Stress Incontinence

Rehabilitation of the pelvic floor muscles is the common goal of treatments through the use of pelvic muscle exercises (also known as Kegel’s exercises), weighted vaginal cones and pelvic floor electrical stimulation. These treatments are believed to increase the resting tension, contractile force and recruitment speed of the voluntary sphincter component of the pelvic diaphragm. Up to 38 percent of motivated patients who follow the exercise regimen for at least three months will experience a cure of pure stress incontinence. Careful supervision produces a dramatic difference in the degree of success that can be achieved. A set of specially designed vaginal weights can be used as mechanical biofeedback to augment pelvic muscle exercises. The weights are held inside the vagina by contracting the pelvic muscles for 15 minutes at a time. As the muscles strengthen, heavier weights are used.
Pelvic floor electrical stimulation with a vaginal or anal probe produces a contraction of the levator ani muscle.

Occlusive devices, such as pessaries, can mimic the effects of a retropubic urethropexy. A properly fitted pessary prevents urine loss during vigorous coughing in the standing position with a full bladder. The patient should be able to comfortably insert and remove the pessary, and it should not cause voiding dysfunction. Other types of occlusive devices include urethral plugging or stenting. Thus far, no urethral plug or stent has become widely accepted by women, and many of these devices have been removed from the market because of the lack of acceptance.

Medications such as estrogens and alpha-adrenergic drugs may also be effective in treating women with stress incontinence (Table 3). The presence of estrogen receptors in high concentrations throughout the lower urinary tract makes it possible to treat women with stress incontinence by localized estrogen replacement therapy (ERT). ERT causes engorgement of the periurethral blood supply and subsequent thickening of the urethral mucosa. Localized ERT can be given in the form of estrogen cream or an estradiol-impregnated vaginal ring.

Alpha-adrenergic drugs such as pseudoephedrine are believed to improve the symptoms of stress incontinence by increasing resting urethral tone. These drugs cause subjective improvement in 20 to 60 percent of patients. Surgery to correct genuine stress incontinence is a viable option for most patients.

Retropubic urethropexies and suburethral slings have long-term success rates consistently reported in the 80 to 96 percent range and are clearly superior to other procedures.

Common Medications Used to Treat Urinary Incontinence
Drug	Dosage
Stress Incontinence
Pseudoephedrine	15 to 30 mg, three times daily
Vaginal estrogen ring	Insert into vagina every three months.
Vaginal estrogen cream	0.5 to 1 g, apply in vagina every night
Overactive bladder
Oxybutynin	2.5 to 10 mg, two to four times daily
Imipramine	10 to 75 mg, every night
Dicyclomine	10 to 20 mg, four times daily

A new minimally invasive suburethral sling ("tension-free vaginal tape") has been shown to cause less postoperative morbidity than traditional surgeries while achieving long-term (five-year) cure rates greater than 86 percent. The sling is placed during surgery under local anesthesia on an outpatient basis.

Another minimally invasive procedure for the treatment of stress incontinence is periurethral injection. This procedure involves injection of material at the bladder neck just under the urothelium and is performed in an office setting under local anesthesia. Currently, two devices, both injectable debulking agents, have been labeled by the FDA for the treatment of stress incontinence by periurethral injection: glutaraldehyde cross-linked bovine collagen.

Both of these devices typically require multiple treatment sessions to achieve cure.