A Closer Look: Optimizing the Management of Stress Urinary Incontinence in Primary Care Practice
A Closer Look:
Optimizing the Management
of Stress Urinary Incontinence
in Primary Care Practice
Diane K. Newman, RNC, MSN, CRNP,
FAAN
Co- Director
Penn Center for Continence and
Pelvic Health
Division of Urology
University of Pennsylvania Medical Center
Philadelphia, Pennsylvania
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A Closer Look: Optimizing the Management of Stress Urinary Incontinence in Primary Care Practice
Module 1
Stress Urinary Incontinence
Prevalence and Risk Factors
What is Stress Urinary
Incontinence (SUI)?
? SUI is a treatable disease characterized by
– Involuntary loss of urine during an
increase in abdominal pressure1
• Concurrent with physical exertion
(eg, coughing, sneezing, laughing,
lifting, or exercising)
– Decreased urethral resistance 1
– Pelvic floor muscle weakness2
1. Culligan PJ, Heit M. Am Fam Physician. 2000;62:2433 -2444, 2447, 2452. 2. Newman DK. Managing and
Treating Urinary Incontinence. Baltimore, Md: Health Professions Press; 2002:88-90.
Urinary Incontinence (UI) Symptoms
Symptom Description
Leakage with physical exertion or with
SUI
sneezing or coughing
Leakage with a strong and urgent desire
Urge UI (UUI)
to void (may be seen in overactive bladder)
Mixed UI Combination of SUI and UUI
Newman DK. Am J Nurs. 2003;103:46-55.
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A Closer Look: Optimizing the Management of Stress Urinary Incontinence in Primary Care Practice
US Prevalence of SUI
? Nearly 15 million
women suffer
from SUI 1
? Nearly equal to
the population
of Florida2
1. Eli Lilly and Company data on file, 2005. 2. US Census Bureau. Available at:
http://quickfacts.census.gov/qfd/states/12000.html. Accessed February 16, 2005.
SUI Affects Women of All Ages
? SUI is seen in 20% to 67% of women
during pregnancy1
? SUI affects 10% to 30% of young
women postpartum 1-3
? In a study of 500 middle-aged women, more
than 40% of those with UI reported SUI 4,5
1. Mason L et al. Midwifery. 1999;15:120-128. 2. Hvidman L et al. Acta Obstet Gynecol Scand.
2003;82:556 -563. 3. Viktrup L. Neurourol Urodyn. 2002;21:2-29. 4. Chiarelli P et al. Neurourol Urodyn.
1999;18:567 -577. 5. Brown WJ, Miller YD. J SciMed Sport. 2001;4:373 -378.
SUI Quality of Life (QOL) Impact
? Avoidance of activities: social, recreational,
and work-related1,2
? Fear of unpleasant odor 3
? Negative effect on sexual activity; urine loss
during intercourse leads to avoidance of
sexual intimacy4
? Secondary depression when UI is severe5
1. Wyman JF. Curr Opin Obstet Gynecol. 1994;6:336 -339. 2. Newman DK. Am J Nurs Pract . 2003;103:46 -
55. 3. Lagro-Janssen T et al. Scand J Prim Health Care.1992;10:211-216. 4. Hilton P. Br J Obstet
Gynaecol. 1988;95:377-381. 5. Dugan E et al. J Am Geriatr Soc.2000;48:413-416.
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A Closer Look: Optimizing the Management of Stress Urinary Incontinence in Primary Care Practice
Risk Factors for SUI in
Women Across the Life Span
Middle-
Young Aged Older
Factor Women Women Women
Effect of pregnancy 1
Type of delivery 2,3 (vaginal vs cesarean)
Parity4
Smoking 2,3
Increased body mass index 5,6
Medications 7,8
Physical exercise9
Estrogen depletion 10
Chronic constipation6,11
Pelvic organ prolapse1 2
.
1. Mason L et al. Midwifery 1999;15:120 -128. 2. Holroyd-Leduc JM et al. JAMA. 2004;291:986- 995. 3. Luber KM, Rev
Urology. 2004;6:S3 -S9. 4. Sampselle CM. J Midwifery Womens Health. 2000;45:94- 103. 5. E s p i n o DV et al. J Am
Geriatr Soc. 2003;51:1580- 1586. 6. Chiarelli P et al. Women Health. 1999;29:1- 13. 7. Grady D et al. Obstet Gynecol.
2001;97:116 -120. 8. Menefee SA et al. ObstetG y n e c o l. 1998;91:853 -854. 9. Bo K. Sports Med. 2004;34:451- 464.
10. Lang JH et al. IntJ GynaecolObstet. 2003;80:35- 39. 11. Alling Moller L et al. ObstetGynecol . 2000;96:446- 451.
12. Bai SW et al. Int Urogynecol J Pelvic Floor Dysfunct. 2002;13:256- 260.
SUI: Other Associated Factors
? Medications 1
– Alpha-adrenergic blockers
(reduce urethral resistance)
– Diuretics (increased bladder volume)
– Angiotensin-converting enzyme inhibitors
(risk for chronic cough)
? Other factors associated with chronic cough 2
– Pulmonary diseases3
– Cigarette smoking 4
1. Steele AC et al. Int Urogynecol J Pelvic Floor Dysfunct . 1999;10:106 -110. 2 . Bump RC, McClish DM.
Am J Obstet Gynecol. 1994;170:579 -582. 3. Bump RC, Norton PA. Obstet Gynecol Clin North Am.
1998;25:723 -746. 4. Sampselle CM et al. Obstet Gynecol. 2002;100:1230 -1238.
SUI: Other Associated Factors
? Occupational and recreational activities 1,2
– Heavy lifting
– Bending
– High-impact sports
1. Davis G et al. Mil Med. 1999;164:182-187. 2 . Thyssen HH et al. Int Urogynecol J Pelvic Floor Dysfunct.
2002;13:15-17.
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A Closer Look: Optimizing the Management of Stress Urinary Incontinence in Primary Care Practice
SUI Screening
? Pelvic exams1
? Screen at-risk populations
– Prenatal and postpartum women2
– Overweight women3
– Participants in high-impact sports 4
– Perimenopausal women3
– Women who smoke5
1. Newman DK. Managing and Treating Urinary Incontinence. Baltimore, Md: Health Professions Press;
2002:88-90. 2. Mason L et al. Midwifery. 1999;15:120 -128. 3. Sampselle CM et al. Obstet Gynecol.
2002;100:1230-1238. 4. Nygaard IE et al. Obstet Gynecol. 1994;84:183-187. 5. Bump RC, Norton PA. Obstet
Gynecol Clin North Am. 1998;25:723-746.
Module 2
Stress Urinary Incontinence
Anatomy and Physiology of the
Lower Urinary Tract
Female Pelvis
Ureter
Uterus
Rectum
Bladder
Spine
Pelvic
bone
Pelvic
floor
Urethra muscles
Gray ML. Am J Nurse Pract . 2004;(suppl):15 -22.
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A Closer Look: Optimizing the Management of Stress Urinary Incontinence in Primary Care Practice
Micturition
Storage Voiding
• Bladder muscle relaxes • Bladder muscle contracts
• Pelvic floor contracts • Pelvic floor relaxes
• Urethral sphincter • Urethral sphincter
contracts (voluntary relaxes (voluntary control)
control)
Bladder filling Bladder emptying
Palmer MH. Am J Nurse Pract. 2004;( suppl):5 -14.
Mechanism of Continence
? Maintaining urinary continence depends on
– Anatomic and functional integrity of the
urethra and bladder
– Strength and integrity of the urethral
sphincters
– Strength of pelvic floor muscles
– Neurologic connections between the brain,
central nervous system, components of the
autonomic and somatic nervous systems,
and the lower urinary tract
Abrams P et al, eds. Incontinence: Proceeding From the Second International Consultat ion on Incontinence.
Plymouth, UK: Health Publication Ltd; 2001.
Innervation of the Lower Urinary Tract
Pelvic nerve
(parasympathetic) ACh*
Hypogastric nerve
(sympathetic) NE†
Pudendal nerve
(somatic) ACh
*Acetylcholine.
†
Norepinephrine.
Information from: Thor KB. Adv Stud Med. 2002;2:667-680.
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Pathophysiology of Stress Urinary
Incontinence (SUI)
? Urethral hypermobility (vaginal wall prolapse)
– Loss of integrity of endopelvic fascia
– Weakened pelvic floor muscles
? Urethral sphincter incompetence
– Congenital defects
– Iatrogenic defects
– Trauma
1. Gray M. J Am Acad Nurse Pract. 2004;16:188-197.
Types of Urinary Incontinence (UI)
? SUI
– Urine loss caused by
increased abdominal
pressure (eg, laugh,
cough, sneeze or other
physical exertion)
? Urge UI (UUI)
– Urine loss associated
with bothersome
urgency and uninhibited
bladder contractions
? Mixed UI
– Combination of SUI and UUI
Sudden increase in intra- abdominal pressure
Uninhibited bladder contractions
Decreased urethral pressure
Module 3
Stress Urinary Incontinence
Assessment, Diagnosis, and
Treatment
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Stress Urinary Incontinence (SUI) Can Be
Effectively Diagnosed in Primary Care Setting
? Assessment can be integrated into1,2
– General screening questions
– Routine or well woman history and
physical examination
– Pelvic exam, including vaginal wall support
and pelvic floor muscle assessment
? Additional ways to assess2
– Urinalysis
– 3-day bladder diary (optional)
1. Gray M. J Am Acad Nurse Pract. 2003;15:102-107. 2. Newman DK. Am J Nurse Pract. 2004;(suppl):23-32.
Identify Reversible and Transient
Causes of Urinary Incontinence (UI)
? Medication side effects 1
– Antihypertensives
– Antidepressants, narcotics, sedatives
– Diuretics
– Muscle relaxants
? Urinary tract infection 1,2
? Atrophic vaginitis 1
? Stool impaction1
1. Wound, Ostomy , and Continence Nurses Society. Ostomy Wound Manage.2003;49:28-33. 2. Landi F et
al. Age Ageing. 2003;32:194-199.
The Mnemonic DIAPPERS Can Be Used
to Identify Transient Causes of UI
Delirium
Infection
Atrophic vaginitis/urethritis
Pharmaceuticals
Psychological
Excessive urine output
Restricted mobility
Stool impaction
Resnick NM. Med Grand Rounds.1984;3:281-290.
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A Closer Look: Optimizing the Management of Stress Urinary Incontinence in Primary Care Practice
Ask the Patient About SUI
and Urge UI (UUI)
During the last week, have you accidentally
leaked urine with
1. A physical activity like coughing,
sneezing, lifting, or exercising?
2. A feeling of strong, sudden need to pass
your urine that did not allow you to get to
the toilet fast enough?
Culligan PJ, Heit MD. Am FamPhysician. 2000;62:2433 -2446, 2447, 2452.
Pelvic Examination
? Inspection of perineal skin 1,2
– Perineal dermatitis
– Signs of urogenital atrophy
? Pelvic examination1,2
– Signs of urogenital atrophy
– Pelvic organ prolapse
– Urine loss with coughing or during
Valsalva’s maneuver 3
– Presence of urine in the vagina and in the
absence of physical exertion (may indicate
genitourinary fistula)
1. Gray M. J Am Acad Nurse Pract. 2003;15:102-107. 2. Gray M. Am J Nurse Pract. 2004;(suppl):15-22.
3. Newman DK. Am J Nurs . 2003;103:46 -55.
Pelvic Floor Muscle Assessment
? Patient’s ability to identify, isolate, and
contract the pelvic floor muscles
? Grading of strength and duration of
contraction
? Change of position of the examiner’s finger
with the contraction
? Pressure or pain associated with the
examination
Newman DK. Managing and Treating Urinary Incontinence. Baltimore, Md: Health Professions Press;
2002:89-90.
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Grading Scale* for Digital Evaluation of
Pelvic Floor Muscle Strength
Scale Grade Description
None 0 No discernible muscle contraction, pressure, or
displacement of examiner’ s finger
Flicker 1/5 Trace but instant contraction of 1 but
? 3 seconds, with or without elevation of
examiner’ s finger
Moderate 3/5 Moderate contraction or compression of examiner’s
-6
finger, held for at least 4 seconds, repeated 3 times
Firm 4/5 Firm contraction with good compression of
-9
examiner’ s finger, held at least 7 seconds,
repeated 4- 5 times, with elevation of finger
toward the pubic bone
Strong 5/5 Unmistakably strong contraction held for at least 10
seconds, repeated 4- 5 times, with posterior elevation
of examiner’ s finger
*Based on Oxford grading system, an internationally accepted muscle grading method.
Adapted from: Newman DK. Managing and Treating Urinary Incontinence. Baltimore, Md: Health
Professions Press; 2002:245.
Treating SUI With the Whole Patient
in Mind
? Role of nurse practitioners, clinical nurse
specialists, and physician assistants
– Screen; evaluate symptoms
– Assess motivation
– Recommend treatment options based on
• Patient’s preferences
• Patient’s lifestyle
• Other factors
– Educate patients
? Refer to specialist when necessary
Mason DJ et al. Am J Nurse Pract. 2003;3(suppl):2-8.
Reasons for Referral
? Uncertain diagnosis
? Uncertain treatment plan
? Lack of response to therapy
? Consultation for surgery
? Hematuria without infection
? Comorbid conditions (eg, recurrent
urinary tract infection, previous
anti-incontinence surgery or radical
pelvic surgery, pelvic organ prolapse,
neurologic condition)
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SUI Can Be Effectively Treated
in Primary Care
? Behavioral interventions
– Lifestyle and other changes1
• Fluid and dietary modifications
• Weight reduction
• Smoking cessation
• Constipation prevention
– Pelvic floor muscle exercise program,
the Knack 2
– Bladder training, if urgency or UUI is present1
? Drug therapy1
1. Newman DK. Am J Nurse Pract . 2004;(suppl);23-32. 2. Miller JM et al. J Am Geriatr Soc.
1998;46:870 -874.
Lifestyle Changes for SUI
? Self-management
– Dietary and fluid management
– Weight loss
– Smoking cessation
– Constipation prevention
Wilson PD. In: Abrams P, et al, eds. Incontinence.Plymouth, UK: Health Publications Ltd; 2002:573-578.
Pelvic Floor Muscle Exercise Program
for SUI
? Identify and isolate the correct muscles
– “Draw in” and “lift up” the perivaginal
and rectal/anal sphincter muscles
– Do not “bear down”
? Correctly perform muscle contractions
– Without use of other/accessory muscles
(abdominal, gluteal, thigh)
– Quick (2-second) contractions followed
by sustained (endurance) contractions
(5 seconds or longer)
Newman DK. Managing and Treating Urinary Incontinence.Baltimore, Md: Health Professions Press;
2002:88-90.
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A Closer Look: Optimizing the Management of Stress Urinary Incontinence in Primary Care Practice
Female Pelvis
Ureter
Uterus
Rectum
Bladder
Spine
Pelvic
bone
Pelvic
floor
Urethra muscles
Gray ML. Am J Nurse Pract . 2004;(suppl):15 -22.
The Knack
? Quick and strong contraction of pelvic
floor muscles
? Performed immediately before and held
throughout the activity that increases intra-
abdominal pressure (eg, cough or sneeze)
? Prevents or reduces leakage during activity
or exertion
Miller JM et al. J Am Geriatr Soc.1998;46:870-874.
Pelvic Floor Muscle Exercise Program
for SUI
? Aids to increase motivation and compliance
– Exercise prescription appropriate to
patient’s pelvic floor muscle strength
and endurance 1
– Biofeedback 1
– Vaginal weights 2
– Audiocassette tape 3
1. Morkved S et al. Obstet Gynecol. 2002;100:730-739. 2. Newman DK. Managing and Treating Urinary
Incontinence. Baltimore, Md; Health Professions Press; 2002:130-131. 3. Palmer MH. Am J Nurse Pract.
2004;(suppl):5-14.
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Bladder Training for SUI
? Bladder training
– Aims to increase interval between voids
– Involves strategies to inhibit urge sensation
– Results in significant decrease in
self-reported frequency of UI and
decreased perception of severity
Wyman JF, FantlJA. Urol Nurs. 1991;11:11-17.
Value of Duloxetine as Oral Therapy
for SUI
? Dual-action serotonin (5HT) and
norepinephrine (NE) reuptake inhibitor (SNRI)
? Stimulates contraction of external urinary
sphincter
? Clinical trials have shown its effectiveness in
reducing SUI episodes 1,2
This information includes a use that has not been approved by the US FDA.
1. Dmochowski RR et al. J Urol. 2003;170(4 pt 1):1259-1263. 2. Millard RJ et al. BJU Int. 2004;93:311 -318.
The Effect of Duloxetine on Lower Urinary
Tract Neurotransmitters: Storage
NE Glutamate Physical
ON exertion
5HT
Duloxetine Striated
urethral
Pudendal sphincter
nerve activity
Onuf’s
nucleus
This information includes a use that has not been approved by the US FDA.
Thor KB. Neurourology: Exploring new horizons. Adapted from Advanced Studies in Medicine.
2002;2(19):677-680.
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The Effect of Duloxetine on Lower Urinary
Tract Neurotransmitters: Voiding
NE Glutamate
OFF
5HT
Duloxetine Striated
urethral
No pudendal sphincter
nerve activity
Onuf’s
nucleus
This information includes a use that has not been approved by the US FDA.
Thor KB. Neurourology: Exploring new horizons. Adapted from Advanced Studies in Medicine.
2002;2(19):677-680.
Decrease in Incontinence Episode Frequency
(IEF) in Women Treated for SUI With Duloxetine
4 wks 8 wks 12 wks
0
-10
Decrease -20 -15
in IEF -21
(%) -30 -27
-40
-50
-50 -50*
-60 -56
Placebo
Duloxetine
*P<.001.
This information includes a use that has not been approved by the US FDA.
Dmochowski RR et al. J Urol. 2003;170:1259-1263.
Other Pharmacotherapy for SUI*
? Alpha-adrenergic agonists ( eg, ephedrine and
pseudoephedrine) 1
– Efficacy not well established
– Significant side effects (agitation, insomnia, anxiety)
? Tricyclic antidepressants ( eg, imipramine) 2,3
– Unacceptable adverse effects
(eg, cardiac arrhythmias, sedation)
? Topical estrogen 4
– For treatment of urogenital atrophy; reduces
symptoms seen with vaginal atrophy including lower
urinary tract symptoms
*At present, no medication is approved by the FDA for the treatment of SUI.
1. Morrison J et al. In: Abrams P et al, eds. Incontinence 2nd ed. Plymouth, UK: Health Publications;
2002:83-164. 2. Sullivan J, Abrams P. Eur Urol. 1999;36(suppl 1):89 -95. 3. Viktrup L, Bump RC. Curr Med
Res Opin. 2003;19:485 -490. 4. Maloney C. Am J Nurs. 2002;102:44 -52.
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Pharmacotherapy for
Overactive Bladder
? Antimuscarinics 1
– Relaxes bladder smooth muscle by inhibiting
muscarinic action of acetylcholine
– Reduces voiding frequency and
frequency of UUI
• Oxybutynin1,2
• Tolterodine 1,2
• Trospium 3
• Solifenacin 3,4
• Darifenacin 3,4
1. Newman DK. Managing and Treating Urinary Incontinence. Baltimore, Md: Health Professions Press;
2002:180 -181. 2. Guay DR. Clin Pharmacokinet. 2003:42:1243-1285. 3. Sand PK. J Am Acad Nurse Pract .
2004;16:8-11. 4. Kershen RT, Hsieh M. Curr Urol Rep. 2004;5:359-367.
Other Treatment Options for SUI
? Surgery1
– Colposuspension
– Suburethral sling
• Autologous or cadaveric fascia 2
• Tension-free vaginal tape
? Injection of bulking agents 1
? Medical devices
– Intravaginal support devices
• Incontinence pessaries
– Disposable intraurethral inserts
1. Newman DK. Am J Nurs . 2003;103:46 -55. 2. Kassardjian ZG. BJU Int. 2004;93:665-670.
Key Points
? By diagnosing and treating SUI in the primary
care setting, clinicians can improve women’s
quality of life
? SUI can be easily assessed via a history,
physical exam, and urinalysis
– Screening and diagnostic tools are available
at the CSUIWH Web site, www.StressUI.org
? Treatment options in primary care include
behavioral interventions, lifestyle changes,
and medical devices
? Duloxetine appears to be well tolerated and
has been shown in clinical trials to reduce
SUI episodes
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Module 4
Stress Urinary Incontinence
Case Studies
Stress Urinary Incontinence
(SUI) Case Study 1
? 36-year-old Hispanic woman
? Presents with urine leakage during active
exercise
– Urine loss: generally small amount
– UI most severe during power walking,
which she does for 30 minutes,
3 times/week
? Uses 3+ feminine hygiene pads each day
? No UI during sexual intercourse
Patient History
? UI began after birth of second child several
years ago, has steadily worsened
? Previous unsuccessful attempts to contract
pelvic floor muscles
? Denies urgency and nocturia
? Defensive voiding used to keep urine volume
low in bladder
? Denies bowel dysfunction or constipation
? Current medications: multivitamins qd
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Obstetric History
? Current status: 1 year postpartum
? Obstetric factors
– All 3 children born vaginally
– All were 9+ lbs at birth
– Significant episiotomy with tearing
at each birth
Physical Examination
? Abdominal examination
– No masses or tenderness
– No suprapubic distension
? External genitalia moist
? Pelvic examination unremarkable
– Vaginal mucosa pink
– No lesions
– Cervix intact
– Vaginal wall well supported
? Normal mood and affect
Physical Examination
? Rectal examination
– Anal sphincter tone firm
– External hemorrhoids visible
– Anal wink positive
? Urinalysis: pH 5; all other parameters negative
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Pelvic Floor Muscle Assessment
? Inability to isolate pelvic floor muscles
? Grade 2 out of 5, weak contraction of the
levator ani muscle
? Able to sustain muscle contraction for
2 seconds
? Small amount of pelvic floor tilt with levator
ani contraction
Diagnosis
? SUI
? Muscle wasting and disuse atrophy
? Urinary frequency
Treatment Plan
? Pelvic floor muscle exercise program
– Both quick (2-second) and sustained
(5-second) contractions
– 30+ exercises, twice a day, in 3 positions
(sitting, standing, and lying down)
– Perform additional exercises with
audiocassette tape
? Use of incontinence perineal pads instead
of feminine hygiene pads
? 3-day bladder diary
? Follow-up visit
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Follow -Up Visit
? Decrease in leakage during active exercise
? Uses 1 to 2 perineal pads (decrease from 3+)
? Difficulty complying with pelvic floor exercise
program (due to family responsibilities)
? SUI management
– Recommended continuation of pelvic floor
exercise program
– Introduction of the Knack (written and oral
instructions)
– This patient may be a candidate for new
pharmacotherapeutic or surgical options
SUI Case Study 2
? 60-year-old white woman
? Presents with urine leakage when coughing,
sneezing, playing golf
? Severity: “damp to a few drops”; worsening
over the past few years
? Uses 1 panty liner each day and a heavier pad
when playing golf
? UI adversely affects her quality of life
? Denies urinary urgency or frequency
? Nocturia 1x; denies nocturnal enuresis
Patient History
? Patient has been adhering to a pelvic floor muscle
exercise program she devised herself
– Subjective success using #2 vaginal weight
? Previous UI treatment
– Periurethral bulking injections almost
10 years ago
– Successful for a time
– Recurrence of SUI
? Significant life-long problem with constipation
? Current medications
– Wellbutrin ™ and Xanax® (for posttraumatic
stress disorder)
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Physical Examination
? Normal mood and affect
? Abdominal examination
– No masses or tenderness
? Genitalia: introitus moist and pink
? Pelvic examination
– Grade 1 cystocele with Valsalva
– Unable to elicit urine leakage
? Rectal examination
– Anal sphincter tone moderate
? Urinalysis: sent for culture
– pH 5, leukocytes +1, nitrates +1, urine cloudy
Pelvic Floor Muscle Assessment
? Grade 4 out of 5 contraction of the
levator ani muscle; elevation of examiner’s
fingers with contraction
? Able to sustain muscle contraction for
7 to 8 seconds
? Initially “bearing down” when attempting
to contract pelvic floor muscles, but corrected
this with instructions
Diagnosis
? SUI
? Constipation
? Muscle wasting and disuse atrophy
? Possible UTI
– Culture subsequently found to be negative
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Treatment Plan
? Constipation management
– Add unprocessed wheat bran to diet;
high-fiber recipes offered
– Discussion of life-long constipation and its
correlation with incontinence and other
bladder symptoms
? Pelvic floor muscle exercise program
– Training patient to perform contractions
correctly
– Addition of Knack to program
– Continue using vaginal weights
? Follow -up visit
Follow -Up Visit
? Improvement in leakage frequency and amount
– Leakage only with a very hard sneeze
? Continuing severe constipation with straining
during defecation
– Some improvement following ingestion
of a mixture of unprocessed wheat bran,
applesauce, and prune juice
– Decaffeinated “Smooth Move” tea effective
in making bowel movements regular and soft
? Diagnosis at follow-up
– SUI
– Muscle wasting and disuse atrophy
– Constipation
Treatment Plan at Follow -Up
? Continue pelvic floor muscle
exercise program
– Increase number of contractions
from 30 to 60 bid
– Continue with vaginal weights
(able to retain #4 weight)
? Constipation management
– Continue on current bowel regimen
? Follow up in 3 months
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Clinician Education
Question & Answer
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