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Major Types of Incontinence
Conservative Treatment of Stress Incontinence The Conservative Approach, The Logical Approach by Brad Porter, RN, BS
Millions of women suffer from stress incontinence each year. Most women, however, go untreated because they never mention it to their doctor for various reasons. (National Association for Continence [NAFC], 2004, p. 1). Many women think it is a normal part of aging and others are simply too ashamed of being incontinent to talk about it. The fact is that only 2% of women affected by incontinence in our communities seek treatment and only 5% of women living inside a medical facility seek treatment (Hu & Wagner, 2000, p. 593). Stress incontinence affects many more individuals than just the stereotypical incontinent elderly woman though. In fact, as many as 30% of middle-aged women in the United States suffer from incontinence (Kulpa, 1996, p. 1). Using noninvasive conservative management strategies can eliminate much of the suffering women go through with incontinence. In fact, noninvasive conservative treatment of stress incontinence is almost always warranted and noninvasive methods should always be recommended as the first-line of treatment whenever it is physically possible.
Stress incontinence is a form of incontinence that is primarily caused by muscle weakness or by muscles that have been overstretched. It is the most common form of incontinence (Strange, 1997, p. 3) and occurs when there is not enough strength in the muscles supporting and surrounding the neck of the bladder to keep it closed (American Urological Association [AUA], 2003, p. 1). This fact does not mean that the bladder has to be full for stress incontinence to occur (Strange, 1997, p. 3). Specifically concerning the mechanism of stress incontinence, the detrusor muscle and the urethral sphincter are responsible for holding the bladder closed and preventing the unplanned release of urine. An incidence of stress incontinence is defined as leakage of urine brought about by pressure increases in the abdominal area (AUA, 2003, p. 1). It is common for this leakage to occur when sneezing and laughing especially, but it can occur during any physical exertion. Other common activities that may trigger an incident of stress incontinence include coughing, getting up from a seated position, lifting something heavy, bending down to pick something up from the floor, or straining in any way to lift, push or pull an object (AUA, 2003, p.1). Diagnosis of stress incontinence can be confirmed by a combination of history taking, presence of symptoms, and performing a stress test with a physician or other health professional which involves first relaxing and then coughing vigorously while looking for signs of urine leakage (National Institutes of Health [NIH], 2004, p. 5). Psychosocial effects resulting from the physical manifestation of stress incontinence include “sleep disturbances, restricted social interactions, reduced sexual activity, loss of self esteem and depression” (Strange, 1997, p. 2).
The National Association for Continence cites multiple childbirths, menopause, pelvic fracture, and bladder surgery as four common causes of stress incontinence (NAFC, 2004b, p. 1). According to the Mayo Clinic, childbirth and hysterectomy are the two leading causes of stress incontinence, with aging being another significant cause in women (Mayo Foundation for Medical Education and Research [MFMER], 2005a, p. 1). Concerning pregnancy, not all women are created biologically equal, so it is possible and in fact very likely to have episodes of stress incontinence without having ever given birth. Pregnancy alone has been shown to cause incontinence in most women (Eason, Labrecque, Marcoux, Mondor, 2004, p. 6). This fact helps illustrate just how widespread stress incontinence is. After giving birth a full one third of women have also been shown to suffer from incontinence (Walling, 2002, p. 1). Other causes of incontinence include, but are not limited to, “urinary tract infections, vaginal infection or irritation, constipation, and certain medications” (Strange, 1997, p. 2). Strange also cites “weakness of the bladder, the sphincter, or the muscles that support the bladder; overactive bladder muscles; a blocked urethra (from prostate enlargement or surgery); neurologic disorders; and immobility” as factors that may produce more chronic occurrences of incontinence (Strange, 1997, p. 2). Because pregnancy, childbirth, and aging are common causes of stress incontinence, it is easy to see that incontinence is an issue that affects all of us whether we are the one suffering or not. Even in trying to improve one’s health it has been shown that nearly fifty percent of women who engage in regular exercise experience stress incontinence (Kulpa, 1996, p. 1).
Stress incontinence has been treated in many different ways over the years. The modalities of treatment for stress incontinence are quite diverse. Traditionally urologists and other health professionals recognize two main types of treatment. These two types of treatment can be classified as either invasive or noninvasive. Invasive treatment is a small category, which includes only surgery and other minor outpatient procedures. In contrast, noninvasive treatment includes all other treatment modalities such as fluid management, bladder training or retraining, pelvic floor exercises, electrical stimulation, other behavioral therapies, medications, urethral inserts and injection of bulking agents (AUA, 2003, p. 2-3; Mayo Foundation for Medical Education and Research [MFMER], 2005a, p. 1). The category of noninvasive treatments can be further divided into conservative and non-conservative treatments. All of the noninvasive treatments would fit into the category of conservative treatments with the exception of medication, which should be classified as noninvasive, non-conservative.
Surgery for stress incontinence was often viewed as the only solution in the past. Overall, the Royal College of Obstetricians and Gynecologists (2003) reports the success rate for surgical intervention to be “83% of patients reporting improvement after surgery, 5% no change and 8% a worsening” (Royal College of Obstetricians and Gynecologists, 2003, p. 1). One surgical procedure considered an option for treating stress incontinence today is the pubovaginal facial sling procedure. In this procedure a piece of “tough tendon like material is attached around the bladder neck to keep urine in” (MFMER, 2005c, p. 1). Positive outcomes for this procedure vary from 80% to 90% depending on the study considered (MFMER 2005c, p. 1; Royal College of Obstetricians and Gynecologists [RCOG], 2003, p. 5). Artificial slings and sphincters are also being experimented with at this time with the hope that someday they will become more viable treatment options (RCOG, 2003, p. 5, 7). Positive patient outcomes are generally increasing overall from surgical interventions because of new techniques and the long history of these types of operations being performed. The risks of surgery, however, are still significant, and hospitalization is almost universally required at this time for a surgical intervention.
Another invasive procedure being used recently is treatment with bulking agents. This procedure involves the injection of a filler substance into the space around the neck of the bladder with the goal of constricting the opening and reducing urine leakage. This procedure is often done on an outpatient basis (MFMER, 2005b, p. 1) and uses filler agents such as collagen, Teflon, fat, silicone, and Durasphere (RCOG, 2003, p. 6). Success rates vary for the treatment of incontinence with bulking agents between 33% and 90%, but the long-term effects of this treatment seem to indicate a diminished success rate over a period of two years (RCOG, 2003, p. 6). Other surgical procedures' respective success rates include anterior vaginal repair, 66%; Burch colposuspension, 85-90%; alternative suprapubic surgery, 70-100% (RCOG, 2003, p. 2-4). Noninvasive conservative treatments for stress incontinence include, but are not limited to, pelvic floor exercises (often referred to as kegel exercises), functional electro stimulation, and urethral inserts. Pelvic floor exercises (PFEs) have been a staple for the prevention and treatment of stress incontinence for over fifty years now. PFEs are noninvasive and cause relatively few, if any, side effects (Sung, Hong, Choi, Baik & Yoon, 2000, p. 306). A pelvic floor exercise regimen is basically a traditional exercise program for the pelvic floor muscles consisting of several sets of muscle contractions, which can be performed with or without the assistance of resistance and or biofeedback. The muscles targeted for strengthening during pelvic floor exercises include the levator ani and the external urethral sphincter (Sung, et al., 2000, p 306). The intended outcome for a PFE program is to strengthen these muscles that control the release of urine and support the bladder (American Academy of Family Physicians, 2004, p. 2). Exercise devices that give the user an indication that they are performing the pelvic floor exercise correctly are considered biofeedback devices. Biofeedback pelvic floor exercising devices have been shown to be more effective than medication for the treatment of stress incontinence (Teunissen, et al., 2004, p. 1). Kegel exercises have been shown to be an effective form of noninvasive conservative therapy for stress incontinence (Bandolier Journal, 1998, p. 2; Moore, 2000, p. 1).
Functional electro stimulation (FES) is a newer form of treatment for stress incontinence. It works in a similar fashion to kegel exercises in that the goal is to increase the strength of the musculature involved in the release of urine. In FES, electrical current is used to alternately contract and relax the pelvic floor muscles. When used in conjunction with biofeedback kegel exercises, it has been shown to produce stronger pelvic floor muscles when compared with a control group than did pelvic floor exercises without biofeedback (Sung, et al., 2000, p. 304). This fact can be construed to be a major advantage, but the evidence seems inconclusive that FES produces better results than kegel exercises with biofeedback. Kulpa (1996) does tout FES as the best first-line treatment for athletic women when the incontinence is related to the performance of their particular sport or the side effects of giving birth (p. 6). FES, unlike kegel exercises, however, has the major drawback of needing to be implemented by a trained therapist.
Urethral inserts are another new noninvasive alternative that like wearing protective undergarments is not a form of curative therapy. These devices are small disposable plugs made of soft silicone, which can be inserted into the urethra. (MFMER, 2005f, p. 1). Urethral inserts are designed to be used for a short period of time when an episode of incontinence would be unacceptable or when it would not be possible or convenient for the user to wear a disposable undergarment or pad. Urethral inserts must be taken in and out of the urethra each time the user wishes to go to the bathroom (MFMER, 2005f, p. 1).
A brief discussion of the economics of incontinence is valuable at this point and well within the scope of invasive versus noninvasive treatments when considering the advantages of noninvasive conservative treatment. In 1995, 27.8 billion dollars were spent on the treatment of incontinence with the average incontinent person spending 3,941 dollars per year (Strange, 1997, p. 1). The cost of invasive treatment for incontinence is approximately fifteen times that of noninvasive conservative treatment (Hu & Wagner, 2000, p. 593). This fact indicates that if only one out of every fifteen surgeries can be avoided with noninvasive conservative treatments then the across-the-board expense of noninvasive treatments prior to surgery has already paid for itself. With these facts in mind, it should be obvious that noninvasive conservative treatments, if standardized as part of incontinence treatment, would save the government, taxpayers, and insurance companies millions, if not billions, of dollars each year.
The desired benefits of invasive and noninvasive treatment are the same in the treatment of stress incontinence, but it is the undesired side effects and risks that truly separate the two categories. The desired benefit in either case is the reduction or elimination of episodes of incontinence by increasing the resistance in the pelvic floor, specifically “in the sphincter and urethra” (Strange, 1997, p. 3). Noninvasive conservative treatments carry the lowest risks, followed by medications, and finally, surgery (Teunissen, et al. 2004, p. 4). Nonsurgical techniques need to be used as part of a treatment regimen, but if they fail, surgery should be considered (Kulpa, 1996, p. 7). The Royal College of Obstetricians and Gynecologists (2003) reiterates this point of view by commenting “Primary surgery should only be considered after a period of conservative treatment from a specialist therapist has been offered and rejected or has failed” (p. 1).
In summary, the strategy of noninvasive conservative management of stress incontinence as first-line treatment is logical for several reasons. First of all, it is obvious that at this point in time a consensus for the role of invasive treatment of stress incontinence has been reached by the medical research community. Surgery should only be the last option. Secondly, similar patient outcomes have been achieved with noninvasive conservative techniques when compared to invasive surgical intervention. This similarity in outcomes comes with few, if any side effects and none of the pain, anxiety, or risk associated with surgery. Thirdly, there will be a significant difference in the overall cost to patients, insurance companies, and the public if noninvasive conservative approaches to the treatment of stress incontinence are more widely instituted. With these three well-documented facts in mind, a logical conclusion is that patients should employ conservative noninvasive techniques as a first-line of treatment for urinary stress incontinence. Physicians and other health care workers should recognize the benefits of conservative noninvasive modalities of care for their patients and promote these types of interventions as an integral part of every incontinent patient’s plan of care. To do otherwise is simply a shame on the medical profession. Every noninvasive conservative option should be explored before any patient should have to undergo surgery.
References
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American Urological Association. (2003). Minimally invasive management of urinary incontinence. Retrieved February 17, 2005 from http://www.urologyhealth.org/adult/index.cfm?cat=06&topic=106
Bandolier Journal. (2005). Stress urinary incontinence in women. Retrieved February 17, 2005 from http://www.jr2.ox.ac.uk/bandolier/band57/b57-6.html
Eason, E., Labrecque, M., Marcoux, S., Mondor, M. (2004). Effects of carrying a pregnancy and of method of delivery on urinary incontinence: a prospective cohort study. Retrieved February 3, 2005 from http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=15053837
Hu, T., Wagner, T. (2000, July). Economic Considerations in Overactive Bladder [Electronic version]. The American Journal of Managed Care. 6:11, S591-8
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Mayo Foundation for Medical Education and Research. (2005). Treatment of Stress Incontinence in Women at Mayo Clinic in Rochester. Retrieved February 17, 2005 from http://www.mayoclinic.org/stressincontinencewomen-rst/
Mayo Foundation for Medical Education and Research. (2005). Urethral Inserts. Retrieved February 17, 2005 from http://www.mayoclinic.org/stressincontinencewomen-rst/urethralinserts.html
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Sung, M., Hong, J., Choi, Y., Baik, S., Yoon, H. (2000, February). FES-Biofeedback versus Intensive Pelvic Floor Muscle Exercise for the Prevention and Treatment of Genuine Stress Incontinence [Electronic version]. Journal of Korean Medical Sciences. 15, 303-8.
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Walling, A. (2002). Exercise to treat postpartum urinary incontinence. Retrieved on February 3, 2005 from http://www.aafp.org/afp/20020401/tips/13.html