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Stress urinary incontinence in women

Jeanette Haslam
MPhil MCSP RP
Senior Visiting Lecturer University of Bradford
Independent Physiotherapy Specialist in women's health

Control of bodily functions is often taken for granted; it is therefore distressing when a woman finds herself leaking urine. Stress urinary incontinence (SUI) is the most common type and is defined by the International Continence Society standardisation committee as "the complaint of involuntary leakage on effort or exertion, or on sneezing or coughing".(1) Although it may sound like a quite trivial problem, the sufferer can find that their life is increasingly impinged on by the worry of leaking urine at any time no matter where she is. Perhaps even more surprising is that 74% of women with longstanding urinary incontinence do not seek help.(2) This should be taken as a challenge by health professionals for more proactive questioning of women to ascertain those with urinary problems so that they can be directed to an adequately trained professional for appropriate care.

Causes of SUI
Pregnancy and childbirth are the commonest causes of stress urinary incontinence in women. Obesity, smoking, the menopause, constipation, chronic cough and pelvic surgery have all been shown to affect the condition; recently a familial risk has also been shown.(3)
 
Pelvic floor muscle exercise
Pelvic floor muscle (PFM) exercises underpin all treatment for SUI and should be offered as first-line therapy.(4) However, PFM exercises are often poorly taught, without appropriate assessment; there needs to be adequate instruction with an individualised assessment of the woman. Verbal and written instructions alone have been found to be inadequate in ensuring that an appropriate PFM contraction is taking place.(5) A starting point needs to be determined by assessing what a women is able to do in terms of strength, duration, coordination and number of PFM contractions, and then with encouragement increase her contraction duration and number of PFM exercises when able. Her exercise programme should be practised with concentrated effort three times daily. She should also be taught fast powerful contractions in order to perform "the knack" - a PFM contraction before and sustained during any raise in intra-abdominal pressure.(6) In other words, both strength and skill training need to be undertaken in a functional way, as it has been shown that there is a positive relation between both pelvic floor muscle strength increase and improvement of stress urinary incontinence.(7)
Although there are many studies that have shown PFM exercise to be effective, so far no specific regimen has been found to be superior to others.(4) It has, however, been shown that within service constraints the most intensive supervision possible should be provided either in individual or group settings.(8,9) It has recently been shown in a multicentred randomised controlled trial that PFM exercises may enhance the effectiveness of duloxetine (Yentreve), the only licensed drug therapy for SUI.(10)
 
Invasive interventions
Other possible interventions include injectables of collagen, or other agents such as dextran co-polymer/hyaluronic acid, minimal access or major surgery (see Table 1).

[[NIP27_table1_79]]

Conclusion
Any nurse encountering female patients should consider the possibility of urinary incontinence and will need to know the referral pathway and provision of treatment in their own locality.
It is possible that no one has actually asked the woman whether she is experiencing a problem with her bladder. By asking the question, nurses can set her on the road to successful therapy.

[[NIP27_pp_79]] 

References

  1. Abrams P, Cardozo L, Fall M, et al. The standardisation of terminology in lower urinary tract dysfunction: report from the standardisation subcommittee of the ICS. Neurourol Urodyn 2002;21:167-78.
  2. Hagglund D, Walker-Engstrom ML, Larsson G, Leppert J. Reasons why women with long-term urinary incontinence do not seek professional help: a cross-sectional population-based cohort study. Int Urogynecol J Pelvic Floor Dysfunct 2003;14(5):296-304.
  3. Hannestad YS, Lie RT, Rortveit G, Hunskaar S. Familial risk of urinary incontinence in women: population based cross sectional study. BMJ 2004;329:889-91.
  4. Wilson PD, Hay-Smith J, Nygaard I, et al. Adult conservative management. In: Abrams P, Cardozo L, Khoury S, Wein, editors. Incontinence: 3rd International Consultation on Incontinence. Plymouth: Health Publications Limited; 2005.
  5. Bump RC, Hurt WG, Fantl A, Wyman JF. Assessment of Kegel pelvic muscle exercise performance after brief verbal instruction. Am J Obstet Gynecol 1991;165(2):322-9.
  6. Miller JM, Ashton-Miller JA, DeLancey JOL. A pelvic muscle pre-contraction can reduce cough related urine loss in selected women with mild SUI. J Am Geriatr Soc 1998;46:870-4.
  7. Bø K. Pelvic floor muscle strength and response to pelvic floor muscle training for stress urinary incontinence. Neurourol Urodyn 2003;22(7):654-8.
  8. Bø K, et al. Pelvic floor muscle exercise for the treatment of female stress urinary incontinence: III. Effects of two different degrees of pelvic floor muscle exercise. Neurourol Urodyn 1990;9:489-90.
  9. Janssen CC, Lagro-Janssen AL, Felling AJ. The effects of physiotherapy for female urinary incontinence: individual compared with group treatment. BJU Int 2001;87:201-6.
  10. Ghoniem GM, Van Leeuwen JS, Elser DM, et al for the Duloxetine/Pelvic Floor Muscle Training Clinical Trial Group. A randomized controlled trial of duloxetine alone, pelvic floor muscle training alone, combined treatment and no active treatment in women with stress urinary incontinence. J Urol 2005;173:1647-53.

Resources
Association for Continence Advice
W:www.aca.uk.com

Continence Foundation
W:www.continence-foundation.org.uk

Incontact
W:www.incontact.org

International Continence Society
W:www.icsoffice.org

Conference
ACA Conference 2006
Riviera Centre Torquay
15-17 May 2006
Fitwise
T:01506 811077