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Treatment of female urinary incontinence - an annotated evaluation of non-surgical therapeutic options
By Hogne Sandvik



Female urinary incontinence (UI) is a condition with severe economic and psychosocial impact. I have studied the epidemiology of UI in the general female population and the prevailing management of UI by Norwegian general practitioners (GPs). Those who are interested in more details, may take a look at this synopsis. The main conclusions that may be drawn from these studies are that UI is very prevalent among adult women, mostly in the form of stress incontinence. At least 6% may be regarded as potential patients. Although complicated by methodological difficulties, studies of GPs' management indicate that available therapeutic tools (described below) are not used to their full potential. A literature review demonstrates that the history is the most important diagnostic tool in general practice, and that the value of clinical investigations is poorly documented.

Pelvic floor exercises

In 1948 Arnold Kegel described pelvic floor exercises as a treatment option in stress incontinence.(1) The purpose of the exercises is to increase the muscle volume and to develop stronger reflex contractions following quick rise in intra- abdominal pressure.(2)

Lack of awareness of these muscles is common, and Kegel stressed the importance of learning how "good" rather than how "bad" the condition is. The patient is asked to draw up, instead of to bear down, and the physician should confirm the contractions by vaginal examination.(3) Many women do not know how to contract their pelvic floor muscles,(4) and a brief verbal explanation or an education pamphlet do not represent adequate preparation for a patient who is about to pursue an exercise programme.(5)

Usually, it is recommended that contractions should be sustained for 5-10 seconds followed by an equal period of relaxation.(2,6-9) Bø et al. demonstrated that a maximal contraction for 6-8 seconds followed by 3-4 rapid contractions were more effective than the usual exercise regimen of lower intensity. However, this intensive exercise group also benefitted from a weekly session with instructor in groups.(2) Development of muscular hypertrophy is a slow process and probably needs longer exercise periods with maximal tension.(2) Repeated series of contractions should be performed every day, but the total number of recommended contractions vary between studies. Bø et al. used 30 per day,(2) Jolleys 40,(10) Burgio et al. 50,(11) Lagro-Janssen et al. 50-100,(9) and Wells et al. 90-160.(12)

As the treatment protocols vary between studies, it is hardly surprising that the results also vary. Bø et al. reported that 60% of the intensive exercise group were cured or almost continent, 17% in the low intensity home exercise group. Only the intensive exercise group demonstrated significant objective improvements (pad test, maximum resting urethral closure pressure, pelvic floor muscular strength).(2) The initial results were maintained five years later.(13) In a larger study Hahn et al. reported that 71% were initially cured or improved. After 2-7 years 25% had undergone surgery, while 55% of the rest continued to be cured/improved. However, the frequency of training during the follow-up period was unsatisfactory in this study.(14)

Two controlled studies on the effect of pelvic floor exercises have been performed in general practice. Jolleys reported that 41% were cured and 46% improved by the exercise programme, while only 2% of controls were improved.(15) Lagro-Janssen reported that 85% were cured or improved, none in the control group.(9)

Who are most likely to benefit from pelvic floor exercises? Bø & Larsen found that responders were older, had a longer history of stress incontinence, a higher body mass index, and more severe incontinence, compared with nonresponders.(16) However, other studies have found best outcome in younger women(17) or in those with mild symptoms.(18)

To help women gain control over their pelvic floor muscles several devices have been constructed. Kegel developed the perineometer, a pneumatic vaginal rubber tube recording intravaginal pressure.(1) Burgio et al. demonstrated that visual feedback of bladder pressure, abdominal pressure, and sphincter activity was more effective than simple verbal performance feedback.(11) Such devices are too sophisticated, however, for routine use in general practice.

Vaginal cones, on the other hand, may prove to be an applicable aid to pelvic floor training in general practice. The cones are carried in the vagina for 15 minutes twice a day. They provide a powerful sensory feedback which makes the pelvic floor contract around the cone and retain it. As the pelvic floor muscles are strengthened, the weight of the cones is gradually increased.(19) In controlled studies cones have been at least as effective as routine pelvic floor exercises, and requiring less time to teach.(20,21)


Bladder training

Different scheduling regimens are often recommended for the treatment of uninhibited detrusor contractions. Timed voiding or habit training implies voiding on a fixed schedule, while in prompted voiding the patient is asked at regular intervals about the need to void.(6,7) These regimens are widely used with patients in nursing homes. For cognitively intact patients bladder training (bladder drill) has become the most popular treatment.(8,22-25)

The main characteristics of bladder training are patient education, scheduled voidings, and positive reinforcement.(26) Emphasis is placed on the brain's control over lower urinary tract function.(27) Patients are requested to void only when scheduled, at progressively increasing intervals.(26,28) A urinary diary should be kept as an aid to treatment and as a motivating factor.(25,27-29) Close supervision and positive affirmation are essential for success, and the patient should be instructed in distraction and relaxation techniques.(27,28) A positive effect is often seen already after a week,(28) and unsuccessful training should not continue beyond 2-3 weeks.(27,28)

The treatment of bladder instability is very dependent on the placebo effect,(30) and uncontrolled studies should therefore be viewed with scepticism. Frewen treated 55 women with urge incontinence, and only one failed to respond. He considered bladder training a therapeutic test of idiopathic bladder instability. Failure to respond should raise suspicion of an organic disorder.(25) Two controlled studies on the management of female incontinence in general practice also included bladder training for urge incontinence, but the results were either not reported separately for this group,(31) or the treatment also included drugs.(15)

Jarvis & Millar did a randomized controlled trial of inpatient bladder drill with 60 women. After treatment 83% were continent and symptomfree, compared with 23% of controls.(32) In another randomized clinical trial with 123 women (aged 55-90) bladder training reduced the number of incontinent episodes by 57% (controls 14%) and the quantity of urine loss by 54% (controls increased 21%). The effect was maintained at six months follow-up, and there was no significant interaction between age group and treatment efficacy.(33)

The latter study also included women with stress incontinence, and the beneficial effect of bladder training was evident for this group, too.(33) This surprising finding has opposite parallels in other studies demonstrating that pelvic floor exercises and vaginal cones may also be effective in the treatment of urge incontinence.(34,35) It is hypothesized that pelvic floor muscle contraction may result in reduced bladder neck electrical conductivity.(35)


Oestrogen

Both general practitioners and patients may seem bewildered with regard to the benefits and risks of postmenopausal hormone replacement therapy.(36-38) The use of the less potent natural oestrogen oestriol for the treatment of postmenopausal urogenital complaints (including UI) should not be confused with contraceptive pills or perimenopausal hormone replacement therapy.(39,40) While oestriol is the most widely used low-potency oestrogen in Norway,(41) synthetic oestrogens are more popular in USA.(6,39)

Oestrogens may be administered orally, vaginally, or transdermally. In a double-blind study using conjugated oestrogen Hilton et al. found that vaginal administration was most effective in relieving incontinence symptoms, while side effects were more common with oral administration.(42) There are, however, reservations as to extrapolating such findings to the use of oestriol.(39) For some women convenience and compliance may favour the use of oral administration.

Most researchers who have developed and evaluated management programmes for female UI in primary care have included the use of oestrogen in postmenopausal women.(15,43-45) Guidelines and review papers also suggest that oestrogen may be beneficial for incontinent women.(6,8,22-24,46,47)

Some randomized double-blind placebo-controlled studies have demonstrated significant effect of oestrogen in stress incontinence.(42,48,49) Others have found good clinical effect in urge incontinence, but not in stress incontinence.(50,51) Benness et al. failed to demonstrate an effect even in urge incontinence, although the urgency symptom was improved.(52) In a meta-analysis Fantl et al. concluded that oestrogen therapy does have a beneficial subjective effect on incontinent postmenopausal women, with an average 46% improvement over placebo. Although still significant, the effect is smaller (26%) when only genuine stress incontinence is considered.(53)


Other drugs

Alpha-adrenergic agonists such as phenylpropanolamine may be beneficial in the treatment of stress incontinence, especially when combined with oestrogens.(42,48,49) A synergistic effect is believed to be due to increased muscular tone of the urethra (caused by phenylpropanolamine) and maturation of the urethral mucosa (caused by oestrogen).(49) In a randomized controlled trial involving 157 women (aged 55-90) the benefit of phenylpropanolamine was comparable to that produced by pelvic floor exercises.(12)

Anticholinergic drugs are recommended for the treatment of urge incontinence.(6,8,22-24,46) Terodiline, a drug with both anticholinergic and calcium antagonistic properties, was effective in reducing urge incontinence,(54) but was withdrawn from the market because of serious side effects.(55) In Norway only emepronium bromide remains as a registered drug for the treatment of urge incontinence. In a double-blind cross-over study comparing terodiline with emepronium bromide most patients preferred terodiline.(56) In several randomized double-blind studies emepronium bromide has failed to show significant effect over placebo.(30,57,58) However, there are other studies in which significant effect has been demonstrated.(59,60)

Tricyclic antidepressants, such as imipramine or doxepine, are also recommended for the treatment of urge incontinence.(6,8,22,23,46) These drugs may work by their anticholinergic effects as well as being alpha-stimulators.(61) In a small double-blind study imipramine tended to be more effective than placebo, but the power of the study was too weak to yield statistically significant results.(62) In a double-blind cross-over study with doxepine similar results were obtained, this time also statistically significant.(61)


Electrical stimulation

Electrical stimulation of the pelvic floor may be effective therapy both for stress incontinence and urge incontinence.(63-67) While urge incontinence is treated by short-term maximal stimulation,(66,67) stress incontinence is usually treated by long-term stimulation of lower intensity.(63,64)

Eriksen & Eik-Nes treated 55 stress incontinent women awaiting surgical repair. After therapy 68% were continent or had improved so much that the operation was cancelled. At two-year follow-up success was maintained in 56%.(63) In a randomized placebo-controlled trial electrical stimulation for stress incontinence proved superior to a sham device, both for objective and subjective parameters.(65) Another study showed electrical stimulation and pelvic floor exercises to be equally effective in the treatment of stress incontinence.(64)

Eriksen et al. also treated 48 women with urge incontinence. Clinical and urodynamic cures were obtained in 50% and a significant improvement in 33%. At one-year follow-up a persisting positive effect was found in 77%.(66) In a Swedish study 63% were cured or had improved significantly.(67) Both studies were done without control groups. So far, no controlled study has been published on the effect of electrical stimulation in urge incontinence.

Since 1992 the Norwegian National Insurance has reimbursed the cost of electrical stimulators for home treatment of female UI. An evaluation report was produced after two years. Approximately one third of the patients were cured or substantially improved. Treatment effect was not dependent on the doctor's status (general practitioner v. specialist), but the effect correlated significantly with patient compliance. Ten per cent found the treatment difficult to accomplish.(68) Close follow-up and motivation for use seem to be necessary for successful electrical stimulation at home.(63,68) This aspect is probably illustrated by the lower success rates found in this unselected general survey(68) compared with the clinical trials.(63-67)


References

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