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Disclaimer: CME certification for these activities has expired. All information is pertinent to the timeframe in which it was released.


Advances in the Understanding of Stress Urinary Incontinence: Diagnostic and Treatment Strategies


GOAL
To provide primary care physicians and obstetricians/gynecologists with information on the most recent developments regarding the evaluation and treatment of stress urinary incontinence.

TARGET AUDIENCE
This activity is designed for primary care physicians and obstetricians/gynecologists. No prerequisites required.

LEARNING OBJECTIVES
The Johns Hopkins University School of Medicine takes responsibility for the content, quality, and scientific integrity of this CME activity. At the conclusion of this activity, participants should be able to:

  • Identify the predominant risk factors for stress urinary incontinence.
  • Distinguish stress urinary incontinence from other types of incontinence using symptom screening.
  • Indicate which neurotransmitters are involved with increasing neural activity of the sphincter.
  • Recognize the potential role of central nervous system modulators in the treatment of stress urinary incontinence.
  • Construct a management plan for treating women who have stress urinary incontinence.

ACCREDITATION STATEMENT
The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

CREDIT DESIGNATION STATEMENT
The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 2 category 1 credits toward the AMA Physician’s Recognition Award. Each physician should claim only those credits that he/she actually spent in the activity.

The estimated time to complete this educational activity:  2 hours.

Release date: February 15, 2004. Expiration date: February 15, 2006.

DISCLAIMER STATEMENT
The opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of Johns Hopkins University School of Medicine name implies review of educational format design and approach. Please review the complete prescribing information of specific drugs or combinations of drugs, including indications, contraindications, warnings, and adverse effects, before administering pharmacologic therapy to patients.

This program is supported by an unrestricted educational grant from Eli Lilly and Company.

Full Disclosure Policy Affecting CME Activities:
As a sponsor accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of Johns Hopkins University School of Medicine to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a sponsor has with the manufacturer(s) of any commercial product(s) discussed in an educational presentation. The Program Director and Participating Faculty reported the following:

PROGRAM DIRECTOR

    Geoffrey W. Cundiff, MD
    Associate Professor
    Department of Gynecology and Obstetrics
    Johns Hopkins University School of Medicine
    Chair, Department of Obstetrics and Gynecology
    Johns Hopkins Bayview Medical Center
    Baltimore, Maryland
    Dr Cundiff reports receiving honoraria from Cook Ob/Gyn and serving as a consultant to Eli Lilly and Company.

PARTICIPATING FACULTY

    Donald R. Ostergard, MD
    Professor of Obstetrics and Gynecology
    University of California, Irvine
    Director, Division of Urogynecology
    Department of Obstetrics and Gynecology
    Associate Medical Director for Gynecology
    Women’s Hospital
    Long Beach Memorial Medical Center
    Long Beach, California
    Dr Ostergard reports serving as a consultant to and receiving honoraria from Eli Lilly and Company.

    David H.Thom, MD, PhD
    Associate Professor
    Department of Family and Community Medicine
    University of California, San Francisco
    San Francisco, California
    Dr Thom reports having no financial or advisory relationships with corporate organizations related to this activity.

    Notice:
    In accordance with the ACCME Standards for Commercial Support, the audience is advised that one or more articles in this continuing medical education activity may contain reference(s) to unlabeled or unapproved uses of drugs or devices. The following faculty members have disclosed that their articles reference the following unlabeled/unapproved uses of drugs or devices:

    Dr Ostergard—alpha-adrenergic receptor agonists, duloxetine, estrogen compounds, and tricyclic antide-pressants for the treatment of urinary incontinence.

    Dr Thom—alpha-adrenergic receptor agonists, duloxetine, estrogen compounds, and tricyclic antidepres-sants for the treatment of urinary incontinence.

    All other faculty have indicated that they have not referenced unlabeled/unapproved uses of drugs or devices.

    Advanced Studies in Medicine provides disclosure information from contributing authors, lead presenters, and participating faculty. Advanced Studies in Medicine does not provide disclosure information from authors of abstracts and poster presentations. The reader shall be advised that these contributors may or may not maintain financial relationships with pharmaceutical companies.

Advances in the Understanding of Stress Urinary Incontinence: Diagnostic and Treatment Strategies
Geoffrey W. Cundiff, MD*

Urinary incontinence occurring at any frequency that the patient views as a problem is estimated to occur in 24% of women.1 The condition is more prevalent than many of the more common chronic diseases in women, such as hypertension, depression, and diabetes.1-3 Predominant risk factors for urinary incontinence include age, female sex, parity, and obesity, the most important of which is age. In women younger than 60 years who suffer from incontinence, 55% have stress incontinence; in women older than 60 years, this percentage shifts to 30%.

Regardless of cause, urinary incontinence has a negative effect on patients’ quality of life; it inflicts a heavy toll on patients’ sense of well-being, affecting social, physical, sexual, psychological, occupational, and domestic quality-of-life indicators. The condition often leads to social isolation, limitation of physical activities, avoidance of sexual activity, decreased work productivity, and depression. About 25% of women report experiencing some bother from incontinence, and only a slightly smaller percentage report being severely bothered. These detrimental effects on quality of life emphasize the importance of diagnosing and treating incontinence.

Since 2002, the International Continence Society has defined urinary incontinence as the complaint of any involuntary leakage of urine. This symptom-based diagnosis does not depend on urodynamic testing, thus supporting diagnosis of incontinence in the primary care setting.

This issue of Advanced Studies in Medicine is based on presentations given at the Pri-Med West 2003 annual meeting. It reviews the epidemiology and evaluation of urinary incontinence as well as existing and new approaches to the treatment of stress incontinence. Dr David H. Thom briefly reviews the different types of incontinence and their underlying causes. He discusses the epidemiology of incontinence, based on varying definitions, as well as the risk factors for developing the condition. Dr Thom also offers a thorough review of the basic evaluation for incontinence, with an emphasis on the patient history and physical examination. The most successful way to determine the occurrence of incontinence is through direct questioning under circumstances that are comfortable for the patient.4 Once incontinence is established through questioning, the physician can use follow-up questioning to begin differentiating between stress and urge incontinence. Thorough physical examination is also important to determine the cause and type of incontinence. Dr Thom’s article includes information on abdominal, vaginal, and neurologic examination as well as urinalysis and pad, stress or cough, cotton-swab, postvoid residual, and urodynamic testing.

Dr Donald R. Ostergard shifts the focus to the pathophysiology and treatment of stress urinary incontinence. He provides a review of the pathophysi-ology and neurophysiology of the condition and the different treatment options available. These treatment options include behavioral, surgical, and pharmacologic approaches. Although several types of medications have been used to treat stress urinary incontinence (eg, estrogen, alpha-adrenergic agonists, and tricyclic antidepressants), no drug has yet been approved by the US Food and Drug Administration specifically for this indication. The dual-reuptake inhibitor of serotonin and norepinephrine, duloxetine, is currently under review for use in patients with stress urinary incontinence. Dr Ostergard reviews the data from the phase 2 and phase 3 studies, which show the safety and efficacy of duloxetine for the treatment of stress urinary incontinence.

Also included in this issue are 2 case studies based on interactive presentations given by Dr Thom, illustrating the presentation, evaluation, and treatment of patients with varying types and degrees of incontinence. Abstracts of selected articles provide further information on the impact of incontinence on quality of life and the success of varying treatment options. I hope you find the information included in this issue of Advanced Studies in Medicine valuable to your practice.

REFERENCES
1. Hampel C, Wienhold D, Benken N, Eggersmann C, Thuroff JW. Definition of overactive bladder and epidemiology of urinary incontinence. Urology. 1997;50(suppl 6A):4-14.
2. American Heart Association. Heart Disease and Stroke Statistics—2003 Update. Dallas, Tex: American Heart Association; 2002.
3. National diabetes statistics. National Institute of Diabetes and Digestive and Kidney Diseases Web site. Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/index.ht m#7. Accessed December 1, 2003.
4. Kravitz RL, Bell RA, Azari R, Krupat E, Kelly-Reif S, Thom D. Request fulfillment in office practice antecedents and relationship to outcomes. Med Care. 2002;40(1):38-51.

*Associate Professor, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine; Chair, Department of Obstetrics and Gynecology, Johns Hopkins Bayview Medical Center, Baltimore, Maryland.

Address correspondence to: Geoffrey W. Cundiff, MD, Johns Hopkins University School of Medicine, Department of Ob/Gyn A1C-125, 4940 Eastern Ave, Baltimore, MD 21224. E-mail:
gcundiff@jhmi.edu.  





Johns Hopkins Advanced Studies in Medicine (ISSN-1558-0334), is published by Galen Publishing, LLC, d/b/a ASiM, PO Box 340, Somerville, NJ 08876. (908) 253-9001. Copyright ©2012 by Galen Publishing. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, without first obtaining permission from the publisher. ASiM is a registered trademark of The Healthcare Media Group, LLC.