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Conservative Treatment of Urinary Stress Incontinence

Patty Kulpa, MD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 24 - NO. 7 - JULY 96


In Brief: Almost half of all women who exercise regularly experience some degree of urinary stress incontinence. The cause is often multifactorial, but physical activity often aggravates it. Because denial is commonplace, at each yearly gynecologic exam primary care physicians should ask patients about urologic problems. If a problem exists, a urinary questionnaire and voiding diary can help determine the nature of the condition. In addition, a thorough medical, urologic, and gynecologic history can help pinpoint the cause. Physical exam can reveal such conditions as neurologic deficits and pelvic floor weakness, and other tests can rule out infection and other disorders. Conservative treatment, which may involve drugs, pelvic floor strengthening, and mechanical devices, often restores continence.

Urinary incontinence is not just a geriatric problem. Its prevalence in healthy middle-aged women is as high as 30% (1), and up to 47% of regularly exercising women have some degree of stress incontinence (2). Denial is common, however, and only 30% to 35% of incontinent women seek medical attention (2). Healthcare providers, therefore, need to ask active patients about stress incontinence, the type often associated with physical activity. Many times, an athletic woman is too embarrassed to raise the issue with her physician. She may wear a tampon or pad, modify her technique, change her sport, or stop exercise altogether to cope with her incontinence.

Efficacious clinical evaluation of incontinence will clarify the patient's symptoms, demonstrate the loss of urine objectively, and determine the cause. It will also help identify women who need referral for further urodynamic studies and evaluation. Often, nonsurgical treatment is effective for urinary stress incontinence.

Multifactorial Etiology

Continence requires a compliant bladder, an active urethra-sphincter mechanism, and the absence of involuntary bladder contractions. Urine storage and expulsion through the urethra are regulated by the somatic and autonomic nervous systems (T10-S4 nerve roots) and modulated by the "micturition centers" in the central nervous system (1). Centrally, bladder filling and the urge to void can be perceived and one can consciously inhibit voiding. Bladder contraction can also be a conditioned response (the basis for timed voiding).

The etiology of urinary incontinence, associated pelvic organ prolapse, and pelvic floor defects is multifactorial. It includes genetic factors; previous gynecologic surgery; vaginal births; underlying neurologic, gastrointestinal, or pulmonary disease; smoking; obesity; and occupational and recreational factors (3). There are three common types of persistent urinary incontinence: stress, urge, and overflow (1). An active woman may have components of all three.

Genuine stress incontinence is socially unacceptable involuntary loss of urine during physical activity. It occurs when intravesical pressure exceeds maximum urethral pressure in the absence of detrusor activity, as seen with anatomic pelvic support abnormalities (4). It may also be caused by intrinsic urethral sphincter deficiency. Normally functioning levator pelvic diaphragm, pubocervical fascia, and ligaments stabilize the pelvic organs above the levator plate. However, chronically high intra-abdominal pressures on the pelvic floor with certain sports, or neuromuscular damage to the pelvic floor, can decrease pelvic floor support, resulting in urinary incontinence and visceral organ prolapse.

In women, high-impact exercises like running and high-impact aerobics (especially jumping with legs apart) result in more episodes of incontinence than with other sports (2). Low-impact activities in which one foot is always on the floor will allow women to continue exercising. High-impact movements subject the pelvic floor to forces three to four times a woman's body weight, and pelvic floor ligaments cannot sustain high loads for prolonged periods. They may become damaged, especially if the woman already has weak levator ani muscles; the amount of urine loss depends on the extent of the mechanical defect. This may explain why young nulliparous women become incontinent during their sports.

Chronically increased intra-abdominal pressure may also lead to weak pelvic floor muscles and subsequent stress incontinence. Sports associated with high abdominal pressure include gymnastics (trampoline, floor exercises, uneven bars), combat sports (karate, judo), team games (basketball, volleyball, handball), horseback riding, body building with heavy weights, and track and field (jumping and hurdling) (5).

Medical, Gynecologic, and Urologic History

Urinary incontinence may be a unique symptom, sign, or condition indicative of an underlying disorder (1). At every yearly gynecologic exam, the physician should ask the patient if she has any urologic problems. If she has urinary problems that interfere with her lifestyle, she should be given a urinary questionnaire (table 1) and voiding diary form, which she should complete before her next visit.

Table 1. Urinary History Questionnaire

NAME_______________________________________________________

Answer yes or no unless indicated

  1. How often do you urinate during the day? _________ during the night? _________

  2. If you urinate more than seven times during the day or more than twice at night, is it: because of a severe urge to urinate? ____ out of mere convenience? ____ an attempt to prevent the loss of urine? ____

  3. How long can you postpone urination once you have the urge to urinate? (specify minutes or hours) ________________

  4. How long can you comfortably go between urinations? (specify minutes or hours) ________________

  5. Do you empty your bladder completely when you urinate? _________ Do you have to lean forward to empty it? _________ need to rest and then urinate again? _________

  6. Do you dribble when you stand after you urinate? _________

  7. What is your urinary stream like? (check one) strong ____ moderate ____ need to strain ____ low ____

  8. Have you lost urine while sleeping? _________ during or after sex? _________ during your period? _________ during pregnancy or after childbirth? _________ at the onset of menopause? _________ at the sound, sight, or feel of running water? _________

  9. Did you lose urine as a child? (daytime or night) _____ If yes, at what age did you stop?_____________

  10. Do you lose control of your urine without warning? ________

  11. How often do you have to wear a pad or use a tampon to stop urine leakage? (check one) all the time _____ only during the day ____ only at night ____ occasionally ____ never ____

  12. If you wear a pad or use a tampon to stop urine leakage, at what age did you start? ________________

  13. If you lose urine, how many years has it been going on? _________ Do you have bladder discomfort when you urinate? _________

  14. What volume of urine do you pass when you urinate? (check one) large ____ medium ____ small ____ very small ____

  15. Do you lose urine with an associated stress? (check all that apply) cough ____ laugh ____ lift ____ sneeze ____ at heel strike while running or walking ____ during household duties ___ rising from sitting or lying down to standing ____ while exercising ____ (if so, in what position? ________________ during which sport or activity? _____________________ )

  16. Have you ever had to switch or stop your sport because you leaked? ________

  17. Do you ever lose gas or stool uncontrollably? ________

  18. Did your natural mother, or any brothers or sisters, have problems with urine loss? ________ Did they ever need surgery? ________ At what age did the problem start? _____

  19. Have you ever had any bladder surgery done? ________________

  20. treatment have you received in the past? (check all that apply) vaginal cones ____ vaginal stimulation ____ biofeedback ____ pessary ____ estrogen ____ tampons ____ drugs____

A thorough medical, gynecologic, and urologic history is necessary to determine the causes of her incontinence. The history should include previous neck, back, pelvic, and bladder surgeries with their outcomes, as well as prior nonsurgical therapies for incontinence, previous back or neck injuries, parity and obstetric history, family history of urinary problems, present medications, occupational and household duties, prolonged travel time, social activities, emotional health, and exercise routines and sports.

Each urinary symptom should be accurately characterized and quantified (6). A 2-day voiding diary can help provide information about functional bladder capacity, the patient's normal voiding pattern, and the severity of the incontinence. It may be especially helpful for the woman who gives an inconsistent history, appears to exaggerate her symptoms, or drinks excessive fluids.

Symptoms of urgency, frequency, nocturia, and urge incontinence suggest detrusor instability with 90% accuracy in neurologically normal women (7). Even the sight of a bathroom, cold weather, or the sound of running water may trigger urinary incontinence in a woman with detrusor instability. Leakage of large volumes of urine or a history of nocturnal enuresis (bed-wetting) also suggests detrusor instability. Urinary tract infections, however, can also cause frequency, urgency, and urge incontinence.

Stress incontinence can produce an involuntary loss of urine as a result of coughing, laughing, sneezing, vigorous physical activity, or a change of position. Urine leakage occurs not during the night but when the patient gets up from bed in the morning. Underlying pelvic wall relaxation, however, can produce similar symptoms.

Constant urine leakage suggests overflow incontinence, functionless urethra, fistula, or ectopic ureter. Postvoid dribbling suggests urethral diverticulum.

Symptoms of pelvic floor relaxation need to be uncovered: pelvic problems, bearing-down sensation, bilateral groin pain, sacral backache, coital difficulty, protrusion from the vagina, spotting, ulcer, bleeding, urinary frequency or urgency, nocturia, urinary incontinence or retention, and difficulty defecating (8). The frequency and severity of the symptoms vary with—but do not always parallel—the severity of the support loss at each site (9). This can be a multiple compartment problem. Losses of pelvic wall support may include a urethrocele, a cystocele, uterine prolapse, vaginal cuff prolapse, an enterocele, a rectocele, and gaping of the perineal body.

Physical Examination

History alone is not reliable in delineating the cause of urinary incontinence. After a general physical examination, a thorough urologic and pelvic exam needs to be done.

Physical exam should include a screening neurologic evaluation of the lower extremities, especially spinal nerve roots T10-S4 (sensation, motor tone, and reflexes). In addition, flexion and extension maneuvers against resistance at the ankle (L4, L5-S1), knee (L5-S1, L3-4), foot (S1-2, L4-5), and hip (L4-5, L2-3) assess motor function of the sacral area. With a fine needle prick, lower-extremity and perineal sensation needs to be tested along its dermatomes.

The anal sphincter ("anal wink") reflex and the bulbocavernosus reflex can produce a reflex contraction of the pelvic floor. This action indicates an intact sacral reflex center. Gentle stroking lateral to the anus causes anal sphincter contraction. Gentle tapping or pressure on the clitoris causes pelvic floor contraction.

The pelvic exam should evaluate estrogen status, pelvic floor support, and any other pelvic pathology. This is also a good opportunity to check the patient's ability to squeeze down her pelvic floor muscles (Kegels) in the lithotomy position. A rectovaginal exam can detect fecal impaction and assess resting sphincter tone and anal contraction. Perineal excoriations may indicate chronic irritation due to urine leakage. Tenderness over the urethra or bladder may reflect inflammation or infection.

A hypoestrogenic state of the vagina also reflects the atrophic changes in the urethra and trigone. The lower blade of a bivalve vaginal speculum (modified Sims retractor) can be used to check each defect of the pelvic wall floor while the woman strains. If any defect or bulging is found, the physician needs to reduce it with the blade. The patient then should strain down to see if she experiences occult incontinence. Such women need anti-incontinent surgery along with surgical correction of their pelvic floor defects.

Laboratory and Special Tests

The physician also needs to elicit overt incontinence during the evaluation. With a full bladder, the woman repeatedly coughs in the sitting, erect, and lithotomy positions. Simultaneous loss of urine highly suggests stress incontinence (positive stress test).

In addition, the examiner should obtain a postvoid residual urine sample and obtain a screening culture. Normal residual is 50 mL to 100 mL (50 mL to 60 mL in women over 65). Urine cytology is done if the woman has irritative voiding symptoms, microscopic hematuria, or a history of smoking.

After catheterizing the patient for the residual, one may use the catheter to check for hypermobility of the urethrovesical junction (Q-Tip test). The clinician measures the angle of deflection from the horizontal with an orthopedic goniometer. A difference greater than 35° between the resting angle and the straining or coughing angle signifies a positive test for urethral hypermobility.

The primary care physician can refer the patient to a urologist or gynecologist who specializes in urinary incontinence (urogynecology) for further urodynamic evaluation including cystometry, cystourethroscopy, or multichannel urodynamics. Referral is needed for:

  1. a suspected neurologic disorder;
  2. significant hematuria without infection;
  3. symptomatic pelvic wall defects;
  4. abnormal postresidual volume;
  5. refractory urinary tract infections without apparent cause;
  6. an uncertain diagnosis with a resultant inability to develop a reasonable management plan;
  7. treatment failures despite adequate trial;
  8. woman older than 65;
  9. multiple failed surgeries;
  10. prior radical pelvic surgery or radiation therapy ; and
  11. a history of mixed stress and urge incontinence.

Conservative Treatment

For most patients, surgical treatment for genuine stress incontinence should be a last resort (and it is beyond the scope of this article, as is treatment for other types of incontinence). Nonsurgical therapy for stress incontinence, however, is often effective and includes various combinations of pharmacologic agents, pelvic floor rehabilitation, and mechanical devices.

Pharmacologic agents. Estrogen treatment may improve symptoms of urgency, frequency, and dysuria by raising the sensory threshold for involuntary detrusor contractions (7). It is recommended to treat either stress or urge incontinence. Estrogen improves urethral mucosa, alpha-adrenergic contractile response of urethral smooth muscle, and pressure transmission ratios, but it does not change the functional urethral length or maximal closure pressures (10). Even a woman on oral estrogen replacement may need supplementation with topical vaginal cream.

A patient who has vaginal atrophy should receive 1/2 to 1 applicator intravaginally two to three times a week for a minimum of 6 to 12 weeks; 1/3 to 1/2 applicator once or twice a week is used for maintenance. If the patient has a uterus and is using only vaginal estrogen cream, periodic progestin therapy will help protect the endometrium lining.

Alpha-mimetic therapy restores continence in up to 14% of patients, and 30% to 60% are subjectively improved (11). These agents stimulate the smooth muscle of the bladder outlet and proximal urethra by increasing outflow resistance. The most common drugs used are pseudoephedrine hydrochloride (15 mg twice a day to 60 mg four times a day) and phenylpropanolamine hydrochloride (75 mg twice a day). Side effects include anxiety, insomnia, and blood pressure increases.

Alpha-mimetic drugs should be used with caution in women with hypertension, cardiovascular disease, or hyperthyroidism. Healthy women, however, can use these drugs and exercise. Pretreatment vaginal estrogen in the postmenopausal woman primes the alpha-adrenergic receptors and enhances these agents. The only drawback is that incontinence recurs if the patient stops taking the drug.

The tricyclic antidepressant imipramine hydrochloride (25 mg to 50 mg twice a day) relaxes smooth muscles, anesthetizes locally, and inhibits norepinephrine uptake into the terminal nerve endings. It helps facilitate urine storage, and its combined alpha-adrenergic and anticholinergic properties help women with mixed incontinence. Side effects from its anticholinergic component include dry mouth, blurred vision, constipation, drowsiness, fatigue, mood changes, and orthostatic hypotension. These side effects may especially cause problems for exercising women.

Caution must be used when prescribing imipramine hydrochloride to women over 65. Dosage should start at 10 mg at bedtime for those over 65, 25 mg to 150 mg for others (starting at 25 mg at bedtime, the dose can be increased by 25 mg every third day until the patient is continent, has side effects, or reached 150 mg). For diurnal problems, replacing it with propantheline bromide (15 to 30 mg twice or three times a day), an anticholinergic, or oxybutynin chloride (5 to 10 mg three times a day), a spasmolytic agent, will reduce some of the side effects. For nocturnal frequency, 25 to 75 mg of imipramine at bedtime may be a good option.

Pelvic floor rehabilitation. The goal of pelvic training is to effectively isolate the anterior portion of the levator ani. Kegel exercises can improve the tone of the external urethral musculature by contracting the pubococcygeal muscle. (See "Preventing Urinary Incontinence in Active Women") However, the woman needs to know and isolate that muscle for the exercise and comply with her regimen. These exercises should be done at rest and not during voiding. To see beneficial results, the patient needs to do at least 40 pelvic floor contractions per day. Her ability to do Kegel exercises should be checked at every annual gynecologic visit. Best success is typically seen with motivated patients and clinicians, younger women with a history of mild urinary stress incontinence and no prior bladder surgery, and patients who have high baseline urethral closure pressures.

When the woman lacks or has weak muscle tone, various devices may aid her in performing pelvic floor exercises. A physical therapist or nurse who specializes in pelvic muscle rehabilitation can give instructions and biofeedback therapy. To enhance pelvic floor muscle strength in these women, functional electrical stimulation ("electronic Kegels") may be needed. Electrical stimulation should be the first line of therapy for athletes whose incontinence is related to high-risk sports or postpartum states. Once the woman has some pelvic muscle tone, vaginal cones—akin to barbells for the vagina—can be used to further strengthen the area.

In active women, standard pelvic training is not effective on its own because of the problems of impact and the need for training while standing. During strenuous activity, an incontinent woman needs to learn to contract her pelvic floor before intra-abdominal pressure increases (12).

Mechanical devices. Vaginal pessaries, such as Milex incontinence rings (Chicago, Illinois) and Cook rings (Spencer, Indiana), contraceptive diaphragms, and moistened tampons can elevate and partially occlude the urethrovesical junction. This compresses the proximal urethra, which may help treat stress incontinence. These devices also stabilize the urethra and urethrovesical junction during stress (7) and, when inserted just before exercise, may benefit active women who have exercise-induced stress incontinence. If the woman has a cystocele, however, a pessary may make her problem worse. Depending on the woman's perineal support, the physician needs to select the correct pessary type to help the woman with pelvic wall relaxation or prolapse with a ring doughnut, Gehrung, Gellharon (Milex), or cube pessaries.

The Introl bladder neck support prosthesis (Johnson and Johnson Medical Inc, Arlington, Texas) is another new option (13). It has two blunt prongs on one end that laterally support the urethra. It has to be custom fitted and the athlete must be taught how to remove it so she can urinate. Unlike the traditional pessary, it fits loosely and works when pelvic floor muscles contract.

Individualized Approach

These approaches produce beneficial results with minimal side effects, but they are only temporary measures. The cure rate for such nonsurgical management is conservatively estimated at 10%, but 40% of patients improve significantly (14). Nonsurgical measures may be an alternative for women who are not surgical candidates or who do not initially want surgery. They may also be a reasonable alternative when surgical measures do not provide satisfactory results. But treatment needs to be individualized. If the woman does not comply with her conservative therapies or if they fail, then surgery should be considered.

References

  1. Weinberger MW: Conservative treatment of urinary incontinence. Clin Obstet Gynecol 1995;38(1):175-188
  2. Nygaard I, DeLancey JO, Arnsdorf L, et al: Exercise and incontinence. Obstet Gynecol 1990;75(5):848-851
  3. Delancey JO: Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet Gynecol 1992;166(6 pt 1):1717-1728
  4. Abrams P, Blaivas JG, Stanton SL, et al: The standardisation of terminology of lower urinary tract function: International Continence Society Committee on Standardisation of Terminology. Scan J Urol Nephrol 1988;114(suppl):5-19
  5. Bourcier A: Conservative treatment of stress incontinence in sportswomen. Neurourol Urodyn 1990;9(2):232-233
  6. Klutke CG, Raz S (eds): The Urologic Clinics of North America: Evaluation and Treatment of the Incontinent Female Patient. Philadelphia, WB Saunders Co, Aug 1995, Vol 22, No. 3
  7. ACOG Technical Bulletin: Urinary Incontinence, No. 213,Oct 1995
  8. ACOG Technical Bulletin: Pelvic Organ Prolapse. No. 213,Oct 1995
  9. Utian WH, et al: Menopause Management: Menopause and Urogynecologic Health (roundtable) 12-22, March/April 1995, Vol 4, No. 2
  10. Fantl JA, Cardozo L, McClish DK: Estrogen therapy in the management of urinary incontinence in postmenopausal women: a meta-analysis: first report of the Hormones and Urogenital Therapy Committee. Obstet Gynecol 1994;83(1):12-18
  11. Urinary Incontinence Guideline Panel: Urinary incontinence in Adults: Clinical Practice Guideline. US Dept of Health and Human Services publication No. 92-0038. Rockville, MD, Agency for Health Care Policy and Research, 1992
  12. Bourcier AP: Physical therapy for female pelvic floor disorders. Curr Opin Obstet Gynecol 1994;6(4):331-335
  13. Nygaard I: Prevention of exercise incontinence with mechanical devices. J Reprod Med 1995;40(2):89-94
  14. Miklos J, Karram M: Nonsurgical management of urinary stress incontinence. Fem Patient 1995;20(1):31-48

Dr Kulpa is a sports gynecologist and urogynecologist practicing in Gig Harbor, Washington, a fellow of the American College of Obstetricians and Gynecologists, and a fellow of the American College of Sports Medicine. Address correspondence to Patty Kulpa, MD, 3705 26th Ave Ct NW, Gig Harbor, WA 98335.


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