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					    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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                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 second; very
                                                 slight compression of examiner’ s finger
                 Weak                 2/5        Weak contraction or pressure, held for >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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                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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    A Closer Look: Optimizing the Management of Stress Urinary Incontinence in Primary Care Practice




                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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    A Closer Look: Optimizing the Management of Stress Urinary Incontinence in Primary Care Practice




                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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    A Closer Look: Optimizing the Management of Stress Urinary Incontinence in Primary Care Practice




                Clinician Education




                Question & Answer




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