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stress urinary incontinence

A form of urinary incontinence characterized by the involuntary loss of urine from the urethra during physical exertion; for example, during coughing, laughing, sneezing, exercise, or sudden movements. Etiology: 1) childbirth, episiotomy [8] 2) surgery/radiation (esp prostate surgery/radiation in men) 3) post-menopausal atrophy of mucosa may contribute 4) urethral infection may contribute 5) women: a) urethral hypermobility b) displacement of the urethra & bladder during physical exertion 6) men & women - intrinsic urethral sphincter deficiency 1] surgery or injury 2] sacral or infrasacral spinal cord lesions 7) obesity [20] Epidemiology: - common among women under age 75 - 40% post radical prostatectomy [13,14] Pathology: 1) weakness & laxity of pelvic floor musculature resulting in hypermobility of the bladder base & proximal urethra 2) urethral sphincter insufficiency: - urethral sphincter pressure generally inadequate (internal sphincter may prolapse through pelvic floor) 3) absence of a detrusor contraction or an overdistended bladder Clinical manifestations: 1) momentary loss of small amounts of urine coincident with an increase in abdominal pressure due to a) coughing b) laughing c) sneezing d) exercise e) sudden movements 2) incontinence occurs in an upright position 3) not associated with desire to urinate Management: 1) general - see urinary incontinence for general measures - eliminate contributory medications - alpha-1 adrenergic antagonists (doxazosin, prazosin ...) 2) pelvic muscle exercises (Kegel exercises) a) first line [4,12] b) more effective than pharmacologic therapy [10,17] c) biofeedback may be needed for correct implementation - adding biofeedback to pelvic floor muscle training does not improve urinary incontinence outcomes d) pelvic yoga no better than Kegel exercises 3) pharmacologic agents a) systemic pharmacologic therapy not recommended [12] b) alpha adrenergic receptor agonists (first line) [3] - increase of smooth muscle tone at bladder outlet - pseudoephedrine (Sudafed) 30-60 mg every 6-8 hours c) tricyclic antidepressants (TCA) - for combined stress incontinence & urge incontinence - decrease in detrusor muscle contractility & increase in bladder outlet resistance - imipramine (Tofranil) 25-100 mg QHS - doxepine (Sinequan) 25-100 mg QHS d) duloxetine (Yentreve) [10] e) topical estrogen if associated atrophic vaginitis [3] - vaginal cream (Premarin): 1-2 gm QHS for 1-2 weeks, then 1 g 1-3 times per week - systemic premarin 0.625 mg PO QD (+/-) Provera 2.5 mg QD actually may worsen urinary incontinence [4,6] 4) acupuncture may be of benefit [15] 5) scheduled toileting (bladder retraining) 6) surgery a) procedures for pelvic prolapse - bladder neck suspension - urethral sling procedure [11]; mid-urethral sling [16] - artificial sphincter implantation - fascial sling surgery better than Burch colposuspension [7] b) artificial urinary sphincter with longest record of satisfactory results for post-prostatectomy stress incontinence [13] 7) injection of autologous stem cells (myoblasts & fibroblasts harvested from the uppe arm) into the urinary sphincter region

Interactions

disease interactions

Related

hypermobility of bladder neck intrinsic urethral sphincter deficiency (ISD) pelvic muscle exercise (PMR); Kegel exercises

General

urinary incontinence (UI)

References

  1. nlmpubs.nlm.nih.gov/hstat/ahcpr/
  2. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 528-30
  3. Guide to Physical Examination & History Taking, 6th edition, Bates B, JB Lippincott, Philadelphia, 1995, pg 82-83
  4. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 16, 17, 18. American College of Physicians, Philadelphia 1998, 2006, 2012, 2015, 2018. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  5. Ouslander & Schnelle, Ann Intern Med 122:438, 1995
  6. Prescriber's Letter 12(4): 2005 Hormone Therapy for Urinary Incontinence Detail-Document#: 210412 (subscription needed) http://www.prescribersletter.com
  7. Albo ME et al Burch Colposuspension versus Fascial Sling to Reduce Urinary Stress Incontinence N Engl J Med www.nejm.org May 21, 2007 (10.1056/NEJMoa070416) http://content.nejm.org/cgi/content/full/NEJMoa070416v1
  8. Shamliyan TA et al, Systematic review: Randomized, controlled trials of nonsurgical treatments for urinary incontinence in women. Ann Intern Med 2008, 148:459 PMID: 18268288
  9. Strasser H, Marksteiner R, Margreiter E, Pinggera GM, Mitterberger M, Frauscher F, Ulmer H, Fussenegger M, Kofler K, Bartsch G. Autologous myoblasts and fibroblasts versus collagen for treatment of stress urinary incontinence in women: a randomised controlled trial. Lancet. 2007 Jun 30;369(9580):2179-86. Erratum in: Lancet. 2008 Feb 9;371(9611):474. PMID: 17604800 - Novara G, Artibani W. Myoblasts and fibroblasts in stress urinary incontinence. Lancet. 2007 Jun 30;369(9580):2139-40. PMID: 17604781
  10. Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010
  11. Labrie J et al. Surgery versus physiotherapy for stress urinary incontinence. N Engl J Med 2013 Sep 19; 369:1124 PMID: 24047061
  12. Qaseem A, Dallas P, Forciea MA et al Nonsurgical Management of Urinary Incontinence in Women: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2014;161(6):429-440 PMID: 25222388 http://annals.org/article.aspx?articleid=1905131
  13. Herschorn S et al. Surgical treatment of stress incontinence in men. Neurourol Urodyn 2009 Dec 22; 29:179. PMID: 20025026
  14. Chughtai B et al. Conservative treatment for postprostatectomy incontinence. Rev Urol 2013 Oct 2; 15:61. PMID: 24082844
  15. Liu Z, Liu Y, Xu H et al Effect of Electroacupuncture on Urinary Leakage Among Women With Stress Urinary Incontinence. A Randomized Clinical Trial. JAMA. 2017;317(24):2493-2501 PMID: 28655016 http://jamanetwork.com/journals/jama/article-abstract/2633916
  16. Judge DE Urinary Incontinence: Yes, It Can Be Treated. NEJM Journal Watch. Jan 22, 2019 Massachusetts Medical Society (subscription needed) http://www.jwatch.org https://www.jwatch.org/na48165/2019/01/22/urinary-incontinence-yes-it-can-be-treated
  17. Balk EM, Rofeberg VN, Adam GP et al Pharmacologic and Nonpharmacologic Treatments for Urinary Incontinence in Women: A Systematic Review and Network Meta-analysis of Clinical Outcomes Ann Intern Med. 2019. March 19. PMID: 30884526 https://annals.org/aim/article-abstract/2728712/pharmacologic-nonpharmacologic-treatments-urinary-incontinence-women-systematic-review-network-meta
  18. Hagen S et al Effectiveness of pelvic floor muscle training with and without electromyographic biofeedback for urinary incontinence in women: multicentre randomised controlled trial. BMJ 2020;371:m3719 PMID: 33055247 Free PMC article. https://www.bmj.com/content/371/bmj.m3719
  19. Dumoulin C, Cacciari LP, Hay-Smith EJC. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev. 2018 Oct 4;10(10):CD005654 PMID: 30288727 PMCID: PMC6516955 Free PMC article https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005654.pub4/full
  20. NEJM Knowledge+ Nephrology/Urology
  21. Huang AJ, Chesney M, Schembri M et al Efficacy of a Therapeutic Pelvic Yoga Program Versus a Physical Conditioning Program on Urinary Incontinence in Women: A Randomized Trial. Ann Intern Med. 2024 Aug 27. PMID: 39186785 https://www.acpjournals.org/doi/10.7326/M23-3051