Clinical Pearls & Morning Reports
Despite its high prevalence, urinary incontinence remains underrecognized and underreported, with fewer than 40% of affected women seeking care for this condition. It is important for care providers to ask about urinary incontinence and to explain that it is not a normal part of aging and that treatment options exist for bothersome symptoms. Read the NEJM Clinical Practice Article here.
Q: What information should be obtained during the evaluation of a woman with stress incontinence?
A: The history should include an assessment of the severity of incontinence, including frequency of leakage (e.g., daily, weekly, or monthly), amount of leakage (e.g., small, moderate, or large), and the use of pads and pad type. A critical factor to assess is the degree of bother from stress incontinence since this information will help to guide decisions regarding treatment. Women should be asked about coexisting pelvic-floor disorders, including urgency incontinence, incomplete bladder emptying, pelvic organ prolapse, and fecal incontinence. Evaluation should also include questions about coexisting medical complications and previous surgical procedures, because these factors can affect treatment decisions.
Q: What are some of the nonsurgical options for the treatment of stress incontinence?
A: Obesity and weight gain are risk factors for stress incontinence. A systematic review of 39 randomized trials, cohort studies, and case series on weight-loss interventions concluded that a 5 to 10% reduction in body weight yielded modest improvements in stress incontinence 1.0 to 2.9 years after the intervention. Pelvic-floor muscle training (Kegel exercises) has been shown to reduce the number of leakage episodes and the quantity of leakage. Although there is no consensus regarding the ideal training program, a regimen in which at least 8 contractions are performed three times a day is recommended. However, long-term outcome data beyond 1 year are limited. Vaginal devices for stress incontinence include pessaries, which are fit by a health care provider, and commercially available devices. Evidence suggests that acupuncture may reduce stress incontinence in the short-term.
A: A referral to a specialist in gynecology, urology, or female pelvic medicine and reconstructive surgery should be considered in patients who have pelvic organ prolapse, incomplete bladder emptying, or an inadequate response to behavioral interventions. Surgery is the most effective treatment option for bothersome stress incontinence, although a patient-centered discussion in which the risks and benefits of surgery are weighed is critical. Evidence supports the benefits of the midurethral mesh sling, Burch colposuspension, pubovaginal sling, and urethral bulking; however, definitions of cure (objective, subjective, or composite), follow-up periods, and quality of evidence vary among the studies in which these options are compared. Overall, midurethral mesh sling surgery is the most commonly performed procedure, because it is a minimally invasive, outpatient, 30-minute procedure that is highly effective and has a relatively low rate of complications.
A: Despite the relatively low rate of complications with midurethral mesh slings, there has been increasing concern regarding their use owing to complications associated with transvaginal mesh procedures for pelvic organ prolapse, which are distinct from midurethral mesh sling procedures. In April 2019, the Food and Drug Administration, after having issued warnings about potential complications in 2008 and 2011, ordered all manufacturers of transvaginal mesh for pelvic organ prolapse surgery to halt distribution. As a result, despite guidelines from national and international professional societies noting the efficacy and safety of midurethral slings, whether they will remain available worldwide is uncertain.