LUBER: But I think we all would agree that simply resupporting a patient’s urethra is unlikely to re-create the continence mechanism that is compromised.
For example, if we assessed urethral support in 100 parous women, 70% to 80% would have what we call hypermobility, but probably only 15% would have stress incontinence.6 So there is something beyond hypermobility that causes incontinence. Yet our surgical enterprises focus exclusively on recreating urethral support. One could argue that, since the sling creates support circumferentially, it is more dynamic. Still, it does not address the neuromuscular component.
When an individual undergoes knee surgery, it is almost intuitive that the muscular support adjacent to the destabilized knee needs to be strengthened in addition to the surgery. So, regardless of the absence of data on the role of pelvic floor rehabilitation in conjunction with surgery, I would stress the importance of helping these patients maintain or improve their pelvic floor tone.
Occlusive devices: Effective yet poorly received
SAND: Are occlusive devices a useful nonsurgical option?
LUBER: A number of devices have become available through the years but have had fairly short half-lives on the market. I think that is because patients often are hesitant to put something in their urethra on a daily basis. That may change in the future, but in our patient population, it still appears to be the rule.
—Dr. Luber
It isn’t clear why women seem to be more comfortable with intravaginal devices than urethral occlusive devices. I suspect it is because many women have had some experience with tampons or diaphragms, so a pessary is not such a foreign concept as urethral occlusive devices seem to be.
MYERS: That has been our experience as well. Patients even resist external obstructive devices. I was surprised at the poor reception the “patch”received.
DAVILA: We have all participated in clinical trials of occlusive devices. In that scenario, patients do pretty well, as long as they are being thoroughly monitored and followed. When it comes to actual usage, however, patients are not as successful as you might expect them to be. So your comments are absolutely correct.
Pharmacologic agents
DAVILA: When it comes to conservative therapy early in the treatment process, the type of incontinence may not be as important as it is with surgery. The agents we are discussing may bring about improvement in women with stress or urgency symptoms. But as you move beyond first-stage therapies, you need to delve a bit further into the history to determine whether symptoms are primarily urgency-related or stress-related in order to avoid prescribing a medication that may not be effective for the patient’s type of incontinence (TABLES 1 and 2).
SAND: That’s an important point. What pharmacologic agents do you use for stress incontinence? And what developments do you foresee?
DAVILA: I frequently encounter the following scenario: A woman with stress incontinence comes in for her initial visit and reports that she is taking Detrol (tolterodine tartrate) or Ditropan (oxybutynin chloride). The first thing I do is tell her that this agent is not the appropriate medicine for her symptoms. Unfortunately, many clinicians are not aware of the differences between stress and urge incontinence. Thus, they may prescribe the wrong medication for the patient. Since medications for overactive bladder (urge incontinence) are widely available, the scenario just mentioned is quite common.
MYERS: I offer patients the tricyclic antidepressant imipramine, which is excellent for people with incontinence symptoms. Imipramine has anticholinergic properties, so it helps urgency symptoms but also improves urethral resistance—consequently, it can improve stress incontinence as well.
DAVILA: Duloxetine is a new antidepressant that has been widely studied.7 By blocking the reuptake of serotonin and norepinephrine in the spinal cord, it increases the activity of the pudendal nerve, which in turn stimulates the urethral sphincter—thus reducing the leakage of urine. Where this drug will ultimately fit remains unclear, however.
—Dr. Myers
Although the data show an improvement in SUI compared with placebo, imipramine or duloxetine certainly doesn’t equal the effects of surgical therapy or bulking agents.8 So perhaps it will be used for mild stress incontinence or as an adjunct for the patient who continues to experience leakage after surgical therapy. Other alpha agonists—besides pheny propanolamine—are being studied as we speak, but we do not know whether their side effects will outweigh their potential benefit. If these agents pass the test, then we may have additional drugs in the near future.