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


Stress Urinary Incontinence in the Female Population: New Approaches for Evaluation and Treatment


GOAL
To provide physicians with current information and new developments in the treatment of stress urinary incontinence in women.

TARGET AUDIENCE
This activity is designed for urologists and obstetricians/gynecologists.

LEARNING OBJECTIVES
After reading this issue, the participant should be able to:

  • Cite recent epidemiologic data on urinary incontinence.
  • Identify alternative management options for poor surgical candidates and for those who have failed initial therapy.
  • Discuss the role of the central nervous system and neurotransmitters in lower urinary tract control.
  • Identify pitfalls in the diagnostic workup of urinary incontinence.
  • Cite current and future potential applications for neurourology in clinical practice.
  • Identify individualized therapies made possible by new therapeutic options.

ACCREDITATION STATEMENT
This activity has been planned and produced in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education. The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to sponsor continuing medical education for physicians. The Johns Hopkins University School of Medicine takes responsibility for the content, quality, and scientific integrity of this CME activity.

CREDIT DESIGNATION STATEMENT
The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 1 hour in Category 1 credit toward the American Medical Association's Physicians' Recognition Award. Each physician should claim only those hours of credit that he/she actually spends on this educational activity. Credits are available until the expiration date of October 31, 2004.

This continuing medical education activity was produced under the supervision of Jacek L. Mostwin, MD, DPhil, Associate Professor, Department of Urology, and Director, Outpatient Urology, The Johns Hopkins University Hospital, Baltimore, Maryland.

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

Publisher's Note and Disclaimer: The opinions expressed in this issue are those of the authors, presenters, and/or panelists and are not attributable to the publisher, editor, advisory board of Advanced Studies in Medicine, or The Johns Hopkins University School of Medicine or its Office of Continuing Medical Education. Clinical judgment must guide each professional in weighing the benefits of treatment against the risk of toxicity. Dosages, indications, and methods of use for products referred to in this issue are not necessarily the same as indicated in the package insert for the product and may reflect the clinical experience of the authors, presenters, and/or panelists or may be derived from the professional literature or other clinical sources. Consult complete prescribing information before administering.

Advanced Studies in Medicine (ISSN-1530-3004) is published by Galen Publishing, LLC, an HMG Company. P.O. Box 340, Somerville, NJ 08876. (908) 253-9001. Web site: www.galenpublishing.com. Copyright ©2001 by Galen Publishing, LLC. 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. Bulk postage paid at Somerville, NJ Post Office and at additional mailing offices. Advanced Studies in Medicine is a registered trademark of The Healthcare Media Group, LLC. Printed on acid-free paper. BPA Membership applied for December 2000.

The contents of this issue of Advanced Studies in Medicine include articles based on presentations given at the Annual Meeting of the American Urological Association held in Orlando, Florida, May 24-28, 2002. A clinician interview and abstracts from related presentations are also included.

FACULTY ADVISOR

    Jacek L. Mostwin, MD, DPhil
    Professor
    Department of Urology
    Director, Reconstructive Neurologic Urology
    The Johns Hopkins University Hospital
    Baltimore, Maryland
    • Dr Mostwin reports receiving honoraria from Eli Lilly and Company.

PARTICIPATING FACULTY

    Karl J. Kreder, Jr, MD
    Professor and Clinical Vice Chair
    Director, Urodynamics and Reconstructive Urology
    Professor of Surgery
    Department of Urology
    University of Iowa College of Medicine
    • Dr Kreder reports receiving grants and/or research support from, serving as a consultant to, and receiving honoraria from Pharmacia Corporation and Eli Lilly and Company; and serving as a consultant to, holding stock in, and receiving honoraria from Merck and Co, Inc.

    Edward J. McGuire, MD
    Professor of Surgery
    Department of Urology
    University of Michigan
    Ann Arbor, Michigan
    • Dr McGuire reports serving as a consultant to Carbon Medical Technologies, Inc, and receiving honoraria from Eli Lilly and Company.

    Karl B. Thor, PhD
    Director, Laboratory of Neurourology
    Duke University
    Chief Scientific Officer
    PPD GenuPro
    Durham, North Carolina
    • Dr Thor reports serving as a consultant to, holding stock in, and receiving honoraria from Eli Lilly and Company.

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.

Off Label Product Discussion
Dr Thor discusses use of duloxetine in animal studies for treatment of incontinence; Dr McGuire discusses use of alpha receptor agonists, estrogen, and antidepressants, including imipramine and duloxetine, for treatment of incontinence.

Stress Urinary Incontinence in the Female Population: New Approaches for Evaluation and Treatment
Jacek L. Mostwin, MD, DPhil*

Urinary incontinence represents a major health problem, particularly among women. Almost one third of women are affected by problematic involuntary urine loss during their lifetime. Urinary incontinence affects more women than do many other well-known chronic conditions, including hypertension, depression, and diabetes. Urinary incontinence also is a growing problem in men, primarily because of the number of men with incontinence secondary to radical prostatectomy.

This issue of Advanced Studies in Medicine summarizes some of the latest findings and clinical opinions related to the diagnosis, evaluation, and management of urinary incontinence, with special emphasis on stress incontinence. By far, stress incontinence is the most common form of urinary incontinence among women, who constitute a large majority of the total population of patients affected by incontinence.

Over the years, several definitions for incontinence have been developed. Recently, the focus has shifted to 3 key concepts that capture the essence of urinary incontinence and its impact on patients: involuntary loss of urine, demonstrable leakage, and social or hygienic problems as a result of incontinence.

Stress incontinence, defined as urine leakage with physical exertion, is associated with a host of predisposing, inciting, promoting, and decompensating factors. Age, race, sex, childbirth, obesity, dementia, and debility are among the common contributors to the development and evolution of stress urinary incontinence. Childbirth has an especially pronounced impact; an estimated 30% of women develop stress incontinence within 5 years of a first vaginal delivery.

Urinary incontinence can pose a diagnostic challenge to the clinician, who must decide how to perform an adequate evaluation in the face of often conflicting information that arises from the history, physical examination, and other sources. Stress incontinence can be particularly vexing, because symptoms have a low predictive value for genuine stress incontinence. At a minimum, evaluation of a patient for incontinence should comprise a thorough medical history, physical examination, urinalysis, and postvoid residual volume.

Recent investigations in neurourology have provided new insights into the control of urinary function and have pointed to potential new directions in treatment. Studies have suggested that increasing neural activity in the striated urethral sphincter, or rhabdosphincter, may improve stress urinary incontinence symptoms. The rhabdosphincter is innervated by axons that originate from motor neurons in a region of the sacral spinal cord known as Onuf's nucleus.

Sphincter motor neurons have a unique neuroanatomy and neuropharmacology. The neurons have a uniform size and unique dendritic bundles that serve as conduits for impulses. These motor neurons have high concentrations of various neurotransmitters and receptors. Notably, bladder filling appears to be facilitated and mediated by serotonin and alpha-adrenergic receptors, but these effects can be overcome during bladder contraction associated with micturition. Such observations hold promise for development of pharmacologic therapies that can increase sphincter activity during urine storage without increasing residual volume.

Neurourologic investigations have produced some peculiar findings that have direct applicability to diagnosis and management of stress urinary incontinence. Conventional wisdom holds that continence depends on the proper function of the reflex and volitional skeletal muscle sphincter, a view that is supported by evidence that loss of pelvic floor muscle activity or muscle weakness can lead to stress incontinence. However, certain neural conditions can result in total loss of internal sphincter function with preservation of pelvic floor muscular activity, including full reflex and volitional contractility of the external sphincter.

Currently, no medication has been approved by the US Food and Drug Administration for the treatment of stress urinary incontinence. Pharmacologic agents that affect function in the volitional skeletal sphincter may improve urethral function after loss of the internal sphincter. Neurourology appears to offer a promising path of basic and clinical investigation for development of new insights and new therapies for treatment of stress urinary incontinence and possibly other forms of urinary incontinence.

*Professor, Department of Urology, and Director, Reconstructive Neurologic Urology, The Johns Hopkins University Hospital, Baltimore, Maryland.





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.