Surgery may benefit women with two types of urinary incontinence

by National Institutes of Health

Credit: CC0 Public Domain

Surgery for stress urinary incontinence (leaking that occurs with a cough or sneeze) improves symptoms of another form of incontinence, called urgency urinary incontinence, in women who have both types, according to a study supported by the National Institutes of Health. The findings challenge current treatment guidelines, which suggest that the surgery may worsen urgency urinary incontinence in women with both forms, also called mixed urinary incontinence. The study appears in the Journal of the American Medical Association. Funding was provided by NIH's Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) and Office of Research on Women's Health.

20 sept 2019--"Women with mixed urinary incontinence may have more bothersome symptoms than women with either stress or urgency urinary incontinence alone," said Donna Mazloomdoost, M.D., study author and program director of the NICHD Pelvic Floor Disorders Network. "The findings show promise in treating a condition that can be hard to manage under existing practices."

Roughly one-third to one-half of all women with urinary incontinence have mixed urinary incontinence. Urgency urinary incontinence results from the spontaneous contraction of bladder muscles, leading to a strong and sudden need to urinate. Stress urinary incontinence occurs when urine leaks out after abdominal pressure increases following a sneeze, cough, laugh or movement, which squeezes the bladder.

Standard treatment guidelines for mixed urinary incontinence often involve treating the two forms of incontinence independently. Urgency urinary incontinence often is first treated with behavioral techniques, such as trying to delay urinating for a brief period after feeling the urge, reducing liquid consumption, exercises to strengthen muscles around the bladder (involving pelvic floor physical therapy) and with medication. Surgery is not usually recommended early on. Stress incontinence also can be treated with exercises, and many women experience symptom improvement. However, in women who do not improve or opt out of the exercises, surgery may be offered.

The Effects of Surgical Treatment Enhanced with Exercise for Mixed Urinary Incontinence (ESTEEM) study is a randomized clinical trial that recruited 480 women with mixed urinary incontinence at centers across the United States. All participants underwent mid-urethral sling surgery, a well-established method that places a thin strip of mesh under the urethra; this helps prevent urine from leaking out during an exertion, such as a sneeze or cough. Participants were randomized to surgery alone or surgery with behavioral and pelvic floor muscle therapy, which included six visits with a trained health professional. They were followed for one year.

The women responded to a questionnaire, the urogenital distress inventory (UDI), which inquired about urinary symptoms. Symptoms are ranked from 0-300 points, depending on severity. They also responded to surveys on quality of life and perceptions of surgical success.

The study team found that both groups had significant improvements in their incontinence symptoms after surgery. The average UDI score for the surgery alone group was 176.8 before surgery and 40.3 a year after surgery; for the surgery and therapy combined group, the UDI score dropped from 178.0 to 33.8. According to the researchers, because the post-treatment UDI scores between the two groups did not differ greatly, adding behavioral and pelvic floor muscle therapy to the treatment may not result in better clinical outcomes.

However, the study team did find differences in other self-reported outcomes. The combined surgery and physical therapy group had fewer instances of incontinence a year after surgery and were less likely to receive additional treatment for urinary tract symptoms, suggesting they had more quality of life improvement than the surgery alone group.

"Current practice guidelines may be unnecessarily delaying surgery for women with mixed urinary incontinence," said Vivian W. Sung, M.D., M.P.H., the study's lead author and a professor at the Warren Alpert Medical School of Brown University in Providence, Rhode Island. "We hope these findings will improve how patients are counseled and treated."

The researchers called for additional research to identify which patients with mixed urinary incontinence are at risk for continued symptoms after surgery and to identify effective treatments for them.

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Explore further

Clinical review published in JAMA

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More information: Vivian W. Sung et al. Effect of Behavioral and Pelvic Floor Muscle Therapy Combined With Surgery vs Surgery Alone on Incontinence Symptoms Among Women With Mixed Urinary Incontinence, JAMA (2019). DOI: 10.1001/jama.2019.12467

Journal information: Journal of the American Medical Association 

Provided by National Institutes of Health 

Urinary incontinence common in older men too

NEW YORK 24 aug 2010– It's not just women who suffer from urinary incontinence: Nearly one in twenty U.S. men have moderate to severe forms of the condition, which is as common as one in six among elderly men, a new study finds.

Research suggests that urinary incontinence affects women about twice as often as it does men. But the new findings, researchers say, underscore the fact that despite their relatively lower risk, men commonly deal with the condition as well.

The study found that among 5,300 U.S. men age 20 or older who participated in a government health survey, 4.5 percent reported symptoms of moderate to severe urinary incontinence -- defined as having leakage at least once a week, or once a month at volumes "more than drops."

Among men age 75 and older, 16 percent met that definition.

In all, that translates to an estimated 8.2 million U.S. men with moderate to severe urinary incontinence, the researchers report in the Journal of Urology.

"It's a common problem," said lead researcher Dr. Alayne D. Markland, of the Birmingham VA Medical Center and the University of Alabama at Birmingham.

Yet, she told Reuters Health, doctors and patients alike may not think to bring up urinary incontinence symptoms. "Older patients often think that it is just part of aging," Markland noted.

But she advised men to discuss any incontinence problems with their doctors, as there are a number of effective treatments.

The options include Kegel exercises -- a set of exercises that help strengthen the muscles of the pelvic floor -- as well as behavioral changes, such as scheduled bathroom trips and limiting fluids at certain times of the day. There are also a number of medications that help treat incontinence, and two of Markland's co-authors had relationships with companies that sell or research such drugs. In more severe cases, surgery may be an option.

Men with urinary incontinence will have the added step of needing a prostate check, because prostate-gland enlargement is a common cause of urinary symptoms.

Markland and her colleagues also found that several factors were linked to an increased risk of moderate to severe urinary incontinence.

One, not surprisingly, was older age. Another was major depression.

Among men who screened positive for major depression, about 11 percent had moderate to severe urinary incontinence, versus 4 percent of men who did not screen positive.

When the researchers accounted for other factors -- including age and the presence of chronic physical diseases -- depressed men had between two and three times the risk of moderate to severe urinary incontinence that non-depressed men had.

Other studies have seen a similar link between depression and urinary incontinence in both men and women, according to Markland. "But we don't know if that's a cause-and-effect relationship," she said.

On one hand, it's possible that serious problems with incontinence contribute to social isolation and depression in some people. Alternatively, there could be physiological effects connected to depression -- such as alterations in the brain chemical dopamine -- that impair bladder function.

Another possibility is that some of the medications used to treat depression cause incontinence as a side effect. Markland noted, however, that there is no evidence that the widely used SSRI antidepressants cause urinary incontinence.

In what Markland said was a rather surprising finding, the researchers also found that men with high blood pressure had an increased risk of incontinence. Roughly 9 percent had moderate to severe symptoms, versus 3 percent of men without high blood pressure. With other factors taken into account, high blood pressure was linked to a 30 percent increase in the risk of urinary incontinence.

As with depression, Markland said, the reasons for the connection between high blood pressure and incontinence are not yet clear. Again, she said it's possible that medications used to treat high blood pressure cause bladder control problems in some men, but that has yet to be shown.

Procedure Significantly Improves Urinary Incontinence

Incontinence, overactive bladder symptoms improved by transobturator tape procedure

02 mar2009-- A transobturator tape procedure resulted in nearly an 80 percent improvement in urge urinary incontinence, according to research published in the March issue of Obstetrics & Gynecology.

Samina Tahseen, of the Luton and Dunstable Hospital in Bedfordshire, United Kingdom, and a colleague conducted follow-up interviews, at a median of 13 months, on 58 women who had undergone a transobturator tape procedure. Based on diagnosis, women were categorized into three groups, either having stress incontinence only, mixed incontinence with predominant stress leakage, or mixed incontinence with predominant urge leakage.

Overall, urge urinary incontinence was cured in 43 percent and improved in 36 percent, the researchers report. In the group of women with stress predominant leakage, incontinence was cured and improved in an equal proportion of patients (43.5 percent each). In women with urge predominant leakage, incontinence was cured in 43 percent and improved in 28.5 percent of patients, the investigators found. Stress incontinence was completely resolved in 77 percent and was improved in an additional 19 percent. No cases of de novo urge incontinence were reported, the authors note.

"The transobturator midurethral sling has been shown in this study to improve urge urinary incontinence and overactive bladder symptoms significantly in mixed urinary incontinence and to provide high postoperative patient satisfaction," the authors conclude.

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Weight loss reduces incontinence for women

Targeted 6-month program diet, exercise and behavior modification cut incontinence by nearly half

BIRMINGHAM, Ala., 29 jan 2009– Starting a weight-loss regimen significantly reduces urinary incontinence for women, according to researchers at the University of Alabama at Birmingham (UAB) and the University of California, San Francisco.

A six-month program of diet, exercise and behavior modification resulted in a loss of 17 pounds and nearly one-half (47 percent) fewer incontinence episodes per week on average, the study authors said.

By contrast, an information-only program on diet and exercise without any direct weight-loss training led to a loss of 3 pounds and 28 percent fewer incontinence episodes per week on average, the researchers said.

The results are published in the New England Journal of Medicine.

"Earlier research has shown that behavioral weight-loss programs have many benefits, including decreasing blood pressure and helping to fight off diabetes. Here we've shown that weight loss has measureable impact on reduced incontinence," said Frank Franklin, M.D., Ph.D., a UAB professor in the School of Public Health and a co-author on the NEJM study.

The NEJM results are from the Program to Reduce Incontinence by Diet and Exercise, or PRIDE study. It included 338 overweight and obese women (BMI 25-30 kg/m²) who experienced up to 10 episodes of incontinence per week.

Those on the diet, exercise and behavior modification program reported feeling significantly more satisfied with the improvements in incontinence compared to the information-only participants, Franklin said.

Urinary incontinence affects more than 13 million women in the United States and has been linked to increased risk of falls and bone fractures.

Considering the PRIDE results and other health benefits, the initiation of weight loss should be added as a first-line treatment in overweight and obese women, said lead study author Leslee Subak, M.D., of the University of California, San Francisco.

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The study was a partnership with UAB, the University of California, San Francisco; Brown University in Providence, Rhode Island and the University of Arkansas for Medical Sciences in Little Rock. Funding is from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and the Office of Research on Women's Health (ORWH), both part of the National Institutes of Health.

Drug adherence poor in women with urinary trouble

NEW YORK , 26 dec 2008 – The odds are high that a woman who is prescribed an "anticholinergic" drug to relieve urinary incontinence or other lower urinary tract symptom will discontinue the medication not long after starting it, a study suggests. This is true regardless of the class of medication used.

Two examples of anticholinergic drugs that are often prescribed for urinary incontinence are oxybutynin (Ditropan) and tolterodine (Detrol).

"Our high discontinuation rates across all anticholinergic drug classes...highlight the need for more effective therapies for lower urinary tract symptoms," Dr. Manish Gopal from Saint Peter's University Hospital, New Brunswick, New Jersey and colleagues conclude.

Using a large database, Gopal and colleagues analyzed 29,369 women aged 18 and older who were initially prescribed an anticholinergic medication, such as Ditropan or Detrol, between 1991 and 2005.

They found that half of women prescribed an anticholinergic stopped taking it by 6 months, and 3 out of 4 women discontinued therapy by 1 year. The median time to discontinuation for all 9 different anticholinergic drugs was about 4 months after initial use.

In a report in the journal Obstetrics and Gynecology, the investigators note that rates of discontinuation increased with duration of use, and "very few women" switched to another drug after initial prescribed treatment before stopping the drug.

Because of the high discontinuation rates of anticholinergic therapy for lower urinary tract symptoms, health care providers "must be vigilant" regarding alternative forms of treatment, such as bladder training and pelvic floor rehabilitation, for overactive bladder "and increase our awareness that this group of women is being treated inadequately," the investigators conclude.

SOURCE: Obstetrics and Gynecology, December 2008.

Research shows physical therapy treatment resolves symptoms of urninary incontinence in women

Silent health issue affects substantial proportion of American women, according to JAMA

ALEXANDRIA, VA, 18 sept 2008— In response to a new study published in the Journal of the American Medical Association showing that pelvic floor disorders, such as urinary incontinence, affect up to one-quarter of American women, the American Physical Therapy Association (APTA) is urging women who suffer from this widespread disorder to consider treatment from a physical therapist.
Recent research has demonstrated physical therapy's effectiveness at treating the symptoms of urinary incontinence. A study published in the Annals of Internal Medicine (March 18, 2008) reports that pelvic floor muscle training, in conjunction with bladder training, resolved the symptoms of urinary incontinence in women. According to APTA, proper preventive measures and treatment by a physical therapist can help patients manage, if not alleviate, this often debilitating condition.
The study, which included 96 randomized controlled trials and 3 systematic reviews from 1990 through 2007, concluded that pelvic floor muscles training and bladder training resolved urinary incontinence in women, as compared to drug therapy, electrostimulation, medical devices, injectable bulking agents, and local estrogen therapy.
"The Annals of Internal Medicine is significant for many reasons, none more so than because it provides the highest levels of evidence to support the importance of intervention by a physical therapist who specializes in treating urinary incontinence," says Cynthia E Neville, PT, BCIA-PMDB, director of Women's Health Rehabilitation at the Rehabilitation Institute of Chicago.
Urinary incontinence, or involuntary loss of bladder control, isn't something that just happens to older patients. In fact, the condition affects men and women alike, young and old. More than 25 million* Americans have urinary incontinence, and the experience can leave them feeling ashamed, socially isolated, and depressed.
Patricia J Jenkyns, a physical therapist at the Department of Rehabilitation Services at Boston's Brigham and Women's Hospital, says that physical therapists are crucial in treating urinary incontinence because of their role in both assessing and treating musculoskeletal conditions. "Patients often think that because of age or medical history, incontinence is something they have to learn to live with, but in reality that couldn't be further from the truth," she says. "Health care professionals need to be aware of the role that physical therapists play in treating incontinence so that their patients know about alternatives to diapers, medication, or surgery."
Jenkyns notes that physical therapists use a variety of methods to help patients correct pelvic floor dysfunction. The initial patient evaluation requires determining the type of incontinence (stress, urge, or both), the extent of incontinence, assessing the strength, motor control and endurance of pelvic floor muscles, and screening for any other musculoskeletal issues, then developing an individualized exercise treatment program, and making sure patients understand their role in the treatment program.
In a case study published in the New England Journal of Medicine (March 6, 2008) regarding urinary incontinence in women, it is noted that "first-line treatment for stress incontinence includes pelvic floor muscle training." Affirming the Annals of Internal Medicine results, this second study points out that women unable to identify their pelvic floor muscles "may benefit from seeing a physical therapist trained in pelvic floor therapy."
Kegel exercises, or pelvic floor muscle exercises that involve contracting, holding, and releasing pelvic floor muscles, are the most effective weapon in the fight against stress incontinence. "Once patients have correctly identified these muscles, a physical therapist will train how to enhance pelvic floor muscle function, coordinate with abdominal muscle exercises and bring these exercises and awareness into functional activities," says Jenkyns. She notes that these exercises need to be brought into daily activities, and can be done when sitting at your desk or on the toilet, while driving, or at the gym. For those with very weak muscles, she recommends starting the exercises while lying down.
Jenkyns always reminds her patients who experience stress incontinence to "squeeze as you sneeze," or to coordinate pelvic floor and abdominal muscles before doing the activity that causes leakage, (eg, sneezing, coughing, laughing, lifting, etc). Physical therapists can also offer tips on lifestyle changes that will help make the bladder less irritable: avoiding common bladder irritants, retraining the bladder, keeping a bladder diary and lifting, moving, and exercising correctly, particularly by avoiding improper sit-up techniques.
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Since 2006, the APTA Section on Women's Health has offered members a Certificate of Achievement in Pelvic Physical Therapy. Known as CAPP, the program provides standardized training for this highly specialized field and currently has 400 members in the certification process.
APTA offers a free brochure to help consumers understand what incontinence is and the different kinds of treatment options physical therapists can provide to manage the condition, or in some cases, regain complete continence. It can be found on the APTA Web site at www.apta.org/consumer.
Physical therapists are health care professionals who diagnose and manage individuals of all ages who have musculoskeletal problems or other health-related conditions that limit their abilities to move and perform functional activities in their daily lives. Physical therapists examine each individual and develop a plan of care using treatment techniques to promote the ability to move, reduce pain, restore function, and prevent disability. Physical therapists also work with individuals to prevent the loss of mobility by developing fitness- and wellness-oriented programs for healthier and more active lifestyles.
APTA (www.apta.org) is a national organization representing physical therapists, physical therapist assistants, and students nationwide. Its goal is to foster advancements in physical therapist education, practice, and research. Consumers can visit www.findapt.us to find a physical therapist in their area, as well as www.apta.org/consumer for physical therapy news and information. Also, for more information on women's health conditions, visit www.womenshealthapta.org.

Panel urges end to incontinence stigma

LAURAN NEERGAARD
One in four U.S. adults will experience incontinence at some point, a surprisingly high toll, and the condition is so embarrassing that many suffer silently, a government panel said Wednesday.
Women are most prone to incontinence, which is the inability to control urination or bowel movements. But everyone's risk rises as they get older. Being overweight and a couch potato adds to the risk.
With the population rapidly graying and fattening, scientists convened by the National Institutes of Health issued an urgent call for research to find better ways to prevent incontinence and to remove the stigma so more people will seek help.
"We as a society need to get over our discomfort with this subject so that incontinence sufferers receive the compassion, acceptance and care they need, and our aging population can take steps to prevent incontinence in the future," said Dr. C. Seth Landefeld, geriatrics chief at the University of California, San Francisco, who led the panel.
Today, fewer than half of the people with incontinence volunteer their symptoms to a doctor, the panel found. That is the case despite a variety of effective treatments, from exercises to medications and surgery.
Prevention is better, but the panel found major gaps in the understanding of the biology of incontinence that hinder that effort. For now, the panel's best advice is for people to seek help.
And for those without the problem, exercise and dropping extra pounds are recommended as protection.
"All of us are walking around with a bag of water and a bag of stool in our pelvis," Landefeld said. "Anything that exerts increased pressure on those, tends to push them out, is potentially leading to incontinence."
Among other suggestions are:
_Women especially should try exercises of their pelvic floor muscles, popularly termed "Kegels," to keep them strong enough for good bladder control. But ask at a checkup if they are being done correctly. Too many women wind up squeezing the wrong muscles.
_Obestricians should end routine use of episiotomies, an incision that enlarges the vaginal opening for childbirth. Obstetric groups long have issued the same advice, saying episiotomies are useful only if the baby is in distress. But Wednesday's panel cited estimates that 1 million women a year still receive a routine one, leading to perhaps 1,000 of them suffering fecal incontinence directly after birth or later in life.
Urinary incontinence is the more common type; previous estimates have put the number of people with this condition at around 13 million. Actually, more than 20 million women and 6 million men have experienced urinary incontinence at some point, the NIH panel concluded.
The two most prevalent subtype are stress incontinence and urge incontinence.
Stress incontinence is leakage caused by physical pressure to the abdomen, such as coughing, sneezing, laughing, jogging or lifting a heavy object. Urge incontinence is a sudden, uncontrollable urge to urinate, sometimes called overactive bladder.
Fecal incontinence is harder to measure, even more stigmatized and thus hardly ever studied. The best estimates suggest it affects up to 5 percent of the general population and up to 39 percent of nursing home residents.
Pregnancy and childbirth can trigger incontinence that can be either temporary or lasting. So can menopause, when the loss of estrogen is thought to weaken some bladder-control muscles.
But other risk factors are myriad and poorly understood: radiation therapy, pelvic injury or surgery, urinary tract infections, neurological diseases, the panel found.
The severity of incontinence varies widely, from a few drops to a major impairment that requires wearing diapers and may strand people in their homes.
It is a huge trigger of nursing home admissions, particularly with dementia patients whose caregivers cannot handle the added stress and physical toll of diapering an uncooperative adult.
Disturbingly, much incontinence in nondemented nursing home patients is not due to biology but lack of staff to help the frail get to the bathroom in time, the panel noted.

Cell Therapy Key to Staunching Stress Incontinence

INNSBRUCK, Austria, June 28 -- A novel treatment to relieve stress incontinence in women, strengthening the urinary rhabdosphincter with cultured autologous tissue, has panned out.
A year after the procedure, 38 of the 42 women who underwent the procedure were completely continent, according to Hannes Strasser, M.D. of the University of Innsbruck.
He and colleagues used autologous muscle and connective tissue cells -- extracted, grown in culture, and re-implanted - and found the approach safe and effective, they reported in the June 30 issue of The Lancet. In contrast, only two of 21 women in a control group given standard collagen injections were continent.
Other outcome measures, including the thickness and contractility of the rhabdosphincter, also improved significantly (P<0.0001), the researchers said
A estimated 165,000 women a year in the U.S. have surgery for stress incontinence.
The findings "can be seen as the beginning of a new era in urogynecology," said Giacomo Novara, M.D., of the University of Padua and Walter Artibani, M.D., of the IRCCS Instituto Oncologico Veneto, both in Padua, Italy, in an accompanying commentary.
Drs. Novara and Artibani said the urological community has been waiting for the results since 2003, when preliminary observations of the procedure were reported.
The results of the current randomized controlled trial are "impressive, both in terms of efficacy and tolerability of the new procedure," they said, although larger multicenter studies, with longer follow-up, should be performed.
Dr. Strasser and colleagues enrolled 63 women with stress incontinence and randomized them in a two-to-one fashion to either endoscopic injections of collagen into the periurethral tissue or to the experimental procedure.
The 42 women in the experimental arm, ages 36 to 84, had a muscle biopsy and blood sample taken, which were then taken to one of two centers in Austria certified to produce myoblasts and fibroblasts. Several of the authors have financial connections with the two centers.
After six to eight weeks of culture, the myoblasts were injected into the rhabdosphincter in 15 to 18 portions at two different levels in the middle third of the urethra, using an ultrasound transducer so the physicians could visualize the organs.
At the same time, the fibroblasts (with a small amount of collagen) were injected into the urethral submucosa in 25 to 30 places.
Because the two procedures were different, the study was not fully blinded, the researchers said, but the randomization was blinded, and those who collected and analyzed data did not know which women were in which group.
A year after the procedure, the researchers found:
90% of the women who got the experimental procedure were continent, compared with 9.5% of those who got collagen injections. The difference was significant at P<0.0001.
On average, the rhabdosphincter of the treated women was a millimeter thicker than those in the control group - 3.38 versus 2.32 mm.
Contractility of the rhabdosphincter was also better - 1.56 mm versus 0.67.
There was no significant difference in the thickness of the urethra.
Dr. Strasser and colleagues said that after a median follow-up of three years no severe side-effects or scars have been reported in any of the 63 volunteers, and postoperative results have not changed. They added that long-term post-operative data are needed and more studies are needed before the procedure can be established as a standard incontinence treatment.
Dr. Strasser and co-author Rainer Marksteiner, Ph.D., are co-owners of Innovacell Biotechnologie, while co-author Martin Fussenegger, M.D. is an owner of IGOR The companies run certified facilities where the autologous cells were grown. Eva Margreiter, Ph.M., is an employee of Innovacell. The study was supported by a grant from the Medical University Innsbruck. Primary source: The LancetSource reference: Strasser S et al. "Autologous myoblasts and fibroblasts versus collagen for treatment of stress urinary incontinence in women: a randomised controlled trial." Lancet 2007; 369: 2179-86 Additional source: The LancetSource reference: Giacomo Novara and Walter Artibani. "Myoblasts and fibroblasts in stress urinary incontinence." Lancet 2007; 369: 2139-40.