Continence Coach: Tackling Stress Urinary Incontinence: The Resourceful Continence Nurse

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Nancy Muller, MBA

  Without a doubt, great strides have been made in recent decades in surgical intervention for treating stress urinary incontinence (SUI) in women. A wide variety of procedures exist — the vast majority involve one of several different pubovaginal (ie, in the vicinity of a woman’s pubis and vagina) slings. The name sling for this category of procedures comes from the sling-like shape of the hammock of muscles that forms the pelvic floor musculature and serves to support the pelvic organs, including the urethra. Sling procedures correct anatomic weakness of the support muscles for these organs. Additionally, these procedures may provide a degree of urethral compression that helps keep the bladder neck closed and subsequently prevents the bladder from leaking urine.

  Synthetic materials have been developed to replace human fascia and procedures have become increasingly less invasive, with shorter hospital stays and faster recovery time. However, many women are not good candidates for or do not wish to have surgery. Moreover, because many women still harbor the myth that the only treatment for SUI is surgery, they fail to reveal their symptoms to physicians and nurses for fear surgery will be recommended. Plus, surgery is not a certain cure for the symptoms. In fact, a recent multicenter, randomized prospective comparison1 of the abdominal Burch procedure to the fascial sling revealed success rates of 49% and 66%, respectively (P <0.001).   Women with a history of previous surgery for SUI are at greater risk of surgical failure than those who have not had prior surgery. If suture or synthetic mesh tension is too great, there is also the risk of de nuovo urgency following the procedure. Other adverse outcomes include urinary tract infection and lingering pelvic pain, particularly in the groin.   No Food and Drug Administration (FDA)-approved prescription medication alternatives are available but there are nonsurgical options. The first step is to recognize/differentiate the two types of SUI in order to categorize a patient’s symptoms accordingly. Urethral hypermobility results when the urethra shifts positions when abdominal pressure is increased, as with a laugh or a sneeze, allowing urine loss. Intrinsic sphincteric deficiency (ISD) refers to the inability of the ring of muscles designed to function as a valve to the bladder to remain tightly closed so urine doesn’t leak. Although no specific test for ISD is available, the general belief is that most women with SUI have at least some degree of ISD.   Once a diagnosis is determined, a nurse specialist can work with the patient to reduce symptom severity. Pelvic muscle exercises (PMEs) to strengthen the pelvic floor musculature and decrease bladder leakage are considered a cornerstone of behavioral treatment techniques. When performed correctly and faithfully, PMEs have been shown to improve mild to moderate urge and stress incontinence and even help maintain bowel control. Nurses should know how to coach their patients on muscle location, establish a workout routine aimed at advancing muscle strength, and explain the different types of contractions — ie, slow versus fast twitch. Regular, motivational follow-up is critical; studies3 show at least one third of patients drop out of studies in 5 months or less. Patients should be given supplemental resources, written instructions, and referrals to other experts such as physical therapists if biofeedback could help identify the muscles to contract or determine whether electrical stimulation could provide the correct external stimulus to nerves to make the muscles contract. Continence nurses should be able to explain these techniques in simple terms and reassure patients about the technology and the absence of pain.   Other behavioral intervention includes encouraging loss of excess weight. Research by the University of California-San Francisco (UCSF) and others4 has demonstrated that women who lost just 10% of their body weight reduced their leakage from SUI by half and maintained these results for 6 months. Smoking cessation also is recommended as a first-line approach to reduce or eliminate SUI episodes because the chronic cough associated with smoking tobacco causes recurrent, downward pressure on the bladder.   Topical estrogen, not to be confused with hormone replacement therapy in considerably higher doses, has been shown helpful in older women, particularly in persons with post-menopausal vaginal dryness and/or atrophy.   Another technique to treat SUI is involves injecting agents to bulk up the tissues around the urethra. The goal of injection therapy is close the sphincter without obstructing it. The best results from injection therapy occur when the leakage is a result of ISD but pelvic muscle support remains good. Many research studies have shown that up to 80% of women become “dry” or improved after three treatment sessions; however, this approach is not considered a permanent solution because the body absorbs the agent over time.5   A newer, nonsurgical approach uses radiofrequency (RF) energy to “remodel” and subsequently thicken the supportive tissue to recreate the natural hammock’s strength. The procedure is performed in an office setting without incisions or sutures and is considered free of adverse events and thus safe.6 After 3 years of follow-up, half of the RF patients demonstrated a 50% or greater reduction in frequency of urine leakage.7   Multiple strategies are available for tackling SUI, especially in women. A continence nurse needs to know the full extent of her resources and keep patients engaged and hopeful.

References

1. Albo ME, Richter HE, Brubaker L, et al. Burch colposuspension versus fascial sling to reduce urinary stress incontinence. New Engl J Med. 2007;356(21):2143–2155. 2. Ouslander J, Staskin D, Raz S, Su HL, Hepps K. Clinical versus urodynamic diagnosis in an incontinent geriatric female population. J Urol. 1987;137(1):68–71. 3. Wells TJ, Brink CA, Diokno AC, Wolfe R, Gillis GL. Pelvic muscle exercise for stress urinary incontinence in elderly women. J Am Geriatr Soc. 1991;39(8):785–791. 4. Subak LL, Wing R, West DS, et al. Weight loss to treat urinary incontinence in overweight and obese women. New Engl J Med. 2009;360(5):481–490. 5. Rackley R, Ingber MS, Faroozi F. Injectible bulking agents for incontinence. Available at: http://emedicine.medscape.com/article/447068. Accessed September 24, 2010. 6. Dillon B, Dmochowski MD. Radiofrequency for the treatment of stress urinary incontinence in women. Curr Urol Rep. 2009;10(5):369–374. 7. Appell RA, Singh G, Klimberg IW, et al. Nonsurgical radiofrequncy collagen denaturation for stress urinary incontinence: retrospective 3-year evaluation. Exp Rev Med Devices. 2007;4(4):455– 461. The National Association For Continence is a national, private, non-profit organization dedicated to improving the quality of life of people with incontinence. The NAFC’s purpose is to be the leading source for public education and advocacy about the causes, prevention, diagnosis, treatments, and management alternatives for incontinence. This article was not subject to the Ostomy Wound Management peer-review process.

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