ABSTRACT: Appropriate diagnosis of incontinence and knowledge of available therapies can decrease and, in some cases, relieve symptoms.

CME OBJECTIVE: The reader will appreciate the distinguishing characteristics of stress and urge incontinence and available therapeutic options.

Patricia S. Goode, MD, no conflicts of interest

For the 13 million Americans — 85% of them women — who live with urinary incontinence, the condition often exacts a substantial personal toll and is associated with enormous health-care costs ranging from $15 billion to $26.3 billion, according to a recent article in Urology (2004;63[Suppl 3A]:58-64) authored by geriatrician and UAB Continence Program Medical Director Patricia S. Goode, MD. "Incontinence often damages a patient's self-image, adversely affects social interactions, contributes to depression and other health problems, and is a common cause of nursing home admissions," she writes.

Urinary incontinence is more prevalent than diabetes, hypertension, or depression among female patients in the primary care practice setting. The National Association for Continence (www.nafc.org) estimates 1 in 4 women aged 18 years and older experience episodes of involuntary leakage; 1 in 5 adults aged 40 years and older are affected by overactive bladder or recurrent symptoms of urgency and frequency. Approximately 10% of women in the United States undergo surgery for urinary incontinence or pelvic organ prolapse, and many women bear the cost of pads, medications, and nonsurgical therapies.

Patients with urinary incontinence often delay seeking treatment because of embarrassment, which is unfortunate because both behavioral therapy (individualized muscle strengthening and bladder control training programs, fluid management, self-monitoring with bladder diaries) and pharmacotherapy improve incontinence and quality of life in most patients, Goode says. In fact, according to results of a trial by UAB Continence Program Director and behavioral psychologist Kathryn L. Burgio, PhD, et al (JAMA. 1998;280:1995-2000), behavioral therapy in older women with urge incontinence was more effective than drug therapy, and patients reported a higher level of satisfaction. Overall, 8 weeks of behavioral therapy resulted in an 81% decrease in incontinence episodes, and 30% of women became dry.

Goode points out, however, there are important gaps in knowledge about therapies for urinary incontinence. "For example, predictors of improvement with various treatments and mechanisms by which these treatments improve incontinence remain unclear," she says. "Such information would enhance clinical decision making by helping clinicians select the most appropriate therapy for individual patients. Additionally, insights into therapeutic mechanisms would help define the potential role of combination therapy."

Studies Underway

The UAB Genitourinary Disorders Center currently is conducting four studies to improve treatment of women with stress and/or urge incontinence. In addition to Goode and Burgio, the research team includes urogynecologists R. Edward Varner, MD, and Holly E. Richter, PhD, MD; urologists L. Keith Lloyd, MD, and Lee N. Hammontree, MD; and radiologist Mark E. Lockhart, MD.

• Enhancing Conservative Therapy for Urge Incontinence

Recruiting 159 patients, this randomized trial, funded by Veterans Administration Rehabilitation Research and Development, will determine if drug therapy is more effective if combined with behavioral therapy. To qualify, participants must have urine leakage with an urge to void at least two times per week and have leakage for >3 months. Veterans and nonveterans are invited to participate. Principal investigator (PI): Burgio, kburgio@aging.uab.edu. Contact: Aline M. (Lennie) Ferner, RN, 205.933.8101 (ext. 7304), lennie@uab.edu.

• PRIDE (Program to Reduce Incontinence by Diet and Exercise)

Recruiting 165 patients and sponsored by the National Institutes of Health, this study will look at effects of weight loss in overweight women with urinary incontinence. PRIDE is being conducted at UAB and The Miriam Hospital/Brown University Medical School, Providence, Rhode Island. Women aged 30 years and older who are overweight (body mass index 25 kg/m2-45 kg/m2) and experience episodes of urinary incontinence may be eligible. Those who qualify receive information on controlling urinary incontinence and are randomized to high-intensity or low-intensity weight-loss interventions. Researchers will compare the two groups for improvements in urinary incontinence and extent of weight loss. Enrolled participants attend group sessions and clinic visits for 18 months. PI: Frank A. Franklin, MD, PhD, frankln@uab.edu. Contact: Penny S. Pierce, RN, BSN, 205.934.9943, ppierce@uab.edu.

• BE-DRI (Behavior Enhances Drug Reduction of Incontinence)

Recruiting 300 patients (33 at UAB), this randomized clinical trial will determine if the addition of behavioral treatment increases the number of women with urge incontinence who can discontinue drug therapy and sustain a significant reduction in incontinence. This study is part of the National Institute of Diabetes and Digestive and Kidney Diseases Urinary Incontinence Treatment Network (UITN), a multicenter consortium of investigators at nine continence treatment centers: UAB; University of California-San Diego; University of Maryland in College Park; University of Pittsburgh in Pennsylvania; University of Texas at Dallas; University of Texas at San Antonio; University of Utah in Salt Lake City; Beaumont Hospital, Royal Oak, Michigan; and Loyola University, Chicago, Illinois. The primary goal of UITN is assessing long-term outcomes of the most commonly applied treatments for women with urinary incontinence. PI: Richter, hrichter@uabmc.edu. Contact: Alice A. Howell, BSN, CCRC, 205.975.8592, ahowell@uabmc.edu.

• ATLAS (Ambulatory Therapies for Leakage Associated with Stress)

Recruiting 450 patients (65 at UAB), this randomized trial compares pessary, behavioral treatment, and combined pessary and behavioral treatment for stress incontinence in women. Pessaries are intravaginal devices that provide pelvic floor support to treat pelvic prolapse and stress incontinence. The study is funded by the National Institute of Child Health and Human Development Pelvic Floor Disorders Network, a multicenter cooperative program designed to conduct clinical trials investigating female pelvic floor disorders, including pelvic organ prolapse, urinary incontinence, and fecal incontinence. Clinical centers include UAB; University of Iowa in Iowa City; Johns Hopkins University, Baltimore, Maryland; University of Pittsburgh; University of North Carolina at Chapel Hill; Baylor College of Medicine, Houston, Texas; and Loyola University. Women who participate in this study will complete six to eight visits over 12 months. PI: Richter, hrichter@uabmc.edu. Contact: Velria B. Willis, BSN, CCRC, 205.975.8522, vwillis@uabmc.edu.

UAB Genitourinary Disorders Center

Thorough evaluation, advanced pharmacologic agents, improved surgical techniques, and individualized behavioral therapy are keystones of patient care at the UAB Genitourinary Disorder Center, which opened in 1997. The only one of its kind in the nation, the center is a collaborative endeavor among obstetrics and gynecology, geriatric medicine, urology, and nursing, integrating clinical, research, and academic programs to provide high quality, cost-effective patient care. The center also conducts clinical, basic science, cost-effectiveness, and outcomes research and trains health-care providers in evaluation and management of genitourinary disorders.

"Urinary incontinence is not a part of normal aging; it can occur in women and men at any age," Goode says. "While the majority of patients we see in the clinic are diagnosed with urinary incontinence, we also see patients with urgency and frequency without incontinence, incomplete bladder emptying, nocturnal enuresis (bedwetting), and fecal incontinence.

"The first step to successful treatment is acknowledgment of the problem, followed by appropriate, individualized assessment and diagnosis," she says, underscoring that the center is available for any patient with incontinence, regardless of severity and complexity, and that self-referrals are welcome. "Virtually every person with urinary incontinence can benefit from the array of treatments available today," Goode says.

DIFFERENTIAL DIAGNOSIS OF STRESS AND URGE URINARY INCONTINENCE

	Stress Urinary Incontinence	Urge Urinary Incontinence
Symptoms	Involuntary loss of urine associated with sneezing, coughing, lifting, or exercising	Involuntary leakage accompanied or immediately preceded by urgency
Causes	Insufficient urethral closure	Uncontrolled bladder contractions
Common Diagnostic Indicators	More likely to be stress incontinence: Leaks urine upon sneezing, coughing, lifting, or exercising Positive cough stress test Positive stress pad test	More likely to be urge incontinence: Urine leakage accompanied by urgency or uncontrollable voiding with little or no warning Negative cough stress test Negative stress pad test

For more information
Dr. Patricia Goode
1.800.UAB.MIST
mist@uabmc.edu

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Published in UAB Insight, Summer 2005