1FEMALE URINARY INCONTINENCE AJMS SEPTEMBER/OCTOBER 2003

F emale urinary incontinence is a common prob-lem that affects not only the patient, but also her

family and society at large. Due to the embarrassingnature of incontinence, it is both underreported andunderdiagnosed. Fewer than half of the persons withurinary incontinence living in the community con-sult health care providers about the problem.1 Familymembers who help care for these patients may findthe extra burden of incontinence too great to dealwith. It is widely accepted that incontinence is amajor factor leading to institutionalization. It is alsocostly. Together, the diagnostic, treatment, routinecare, and consequence costs of urinary incontinencein men and women totaled $25.6 billion in 1995,with an additional $704 million in lost earnings.2

Estimates of the prevalence of urinary inconti-nence vary depending on the type of research, thepopulation under study, and the operational defini-tion. One study3 reported a prevalence range of3%–14% for women in the community when severi-ty of urine loss was defined as “daily,” “weekly,” or“most of the time.” However, in another study in-volving 2763 postmenopausal women, 56% report-ed urinary incontinence at least weekly.4 Nonethe-less, incontinence affects many women and the inci-dence is increased in those with the following riskfactors: vaginal parity, morbid obesity, diabetes, ad-vanced age, smoking, and estrogen depletion.

Research has shown that urinary incontinenceand depression are linked,5 and successful treatmentof incontinence is associated with improved psycho-logical functioning and reduced depression.6 Urinaryincontinence can also be the presenting symptom forother conditions as varied as multiple sclerosis anddiabetes. A solid knowledge base of incontinence ishelpful for any physician who treats adult women.This article offers a basic guideline in the evaluationand treatment of female urinary incontinence.

Types of Urinary Incontinence

Urinary incontinence can be categorized into six sub-types: stress incontinence, overactive bladder, mixed

Evaluation and Treatment of Female Urinary Incontinence

Urinary incontinence in women is a com-mon problem and one that will increase inprevalence as the population ages. Thiscondition can be categorized into threebasic types: stress, urge, and mixed inconti-nence. Careful history taking and a com-prehensive physical exam will provide thediagnosis in many cases. With the properknowledge base, physicians can counseltheir patients on the various forms of treat-ment for incontinence, which range fromcompletely noninvasive behavioral thera-pies to surgical management. This articleoffers a basic guideline for the evaluationand treatment of female urinary inconti-nence. (Am J Med Sports. 2003;5:XXX-XXX.) ©2003 Le Jacq Communications, Inc.

Address for correspondence: Miles Murphy, MD, 315 East Broadway M-18, Suite 4002, Louisville, KY 40202E-mail: m0murp01@louisville.eduManuscript received October 15, 2002; revised February 24, 2003;accepted March 6, 2003

Miles Murphy, MD; Michael Heit, MD; Patrick J. Culligan, MDUniversity of Louisville Health Sciences Center, Louisville, KY

[AU: PLS NOTE DRUG BRAND NAMES HAVE BEENDELETED THROUGHOUT PER JOURNAL STYLE.]

FEMALE URINARY INCONTINENCE AJMS SEPTEMBER/OCTOBER 2003

incontinence, overflow incontinence, functional in-continence, and lack of continuity or deformity.Having these categories in mind during an initialevaluation can help guide an examiner toward thecorrect diagnosis. The majority of women will fallinto one of the first three types.

STRESS INCONTINENCE. Stress incontinence is theinvoluntary loss of urine during an increase inintra-abdominal pressure caused by actions such ascoughing, sneezing, laughing, or exercising. Theputative mechanism, which leads to this loss ofcontinence, is a lack of normal support beneaththe urethra. Defects in fibromuscular support tothe urethra cause an overabundance of intra-ab-dominal pressure (e.g., during coughing and sneez-ing) to be transmitted to the urethra thus resultingin urine loss. Parity is correlated with inconti-nence,7 and many believe that damage to the en-dopelvic fascia and nerve supply to the levator animuscles during vaginal childbirth is at least partlyresponsible for this lack of normal support inmany incontinent women.

Other factors also contribute to the developmentof this type of incontinence. In some women theseverity of urine loss is out of proportion to thestress. In these patients advanced age, inadequate es-trogen levels, and previous vaginal surgery can leadto poor urethral sphincter function known as intrin-sic urethral sphincter deficiency. Patients with thissubtype of stress incontinence lack not only supportto the urethra, but intrinsic pressure within the ure-thra as well. It is diagnosed based on a combinationof clinical symptoms and specialized tests such asurodynamics and cystourethroscopy.

OVERACTIVE BLADDER. Overactive bladder is achronic and distressing medical condition charac-terized by urinary urgency and frequency.8 Whenurgency is coupled with an involuntary loss ofurine, it is termed urge incontinence. Related termssuch as detrusor instability and detrusor hyper-reflexia are used to describe the presence of invol-untary contractions seen during urodynamic stud-ies. Detrusor instability is an idiopathic condition,whereas hyperreflexia is the result of a known neu-rologic lesion of the suprasacral cord and above(i.e., spinal cord injury and multiple sclerosis).

Because patients with urge incontinence are treatedwith the same medications as continent women whoexperience the urgency/frequency syndrome, the USFood and Drug Administration has adopted the term“overactive bladder” to pool these patients together forclinical trials. In this article, this term will be used inplace of urge incontinence, detrusor instability, anddetrusor hyperreflexia. In addition to neurologicalconditions, some patients with overactive bladdersymptoms can suffer from specific lower urinary tract

conditions such as chronic and acute infections, aswell as bladder cancer and stones. However, most pa-tients who present with these symptoms have an idio-pathic inability to suppress detrusor contractions.

MIXED INCONTINENCE. It can be helpful to thinkof urinary incontinence as a spectrum, with stressincontinence on one end and overactive bladderon the other. Many patients fall at each end of thespectrum with a distinct disorder, but others fallsomewhere in the middle. These women are saidto have mixed incontinence. In these cases, thegoal of the physician is to quantify which type ofincontinence is greater and treat accordingly.However, if the plan is surgery, it is best to confirmthe diagnosis with urodynamic testing. This way,if the patient has overactive bladder symptomspostoperatively, one can be assured that the condi-tion was pre-existing rather than de novo.

OVERFLOW INCONTINENCE. Overflow inconti-nence is any involuntary loss of urine associatedwith overdistention of the bladder. Overdistentionis usually caused by outlet obstruction, an under-active detrusor muscle, or both. Although outletobstruction is much more common in men, it canbe seen in women with severe pelvic organ pro-lapse or prior anti-incontinence surgery. Weak de-trusor contraction can be caused by psychotropicmedications, diabetic neuropathy, multiple sclero-sis, low spinal cord injury, and radical pelvicsurgery. Patients with overflow incontinence failto adequately empty their bladders, resulting inlarge postvoid residual volumes. They can presentwith symptoms ranging from frequent dribbling tochronic urinary tract infections.

FUNCTIONAL INCONTINENCE. Women with cog-nitive, psychological, or physical impairments thatmake it difficult to reach the toilet in time or en-gage in appropriate toileting are said to have func-tional incontinence. Many functionally impairedwomen can also have other forms of urinary in-continence; therefore this is a diagnosis of exclu-sion. An accurate pathophysiologic diagnosis is aprerequisite to successful treatment.9

LACK OF CONTINUITY OR DEFORMITY. Urinary fis-tulas, ectopic ureters, and urethral diverticulae repre-sent the most rare form of urinary incontinence.What they share in common is an anatomic bypassof the normal continence mechanism. Fistulas andectopic ureters present with constant dribbling. Fistu-las most commonly form after extremely prolongedor traumatic childbirth or following complicatedpelvic surgery. Urethral diverticulae present with ei-ther a painful, suburethral mass or postvoid dribblingupon arising from the commode.

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Evaluation

One of the largest obstacles to making a diagnosisof urinary incontinence is a reluctance on the partof the physician to inquire about its symptoms.Simple questions during a routine annual examsuch as, “Do you have problems with urine loss?” or“Do you leak urine?” can establish a need for fur-ther evaluation. If the patient answers in the affir-mative, a follow-up visit to address this specificissue can be scheduled. In preparation for that visit,the patient should be instructed to complete a 24-hour bladder diary that will be reviewed at the sub-sequent appointment (Figure 1).

A preliminary diagnosis of urinary incontinencecan be made the basis of a history [AU: WORDSMISSING], physical examination, and a few simplelaboratory tests. All of these processes can be complet-ed in one dedicated follow-up office visit, and initialtherapy can be started based on the findings. If thecondition is more complex or the initial therapy isunsuccessful, more specialized testing or referral to aspecialist may be necessary.

HISTORY. A relatively small number of questionscan be used to assess the severity of a patient’ssymptoms and to determine the most likely type ofincontinence. A sample of these valuable questionsis listed in Table I. The goal of these questions is todetermine the events or sensations associated witheach incontinent episode, as well as the frequencyand volume of urine lost. Determining the compen-satory measures thus taken, will also allow thephysician to assess how substantially this conditionhas affected the patient’s quality of life. These ques-tions can also help diagnose more rare conditionssuch as interstitial cystitis and outlet obstruction.

The medical history should also identify suchcontributing factors as diabetes, stroke, lumbar diskdisease, chronic lung disease, fecal impaction, andcognitive impairment. An obstetric and gynecologyhistory is imperative and should include gravity;parity; the number of vaginal, instrument-assisted,and cesarean deliveries; the time between intervaldeliveries; sterilization procedures; previous abdomi-nal/vaginal hysterectomy and indication; recon-structive vaginal or bladder surgery; pelvic radiation;trauma; and estrogen status.

Patients should also be questioned about pelvicorgan prolapse symptomatology, as this is a com-mon comorbidity. Factors that suggest a history ofprolapse include dyspareunia, prior use of a pes-sary, and the sensation of vaginal pressure or full-ness. Likewise, because fecal impaction has beenlinked to urinary incontinence,10 information re-garding frequency of bowel movements, length oftime to evacuate, and whether the patient must

splint her vagina or perineum during defecationshould be obtained. Although it is beyond thescope of this article, patients should also be askedabout fecal incontinence. In general, people areeven more reluctant to discuss this than urinaryincontinence, so direct questioning is necessary.

A number of pharmacologic agents that can affectcontinence are listed in Table II. It is important to ob-tain a complete list of all the prescription and non-prescription drugs a patient is taking because some ofthem may be exacerbating the problem. When ap-propriate, these medications should be stopped orchanged to help manage the patient’s incontinence.

BLADDER DIARY. A bladder diary is a 24-hourrecord of the type and amount of fluid consumed,the number and volume of voids and leaks in eachhour, and what the patient was doing at the timeof each leak. It serves as a diagnostic tool as well asa record of each patient’s baseline condition.

Events associated with incontinent episodes canhelp guide the diagnosis (i.e., leaking while un-locking the front door suggests an overactive blad-der). The document can also uncover problematic

3FEMALE URINARY INCONTINENCE AJMS SEPTEMBER/OCTOBER 2003

TABLE I. Ten Important Questions in the Evaluation ofIncontinent Patients

1) Do you leak urine with activities such as laughing,sneezing, coughing, and/or exercise?

2) Are there times when you have the urge to urinate butleak before you get to the bathroom?

3) Do you leak urine daily, weekly, monthly, or less thanonce a month?

4) When you leak would you characterize the loss asdrops, small splashes, or more than small splashes?

5) Do you wear protective pads, and if so, how many per day?6) How often do you get up at night to urinate?7) How many times do you void during the course of the day?8) Do you ever leak without a preceding urge or stress?9) Do you ever feel that you do not completely empty

your bladder?10) Do you have bladder pain or pain with voiding?

TABLE II. Drugs That Affect Urinary Function

DRUG SIDE-EFFECT

Alpha-adrenergic blockersAlpha-adrenergic agonistsBeta-adrenergic agonists

Calcium channel blockersAntidepressants,

antipsychoticsAnticholinergicsNarcoticsDiureticsCaffeineAlcohol

Decrease urethral toneIncrease urethral tone, urinary retentionInhibited detrusor function,

urinary retentionUrinary retentionUrinary retention

Urinary retentionUrinary retentionUrinary frequency and urgencyUrinary frequency and urgencyUrinary frequency and urgency

FEMALE URINARY INCONTINENCE AJMS SEPTEMBER/OCTOBER 2003

types of intake. Excessive caffeine consumption,for example, can create or exacerbate overactivebladder symptoms, and drinking after dinnertimecan lead to increased nocturia.

The bladder diary also serves as a good referenceto gauge the success of whatever treatment has beeninstituted as time passes. Patients, who are discour-

aged because they still leak after taking a medicationfor three months, may be reassured when it is notedthat their number of incontinent episodes has beendecreased from six to two per day.

PHYSICAL EXAMINATION. When a patient is sched-uled for an appointment she should be given or sent

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Your Daily Bladder Diary Your name:This diary will help you and your health care team understand your bladder function. It is a 24 hour recordof your intake and output as well as leakage episodes. The "sample" line (below) will show you how to usethe diary.Date: ACCIDENTS

Time Drinks UrineAccidental

Leaks

Strongurgeto go?

What wereyoudoing at thetime?

How much? (√)

What kind?How much?How many timesdid you "pee"?

How much?Use measuring

cup (ml's or oz's)��sm med lg

Circleone

Sneezing,exercisinghaving sex,lifting, etc.

Sample Coffee 2 cups 2 2 oz or 2 ml √ YesNoRunning6-7 am YesNo 7-8 am YesNo 8-9 am YesNo 9-10 am YesNo 10-11 am YesNo 11-12 noon YesNo 12-1 pm YesNo 1-2 pm YesNo 2-3 pm YesNo 3-4 pm YesNo 4-5 pm YesNo 5-6 pm YesNo 6-7 pm YesNo 7-8 pm YesNo 8-9 pm YesNo 9-10 pm YesNo 10-11 pm YesNo 11-12 mid YesNo 12-1 am YesNo 1-2 am YesNo 2-3 am YesNo 3-4 am YesNo 4-5 am YesNo 5-6 am YesNo

Figure 1. Twenty-four hour bladder diary

a bladder diary (to be completed before the visit) andasked to arrive with a full bladder. When she arrives,a standing stress test should be conducted. In thistest, a patient is asked to stand over an absorbentpad or towel with her feet shoulder-width apart andtold to cough vigorously while the examiner watch-es for leakage of urine. This is an objective sign ofstress incontinence. She may then use the lavatorywith instructions to void as normally and complete-ly as possible. Record this volume (using a graduatedcontainer placed under the seat of the commode),and then check a postvoid residual volume. Theresidual volume can be estimated with ultrasonogra-phy,11 but catheterization is preferable when a speci-men for culture and analysis is desired. Residual vol-ume greater than 100 mL is considered abnormaland suggests the diagnosis of overflow incontinence.

A focused physical examination can then be per-formed. Pulmonary examination should rule outany possible cause of chronic cough. Cardiac and ex-tremity examination should monitor evidence ofdaytime third spacing, which can lead to nighttimediuresis and nocturia. The abdomen should bechecked for evidence of diastasis recti, masses, as-cites, and organomegaly that can influence intra-ab-dominal pressure and urinary tract dysfunction.

The pelvic examination should include an evalu-ation for inflammation, infection, and atrophy.These conditions can increase afferent sensation andthereby urinary urgency, frequency, dysuria, andoveractive bladder. Estrogen status should also be as-sessed. Signs of estrogen depletion include loss ofrugae, atrophy of the labia minora, urethral carun-cle, and thinning and paleness of the vaginal epithe-lium. Estrogen replacement therapy has been shownto improve subjective symptoms of stress inconti-nence12 and objective urodynamic values.13

Defects in the support of the anterior vaginal wallcan be detected by supporting the posterior vaginalwall with the disarticulated lower blade of a Simsspeculum while instructing the patient to Valsalva.If the patient leaks in the dorsal lithotomy positionsoon after emptying her bladder while bearing downin this manner, this puts her at an increased risk forintrinsic sphincter deficiency, a severe form of stressincontinence.14 With the anterior vaginal wall ex-posed, the urethra should be examined for evidenceof a diverticulum. Palpate from the bladder neck tothe urethral meatus, feeling for any masses, and lookfor milking of purulent discharge from the meatus.

Finally, a bimanual exam should be performed.Levator ani muscle function can be assessed by ask-ing the patient to tighten her “vaginal muscles” andhold the contraction for as long as possible (this mo-tion is also known as a Kegel exercise). Evaluate thestrength of the contraction by applying resistance inthe direction of the posterior vaginal wall and notingthe time it takes for the muscles to fatigue. Five to ten

seconds is a normal duration for a Kegel contraction.Bimanual examination should rule out any pelvicmasses that may be putting extra pressure on thebladder. The sensitivity of this exam can be improvedby performing a recto-vaginal examination. The rec-tal portion of this exam also allows the physician todetect fecal impaction and occult blood.

It is customary to include the Q-tip test, neuro-logical exam, and basic cystometry as part of theroutine evaluation of the incontinent woman. How-ever, we believe the findings we gain from theseevaluations almost never change the way we man-age our patients, so we omitted them from this arti-cle. If, for example, we believe a patient will requiresurgery or if her presentation is so complex that cys-tometry is needed, we prefer to send her for multi-channel urodynamic testing rather than perform themore imprecise office cystometry.

Some conditions require further evaluation [AU:ON?] an outpatient basis. If a patient with dampnessin her undergarments is unsure whether it is beingcaused by vaginal discharge or incontinence, she canundergo a phenazopyridine (Pyridium) test. This drugturns the patient’s urine bright orange but does not af-fect the color of vaginal discharge. She is asked to weara pad after taking the medication. If she truly has uri-nary incontinence, her pad will be stained orange.

Treatment

As mentioned earlier, the vast majority of womenwith urinary incontinence suffer from stress inconti-nence, overactive bladder, or a combination of thetwo. Overflow incontinence is initially treated withintermittent self-catheterization, but ultimately thegoal should be to treat the underlying etiology (e.g.,tighter diabetes control). Likewise, therapy for func-tional incontinence is focused on the debilitatingcondition rather than incontinence per se. Solutionsto these problems can be as simple as placing a com-mode at the bedside of a patient who has difficultyambulating. Patients with a pelvic deformity or lackof continuity usually require surgery by a urogynecol-ogist or a urologist. The remainder of this section willaddress the treatment of overactive bladder and stressand mixed incontinence.

TREATMENT FOR STRESS INCONTINENCE. Thetreatment of stress incontinence can be divided intothe following four approaches: occlusive, behavioral,pharmacologic, and surgical. Some occlusive devices,like pessaries, can mimic the effects of incontinencesurgery. Like retropubic urethropexies, the goal ofthe “incontinence dish” pessary is to maintain theurethrovesical junction in an intra-abdominal place-ment in the face of a cough or sneeze. The patientshould be able to comfortably insert and remove the

5FEMALE URINARY INCONTINENCE AJMS SEPTEMBER/OCTOBER 2003

FEMALE URINARY INCONTINENCE AJMS SEPTEMBER/OCTOBER 2003

pessary, and it should not cause voiding dysfunc-tion. Other types of occlusive devices, such as ure-thral plugs and stents, have not been widely accept-ed for use. In fact, most have been removed fromthe marketplace as a result of poor response.

Behavioral techniques focus on rehabilitating thepelvic floor musculature. Patients work to strength-en their pelvic muscles by performing Kegel orpelvic muscle exercises (with or without biofeed-back), using weighted vaginal cones, and undergo-ing pelvic floor electrical stimulation. There is someevidence that using biofeedback with pelvic muscleexercise significantly improves pelvic muscle elec-tromyogram [AU: PLEASE CONFIRM THATELECTROMYOGRAM IS THE CORRECT TERMHERE] activity over exercise alone.15 Nonetheless,up to 38% of motivated patients who follow an ex-ercise regimen for at least three months will experi-ence a cure of pure stress incontinence.16

Vaginal cones work by fostering sustained in-creased vaginal muscle tone. The cones come inincreasing weight gradations and are worn for fif-teen minutes twice a day while the patient is am-bulatory. In premenopausal women, success ofhome vaginal weight training is comparable totreatment in the office with a physiotherapist.17

Likewise, passive contraction of the pelvic floorwith transvaginal electrical stimulation used twicedaily for 12 weeks has been shown to improve ob-jective signs of stress incontinence in 62% of sub-jects vs. 19% of controls.18 As these methods oftherapy are predicated on the intent of returningstrength to muscles that have become weak ordamaged over time, they have limited use in pa-tients who demonstrate excellent pelvic musclestrength on initial physical examination.

The benefits from medical therapy in the treat-ment of stress incontinence are limited. There are,however, two categories of drugs that are generallyaccepted as helpful in the treatment of stress incon-tinence: estrogens and α-adrenergic agonists. Thebladder and urethra are responsive to estrogens, andin postmenopausal women, estrogen replacementtherapy increases the vascular supply to the urethraleading to a thickening of the urethral mucosa.19

Studies report mixed results20,21 on the effect of es-trogen over placebo on stress incontinence. Overall,however, estrogen is considered to be a good adjunctto other forms of therapy for female incontinence.Fear of systemic side-effects from estrogen shouldnot prohibit patients from use of this hormone aslow-dose forms can be given locally in the form ofestradiol-impregnated vaginal ring or vaginal tablets.

Sustained-release phenylpropanolamine is themost studied α-adrenergic agonist. Its mechanism ofaction is believed to be an increase in resting ure-thral tone. Although some women have an improve-

ment in their symptoms, it is not a cure for stress in-continence, and the side effect profile is more exten-sive than estrogen. Patients can experience anxiety,insomnia, agitation, and cardiac arrhythmias.

The therapy that has proved to be the most suc-cessful in the treatment of stress incontinence issurgery. The gold standard of surgical treatment isretropubic urethropexy (e.g., the Burch and Mar-shall-Marchetti-Krantz procedures). For patients withintrinsic sphincter deficiency or prior failed ure-thropexies, treatment with a suburethral sling is ap-propriate. Together these types of surgeries have80%–93% cure rates.22 Anterior colporrhaphy for thetreatment of stress incontinence is no longer consid-ered to be within the standard of care.

Some new, minimally invasive suburethral slingprocedures are now being widely used as first line sur-gical therapy for patients with or without intrinsicsphincter deficiency. The tension-free vaginal tapesling procedure has less postoperative morbidity thantraditional slings, while still achieving long-term (5year) cure rates greater than 86%.23 A similar, newminimally invasive sling, the SPARK device [AU:PLSPROVIDE MANUFACTURER INFO], shows greatpromise, but comparable long-term cure data are notavailable at this time. These procedures are typicallydone in the operating room on an outpatient basisunder local anesthesia with mild intravenous sedation.

Another minimally invasive procedure for thetreatment of stress incontinence is the periurethralinjection of bulking agents. This procedure can bedone in the office with local anesthesia in womenwho have a weakened sphincteric mechanism. It in-volves injection of material just under the urotheli-um at the level of the bladder neck. The injectioncan be performed using either a periurethral ortransurethral approach. The two materials that havebeen labeled by the US Food and Drug Administra-tion for treatment of stress incontinence are glu-taraldehyde cross-linked bovine collagen (ContigenBard Collagen Implant, C.R. Bard, Inc., Covington,GA) and carbon-coated beads (Durasphere, Ad-vanced Uroscience, Inc., St Paul, MN) (Figure 2). Themost suitable patients for peri-urethral injection areelderly women, patients who constitute high opera-tive risk, and those with stress incontinence due tointrinsic sphincter failure.24

TREATMENT FOR OVERACTIVE BLADDER. In mostpatients, the first line of therapy for overactive blad-der should be behavior modification. Initial stepsinclude fluid management and altering the patient’sdiet. Patients should be told to only drink whenthirsty and to avoid fluids after dinner if they havetrouble with excessive nocturia. They may also ben-efit from avoiding spicy foods and acidic drinks thatcan irritate the bladder. Patients should limit their

6

intake of fluids that contain diuretic substancessuch as caffeine and alcohol.

The final component of behavior modification isbladder retraining. Most women understand that eventhough they may get the urge to void every 30 min-utes, they do not have to void that frequently. Bladderretraining teaches the patient to void by the clock. Forthe women who voids twice an hour, she should startby making herself wait 1 hour between voids. Whenurges come more frequently than that, she can engagein relaxation techniques like taking three deep breaths.When the hour is up she then voids whether or notshe has an urge. When she can go 1 hour withoutvoiding on a regular basis, she is instructed to wait 90minutes between voids and so on until the intervalreaches an acceptable (i.e., 3 hours) time span. In onecontrolled trial,25 bladder training reduced the numberof incontinent episodes by at least 50% in 75% of thesubjects, and 20% reported complete dryness.

For patients in whom this type of therapy is un-successful or in those who do not wish to attempt it,pharmacological agents are the next step. Anticholin-ergic medications are the mainstay of drug therapyfor overactive bladder. Table III lists these drugs alongwith the other medications that are used to treat uri-nary incontinence. Two medications have recentlybeen introduced that offer once-a-day dosing withequivalent or better efficacy than their precursors.The extended-release forms of tolterodine and oxy-butynin chlorine [AU: CHLORIDE?] are more ex-pensive than generic oxybutynin, but, in general, theonce-daily medications offer benefits beyond theirconvenient dosing. In one study,26 extended-releasetolterodine was shown to be 18% more effective thanimmediate-release with 23% less dry mouth overall.In another study comparing extended-release oxybu-tynin to immediate-release tolterodine,27 both drugshad similar rates of dry mouth and other adverseevents, but the extended-release oxybutynin wasmore effective in reducing urge incontinenceepisodes over 12 weeks. Trials comparing the two ex-tended-release medications have not yet been pub-lished. [AU: PLEASE UPDATE PREVIOUS IFANY PUBLISHED TO DATE]

Hormone replacement therapy appears to treatpostmenopausal irritative urinary symptoms suchas frequency and urgency.28 As with stress inconti-nence, the benefit of estrogen replacement in over-active bladder is most likely the result of increasedblood flow to the lower urinary tract and reversalof urogenital atrophy. In fact, even patients whoare already taking oral estrogen may benefit fromlocalized vaginal estrogen therapy. None of theabove-mentioned treatments are mutually exclu-sive. Often the synergy of behavioral modificationand pharmacologic therapy result in the best out-come for these patients.

One of the new, exciting methods for treatingoveractive bladder is sacral nerve stimulation (Inter-stim, Medtronic Inc, Minneapolis, MN). This surgicaltherapy provides one further option for patients whoare unresponsive to both behavioral and pharmaco-logic treatment. This new technique providesstimulation to the sacral nerve roots via an electrodethat is placed through the sacral foramina. Onestudy,29 in which the authors postulated that sacralnerve stimulation induces reflex-mediated in-hibitory effects on the detrusor through afferentand/or efferent stimulation, showed that morethan 75% of subjects were either completely dry or

7FEMALE URINARY INCONTINENCE AJMS SEPTEMBER/OCTOBER 2003

TABLE III. Medications Used to Treat Incontinence andOveractive Bladder

DRUG DOSAGE

Stress incontinencePseudoephedrineVaginal estradiol ring

Vaginal estrogen creamOveractive bladder

Generic oxybutynin

Extended-releaseoxybutyninTolterodineExtended-releasetolterodineImipramineDicyclomineHyoscyamine

15–30 mg, three times dailyInsert into vagina, everythree months0.5–1 g in vagina, nightly

2.5–10 mg, two to fourtimes daily5–10 mg, daily

1–2 mg, two times daily4 mg, daily

10–75mg, two times daily10–20 mg, four times daily0.375 mg, two times daily

Figure 2. Periurethral injection of carbon-coated beadsfor the treatment of intrinsic sphincter deficiency (illus-tration courtesy of Carbon Medical Technologies, Inc.)

FEMALE URINARY INCONTINENCE AJMS SEPTEMBER/OCTOBER 2003

demonstrated ≥50% reduction in incontinenceepisodes after 6 months of treatment. Candidatesfor this therapy must have previously failed con-servative management. They then keep bladder di-aries before and after a staging procedure in whichan electrode is connected to an external stimula-tor. If a candidate shows ≥50% objective improve-ment (per diaries) in symptoms, a permanent stim-ulator can then be implanted subcutaneaously.

TREATMENT FOR MIXED INCONTINENCE. Treatmentof mixed incontinence should start with the treatmentof a patient’s most bothersome symptoms. If a patientsuffers predominantly from overactive bladder, behav-ioral and/or pharmacologic therapy can be initiated. Ifthis effectively controls her overactive symptoms, andher quality of life is not significantly affected by an oc-casional small leak with a cough or sneeze, she maywaive any further treatment at that point. On theother hand, effective treatment of overactive bladdercan sometimes result in an increase in average bladdercapacity, which can subsequently lead to more volu-minous stress incontinence episodes. In these situa-tions the patient and physician must pursue furthertreatment of the stress incontinence.

When stress incontinence is the predominantcomplaint, initial conservative treatment is warrant-ed. If, however, definitive surgical treatment is re-quired, it is wise to perform urodynamic testing onpatients with mixed symptoms preoperatively. Thisallows both patient and physician to understand theextent of any pre-existing detrusor instability. Its exis-tence should not necessarily discourage one from pro-ceeding with surgery. Our experience shows that ap-proximately half of patients with mixed incontinencehave an improvement in their overactive bladdersymptoms following surgery for stress incontinence.

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