New techniques for treating stress urinary incontinence

Stress urinary incontinence (SUI), defined by the International Continence Society as the complaint of involuntary leakage on effort or exertion or on sneezing or coughing,¹ affects 23% to 38% of the female population in the United States over the age of 20 years.² Of the women affected, it is estimated that 7% to 10% of cases are severe with frequent leakage.³

Analysis of Medicare data suggests that annually only 10% of women diagnosed with incontinence undergo surgical correction.⁴

Given that the US population is aging and that the incidence of urinary incontinence increases with age, it is important for the clinician to maintain a working knowledge of current treatment options for this increasingly common condition.

Nonoperative management

Pharmacologic management

In addition to surgical correction, nonsurgical options exist for SUI. To date, the only pharmacologic agent to have shown efficacy for this condition is duloxetine. Duloxetine is a balanced serotonin and norepinephrine reuptake inhibitor approved by the US Food and Drug Administration (FDA) for the treatment of major depressive disorders, generalized anxiety disorders, and pain caused by fibromyalgia or diabetic neuropathy. It also has been noted in animal studies to increase bladder storage capacity and urethral striated muscle sphincter function through its effects on the central spinal cord.⁵

In a number of double-blind, placebo-controlled, randomized trials duloxetine has been shown to significantly improve symptoms of stress incontinence compared with placebo.^6-9 For example, in the North American study of duloxetine conducted by Dmochowski, et al, women receiving duloxetine 40 mg twice daily were shown to have a 51% decrease in weekly incontinence episodes compared with a 27% reduction in patients receiving placebo. In addition, significant increases in quality-of-life measure subscales (ie, avoidance/limiting behavior, psychosocial and social embarrassment) were seen in the duloxetine-treated patients. These results were tempered by the fact that 24% of patients discontinued duloxetine because of adverse side effects (eg, nausea, fatigue, insomnia, somnolence, dizziness, and blurred vision) compared with 4% of placebo-treated patients.⁶

Duloxetine was approved for the treatment of stress incontinence by the European Union in 2004. In the United States, however, a black box warning issued by the FDA related to potential increases in suicidal ideation with duloxetine led the manufacturers to withdraw their application for approval of the additional indication of duloxetine for the treatment of stress incontinence. Thus, any treatment of stress incontinence in the United States with duloxetine therapy is considered off-label usage.

Other nonsurgical treatments

The current mainstays of nonsurgical therapy for SUI are pelvic floor muscle training, pessary devices, and behavioral or lifestyle modifications such as weight loss, fluid restriction, and avoidance of stressful maneuvers. Each of these approaches has been shown to have efficacy in motivated patients,¹⁰ and in our practice these are always offered as first-line approaches to any willing patient.

In patients who are able to properly perform Kegel maneuvers, we typically prescribe a self-directed exercise program. Pelvic floor muscle training is offered in combination with biofeedback training if the patient demonstrates an inability to properly perform a Kegel maneuver on exam or requests treatment by a physical therapist. Patients who do not achieve satisfactory symptom control with nonsurgical therapy or who are unwilling to participate in more conservative treatments generally are offered surgical therapy.