Urinary incontinence (UI) is a growing problem that affects millions of people worldwide. In 2007, the National Institutes of Health, State of the Science Conference on the Prevention of Urinary and Fecal Incontinence noted that over 20 million women and about 6 million men suffer from UI.1,2 It is estimated that up to 35% of the total population over 60 years of age is incontinent. Women are twice as likely as men to experience incontinence,3 and female Medicare beneficiaries are 2.5 times more likely to suffer from the condition.4 Despite its prevalence, UI is both underreported and undertreated, and can lead to a decreased quality of life (QOL) for patients as well as financial burden for both the healthcare industry and society in general. This article outlines the role of the nurse practitioner (NP) in identifying, diagnosing, managing, and treating stress UI (SUI) in both men and women. The guidelines for obtaining the necessary history as well as information on completing a thorough exam of patients complaining of incontinence and treatment options will be discussed.
Worldwide, over 200 million people are living with UI.5 An estimated 19% of women under the age of 45 experience UI and 29% of women over the age of 80 also experience the condition.2 SUI is commonly found in healthy adult women—approximately 30% of women under 30 years old and 14% to 41% of women between the ages of 30 to 60.3 The prevalence of any type of UI in women is higher in non-Hispanic Whites (41%) than non-Hispanic Blacks (20%) or Mexican Americans (36%).6 The prevalence of daily UI increases with age, ranging from 12.2% in all women 60 to 64 years of age to 20.9% in those 85 years of age and over.1–3
Similar to the prevalence in women, the prevalence of UI in men also increases with age, however at a more constant rate. After the age of 65, the occurrence of SUI decreases while the incidence of urge and mixed UI increases. About 5% of men under the age of 45 and 16% of men over the age of 75 complain of UI.2,7,8 A recent study found no differences in prevalence by racial/ethnic groups who had factors significantly associated with UI including age, major depression, and hypertension.8 In relation to men experiencing SUI, it is most often seen as a complication of treatment for prostate cancer. Depending on the definition of continence (e.g. dry, no pads, etc.) and surgeon's skill, about 2.5% to 87% of men experience SUI at 1 year following a prostatectomy.9,10
Pathophysiology and types of incontinence
It is important to understand the function of the bladder (detrusor muscle) and the urinary sphincters to differentiate between the types of UI. The bladder wall is made of smooth muscle that communicates through the parasympathetic nervous system.10 In general, once the bladder fills to about 400 to 500 mL, nerve impulses are sent to the brain to identify the bladder as full. When ready to void, the detrusor muscle contracts, forcing urine through the bladder neck. The internal and external sphincters relax, and urine is pushed through the urethra and out of the body (see Nerve supply to the bladder and urethra). Incontinence occurs when there is a storage dysfunction (urge UI), sphincter dysfunction (SUI), or both (mixed). As long as bladder pressure does not overcome the pressure of the urethra, continence is sustained.
In addition to physiologic changes, there are certain risk factors that contribute to SUI including pregnancy and childbirth, pelvic surgery, obesity, and physical activity. Normally, the sphincter muscle is able to contract tightly to avoid urine leakage. However, once the pelvic floor muscles (PFMs) weaken or the external sphincter and bladder neck change position and are no longer supported, due to childbirth, pelvic organ prolapse, or complications following pelvic surgery, incontinence, specifically SUI can occur.12 The PFMs are essential to support the pelvic organs and strengthening them is important for preventing incontinence, particularly SUI. It is important for patients to understand that SUI is not related to emotional stress but is caused by increased pressure or "stress" on the bladder as well as anatomical changes to the urethra and PFM weakness.
In order to fully understand the management and treatment of UI, the different types and underlying concepts need to be defined. UI can be divided into three main classifications (see Identifying types of UI). The first classification is SUI, which is involuntary leakage of urine associated with increased Valsalva or intra-abdominal pressure, such as during coughing, sneezing, laughing, and physical activity or effort.13,14 Continence during these types of physical stress requires anatomic urethral support and urethral integrity. Support is provided by intact and healthy
* ligaments along the lateral aspects of the urethra, termed the pubourethral ligaments;
* anterior vaginal wall and its lateral fascial condensation;
* arcus tendineus fascia pelvis; and
* levator ani muscles (see PFM fibers).
Together, these structures provide a firm backboard that supports the urethra during increases in intra-abdominal pressure. Without this support, downward forces, such as from a cough, sneeze, or laugh, are not countered as they should be. The urethra funnels at the urethrovaginal junction, becomes more patent, and has a reduced closing pressure, leading to incontinence.
Urge UI (now referred to as urgency UI) is caused by uninhibited (involuntary) contraction of the bladder, overactivity, or poor compliance of the bladder.12 Urgency UI is defined as an involuntary leakage of urine associated with a feeling of urgency.12,13 Patients often complain of an increased urge to urinate but are unable to make it to the bathroom before they leak. The myogenic and neurogenic theories attempt to explain overactivity of the bladder. Myogenic theory proposes that a change in the muscle fibers causes an increased sensitivity, which in turn causes overactivity.15 In contrast, the neurogenic theory states that injury to the central or peripheral nervous system may cause overactivity related to voiding reflexes.16 Neurogenic theory is evident in patients with a neurologic disease, spinal cord injuries, multiple sclerosis, strokes, and diabetes to name a few. Both theories attempt to explain the reasoning behind the overactivity of the bladder. Another classification associated with urge UI is overactive bladder (OAB), a symptom syndrome. OAB is defined as urinary urgency, with or without urge incontinence, usually with frequency and nocturia, in the absence of pathologic or metabolic factors.14 Roughly one-third of patients with OAB also suffer from urgency UI.17
The last classification is mixed incontinence, which is a combination of symptoms of both urgency UI and SUI.13,14
Impact on QOL
Most incontinence experts who treat men and women with UI see the impact this condition has on QOL. UI is linked to an increase in social detachment, falls/fractures, depression, decreased ability to concentrate, increased anxiety, and admissions to long-term-care facilities resulting in immeasurable economic and quality-of-life deficits.17 Diagnosing UI early may prevent many consequences created by incontinence. The separation between UI as a symptom and UI as a disease is far from clear, however. For example, although a significant number of athletes lose urine when exercising, many do not consider this a problem. The view that slight urine leakage occuring with physical activity, is insignificant and not a major health problem is shared by many experts.21 But many women and most healthcare providers would also agree that middle-aged women who lose urine throughout the day, wear pads, or limit desired activities because of leakage, do suffer from a disease and would benefit from treatment. The impact of UI on the person's QOL is a predictor of treatment-seeking for this condition.
Lack of care-seeking behavior
Most surveys on care-seeking behavior note that less than half of people with UI symptoms report them to primary care providers including NPs.19 People with UI are most likely to contact a healthcare provider if they use pads, have large volume accidents, and if daily activities are impaired.20 As SUI usually results in only small amounts of urine leakage, none of these triggers for seeking care may exist. In addition, men are more likely to seek medical care than women.
Instead of seeking treatment, many individuals with UI practice behavioral modifications such as limiting trips, fluids, and routine activities. Individuals often feel embarrassed or assume that UI is a normal part of aging21; as a result, they may never consult a provider about the problem. Furthermore, only 40% of patients who do consult a healthcare provider regarding UI symptoms actually receive treatment and counseling.22 Patients are reluctant to bring up the subject of UI for many reasons and many barriers exist, including embarrassment, misconceptions that it is not a legitimate medical problem, attitudes toward healthcare, duration of symptoms, severity of symptoms, and the impact on QOL.23 On the other hand, patients who consulted their healthcare provider were more likely to consider medication and/or surgery, were not embarrassed by their condition, and were more likely to disagree that incontinence was related to aging.23 Other reasons for seeking help included worry that the incontinence might worsen and the fear of odor in patients who were already managing urine leakage with pads or liners.24
It is important for NPs to screen for incontinence issues because most patients complaining of SUI can initially be managed and treated effectively (see Clinical Decision Support Tool for the diagnosis and management of SUI).24
There are identified risk factors for SUI including age, parity, menopause, smoking, obesity, prostate enlargement, or cancer, gynecologic and urologic surgery. Patients who have symptoms of mixed UI and OAB may have additional factors including diabetes or neurologic impairment (such as multiple sclerosis, stroke, spinal cord injuries or defects).
The following is a review of risk factors for SUI:
Pregnancy and childbirth. SUI is a common problem among women who have a history of vaginal delivery, multiparity, direct trauma to the urethral sphincter, or have experienced instrumentation during childbirth (e.g. use of forceps).25 A systematic review of population-based studies of women up to 1 year postpartum showed that during the first 3 months postpartum, UI prevalence was 33% with mean prevalence double in the vaginal delivery group (31%) compared to the cesarean section group (15%).25 A study of 12,000 Norwegian primiparous women found similar prevalence: 31% of women reported postpartum UI.26 Mode of delivery in these women was 36% instrumental, 34% spontaneous, and 17% vaginal delivery. Urine leakage following childbirth is usually infrequent and results mostly in SUI episodes. Only 12% of women report weekly UI and only 3% report daily episodes.25 During pregnancy and delivery, PFMs stretch and relax, which could damage the nerves of the pelvic floor and tissue of the bladder neck.27 Denervation injury of the pelvic floor may occur from traction and straining during vaginal delivery and has been reported after 42% to 80% of vaginal deliveries.28,29 Presence of neuropathy is related to the length of the second stage of labor, size of the baby, and instrumental delivery.30 A 2008 Cochrane review noted evidence-based research showing that pelvic floor muscle training (PFMT) in women having their first baby can prevent UI in late pregnancy and postpartum. This training was also recommended as an appropriate treatment for women with persistent postpartum UI.31
Hypoestrogenization. The loss of estrogen during menopause or following a hysterectomy can put women at risk for SUI and associated urgency and frequency. The decrease in estrogen weakens the PFM and can cause the tissues of the urethra and vagina to become atrophic, which, in turn, can cause SUI. The weakening of the pelvic floor can also lead to pelvic organ prolapse of the bladder, uterus, bowel, or rectum.
Pelvic surgery. Men develop incontinence related to intrinsic sphincter dysfunction27 secondary to prostate surgery (such as prostatectomy, transurethral resection of the prostate) or after pelvic trauma. Incontinence in men can also be related to neurologic deficits. About 6% to 25% of men report SUI at 1 year following open, laparoscopic, or robotic prostatectomy.32 During the removal of the prostate, the internal sphincter mechanism of the bladder neck becomes impaired or damaged, rendering the external sphincter the only source of maintaining continence. The PFM can become fatigued throughout the day causing unexpected episodes of incontinence in the evening.27 In women, pelvic surgery can cause damage to the innervation and supportive tissues and incontinence may result, particularly after vaginal hysterectomy.
Obesity. There is growing research that indicates obesity is an independent risk factor for SUI and that weight loss, even a moderate loss of 5% to 10% of body weight is sufficient to decrease symptoms in obese women.34 The cause may be secondary to increases in intra-abdominal and intra-vesical pressure on the urethra, leading to greater urethral mobility. Also, obesity may impair blood flow or nerve innervation to the bladder.27 An epidemiologic study focusing on obesity and UI found that weight-loss programs for moderately obese women and weight reduction surgery for morbidly obese women resulted in a significant decrease in UI.34 Women (n = 338), with body mass indexes between 25 and 50 and complaints of at least 10 episodes of incontinence a week, were randomized to either a 6-month weight-loss program (diet, exercise, and behavior modification) or a control group.35 The participants in the weight loss program met weekly for 6 months in groups of 10 to 15 for 1-hour sessions led by experts in nutrition, exercise, and behavior change. The participants were given a standard reduced-calorie diet (1200 to 1500 kcal/day), with a goal of providing no more than 30% of the calories from fat. To improve adherence, the participants were provided with sample meal plans and were given vouchers for a meal-replacement product to be used for two meals a day during months 1 to 4 and for 1 meal a day thereafter. The study found a 57.6% decrease in episodes of SUI after the end of 6 months versus 32.7% decrease among the control group.35
Exercise. Another population at risk for SUI is female athletes, especially runners, and those who participate in high-impact sports involving abrupt, repeated increases in intra-abdominal pressure that exceed PFM resistance (e.g. basketball, aerobic exercise, jumping jacks). Several studies have documented a high prevalence of UI among elite female athletes and dancers.36 The highest prevalence is found in high-impact activities: 80% in trampoline jumping.37 The prevalence of SUI among this population is increased regardless of age.38 For example, a group of female athletes ages 14 to 21 were surveyed regarding symptoms of SUI and/or urgency UI while playing sports. Twenty-five percent reported SUI and/or urgency UI. Only 10% with SUI reported their symptoms to a healthcare provider, even though 15% of them felt it had affected their QOL.39
Although it is important for NPs in primary care to screen for UI, the guidelines for diagnosing incontinence can be time-consuming for a busy clinician and are often not put into practice. The first step in diagnosing UI is identifying a patient at risk and identifying the most bothersome symptom. Assessing both subjective and objective information is essential to diagnose the type of incontinence the patient is experiencing. While obtaining the history, the NP should ask questions about the onset, duration, and characteristics of their UI, as well as any alleviating factors, aggravating factors, and treatment to date.40 Other questions should assess the frequency of urination during the day and night, how many and what type of incontinence products (such as perineal pads) are used, how often and the amount of leakage per day/week, whether or not burning or pain with urination is present, and how much the leakage affects QOL and activities of daily living.27 Many patients are not aware of the type of incontinence they are experiencing. Questions such as, "do you leak because you can't make it the bathroom in time or because you coughed, sneezed, and/or laughed or both" can determine the type of UI. Patients might then be able to relate their symptoms to one or both of the questions asked. Past medical history is important to help identify any risk factors associated with UI.
Using a screening tool or questionnaire may help identify patients with lower urinary tract symptoms.41 The 3IQ tool is easy to administer and helps identify patients with symptoms of stress or urge UI. This questionnaire was not intended for patients complaining of recurrent urinary tract infections or those with neurologic problems, however (see The 3 Incontinence Questions (3IQ)).
The sensitivity of the tool for detecting SUI is 0.86 (confidence interval [CI] 0.79 to 0.90) and the specificity is 0.60 (CI 0.51 to 0.68).42
The physical exam may be less useful for initial assessment than a good history, but it is an excellent opportunity to teach proper PFM contraction technique. An abdominal and pelvic exam is helpful in women and an abdominal and rectal exam is indicated for men. Before the exam begins, the patient should void completely and a urine specimen should be obtained for urinalysis and culture. In patients suspected of incomplete bladder emptying (such as presence of neurologic disease, enlarged prostate in men), a postvoid residual should be obtained by either catheterization or ultrasound.12 The postvoid residual should be less than 100 mL.
During the pelvic exam, the provider can evaluate the strength of the PFMs by digital measurement.27 In women, the PFMs are evaluated by inserting one or two fingers to the first knuckle into the vagina and palpating bilaterally at the 5 o'clock and 7 o'clock positions. The woman is asked to contract the PFM around the examiner's fingers with as much force and for as long as possible. During the pelvic exam, the patient should be asked to cough or bear down and the provider can assess for any leakage from the urethra (called a cough-stress test) and for prolapse.43 If a prolapse is present, the type (rectocele, enterocele, or cystocele) and degree of prolapse should be recorded.
In men, PFM exam is performed via digital rectal exam. During this exam, the clinician should ask the patient to contract the rectal sphincter with as much force and for as long as possible, while assessing strength according to three criteria: pressure, duration, and alteration in position. In a well-supported muscle, the contraction can lift the base of the examiner's finger.
As part of evaluation for SUI, patients should be asked to complete a 3-day voiding diary, a useful tool in assessing a patient's leakage episodes and voiding pattern. Information included in the diary should be intake (volume), voiding frequency, incontinence (type and severity), and if possible, output (voided volume). This diary provides information regarding sensation and leakage, objective information about time and amounts of voids, and accounts for events preceding the incident.43 The diary can give the patient and the provider a better understanding of the condition and the severity. Self-monitoring of symptoms with a voiding diary is a subjective measure that can be a valuable clinical tool for the patient as well as the NP as during treatment.
Treatment options for stress incontinence
Treatment options for SUI range from more conservative or behavioral approaches, including pelvic floor muscle exercises (PFMEs), to more aggressive options such as surgery. Although surgical treatments are generally safe and effective, women with SUI symptoms may wish to avoid or defer surgery for medical or personal reasons. Evidence-based nonsurgical therapies for treatment of SUI include behavioral treatment, which combines PFM training and exercise with skills and strategies to actively use the muscles to prevent urine loss.27,45 Behavioral interventions improve UI by teaching skills to change a patient's behavior. These usually involve multiple individualized components that can include self-monitoring (bladder diary), lifestyle changes (such as weight loss, smoking cessation, fluid and diet management), voiding regimens (such as scheduled voiding, delayed voiding), PFMEs, bladder training, and urge suppression strategies for patients who have mixed UI symptoms.27,46,47 Exercising to strengthen the PFMs may include the use of biofeedback and electrical stimulation. More aggressive interventions include bulking material injections and surgery (artificial urinary sphincter [AUS], sling procedures, and bladder neck suspension). Currently, there are no FDA-approved medications for SUI.
Pelvic floor muscle training and exercises
First-line therapy for SUI is PFMEs, also known as "Kegels." A review of the current evidence-based research for these exercises concluded that they are particularly beneficial in the treatment of SUI in females across all age groups, with up to 70% improvement in symptoms.48 The authors note that women perform better with exercise programs supervised by continence nurse specialists and physical therapists, as opposed to unsupervised or leaflet-based care. The purpose of PFMEs is to strengthen muscle tone, increase sphincter resistance, and provide urethral support to prevent urine leakage during increases in abdominal pressure incontinence.
There may be some benefit to offering biofeedback-assisted PFMT to men early in the post-prostatectomy period immediately following removal of the catheter because this may promote an earlier return to continence.49
The patient is instructed to perform PFMEs daily for at least 40 to 60 exercises (see Patient Education Tool: Exercising Your Pelvic Floor Muscles). Because patients should do this as a daily routine, it often helps for them to think of something they do several times a day (that is, stopping at a red light, answering the phone, or watching a commercial) to remind them to do their exercises. PFME should not be performed while urinating. If done properly, PFMEs can reduce episodes of UI by 60% to 85%.45
Patients can prevent SUI by consciously using the PFMs to occlude the urethra during activities that precipitate leakage, such as before coughing if this is the triggering event for urine leakage.50 This skill is called the knack or quick squeeze, and it is a learned skill that can become reflexic over time.
Dr. Arnold Kegel's initial work involved women with SUI learning how to identify and train their PFMs using a biofeedback device called a perineometer, a pressure-sensitive device. He termed this "biofeedback therapy." Many clinicians (including these authors) have found this therapy to be useful treatment for the purpose of teaching, motivating, and improving compliance in persons with all types of UI.27 Most clinicians will use a method of measurement that uses surface electromyogram (sEMG) via skin electrodes or internal sensors in the vagina or rectum to "feedback" PFM activity to the patient.
Surgical treatment for SUI
Surgical intervention is also a treatment option available to men and women suffering from SUI.27 Options for women are numerous and the following are the most common procedures performed today:
* Colposuspension, best known as Burch colposuspension, is a procedure that lifts the neck of the bladder, resulting in a tight closure of the urethra once intra-abdominal pressure rises. Colposuspension can be done as an open procedure (incision across the lower abdomen) or laparoscopically.
* Tension-free sling procedures (mid-urethral) use a polypropylene tape placed tension-free under the middle part of the urethra and pulled out either retropubically or bilaterally through the obturator foramen. An abdominal incision is not required and this can be performed as an outpatient procedure.
* Intra or periurethral injections use bulking agents (carbon beads, copolymers, polyacrylamide hydrogels) to plump up the urethral mucosa so that the urethra remains closed under stress. These tend to be more successful in the short term.
The number of retropubic and transobturator sling procedures to treat SUI has increased dramatically in the United States.52 Assessing objective and subjective data among women, the success rate of slings in relation to long-term cure rate is about 80% to 90%.53 One study randomly assigned 597 predominately middle-aged, non-Hispanic White women to either a retropubic sling group or a transobturator sling group.55 The rates of subjectively assessed or patient-reported success at 1 year were 62.2% for the retropubic sling group and 55.8%, transobturator sling group. Subjective measures in this study were defined as absence of self-reported symptoms of stress-type UI, as assessed with the use of a questionnaire, no leakage recorded in a 3-day voiding diary, and no re-treatment for SUI. Complications such as bladder perforations from trocar passage and voiding dysfunction (elevated post void residual) requiring surgical intervention were uncommon but occurred only in women who received the retropubic sling (n = 6) while more vaginal perforations occurred in the transobturator-sling group (n = 13). The frequency of neurologic symptoms (such as weakness in the upper leg) was also higher in the transobturator sling group (9.4%) than in the retropubic-sling group (4%). Patient satisfaction rates in this study were similar but research has shown that women who develop new or worsening urge UI and/or OAB symptoms following surgery for SUI report lower satisfaction.55
Surgical treatment of SUI in men includes urethral injection with bulking agents, male perineal slings, and AUS.56 Surgical interventions for male SUI occurring after prostatectomy surgery are usually reserved for moderate-to-severe incontinence, but many men are reluctant to undergo another surgery.
Surgical procedures in men
In urethral bulking, synthetic or autologous fibers are injected into the walls of the urethra to promote coaptation, therefore restoring continence. The treatment is short-term, requires reinjections, and has effectiveness of only 40%; however, this provides a viable option for patients who are not surgical candidates.56
Bone-anchored and transobturator retrourethral slings are becoming increasing common in men with postprostatectomy incontinence (PPI). Bone-anchored slings have a success rate of 70% to 80%, 3 to 4 years following placement, while transobturator have a success rate of about 62% to 83%, 6 to 12 months following placement.57 However, success is often dependent on the degree of incontinence; men with severe incontinence tend to experience lower success rates.58 Complications related to slings occur in both men and women; these include urinary retention, urethral erosion, mesh infection, and perineal pain.
Implantation of an AUS is an option in men who have moderate to severe SUI. This is a surgically implanted device that involves placing a water fill cuff around the urethra that is connected to an internal scrotal pump and reservoir near the bladder. Once a patient is ready to urinate the pump is pressed and water is released from the cuff to the reservoir allowing the flow of urine. After several minutes, the water is automatically transferred back into the cuff causing the urethra to close and preventing incontinence. At least 80% of men report a decrease in urine leakage following placement of an AUS however, the rate for mechanical failure and need for replacement at 10 years is about 30% to 45%.53
Interventions for mixed symptoms
Patients complaining of urgency, frequency, and mixed incontinence can benefit from lifestyle changes such as:
* Reducing excessive amounts of fluid intake
* For patients complaining of nocturia, spreading fluids throughout the day with no intake 3 to 4 hours before bedtime, elevation of legs during daytime, and use of support stockings
* Avoiding certain foods that can adversely affect normal bladder function (caffeinated products, alcohol, acidic spicy and tomato-based foods/drinks)
* Avoiding constipation.
Another type of behavioral treatment used for individuals with urge or mixed UI symptoms is timed voiding that uses incremental voiding schedules to decrease OAB symptoms of urgency and frequency.27,59 Patients are instructed to increase time between voids by 10 to 15 minutes every couple of days to weekly. If a patient complains of voiding every 30 minutes, they would be instructed to wait 45 minutes before voiding. Once the patient is able to wait 45 minutes time is then increased to 1 hour. Ideally, by the end of treatment, the patient will be able to wait 2 to 4 hours to void.26
Conscious PFM contraction (such as the knack) can also be used to suppress detrusor contractions and reduce urgency. This is a key component of behavioral or bladder training for urgency incontinence and related OAB symptoms.27,59 Urge suppression techniques teach patients not to rush to the toilet, which can trigger incontinence, and instead to remain still use their muscles to suppress urgency, and wait for the urge to pass. PFMEs can be an option for OAB and urge UI. Some patients with SUI may complain of OAB symptoms, so combining lifestyle changes and timed voiding with bladder training and urge suppression strategies may be helpful.
Adding an anticholinergic drug to a behavioral program can decrease urge UI and OAB symptoms in patients who have mixed symptoms. Anticholinergics (such as darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine, trospium) block the effects of acetylcholine, which reduces the spasm of smooth muscle especially in the heart, stomach, and bladder. This class of medication could cause blurred vision, constipation, urinary retention, dry mouth, and altered mental status and should be used cautiously especially in the elderly.
Products and services for SUI
Perineal pads and pantiliners are commonly used by women to absorb mild-to-moderate urine leakage. If the woman has any type of incontinence, the NP should recommend the use of incontinence pads as opposed to feminine hygiene pads, as the former are designed to absorb urine. There products can be found in various sizes and absorbency.
An intraurethral insert devices is inserted into the urethra to block leakage occurring in women with SUI.27 The current one available, the FemSoft Insert is a sterile, disposable, single-use intraurethal device. It consists of a narrow, silicone tube entirely enclosed in a soft, thin, mineral oil-filled silicone sleeve. The silicone sleeve forms a balloon on the tip of the insert. As the device is advanced into the urethra, fluid in the balloon is transferred toward the external retainer to facilitate passage through the urethra. Once the tip of the insert has entered the bladder, the fluid returns to fill the balloon forming a mechanical barrier to retain urine within the bladder. To assist with insertion, the insert is supplied on a disposable applicator and with a lubricating gel. The device is easily removed for normal voiding and should be removed at least once every 6 hours. This product is a one-time use, disposable device.
There are vaginal devices that can be used to support the bladder neck to prevent SUI. Women who leak urine during strenuous exercises and other physical activities may benefit from a mechanical device that provides pelvic support. Devices such as tampons have been used successfully by women, but have not been researched to demonstrate effectiveness. The use of an intravaginal incontinence pessary may also be effective in alleviating SUI symptoms. This type of pessary is usually round (such as ring with or without a support diaphragm in the center support) and has a knob that adds an additional centimeter to the size of the pessary. The knob should be situated so it is suburethral behind the symphysis, ideally at the level of the urethrovesical junction so as it is intended to stabilize and support the bladder neck and compress the urethra to prevent urine leakage with an increase in pressure from above. In 2006, a Cochrane review of mechanical devices for UI concluded there is little evidence from controlled trials to judge if pessary use is better than no treatment.60 A recent study that randomized women with SUI to either an incontinence pessary or a behavioral treatment program showed no difference between the groups with combination therapy was not superior to single-modality therapy.61
The prevalence of UI is overwhelming. Unfortunately, UI remains underdiagnosed and undertreated in the primary care setting. Most patients are reluctant to initiate the subject of UI to their NPs for a number of reasons. Therefore, identifying patients at risk and patients already suffering from UI is the NPs' responsibility. Time restraints related to office visits often lead to providers overlooking non-life-threatening problems such as UI. However, even though a patient suffering from UI is not in immediate danger, the QOL is significantly diminished. Easy-to-use questionnaires can be an effective tool in identifying and diagnosing UI in patients. However, these tools are simply not being used enough if patients are still not being identified. NPs need to be aware that UI is a debilitating and embarrassing problem for many patients. Therefore, it cannot be assumed that patients will bring it up first. Providers should screen all patients, especially those at risk for UI. Once screened, there are effective treatments that can be initiated by NPs in the primary care setting.
The pelvic floor consists of muscles (including the levator ani) and connective tissue that stretch from the coccyx to the pubic bone (the anterior portion of the levator ani is called the pubococcygeus). These muscles and connective tissue act as a flexible sling that supports the lower urinary tract organs as well as the uterus and rectum. The pelvic floor muscles form a striated, voluntarily controlled skeletal muscle group with two types of muscle fibers:
Type 1, "slow twitch"
At least 80% of the levator ani consists of type 1 fibers. These fibers generate slower, more sustained but less forceful contractions. Type 1 fiber contractions serve to maintain muscle tone, organ support, and urethral closure pressure (exerted by the external urethral sphincter).
Type 2, "fast twitch"
These fibers generate faster, more forceful contractions and help to offset sudden increases in intra-abdominal pressure by increasing urethral closure pressure.
Adapted from Newman DK, Wein AJ. Managing and Treating Urinary Incontinence. 2nd ed. Baltimore, MD: Health Professions Press; 2009.
Patient education tool: Exercising your pelvic floor muscles
What are the pelvic floor muscles?
As shown in the picture below, your pelvic floor muscles provide support to your bladder and rectum. In women, they also support the vagina and uterus, in men, they surround the prostate. If they weaken, they cannot properly support these organs, whose position can change. A change in position can cause unwanted urine leakage. Keeping the muscles strong can help prevent urine leakage. You can strengthen these muscles by doing certain exercises, called pelvic floor muscle exercises, a type of "Kegel" exercises.
Finding the proper muscles
Without tensing the muscles of your legs, buttocks, or stomach, think about trying to control the passing of gas or pinching off a stool. Or imagine you are in an elevator full of people and you feel the urge to pass gas. What do you do? You tighten or squeeze the ring of muscles around your rectum—the back part of these muscles. If you are a woman, you should feel a lifting sensation in the area around the vagina. If you are a man, you may feel your penis move. Both men and women should feel a pulling in of the rectum.
Types of exercises
There are two type of muscle contractions (called "squeeze") you will need to practice: quick (2-second) or short contractions, and slow (3- or 5- or 10-second) or long contractions. To do the quick contraction, squeeze your pelvic muscle quickly and hard, then right away relax it. For the slow or long (sustained) contractions, squeeze your pelvic muscle and hold it for a count of 3 seconds, increasing to 5 or 10 second holds over several weeks. Always relax the muscle right after squeezing it. Do about 45 of the quick and 45 of the long exercises each day. You can do the exercises anywhere, anytime, and in any position. Most like to do the exercises sitting.
Using this muscle to prevent urine leakage
You should also practice squeezing your pelvic floor muscle at the times when your urine leakage usually occurs. This will give you the "Knack" for stopping urine leaks. The Knack is a motor skill you can learn. It requires you to anticipate your urine leakage, like when coughing, sneezing, laughing, or bending or lifting. You should contract your muscle right before and during any activity that causes an increase in pressure in your abdomen. So you should practice the Knack right before the activity that causes you to leak and hold the contraction throughout the cough.
* When you squeeze the pelvic floor muscles, DO NOT tighten your thighs, buttocks, or stomach. If you feel your stomach move, then you are also using these muscles.
* DO NOT hold your breath. Breathe normally or count out loud, or both.
When will I see a change?
It takes time and effort to strengthen any muscle, including the pelvic floor muscles. At first, your muscles may be very weak. You may only be able to hold the muscle squeeze for only a few seconds. Don't be discouraged. With practice, you will get better. After exercising every day for 4 to 6 weeks, you may begin to notice more bladder control and less urine leakage. But it may take 3 or 4 months to get the most benefit. Make the exercises part of your daily life. Squeeze the muscles when you walk, as you stand up, and on the way to the bathroom.
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