = 17), PFMT in individual treatment session (IT) (n = 17) and control group (CG) (n = 15). The study was carried out in an outpatient physical therapy department in São Carlos, Brazil. Subjects on intervention groups were treated with the same PFMT protocol for 6 weeks, with two 1-h weekly sessions. The GT group carried out the PFMT in group treatment session and IT group in individual treatment session. The CG did not receive any treatment during the corresponding time. They were evaluated before and after treatment for primary outcome, urinary loss, and secondary outcomes, King's Health Questionnaire, pressure perineometry, pelvic floor muscle strength by digital palpation and subjective satisfaction. Participants, evaluator and the physical therapist were not blinded. Forty-five women completed the study and were included in the analysis. The statistical analysis was performed using Wilcoxon test for intragroup analysis and Kruskal–Wallis and Mann–Whitney test for intergroup analysis (p < 0.05).

Results

In intragroup analysis, there was a significant reduction in urinary loss measured by pad test only in the IT group. For primary outcome, there was a significant difference only after treatment between GT and CG (p < 0.0001; effect size −0.91; 95% confidence interval from 0.56 to 5.80) as well as between IT and CG (p < 0.0001; effect size −0.90; 95% confidence interval from 0.54 to 5.84). There were differences after treatment in GT and IT groups for secondary outcomes: perineometry, muscle strength and in the domains of the quality of life questionnaire. For the CG group, there were not significant differences in any variables. In intergroup analysis for all variables, there were no differences between GT and IT groups. The two treated groups had similar subjective satisfaction (86%). There were no complaints of adverse effects due to treatment from either group.

Conclusion

The results indicated similar improvement in clinical variables and in satisfaction with the treatment between IT and GT.     

Surgical treatment of stress urinary incontinence in women

Stress urinary incontinence is a common problem with 13.6% of women requiring surgery for it in their lifetime. Surgical treatments either create suburethral support or augment urethral closure. Colposuspensions and autologous rectus fascial slings are effective first-line surgical options. The use of midurethral tapes is currently suspended due to concerns with chronic pelvic and vaginal pain.     

Physiotherapy for female stress urinary incontinence: a multicentre observational study

BACKGROUND: No previous data are available on the effectiveness of physiotherapy management of urinary stress incontinence with relevance to the Australian health system. AIMS: To evaluate Australian ambulatory physiotherapy management of stress urinary incontinence. METHODS: Observational multicentre clinical study of physiotherapy management of female stress urinary incontinence between February 1999 and October 2000, with 1-year follow-up. Outcome measures were a stress test and a 7-day diary of incontinent episodes (pretreatment and at every visit) and a condition-specific quality of life (QoL) questionnaire (pre- and post-treatment). Subjects were followed-up 1 year after treatment by questionnaire with a 7-day diary, QoL questionnaire, and assessment of subjective outcome, subjective cure, satisfaction and need for surgery. RESULTS: Of the 274 consenting subjects, 208 completed an episode of physiotherapy care consisting of a median (IQ range) of five (four to six) visits. At the end of the episode, 84% were cured and 9% improved on stress testing, whilst 53% were cured and 25% improved according to the 7-day diary. Mean volume of urine loss on stress testing reduced from 2.4 (2.5) mL to 0.1(0.4) mL after treatment. There was a significant improvement in all QoL domains. Median (interquartile range) incontinent episodes per week were reduced from five (three to 11) to zero (zero to two) (P < 0.05) after treatment and to one (zero to four) at 1 year (P < 0.05). At 1 year, approximately 80% of respondents had positive outcomes on all outcome measures. CONCLUSIONS: Physiotherapy management in Australian clinical settings is an effective treatment option for women with stress urinary incontinence.     

Early diagnosis and treatment of genuine stress urinary incontinence in women after pregnancy: midwives as detectives

Genuine stress incontinence is often a hidden problem in that many women suffering from genuine stress incontinence after delivery do not seek medical advice. This article reviews signs and symptoms of genuine stress incontinence that, when identified, may enable midwives to initiate or suggest treatment as needed. A comprehensive literature search was performed in relevant medical databases. The following adverse risk factors for the development of genuine stress incontinence are vaginal delivery, multiparity, and obesity, with an increased risk for women who did not actively exert pelvic floor training. Prolonged second stage of labor and heavier babies were two factors associated with an increase in the risk of damage to the pelvic floor innervation as well as genuine stress incontinence. Several conservative treatment options, such as special instructions for pelvic floor training, the use of weight cones, and electrical stimulation, are reported to alleviate genuine stress incontinence symptoms.     

北京郊区女性尿失禁及盆腔脏器脱垂发病情况及其对生活质量影响的抽样调查

目的 调查北京郊区女性尿失禁及盆腔器官脱垂发病情况及其对生活质量的影响。方法 按照整群抽样的方法，选取生活在北京市房山区某自然村18岁以上的常住已婚女性，进行问卷调查，并行妇科检查和B超检查。结果 全村符合调查的女性202人，回收问卷190份，应答率94．1％。调查结果显示，尿失禁的患病率为67例（35．3％）。子宫脱垂49例（25．8％），阴道前壁膨出79例（41．6％），阴道后壁膨出61例（32．1％）。尿失禁对女性日常生活、情绪和性生活的影响率分别为29．9％、23．9％、29．9％，尿失禁以轻度尿失禁为主（占82．1％），尿失禁合并子宫脱垂占31．3％，合并阴道前壁膨出59．7％，合并阴道后壁膨出44．8％。结论 整群抽样调查显示，北京郊区女性尿失禁及盆腔脏器脱垂均较常见，尿失禁患者多合并盆腔脏器脱垂，尤其是阴道前壁膨出，并对生活质量有较大影响。     

Safety and tolerability of duloxetine in women with stress urinary incontinence

Background  The serotonin/noradrenaline uptake inhibitor duloxetine has been shown to be effective in the medical treatment of stress urinary incontinence (SUI) in women.
Aim  To review the safety and tolerability of duloxetine with SUI.
Methods  A systematic Medline search for the key word 'duloxetine' was performed, and abstracts from recent international gynaecological and urological meetings were also considered.
Results  Various unpleasant adverse effects exist, among which nausea is the most frequent, but is mild to moderate and transient in most cases. Dose escalation upon initiation of treatment improves the tolerability of duloxetine. The use of duloxetine appears safe as it lacks the cardiovascular adverse effects of older amine reuptake inhibitors.
Conclusions  Duloxetine has an acceptable safety profile. Dose escalation combined with patient counselling on the intensity and transient nature of adverse effects may help to further improve the benefit/tolerability ratio of duloxetine in the treatment of SUI.     

The efficacy of venlafaxine in the treatment of women with stress urinary incontinence

Objective  To examine the efficacy of venlafaxine, which is used as an antidepressant, in the treatment of stress urinary incontinence. Materials and methods  The study was designed as a placebo-controlled, double-blind and randomized clinical study. Patients in Group 1 (n = 20) were administered 75 mg venlafaxine, those in Group 2 (n = 20) were administered placebo for 12 weeks. All the cases were evaluated in terms of weekly incontinence episode frequency (IEF), change in void interval (VI), the Incontinence Quality of Life (I-QOL) in weeks 0, 4, 8 and 12. Additionally, PGI-S was assessed at baseline and was followed by PGI-I evaluations in weeks 4, 8 and 12. Results  Evaluations in weeks 0, 4, 8 and 12 did not show any significant difference in IEF, VI, IQOL and PGI-I values of placebo group (p > 0.05). However, in the patients who were administered venlafaxine declines in IEF and PGI-I values as well as the elevations in VI and IQOL scores showed significant changes parallel to the increasing follow-up period (p < 0.05). Nausea was observed in 40% of cases in venlafaxine group, and 15% of those in placebo group (p < 0.05). Conclusion  It was seen in our study that efficacy of venlafaxine started early and the clinical efficacy associated with the use of the drug continued in the following months. Venlafaxine should be considered a clinically efficient alternative drug in the treatment of SUI.