Practice Guidelines
ACOG Guidelines on Urinary Incontinence in Women
The American College of Obstetricians and Gynecologists (ACOG) has released recommendations on the diagnosis and treatment of urinary incontinence in women. ACOG Practice Bulletin No. 63 was published in the June 2005 issue of Obstetrics and Gynecology.
Urinary incontinence affects up to 70 percent of community-dwelling women and up to 50 percent of nursing home residents. Prevalence increases gradually during young adulthood, peaks broadly around middle age, then steadily increases in the elderly. In up to 75 percent of ambulatory women with incontinence, urodynamic stress incontinence is the main condition. Most women with incontinence do not seek medical help.
Common causes of urinary incontinence include urinary tract infections; urethritis; atrophic urethritis or vaginitis; pregnancy; increased urine production from hyperglycemia, hypercalcemia, excess fluid intake, or volume overload; delirium; restricted mobility; stool impaction; and psychologic causes. The differential diagnosis includes filling and storage disorders; fistulas; congenital conditions such as ectopic ureters and epispadias; and neurologic, cognitive, psychologic, physical, pharmacologic, and metabolic conditions. Some conditions that cause or contribute to urinary incontinence are potentially reversible.
Diagnosis
The loss of small amounts of urine in spurts during coughing and in the absence of urge strongly suggests a diagnosis of urodynamic stress incontinence. Prolonged loss of urine (i.e., leaking five to 10 seconds after coughing) or no urine loss with provocation may indicate other causes of incontinence, especially detrusor overactivity. The inability to demonstrate the sign of stress incontinence during simple bladder filling and cough stress testing correlates with the absence of urodynamic stress incontinence. However, interpretation of these tests can be difficult. To maximize diagnostic accuracy, tests in patients with borderline or negative results should be repeated.
Even under the most typical clinical situations, the diagnosis of incontinence based only on clinical evaluation may be uncertain. This uncertainty may be acceptable if medical or behavioral treatment, as opposed to surgery, is planned because of the low rate of morbidity and cost of these treatments and because the ramifications of continued incontinence are not severe. When surgical treatment of stress incontinence is planned, urodynamic testing often is recommended to confirm the diagnosis unless the patient has an uncomplicated history and compatible physical findings of stress incontinence and has not had previous surgery for incontinence.
Cystometric testing is indicated as part of the evaluation of more complex disorders of bladder filling and voiding, such as the presence of neurologic disease and other comorbid conditions, but there are only limited data suggesting its need in the routine evaluation of women with urinary incontinence. Multichannel or subtracted cystometry allows more precise measurements of detrusor pressures with filling and voiding, although both false-negative and false-positive results routinely are found with cystometry. No studies have determined whether the addition of multichannel cystometry or video assessment over simple filling cystometry improves diagnostic accuracy or outcomes after treatment. Other complex urodynamic tests, such as pressure-flow voiding studies, uroflometry, and electromyography of the urethral sphincter, are available for the assessment of complex and neurogenic causes of urinary incontinence and voiding disorders.
Cystoscopy is indicated for the evaluation of patients with incontinence who also have hematuria or pyuria; irritative voiding symptoms such as frequency, urgency, and urge incontinence in the absence of reversible causes; bladder pain; recurrent cystitis; suburethral mass; and when urodynamic testing fails to duplicate symptoms of urinary incontinence. Bladder lesions are found in less than 2 percent of patients with incontinence; therefore, cystoscopy should not be performed routinely in patients with incontinence to exclude neoplasm.
Urethral pressure profilometry is not standardized, reproducible, or able to contribute to the differential diagnosis in women with stress incontinence symptoms, and therefore does not meet the criteria for a useful diagnostic test. Leak point pressure measures the amount of increase in intra-abdominal pressure that causes stress incontinence, although its usefulness also has not been proved.
Treatment
A substantial percentage of women who are thought to have detrusor overactivity can be expected to respond to appropriate medical or behavioral therapy. Even women with mixed disorders (i.e., coexistent stress and urge incontinence) respond to various forms of conservative therapy.
pessaries
Pessaries and other mechanical devices modified to selectively support the bladder neck may be effective for treating some patients with urinary incontinence, but there is no objective evidence of their effectiveness. Replacement of the prolapsed anterior vaginal wall with a pessary may unmask incontinence by straightening out the urethrovesical kinking that may have been responsible for continence or some degree of urinary retention.
behavioral therapy
Behavioral therapy improves symptoms of urge and mixed incontinence and is recommended as a noninvasive treatment in many women. Behavioral therapy that includes group and individual instruction, individualized scheduled voiding, diary keeping, and instructions on pelvic muscle exercises may reduce the mean number of incontinence episodes by as much as 50 percent. Data show that behavioral training with biofeedback results in a 63 percent mean reduction in incontinence episodes, compared with a 69 percent mean reduction following verbal feedback and a 59 percent mean reduction after receiving a self-help booklet. For patients with stress incontinence, behavioral training reduced the mean number of incontinence episodes by 69 percent.
Combining drug and behavioral therapy in a stepped program can produce added benefit for patients with urge incontinence. However, there is not enough evidence to show whether drug therapy is better than bladder training or as useful as a supplement.
Obesity may be an independent risk factor for the development of incontinence, with obese women having a 4.2-fold greater risk of stress urinary incontinence than women with normal body mass indices. However, few published studies have addressed the effects of weight loss on incontinence, and those that have addressed this issue only examined the effects of massive weight loss in morbidly obese women.
Pelvic floor training appears to be an effective treatment in adult women with stress and mixed incontinence, and pelvic muscle exercises appear to be better than no treatment or placebo. Pelvic floor exercise reduces incontinence and increases vaginal pressure measurements, but direct correlations between these changes are weak. Pelvic muscle exercise appears to be superior to electric stimulation and vaginal cones in the treatment of stress incontinence. Generally, the effect of adding pelvic muscle training to other treatments for stress incontinence and the effects of pelvic muscle exercise on urge incontinence alone remain unclear.
pharmacotherapy
Combined hormone therapy and unopposed estrogen therapy have been found to increase the incidence of urinary incontinence in women without symptoms at baseline. In initially symptomatic women, urinary frequency increased with both treatments. Smaller studies examining the use of oral estrogen preparations in the treatment of stress or urge incontinence found that the use of estrogen did not reduce incontinence. Therefore, oral estrogen therapy is not recommended for treatment or prevention of any type of urinary incontinence.
The anticholinergic drugs oxybutynin chloride (Ditropan) and tolterodine (Detrol) may have a small beneficial effect in women with urge incontinence. However, the observed differences between treatment with anticholinergics and placebo may be of questionable clinical significance. The most typical side effect of anticholinergics is dry mouth; other side effects include blurred vision, constipation, nausea, dizziness, and headache.
In women with extensive comorbidity that precludes surgery or anesthesia, injection of bulking agents may be a useful option for relief of symptoms for up to 12 months. Multiple injections may be required to achieve a satisfactory result.
surgery
Surgery is indicated for the treatment of stress incontinence when conservative treatments have failed to relieve symptoms satisfactorily and when the patient wishes further treatment in an effort to achieve continence. Although retaining fertility potential is not a contraindication, surgery is a better option if the patient does not wish to have more children.
Not all patients with urinary incontinence need urodynamic testing before surgery. These patients include nonpregnant women who lose urine only with physical exertion and those who have normal voiding habits (i.e., fewer than eight voiding episodes per day and fewer than two per night); no associated neurologic or physical findings; no history of anti-incontinence or radical pelvic surgery; a hypermobile urethra, pliable vaginal wall, and adequate vaginal capacity on physical examination; and a normal postvoid residual volume.
Retropubic colposuspension procedures are indicated for women with urodynamic stress incontinence and a hypermobile proximal urethra and bladder neck. Selection of a retropubic approach (versus a sling) depends on factors such as the need for laparotomy for other pelvic disease, the amount of pelvic organ prolapse, the age and health status of the patient, and whether a vaginal or abdominal procedure will be used to suspend the vagina. Retropubic procedures can be used for intrinsic sphincter deficiency with urethral hypermobility, but sling operations may yield better long-term results. Hysterectomy adds little to the efficacy of Burch colposuspension in curing stress incontinence and should be performed only in patients with specific uterine pathology or uterine prolapse.
One consensus panel review indicated that after 48 months, retropubic suspensions and sling procedures may be more effective than transvaginal needle suspension procedures or anterior colporrhaphy. Retropubic suspensions and sling procedures are associated with slightly higher complication rates, including longer convalescence and postoperative voiding dysfunction.
Long-term data suggest that Burch colposuspension and sling procedures have similar objective cure rates; therefore, treatment selection should be based on patient characteristics and physician experience. Tension-free vaginal tape and open Burch colposuspension have similar success rates.
Practice Guideline Briefs
ACOG Guidelines on the Management of Human Papillomavirus Infection
The American College of Obstetricians and Gynecologists (ACOG) has released guidelines on the clinical management of women with human papillomavirus (HPV) infection. ACOG Practice Bulletin No. 61 was published in the April 2005 issue of Obstetrics and Gynecology.
HPV infection can be diagnosed clinically (genital warts), cytologically (Papanicolaou smear), or virologically (DNA testing). The more severe abnormalities attributed to HPV infection correspond to the traditional classification of precursor lesions of invasive cervical cancer: mild, moderate, or severe cervical intraepithelial neoplasia (CIN, which includes low-grade and high-grade squamous intraepithelial lesions [LSIL and HSIL, respectively]). Each year in the United States, up to 3 million women are diagnosed with atypical squamous cells of undetermined significance (ASCUS) and more than 1 million women are diagnosed with LSIL. Results of a 2001 study by the National Cancer Institute showed that 83 percent of women with LSIL tested positive for high-risk HPV DNA. Most cervical HPV infections diagnosed by polymerase chain reaction and other nucleic acid detection methods seem to be transient. However, older patient age and high-risk HPV types are associated with infections of longer duration.
Treatment for genital warts should be guided by patient preference and physician experience. Because of a similar risk of recurrence, no single treatment for external genital warts can be recommended over other treatments. Visible genital warts often resolve spontaneously. Warts that are small in size and few in number will respond to almost any treatment or to no treatment at all. Warts on moist or mucosal surfaces generally are more responsive to topical treatments compared with warts on dry surfaces. Warts that do not respond to a particular treatment after three physician-administered treatments, and warts that are not cleared completely after six treatments, should be re-evaluated. Pregnant women should not use patient-applied topical treatments.
Although evidence that condoms offer complete protection from HPV infection is lacking, condom use may reduce the risk of HPV-related disease such as genital warts and cervical neoplasia. Condom use may be effective in the clearance of HPV and HPV-related lesions.
A combination of cervical cytology and HPV DNA testing is appropriate in women 30 years and older. If this combination is used, women with negative results on both tests should be rescreened no more than every three years. Women older than 30 years with negative cytology who test positive for high-risk HPV DNA should repeat both tests in six to 12 months. Patients with persistent high-risk HPV should undergo colposcopy regardless of the cytology result.
Studies using combined HPV DNA testing and cervical cytology have a 99 to 100 percent negative predictive value for CIN grades 2 and 3; women with negative concurrent test results can be reassured that their risk of unidentified CIN grades 2 and 3, and of cervical cancer, is approximately only one in 1,000. HPV DNA testing is not recommended in women with LSIL, atypical squamous cells that cannot exclude HSIL, or atypical glandular cells. Women with high-risk HPV types who have ASCUS or LSIL, but who are not found to have CIN grade 2 or 3 at their initial colposcopy, have an approximately 10 percent risk of developing CIN grade 2 or 3 within two years.
HPV DNA testing could be used as a test of cure in women with CIN grade 2 or 3 at six to 12 months after excision or ablation of the transformation zone. Women with high-risk HPV should be referred for colposcopy.
Which Patients Benefit from CRT?
The American Heart Association has published a science advisory on selecting patients for cardiac resynchronization therapy (CRT). The advisory, "Patient Selection for Cardiac Resynchronization Therapy," appears in the April 26, 2005 issue of Circulation.
CRT is a somewhat new therapy that can be added to the treatment regimen of patients with symptomatic heart failure caused by systolic dysfunction. CRT is accomplished by simultaneously pacing the left and right ventricles, which resynchronizes the timing of global left ventricular depolarization and consequently improves mechanical contractility and mitral regurgitation.
CRT has been shown in trials to improve functional status and quality of life for patients with symptomatic heart failure. It also has been shown to significantly reduce the combined endpoint of all-cause mortality and hospitalization.
The best candidates for CRT are patients with dilated cardiomyopathy on an ischemic or nonischemic basis, a left ventricular ejection fraction of 0.35 or less, a QRS complex of more than 120 milliseconds, sinus rhythm, and New York Heart Association (NYHA) functional class III or IV symptoms despite maximal medical therapy for heart failure.
The use of CRT for patients with minimal heart failure has not been studied widely and is not recommended at this time. Most patients in the CRT trials had a wide QRS complex on the basis of a left bundle branch block. The benefit for patients with a left versus a right bundle branch block is unclear; however, the current recommendation for CRT is based on QRS duration, not QRS morphology. Other unresolved issues regarding CRT include the risks and benefits of left ventricular pacing without a right ventricular lead, the risks and benefits of surgical placement of a left ventricular pacing lead versus a nonthoracotomy approach, and the use of CRT for patients with NYHA class IV symptoms who are nonambulatory and dependent on intravenous inotropes for hemodynamic support.
The risks associated with implanting a CRT device are small and similar to those associated with the transvenous implantation of a conventional permanent pacemaker or implantable defibrillator. These risks include bleeding, infection, hematoma, pneumothorax, pericardial effusion, myocardial infarction, stroke, and death.
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