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THE PHYSICIAN AND SPORTSMEDICINE - VOL 31 - NO. 9 - SEPTEMBER 2003


Managing Stress Incontinence

Updates on Efficacy, New Treatments

Stress incontinence—a well-known exercise obstacle—is the most common cause of urine leakage in younger women. Though an array of treatment options exists, with new ones on the horizon, physicians face challenges in keeping up with new developments and getting women to reveal their incontinence concerns.

New Findings on Behavioral Treatments

Behavioral training and pelvic floor electrical stimulation (PFES) are both used to strengthen pelvic floor muscles. Researchers reporting in the Journal of the American Medical Association1 recently examined if combining the two treatments was more effective than behavioral therapy alone.

The study group included 200 ambulatory community-dwelling women aged 40 to 78 years who had stress incontinence or mixed incontinence with stress as the primary pattern. During the randomized 8-week trial, one intervention group received PFES alongside clinic-based behavioral training that included biofeedback; the other intervention group received the same behavioral training but without PFES. The control group received a self-help booklet that detailed at-home behavioral training. All three groups completed weekly bladder diaries.

At the end of the trial, researchers found that behavioral training plus PFES was not more effective for reducing incontinence episodes than clinic-based behavioral therapy alone. (The PFES-behavioral therapy group had a 71% reduction, and the behavioral therapy-only group had a 69% reduction; the difference was not statistically significant.) The researchers concluded that both are not needed in the same treatment plan for most women who have stress incontinence.

Researchers were surprised by the performance of the self-help group, which had about a 50% decrease in incontinence episodes. They note that this finding is promising because a booklet can be given to women with incontinence in many clinical settings, including primary care.

An accompanying editorial2 lauded the study but pointed out that participants were from a highly motivated demographic group (a continence specialty clinic) and that the clinicians had a high degree of expertise. As such, success rates for the interventions could be lower in different settings. The editorial authors were also impressed by the results in the self-help group.

Surgery Trends

When conservative measures like PFES fail, sling procedures have been surgical options. However, bladder spasms and difficulty urinating are common complications of the surgery. Also, long-term results with traditional sling procedures have been disappointing.

Dee E. Fenner, MD, director of gynecology at the University of Michigan Health System in Ann Arbor, says a modification of the sling procedure—tension-free vaginal tape (TVT)—improves bladder control with fewer complications. A synthetic mesh is placed under the middle of the urethra for support. The 30-minute procedure is performed under local or spinal anesthesia and requires three small incisions. Surgeons fill the patient's bladder during surgery, then have her cough. This allows the surgeon to adjust the tension of the tape so that it stops leakage without creating voiding difficulties.

"Long-term studies show that it does not appear to fail over time," says Fenner, who is also a Harold A. Furlong Professor of Obstetrics and Gynecology and associate chair for surgical services. Like all surgeries, TVT has some complications, she notes. "Erosion into the bladder or urethra over time has not been documented in many patients, but it remains a concern."

A Promising Medication

Though physicians have a wide array of conservative treatments for patients with stress incontinence, from exercises to plugs to patches to pessaries, there are new treatments under investigation, including gene therapy and stem-cell implants.2 Fenner says the next new treatment will be a medication: duloxetine hydrochloride. "It should be on the market some time in 2004, and it will be the first medication that has been shown to be effective for stress urinary incontinence," she says. A representative at Eli Lilly says a new drug application for duloxetine was submitted to the US Food and Drug Administration in late 2002.

According to background information from Eli Lilly,3 duloxetine is a balanced dual-reuptake inhibitor of serotonin and norepinephrine. Its effect in stress urinary incontinence is thought to be from blocking the two neurotransmitters, which appears to stimulate the pudendal nerve, increasing contractions of the urethral sphincter.

Talk Points for Patients

The main hurdle for physicians is to get patients to talk about stress incontinence. Some women are embarrassed to raise the topic of urine leakage, and others may avoid reporting symptoms because they fear surgery. Fenner advises, "First, ask in a way that lets the patient know that you expect her to say 'yes, I leak.'" One example is: "Many women have some difficulty holding urine. How often is that a problem for you?" Fenner also notes that patients are more likely to share symptoms by filling out a questionnaire rather than telling them verbally.

Knowing that a patient struggles with stress incontinence allows physicians to choose among the many treatment options to finely tune a treatment plan. Fenner offers the following caveats:

  • Pelvic floor exercises should be recommended for all patients, and those who have difficulty learning the exercises can benefit from the assistance of biofeedback or electrical stimulation.
  • Injectable treatment lasts only 6 months to 1 year, but it may be a good option for elderly women or those who can't have surgery.
  • Plugs and patches work well for women who leak only with exercise, but only for those who feel comfortable inserting such items into the urethra.
  • Those who aren't comfortable using a patch or a plug may experience relief by wearing a tampon during activity or by using a pessary.

Lisa Schnirring
Minneapolis

REFERENCES

  1. Goode PS, Burgio KL, Locher JL, et al: Effect of behavioral training with or without pelvic floor electrical stimulation on stress incontinence in women: a randomized controlled trial. JAMA 2003;290(3):345-352
  2. Resnick NM, Griffiths DJ: Expanding treatment options for stress urinary incontinence in women. JAMA 2003;290(3):395-397
  3. Duloxetine reduced stress incontinence for women in worldwide studies. Eli Lilly product news. Available at https://newsroom.lilly.com/news/Product/2003-04-26_duloxetine_SUFU_SUI.html. Accessed August 8, 2003


Field Notes

Sunscreen and Bug Repellent: A Bad Combination?

Concerns about West Nile virus may prompt many outdoors enthusiasts to apply insect repellent when they lube up with sunscreen. However, using the products together may have some undesirable effects, according to a researcher at the University of Manitoba in Winnipeg.

Xiaochen Gu, PhD, professor of pharmacy, says that his lab has found that when sunscreen and insect repellent are applied to the skin at the same time, the two products increase absorption of each other. N,N-diethyl-3-methylbenzamide (DEET), the active ingredient of most repellents, is intended to remain on the surface of the skin, said Gu in a press release from the University of Manitoba. "If absorbed, it can cause skin allergy, hypotension, headaches, disorientation, and encephalopathy, especially in children," he said. Because of these concerns, Gu's group is attempting to modify the nonmedicinal ingredients in sunscreen and repellents to reduce unwanted absorption rates.

New Stretching Protocol for Plantar Fasciitis?

A non-weight-bearing stretch that specifically targets the plantar fascia was superior to traditional Achilles tendon stretches at reducing the pain of chronic plantar fasciitis, according to a study published in the July issue of The Journal of Bone and Joint Surgery.

The study is the first prospective, randomized clinical trial to evaluate response rates to different stretching protocols in patients who have chronic, disabling proximal plantar fasciitis. The 8-week study involved 101 patients whose plantar fasciitis had not responded to 10 months of conservative treatments.

The non-weight-bearing exercise consisted of having patients cross the affected leg over the contralateral leg. While placing the fingers across the base of the toes, patients were instructed to pull the toes back toward the shin until they felt a stretch in the arch or plantar fascia. They were taught to confirm the stretch by palpating tension in the plantar fascia. Patients in the traditional Achilles tendon stretch were instructed to place a shoe insert under the affected foot, which was placed behind the contralateral leg. Patients were asked to point the toes of the affected foot toward the heel of the front foot while leaning into the wall. Both groups were told to perform the exercises immediately upon rising in the morning in addition to twice more per day. The two groups also received prefabricated soft insoles and a 3-week course of anti-inflammatory medication (celecoxib).

Both groups reported an overall reduction in pain; however, the non-weight-bearing plantar fascia stretching group reported greater pain relief with regard to morning pain and severity of worst pain. Researchers concluded that both stretches are beneficial, but that the Achilles stretch should be considered supplemental to the more specific plantar fascia stretch.


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