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CLINICAL GYNECOLOGIC SERIES: AN EXPERT'S VIEW |
From the *University of Iowa Carver College of Medicine, Iowa City, Iowa; and Urogynecology Specialists of Kentucky, PLLC, Elizabethtown, Kentucky.
Address reprint requests to: Ingrid E. Nygaard, MD, University of Iowa, Department of Obstetrics and Gynecology, 200 Hawkins Drive, 2 BT, Iowa City, IA 52242; e-mail: ingrid-nygaard{at}uiowa.edu.
We have invited select authorities to present background information on challenging clinical problems and practical information on diagnosis and treatment for use by practitioners.
Stress urinary incontinence, the complaint of involuntary leakage during effort or exertion, occurs at least weekly in one third of adult women. The basic evaluation of women with stress urinary incontinence includes a history, physical examination, cough stress test, voiding diary, postvoid residual urine volume, and urinalysis. Formal urodynamics testing may help guide clinical care, but whether urodynamics improves or predicts the outcome of incontinence treatment is not yet clear. The distinction between urodynamic stress incontinence associated with hypermobility and urodynamic stress incontinence associated with intrinsic sphincter deficiency should be viewed as a continuum, rather than a dichotomy, of urethral function. Initial treatment should include behavioral changes and pelvic floor muscle training. Estrogen is not indicated to treat stress urinary incontinence. Bladder training, vaginal devices, and urethral inserts also may reduce stress incontinence. Bulking agents reduce leakage, but effectiveness generally decreases after 1–2 years. Surgical procedures are more likely to cure stress urinary incontinence than nonsurgical procedures but are associated with more adverse events. Based on available evidence at this time, colposuspension (such as Burch) and pubovaginal sling (including the newer midurethral synthetic slings) are the most effective surgical treatments.
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