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

New Horizons in Stress Urinary Incontinence Treatment

To provide urologists, obstetricians/gynecologists, and urogynecologists with the most recent developments regarding the nonsurgical treatment of stress urinary incontinence (SUI).

This activity is designed for urologists, obstetricians/gynecologists, and urogynecologists. No prerequisites required.

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:

  • Discuss the pathophysiology of SUI.
  • Evaluate the process of SUI diagnosis in the office.
  • Review the role of neurotransmitters and the central nervous system in lower urinary tract function.
  • Evaluate present and future nonsurgical therapies for SUI.

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

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: March 15, 2004. Expiration date: March 15, 2006.

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. Program Directors and Participating Faculty reported the following:


    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 grants and/or research support from Cook Ob/Gyn; and serving as a consultant to Eli Lilly and Company.


    Nicolette S. Horbach, MD, FACOG
    Associate Clinical Professor
    Department of Obstetrics and  Gynecology
    George Washington University Medical Center
    Washington, DC
    Practicing Physician
    Northern Virginia Pelvic Surgery Associates, PC
    Annandale, Virginia
    Dr Horbach reports receiving grants and/or research support from and serving on the advisory board and speakers' bureau for Eli Lilly and Company; and serving on the Board of Trustees for the Berlex Foundation.

    Donald R. Ostergard, MD, FACOG
    Professor of Obstetrics and Gynecology
    University of California, Irvine
    Irvine, California
    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 for and receiving honoraria from Eli Lilly and Company.

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 referenced the following unlabeled/unapproved uses of drugs or devices:

Dr Horbach - Duloxetine, alpha-adrenergic agonists, estrogen, tricyclic antidepressants
Dr Cundiff - Duloxetine

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.

New Horizons in Stress Urinary Incontinence Treatment
Geoffrey W. Cundiff, MD*

Stress urinary incontinence (SUI) remains a widely prevalent condition that exacts a substantial personal, social, and economic toll on affected individuals. Primarily a condition that affects social functioning, SUI often goes undiagnosed and untreated. Because of embarrassment, many patients are reluctant to broach the subject with healthcare providers. Physicians might neglect to inquire about SUI during routine checkups and history taking. Physicians and patients alike might erroneously dismiss SUI as an unavoidable consequence of childbearing or aging.

Recognizing that SUI is a common condition and exploring the condition are the first steps toward development of a strategy to achieve a cure or minimize the impact of SUI on a woman's life. Patients differ greatly with respect to the degree of bother that SUI causes and their tolerance for the urine leakage that results from the condition. For example, the needs of physically active women who experience urine leakage during exercise or other activities might be quite different from those of women who lead relatively sedentary lifestyles. Similarly, urine leakage during sexual intercourse poses a great problem for some women but not others. Determining the degree to which SUI interferes with an individual patient's life will influence consideration of different treatment options and strategies.

Most patients should be offered conservative (nonsurgical) therapy as the initial approach to SUI management. Conservative therapy comprises a variety of individual treatments and combinations; however, any strategy should start with behavior modification. A simple assessment of the patient's typical pattern of consuming liquids and the associated voiding pattern often can suggest behavior modification strategies that help reduce urine leakage. Weight loss, cough control (including smoking cessation), and other interventions that help reduce intra-abdominal pressure can also help manage SUI and associated urine leakage.

Among conservative treatment options, the most conservative approach is pelvic floor muscle training (Kegel exercises) used alone. The exercises rarely provide a cure for SUI but can achieve a level of improvement that some patients find acceptable. Moreover, Kegel exercises can be used effectively in combination with virtually any other nonsurgical treatment option for SUI. Other nonsurgical options include pessaries and other obstructive or occlusive devices, biofeedback training, and electrical stimulation. A thorough patient evaluation and discussion of the various options can guide the selection of treatments that best meet the personal needs and lifestyle requirements of an individual patient.

Notable by its absence among current nonsurgical treatment options for SUI is medical therapy. No US Food and Drug Administration (FDA) approved medication for SUI currently exists, although several types of drugs have been used for years. In general, medical therapy for SUI has been marked by lack of efficacy and clinical trial data and, in some cases, by side effects that many patients find intolerable.

Recent advances in the understanding of the neuroanatomy and neurophysiology of normal micturition and the pathophysiology of SUI have suggested new therapeutic strategies, particularly new approaches to medical therapy. Micturition has proven to be a complex process that involves multiple neural pathways and neurotransmitters; however, the complexity of the system affords new opportunities for intervention. An example of the ongoing investigation of potential new therapies for SUI is duloxetine, which could become the first FDA-approved medication for treatment of the condition. A dual-reuptake inhibitor of serotonin and norepinephrine, duloxetine has demonstrated statistically significant efficacy for reducing episodes of SUI in placebo-controlled clinical trials.

This issue of Advanced Studies in Medicine reflects the current status of investigation and clinical management related to SUI. The material reviews the advances in understanding the origin of SUI, current approaches to nonsurgical treatment of SUI, and emerging options for management of the condition. The information includes presentations by recognized authorities in the field and data from new clinical studies. Physicians who care for patients with SUI will find the material readily applicable to clinical practice, regardless of the practice environment.

*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 Avenue, Baltimore, MD 21224. E-mail:

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