frequent urination in women

Frequent Urination In Women ~ New Options for Non-surgical Treatment of Female Stress
Urinary Incontinence—A Practical Perspective US GENITO-URINARY DISEASE 2006 39

Coughing, sneezing, laughing, exercise. Common daily occurances that can be embarrasing and uncomfortable for the large number of individuals who suffer from stress urinary incontinence (SUI), an involuntary loss of urine that occurs during physical activity. SUI is the most common type of urinary incontinence in women. Studies indicate that about 50% of all women have occasional urinary incontinence, as many as 10% have frequent incontinence, and nearly 20% of women over 75 years of age experience daily urinary incontinence. SUI is rare in men, and is usually a result of injury or prostate surgery. SUI occurs when the bladder neck and provunal wethral open inappropriately (sometimes refered to as ‘funnelling’) during periods of intra-sbdom pressure. SUI is often seen in women who have had multiple pregnancies and vaginal childbirths, or who have pelvic prolapse. Other risk factors include advancing age, smoking, obesity, and menopause.

Treatments for SUI depend on the severity of the symptoms and the extent to which the symptoms interfere with an individual’s lifestyle. The traditional non-invasive methods to control SUI include behavioral changes such as changing fluid intake, urinating more frequently, timed voiding, and pelvic floor muscle training (known as Kegel exercises). Kegel exercises were developed by a gynecologist in 1948 to strengthen the levator and perineal muscles of the pelvic floor. Patients squeeze and relax the pelvic floor repetitively. If patients are unable to correctly perform pelvic muscle exercises, biofeedback and electrical stimulation may be used to help identify the correct muscle group to work.These exercises are similar to any other exercise to strengthen a voluntary muscle group.The patient must make the effort to perform them on a regular basis. Pelvic floor muscle training and biofeedback may be more effective when working with a physical therapist. Biofeedback uses a visual or auditory signal to help monitor progress; it may also be more useful to treat urge incontinence. Electrical stimulation can be added to stimulate the muscles to contract, further strengthening the pelvic floor.When a patient presents to the urologist with SUI they have usually already tried behavioral changes and Kegel exercises under the guidance of their family doctor, and have not been satisfied with the result.

Pessaries can also be utilised to treat SUI, but tend only to be used in elderly women. They provide support for pelvic prolapse. They come in multiple shapes and sizes, and must be fitted, cleaned, removed, and replaced. Many patients have difficulty taking them out and replacing them. Pessaries do not solve the problem of SUI and are usually just a temporary measure.They may be irritating, cause erosion of the vaginal tissue and increase bladder infections. In some cases they may be obstructive to urinary flow or cause an increase in incontinence. Surgical procedures to treat SUI are an option for individuals who want the best possible outcome and who are not concerned about restriction of acitivities for a prolonged period of time during recovery. Patients can expect between 75% and 95% improvement in their condition with careful surgical selection. Surgical options include: Bladder Neck Suspension There are several surgical procedures, such as the modified Pereyra and Stamey procedure, that differ based on the structures that are used to anchor and support the bladder neck.Women treated with these procedures have a 40–80% cure rate. Because the success rate tends to be lower than that achieved with retropubic suspensions or sling procedures, these procedures are now performed less often than in the past. Possible complications include urinary tract infection (UTI), urinary retention, wound infection, fistula (rarely), and new onset of urge incontinence. Special needle instruments are utilised during the surgery, which requires only a small abdominal incision.

Nancy A Little, MD, FACS, is in private practice in Lodi, CA. She completed her residency in urology at Duke University Medical Center, followed by a fellowship in neurourology, female urology, and reconstructive surgery with Dr Shlomo Raz at UCLA. She is a fellow of the American College of Surgeons (ACS) and a member of the American Urological Association (AUA) and the Society for Urodynamics and Female Urology. Dr Little was on the faculty of the University of Texas Health Science Center in San Antonio, TX, before moving to private practice in California. Little_edit.qxp 24/6/06 10:10 am Page 39Overactive Bladder & Urinary Incontinence 40 US GENITO-URINARY DISEASE 2006 Retropubic Suspension Retropubic suspension is used to describe a group of surgical procedures performed to elevate the bladder and urethra within the pelvic region. These procedures are performed through an abdominal incision.The procedures (Burch colposuspension and Marshall–Marchetti–Krantz) differ based on the structures that are used to anchor and support the bladder. Women treated with these procedures have a 75–90% cure rate. Possible complications include UTI, urinary retention, wound infection, fistula (rarely), and new onset of urge incontinence.

Sling Procedures These are used to treat women who have stress incontinence caused by weakened urethral sphincter muscles. These procedures are an evolution of the retropubic suspensions and the bladder neck suspensions.A sling is formed by taking a piece of the abdominal tissue (fascia) or a piece of synthetic material and using it to support the urethra, preventing leakage of urine during stress manoeuvers. These procedures require a small abdominal incision and a vaginal incision. Many modifications of the sling procedure have been developed, including most recently the variation of the mid-urethral sling utilizing polypropylene mesh. This type of sling procedure is performed through smaller incisions and can be carried out as an out-patient surgery. Among the people who have undergone sling procedures to correct their stress incontinence, there is an 80–90% cure rate. Possible complications include infection, erosion of the sling, non-healing vaginal wall, fistula or abscess formation, urgency, urge incontinence, and urinary retention.

Minor of Surgical Procedures The most to treat intrinsic sphincter deficiency, a specific type of SUI, is injection with a material such as collagen.The procedure may need to be conducted two or three times initially and then repeated every year or so to maintain bladder control. The collagen injection helps control urine leakage by bulking up the area of the bladder neck, thus helping to create coaptation of the urethra at the level of the bladder neck. Potential complications that can occur after a collagen injection include infection and urine retention. Any potential candidate for collagen injection must have a skin test prior to treatment to check for an allergic reaction.

For women who want improvement of the condition with the least amount of disruption to their lives, there is a clear need for treatments that bridge the gap between traditional non-surgical treatment options and surgery. In 2005, the US Food and Drug Administration (FDA) approved for sale two new options for the treatment of SUI. Coaptite, approved in November 2005, is a permanently implanted synthetic injectable material used to treat women who have SUI owing to an intrinsic sphincter deficiency (ISD). Coaptite, manufactured by Bioform Medical, is composed of smooth CaHA (calcium hydroxyapatite) microspheres that have a diameter range of 75–125µm, suspended in an aqueous gel carrier. The gel is injected transurethrally at the level of the bladder neck to aid coaptation of the urethra. It helps prevent uncontrolled urination, similar to collagen injections. However, no allergic skin test is required and the product may be more durable than collagen. Common side effects of the treatment have included urination retention in 41% of patients, blood in urine in 20%, dysuria in 15%,UTI in 8%, a feeling of sudden urge to urinate without incontinence (urgency) in 8%, frequent urination in 7%, and urge incontinence in 6%. Coaptite should not be used in patients who have a significant history of UTI without resolution; current or acute conditions of cystitis or urethritis; or a fragile urethral mucosal lining. The implant was previously approved for SUI in the EU,where it is also used for the Treatments for SUI depend on the severity of the symptoms and the extent to which the symptoms interfere with an individual’s lifestyle.

Little_edit.qxp 24/6/06 10:11 am Page 40New Options for Non-surgical Treatment of Female Stress Urinary Incontinence US GENITO-URINARY DISEASE 2006 41 treatment of pediatric vesicoureteral reflux (VUR) and radiographic tissue marking. It is also approved in Canada for the treatment of VUR. In August 2005, the FDA approved a radiofrequency microremodeling treatment called Renessa (which is made by Novasys Medical) for the treatment of SUI due to hypermobility in women. The non-surgical procedure can be performed in about 20 minutes in an outpatient or office setting, and the majority of women can return to most daily activities immediately. A urethral block with lidocaine is used, similar to that used in collagen injection. A single-use transurethral radiofrequency probe is used to deploy four nickel–titanium needle electrodes that heat submucosal tissue in the lower urinary tract and denature collagen without significant necrosis or small vessel thrombosis. On cooling and healing, the collagen areas renature in a significantly more compact, less compliant architectural pattern.The microscopic sites are organised in a helical pattern around the proximal urethra and bladder neck to increase tissue resistance to involuntary leakage at times of increased intra-abdominal pressure, thereby reducing or eliminating SUI episodes.

According to the company, the remodeling is so limited that there is no gross luminal narrowing or significant effect on static compliance and therefore no risk of developing a ‘lead pipe’ urethra. In multiple clinical trials there were no significant adverse events. Adverse events seen during the trials were minor and simular to those seen with brief bladder catheterization. The approval was based on outcomes of a one-year randomized controlled multicenter clinical trial in more than 170 women, showing that 76% of treated women experienced a reduction in daily incontinence episodes, and 35% of treated women became continent as a result of the treatment. Urologists in private practice have related comparable results to those of the clinical trials. These statistics mean Renessa is proving to be a significant new treatment option for busy women with SUI who do not wish to undergo an invasive surgical procedure provides an improvement in quality of life for most women. It is an option that allows treatment without disruption of most of their daily activities, without limitations of their activities for a significant period of time.

Medications used to treat stress incontinence are aimed at increasing the contraction of the urethral sphincter muscle. Treatment tends to be more successful in patients with mild-to-moderate stress incontinence. Alpha-adrenergic agonist drugs, such as phenylpropanolamine and pseudoephedrine, work by increasing the contraction of the urethral internal sphincter, and improve symptoms in about 50% of patients. Additionally, the tricyclic antidepressant imipramine has similar properties, and may also be useful. However, these medications may have significant side effects or medication interactions. Estrogen therapy can be used to improve symptoms of urinary frequency, urgency and burning in post-menopausal women, and it has also been shown to increase the tone and blood supply of the urethral sphincter muscles. However, whether it improves SUI is controversial. A recent study showed an increase in SUI in women on oral estrogens.Vaginal estrogens are often used to decrease the symptoms of vaginal burning and urinary urgency and there are distinct studies in this area. No drugs are currently approved by the treatment of SUI and so use in these patients is off-label. The exciting developments in non-surgical treatment of female SUI are providing women with more choice along with the possibility of avoiding invasive procedures.This is an encouraging situation for women.  blog