Nonsurgical Treatment of Urinary Incontinence

Transcutaneous tibial nerve stimulation to treat urgency urinary incontinence in older women: 12-month follow-up of a randomized controlled trial

INTRODUCTION AND HYPOTHESIS

Urgency urinary incontinence (UUI) is highly prevalent in elderly individuals and has a great impact on quality of life. Transcutaneous tibial nerve stimulation (TTNS) can be an effective treatment option for UUI in older women.

METHODS

This is a single-center randomized clinical trial with a 12-month follow-up involving 106 women > 60 years of age. Kegel exercises and bladder retraining were performed alone or in combination with TTNS, which consisted of using a transcutaneous electrical nerve stimulator for 30 min once a week for 12 weeks with the following settings: continuous mode, 10 Hz, 200 ms, and 10 to 50 mA (according to hallux mobilization). Responders to therapy who experienced failure during follow-up were invited for a 3-week protocol with the same parameters as those used for the initial therapy. Patients were evaluated at baseline, 4 weeks after the 12-week protocol, and every 3 months for 12 months, through subjective satisfaction questionnaires, a 3-day bladder diary and the International Consultation on Incontinence Questionnaire-Short Form. King's Health Questionnaire was applied pretreatment and 4 weeks after the last session of the 12-week protocol.

RESULTS

A total of 101 women completed the initial 12-week protocol. TTNS patients reported 66.7% subjective global satisfaction vs. 32.0% in the control group (p < 0.001). The TTNS group showed statistically significant improvement in quality of life (QoL) and UUI parameters compared with the control group. Forty-eight patients were satisfied after the 12-week protocol and completed the 12-month follow-up (32 in the TTNS group and 16 in the control group). A total of 80.5% of responders to TTNS were still satisfied at the end of the 12-month follow-up vs. 30.8% in the control group (p = 0.009).

CONCLUSION

TTNS is effective at the 12-month follow-up for the treatment of UUI in elderly women.

Improving Outcomes in Patients With Refractory Idiopathic and Neurogenic Detrusor Overactivity: Management Strategies

Neurogenic detrusor overactivity (NDO) is a lower urinary tract dysfunction commonly seen in rehabilitation settings. The emotional, medical, and financial consequences of NDO can be substantial and management typically requires a multidisciplinary team approach. Physiatrists need to be able to identify patients who require referral to specialists for diagnostic testing or higher-tiered treatment and need to engender open lines of communication between their patients and all treating clinicians. This requires an understanding of the evaluation, diagnosis, and treatment of neurogenic lower urinary tract dysfunctions.

Comparison of mindfulness-based stress reduction versus yoga on urinary urge incontinence: a randomized pilot study. with 6-month and 1-year follow-up visits

OBJECTIVES

The objective of this study is to compare the effects of mindfulness-based stress reduction (MBSR) versus yoga on urinary urge incontinence (UI) at 8 weeks, 6 months, and 1 year after beginning an 8-week program.

MATERIALS AND METHODS

Participants in this prospective randomized single-masked pilot study were women aged 18 years or older with urge-predominant incontinence, 5 or more UI episodes (UIEs) on a 3-day voiding diary, and no recent anticholinergic use. Women were randomized to MBSR or yoga. The primary outcome was the percent change of UIE.

RESULTS

Of 30 enrollees (15 in MBSR, 15 in yoga), 24 completed at least 5 of 8 sessions (13 in MBSR and 11 in yoga). Twenty and 21 women completed the 6-month and 12-month follow-up visits, respectively. At 8 weeks, 6 months, and 12 months, the median percent change from the baseline in UIE on the intention-to-treat analysis was greater for the MBSR group (-55.6, -71.4, and -66.7, respectively) compared with that for the yoga group (-33.3, -11.8, and -16.7, respectively), with P values ranging from 0.01 to 0.08. On intention-to-treat analysis, the median percent change in the Overactive Bladder Symptom and Quality of Life-Short Form and the Health-Related Quality of Life was greater at each time point for MBSR than for yoga but was statistically significant only at 8 weeks (P = 0.003 and 0.02, respectively). As per protocol analysis, at 8 weeks, 6/13 and 0/11 women in MBSR and yoga, respectively, reported they were very much or much better (P = 0.02), whereas at 1 year, 6/12 and 1/9 women in MBSR and yoga, respectively, did so (P = 0.16).

DISCUSSION

These results support larger scale trials to evaluate MBSR, which seems to be a promising treatment of UI.

Electrical stimulation for urinary incontinence in women: a systematic review

BACKGROUND

Electrical stimulation is commonly recommended to treat urinary incontinence in women. It includes several techniques that can be used to improve stress, urge, and mixed symptoms. However, the magnitude of the alleged benefits is not completely established.

OBJECTIVES

To determine the effects of electrical stimulation in women with symptoms or urodynamic diagnoses of stress, urge, and mixed incontinence.

SEARCH STRATEGY

Our review included articles published between January 1980 and January 2012. We used the search terms ″urinary incontinence″, ″electrical stimulation ″, ″ intravaginal ″, ″ tibial nerve ″ and ″ neuromodulation ″ for studies including female patients.

SELECTION CRITERIA

We evaluated randomized trials that included electrical stimulation in at least one arm of the trial, to treat women with urinary incontinence.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed the data from the trials, for inclusion or exclusion, and methodological analysis.

MAIN RESULTS

A total of 30 randomized clinical trials were included. Most of the trials involved intravaginal electrical stimulation. Intravaginal electrical stimulation showed effectiveness in treating urge urinary incontinence, but reported contradictory data regarding stress and mixed incontinence. Tibial-nerve stimulation showed promising results in randomized trials with a short follow-up period. Sacral-nerve stimulation yielded interesting results in refractory patients.

CONCLUSIONS

Tibial-nerve and intravaginal stimulation have shown effectiveness in treating urge urinary incontinence. Sacral-nerve stimulation provided benefits in refractory cases. Presently available data provide no support for the use of intravaginal electrical stimulation to treat stress urinary incontinence in women. Further randomized trials are necessary to determine the magnitude of benefits, with long-term follow-up, and the effectiveness of other electrical-stimulation therapies.

Urinary incontinence among Turkish women: an outpatient study of prevalence, risk factors, and quality of life

PURPOSE

The aim of this study was to determine the prevalence and potential risk factors associated with urinary incontinence (UI) in women and to assess its impact on quality of life (QOL).

DESIGN

We undertook a cross-sectional study based on interviews, using a structured questionnaire.

SUBJECTS AND SETTING

Two hundred eighty-eight women, aged 19 years and older, from gynecology outpatient clinics attached to a university hospital in Ankara, Turkey, were interviewed.

INSTRUMENTS

Data were collected via a Turkish version of the international consultation on incontinence questionnaire short form (ICIQ-SF) and the Wagner's quality of life scale.

METHODS

Data were collected by face-to-face interviews with subjects and took approximately 30 minutes to complete. Potential risk factors were analyzed using logistic regression.

RESULTS

The prevalence of UI was 31.9%. Logistic regression analysis indicated that the number of pregnancies (odds ratio [OR] = 0.53, 95% CI: 0.28-0.99), UI in mother (OR = 2.46, 95% CI: 1.35-4.50) and sister (OR = 0.34, 95% CI: 0.16-0.77), previous UI during pregnancy (OR = 12.22, 95% CI: 4.11-36.36) and postpartum period (OR = 11.28, 95% CI: 3.66-34.76), and body mass index (OR = 0.49, 95% CI: 0.29-0.85) were associated with a higher likelihood of incontinence (P < .05). Ninety-two of 288 women (31.9%) stated that UI has a negative impact on their QOL and only 40 of 92 (43.5%) had asked for medical help. Impairment of QOL was related with the type of UI, frequency of UI episode, and amount of leakage.

CONCLUSION

Our study results determined that UI is common in Turkish women. The QOL of women was mostly mildly or moderately affected by UI.

Mindfulness-based stress reduction for treatment of urinary urge incontinence: a pilot study

OBJECTIVE

The objective of the study was to evaluate if a mindfulness-based stress reduction program is a viable treatment worthy of further evaluation for the treatment of urinary urge incontinence.

METHODS

This was a single-arm pilot study of 7 women who participated in an 8-week mindfulness-based stress reduction program to evaluate its effectiveness in reducing urinary leakage episodes. Improvement was measured by 3-day bladder diary, Overactive Bladder Symptom and Quality of Life-Short Form, Health-Related Quality of Life, and Patient Global Impression of Improvement. Outcome data were analyzed by means of paired t tests.

RESULTS

Mean incontinence episodes per day decreased from 4.14 (SD, 1.96; range, 2.67-7.67) at baseline to 1.23 (SD, 0.93; range, 0.33-2.67) after treatment (P = 0.0005 for change). After treatment, 5 of 7 women were improved based on the Patient Global Impression of Improvement, and 2 were unchanged. Significant improvements on both Health-Related Quality of Life and Overactive Bladder Symptom and Quality of Life-Short Form were reported after treatment. Results were sustained at 1 year in 4 of 7 women. Two women sought treatment, and one was lost to follow-up at 12 months.

CONCLUSIONS

Mindfulness-based stress reduction appears to be a treatment worthy of further study, as in the short term, it is as effective as historical studies of drug treatment and bladder training in reducing urge incontinence and incontinence-related quality of life.

Mouse models of neuronal ceroid lipofuscinoses: useful pre-clinical tools to delineate disease pathophysiology and validate therapeutics

The neuronal ceroid lipofuscinoses (NCL, also known as Batten disease) is a devastating neurodegenerative diseases caused by mutations in either soluble enzymes or membrane-associated structural proteins that result in lysosome dysfunction. Different forms of NCL were defined initially by age of onset, affected population and/or type of storage material but collectively represent the most prevalent pediatric hereditary neurovisceral storage disorder. Specific gene mutations are now known for each subclass of NCL in humans that now largely define the disease: cathepsin D (CTSD) for congenital (CLN10 form); palmitoyl protein thioesterase 1 (PPT1) for infantile (CLN1 form); tripeptidyl peptidase 1 (TPP1) for classic late infantile (CLN2 form); variant late infantile-CLN5, CLN6 or CLN8 for variant late infantile forms; and CLN3 for juvenile (CLN3 form). Several mouse models of NCL have been developed, or in some cases exist sporadically, that exhibit mutations producing a progressive neurodegenerative phenotype similar to that observed in human NCL. The study of these mouse models of NCL has dramatically advanced our knowledge of NCL pathophysiology and in some cases has helped delineate the function of proteins mutated in human NCL. In addition, NCL mutant mice have been tested for several different therapeutic approaches and as such they have become important pre-clinical models for validating treatment options. In this review we will assess the current state of mouse models of NCL with regards to their unique pathophysiology and how these mice have helped investigators achieve a better understanding of human NCL disease and therapy.

Randomized trial of transcutaneous tibial nerve stimulation to treat urge urinary incontinence in older women

INTRODUCTION

The aim of this study was to examine the efficacy of transcutaneous electrical tibial nerve stimulation (TTNS) to treat urge urinary incontinence (UUI) in older women.

MATERIAL AND METHODS

The study design was a randomized clinical trial conducted on 51 elderly women (>60 years) with UUI. All were treated with 12 weeks of bladder retraining and pelvic floor muscle exercises, and 25 were randomly selected to receive TTNS in addition to the standard therapy. The cases were evaluated at the baseline and after the end of therapy by 3-day bladder diary, quality of life questionnaires (QoL), and subjective response.

RESULTS

Of the patients, 68.0% in TTNS group reported cure or improvement vs. 34.6% in the control group (P = 0.017). TTNS showed significant improvement in most areas of QoL and in UUI parameters when compared with the control group.

CONCLUSION

TTNS is efficacious to treat UUI in older women.

The effect of ankle position on pelvic floor muscle contraction activity in women

PURPOSE

Stress urinary incontinence is extremely common in women. Conservative management includes pelvic floor muscle exercises to increase strength and muscular contraction forces to improve incontinence. We examined the effects of passive and active ankle flexion on pelvic floor muscle activity during exercises.

MATERIALS AND METHODS

A total of 31 married women performed random pelvic floor muscle contractions while standing, and in 8 passive and active positions while pelvic floor muscle activity was simultaneously measured by electromyography.

RESULTS

All ankle positions resulted in greater pelvic floor muscle activity than the horizontal foot position. Significantly greater muscle activity was seen with ankles in the plantar position with raised arms (p = 0.0051).

CONCLUSIONS

Pelvic floor muscle exercises performed with active ankle positions may increase the effectiveness of these exercises. Further studies are required to elucidate mechanisms for this finding.

Evaluation and management of refractory overactive bladder

The refractory overactive bladder patient is a complex new entity for the urologic community. We present the most current review of this difficult subject matter with an emphasis on evaluation and new treatment options such as sacral neuromodulation and botulinum toxin injection. It is hoped that in this new era of medical innovation, extirpation and reconstruction of the bladder will become historic in nature and refractory therapy can be transitioned to the office and outpatient operation rooms.

Design of the Behavior Enhances Drug Reduction of Incontinence (BE-DRI) study

PURPOSE

To describe the design of a multi-center randomized clinical trial of behavioral training combined with drug therapy for the treatment of urge incontinence. The study aims are to determine whether adding behavioral training will increase the number of women who can discontinue drug therapy and sustain a significant reduction of incontinence; to test whether the short-term effectiveness of drug therapy can be enhanced by combining it with behavioral training; and to determine the cost-effectiveness of combined therapy.

DESIGN

Two-stage randomized clinical trial currently being conducted by the Urinary Incontinence Treatment Network, a clinical trials network established by the National Institutes of Health.

METHODS

Participants are 307 community-dwelling women with pure or predominant urge incontinence. Stage 1 consists of 10 weeks of drug therapy with sustained-release tolterodine alone or combined with behavioral training (pelvic floor muscle exercise training, bladder control techniques, fluid management). In stage 2, drug is withdrawn and behavioral training stopped. The primary outcome, measured at 8 months, is a composite of two endpoints (1) successful drug withdrawal (i.e. not requesting any other treatment for incontinence) and (2) achieving and maintaining > or =70% reduction in the frequency of incontinence episodes on bladder diary. The effects of treatment and drug withdrawal are measured at week 10 and months 4, 6, 8, 14, 20, and 26. Assessments include: the Medical Epidemiological and Social Aspects of Aging (MESA) incontinence questionnaire, pelvic floor muscle strength assessment, Incontinence Impact Questionnaire, Urogenital Distress Inventory, Overactive Bladder Questionnaire, Short-Form Health Survey (SF-12), costs associated with incontinence care, Health Utility Index Mark 3, Willingness to Pay Scale, and Patient Satisfaction Questionnaire.

SIGNIFICANCE

The BE-DRI study is the first clinical trial to investigate the use of drug therapy combined with behavioral therapy with the pre-established goal of discontinuing the medication. The concept of drug cessation represents a new paradigm in this field of research and has important implications for future treatment approaches to urge incontinence.

Female urinary incontinence in China: experiences and perspectives

We sought to understand the perceptions and experiences of Chinese women living with urinary incontinence (UI), a problem that has not yet been characterized in China. We conducted the study using semistructured interviews with 15 women, aged 24-81, diagnosed with UI at the Obstetrics and Gynecology Clinic of Fuzhou General Hospital, Fujian, China. We conducted and analyzed the interviews according to the Interpretative Phenomenological Analysis model. The five core themes we derived from the participants' responses were uncertainty about UI, self-blame, avoidance, emotional isolation, and desire for treatment. The negative impacts of UI we documented, such as limiting exercise and causing embarrassment, demonstrated that UI is a problem for the affected women in China. Our study was limited by the small sample size and the need for additional reliability/validity measures, but we believe it presented a strong foundation and justification for more rigorous research into UI in China.

A critical review on magnetic stimulation: what is its role in the management of pelvic floor disorders?

PURPOSE OF REVIEW

This review looks at the acute effects of magnetic stimulation on urodynamic parameters and reviews the data on its use in the management of urinary incontinence.

RECENT FINDINGS

Reported cure rates for stress incontinence immediately after a course of perineal magnetic stimulation range from 12.5 to 52.9% with good improvement occurring in 32% to 41%. However the effect seems temporary and dependent on the number of sessions. Sacral and pelvic floor magnetic stimulation have also been shown to increase cystometric capacity, inhibit detrusor overactivity and resolve overactive bladder symptoms acutely. Persistence of this effect with symptomatic improvement one week after sacral magnetic stimulation has been demonstrated. How magnetic stimulation suppresses detrusor contraction is not known. Prospective trials with the Neocontrol chair (Neotonus Inc, Marietta, Georgia, USA) also showed symptomatic improvement in 71 to 87% in the short term. However, the longer term data appear mixed.

SUMMARY

Overall, the data available vary too much in terms of treatment protocols, patient mix and symptom severity to determine which group of patients might benefit most and what the optimal stimulation parameters are for each condition. Mean reductions in leak parameters, although statistically significant, may not always be clinically satisfactory. The beneficial effects also appear to be temporary and continuous treatment will probably be required. Further trials are needed to determine the optimum stimulation protocols for different situations and to compare magnetic stimulation with other forms of conservative pelvic floor therapy.

Urethral slings placed by the transobturator approach: Evolution in the technique and review of the Literature

Midurethral slings have proven to be efficacious in the surgical treatment of stress urinary incontinence (SUI) in women. A relatively new approach to the midurethral sling technique is the transobturator route for placement of the sling. This approach offers the theoretical safety advantage of avoiding the retroperitoneal space. The procedure has been pioneered in Europe and is now being practiced in the United States. In this article, we describe the theory behind urethral slings for SUI, the anatomy of the obturator canal, and early data on the safety and efficacy of transobturator urethral slings in the treatment of SUI.