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Sunday, 24 November 2013

Urinary Incontinence Treatments In conventional medicine

Urinary Incontinence, a medical, psychological, social, economic, and hygienic problem, is defined as a condition of loss of the bladder to control that can lead to mild or severe form of involuntary leakage of urine. Involuntary urine leakage or urinary incontinence is frequent among elderly women, adult women, even among adolescent women.
VI. Treatments In conventional medicine perspective
A.1. Non medical treatment
In the study to investigate of  total of 33 interventional studies found that toileting programs and incontinence pads are the mainstays of treatment, with some studies implying significant economic and labor costs, drug therapy as an adjunct to toileting programs has so far shown only moderate benefits, combined physical therapy/behavioral therapies have shown effective short-term improvements. Adaptations to physical environment and staff training techniques might also be paramount, exercise and Functional Incidental Training programs, although expensive, might provide additional benefit by reducing wetness rates and improving appropriate toileting rates. combined complex behavioral interventions are now a common feature and their effectiveness for the management of urinary incontinence should be determined in future studies(28).
1. Physical therapy
Stress urinary incontinence (SUI) is an involuntary release of urine through the urethra during the increase of abdominal pressure in the absence of m. detrusor contraction, in the study of[Physical therapy in the treatment of stress urinary incontinence], showed that strengthening of pelvic floor muscles by exercises results in a significant increase of pelvic floor muscle strength and reduction of SUI symptoms, regardless of the used exercise program, PNF spiral dynamic technique or Kegel exercise program(29).
2. Behavioral therapies
In the study to to identify correlates of patient satisfaction with drug and behavioral treatments for urge-predominant incontinence, researchers found that clinical trial randomizing 307 women to 10 weeks of tolterodine alone or combined with behavioral training. Satisfaction was measured using the Patient Satisfaction Question (PSQ). Potential correlates included baseline demographics, incontinence characteristics and prior treatments, history and physical parameters, expectations of treatment success, and outcome variables including the Global Perception of Improvement (GPI) and Urogenital Distress Inventory (UDI)(30).
3. Individual biofeedback
Four weeks of both intensive group physical therapy or individual biofeedback training followed by an unsupervised home exercise program for 2 mo are effective therapies for female urinary stress incontinence and result in a significantly reduced nocturnal urinary frequency and improved subjective outcome. Only group physical therapy resulted in reduced daytime urinary frequency. BF therapy resulted in a better subjective outcome and higher contraction pressures of the pelvic floor muscles said Dr. Pages IH and the research team at the University Hospital Charité, Humboldt University(31).
4. EMG relaxation
There is a report of a 27-year-old woman with chronic urinary retention and incontinence since infancy was treated for 8 months with frontal electromyographic relaxation training. Urinary control and sensations of bladder fullness were obtained for the first time in the patient's history. Residual urine readings showed marked improvement(32).
5. Etc.
A.2. Medical treatments
Medication used to treat Urinary Incontinence often are accompanied with therapical treatments and depended on the causes of the diseases
A.2.1. Medication
1. Anticholinergics
 a. Anticholinergics often used to treat overactive bladder of patients with urge incontinence, but in many case it is used  patients with dementia and urge incontinence, this combination would seem to violate basic principles of geriatric pharmacology, as the drugs appear to be working at cross-purposes and anticholinergic medications are notorious for worsening cognitive function in susceptible patients(33)
b. Side effects are not limit to
b.1. Dry mouth and dry warm skin
b.2. Constipation
b.3. Blurred vision
b.4. Flushing
b.5. Increased heart rate
b.6. Headaches
b.7. Confusion
B.8. Etc.
2. Hormone therapies
a. Urge urinary incontinence is more prevalent after the menopause, and the peak prevalence of stress incontinence occurs around the time of the menopause. Many studies, however, indicate that the prevalence of stress incontinence falls after the menopause. Until recently, estrogen, usually as part of a hormone replacement therapy (HRT) regimen, was used for treatment of urinary incontinence in postmenopausal women. Although its use in the treatment of vaginal atrophy is well established, the effect of HRT on urinary continence is controversial. A number of randomized, placebo-controlled trials have examined the effects of estrogen, or estrogen and progestogen together, in postmenopausal continence and concluded that estrogens should not be used for the treatment of urge or stress incontinence(34). Other suggested that Local oestrogen treatment for incontinence may improve or cure it, but there was little evidence from the trials on the period after oestrogen treatment had finished and none about long-term effects. However, systemic hormone replacement therapy, using conjugated equine oestrogen, may make incontinence worse. There were too few data to reliably address other aspects of oestrogen therapy, such as oestrogen type and dose, and no direct evidence on route of administration. The risk of endometrial and breast cancer after long-term use suggests that oestrogen treatment should be for limited periods, especially in those women with an intact uterus(35).
b. Side effects are not limit to 
b.1. Headache 
b.2. Upset stomach
b.3. Diarrhea Appetite
b.4. Changes in sex drive 
b.5. Etc.
3. Antidepressants
3.1. Imipramine 
a. Imipramine is the types of antidepressant used to treat patients with mixed urge and stress incontinence and urinary incontinence associated with spontaneous unstable detrusor contractions. Imipramine was given orally at night to 10 elderly patients with urinary incontinence associated with spontaneous unstable detrusor contractions. The dose was increased for each patient up to a maximum of 150 mg. at night, or until continence was achieved or side effects occurred. Of the 10 patients 6 became continent. In 3 of the 6 patients who underwent repeat cystometry bladder capacity had increased (mean 105 cc), bladder pressure at capacity decreased (mean 18 cm. water) and urethral pressure increased (mean 30 cm. water). There was no correlation between plasma desmethylimipramine and dose, or clinical or urodynamic effect(36).
b. Side effects are not limit to
b.1. The medicine may drug interreaction to certain patients, such as barbiturates, benzodiazepines, etc.
b.2. Agitation and anxiety
b.3. fever
b.4. Convulsion
b.5. Etc.

3.2.. Duloxetine
a. The medication used to treat patient with stress causes of Urinary Incontinence. Dr. Basu M,  and Dr. Duckett JR. at the Medway Maritime Hospital, in the study of Update on duloxetine for the management of stress urinary incontinence, wrote that Duloxetine is a relatively balanced serotonin and noradrenaline reuptake inhibitor (SNRI), which is the first drug with widely proven efficacy to have been licensed for the medical treatment of women with stress urinary incontinence (SUI). Despite favorable results from randomized controlled trials, surgical management continues to be the mainstay of treatment for SUI(37).
b. Side effects are not limit to
b.1. Constipation;
b.2. Decreased sexual desire
b.3. Diarrhea;
b.3. Dizziness and drowsiness
b.4. dry mouth
b.5. Headache
b.6.  Nausea
b.7. Tiredness
b.8. Trouble sleeping
b.9. Etc.
3.3. Etc.
A.4. Medical devices
Certainl medical devices have been used to treat patients with Urinary Incontinence but mostly for women with the diseases.
1. Urethral insert
  Urethral insert is a type of medical device used to protect women against leakage in certain activity, such as certain sport. The device must be removed before urination. In a 5-year ongoing, controlled multicenter study enrolled 150 women. Outcome measures included pad weight tests (PWT), voiding diary (VD), quality of life (QOL) and satisfaction questionnaires with with and without device used, showed that Statistically significant reductions in overall daily incontinence episodes (P<0.001) and PWT urine loss (P<0.001) were observed with the device at all follow-up intervals, and 93% of women had a negative PWT at 12 months. Women were satisfied with ease of use of the device, comfort and dryness, and significant improvements in QOL were observed (P<0.001). Subgroup analysis revealed that the insert was effective, despite the presence of urgency, low LPP, failed surgery and advanced age. AE included symptomatic urinary tract infection in 31.3%, mild trauma with insertion in 6.7%, hematuria in 3.3%, and migration in 1.3% of women. The results of PWT and VD demonstrated device efficacy. Women were satisfied and significant improvements in QOL were observed. AE were transient and required minimal or no treatment. The urethral insert should be considered as an option for the management of SUI. The results of PWT and VD demonstrated device efficacy. Women were satisfied and significant improvements in QOL were observed. AE were transient and required minimal or no treatment. The urethral insert should be considered as an option for the management of SUI(38).
2. Pessary 
a. Pessary is a stiff ring inserted into your vagina and wear all day with female patients with Urinary Incontinence to hold up bladder to prevent leakage. The device present a good option for patients who have not completed childbearing, do not desire surgery, or are poor surgical candidates. Long-term pessary use is a safe and effective option for patients with pelvic organ prolapse (POP) and stress urinary incontinence. Although serious side effects are infrequent, insertion and removal of most pessary types still pose a challenge for many patients. Pessary design should continue to improve, making its use a more attractive option(39).
b. Side effects are limit to
b.1. Vaginal discharge and odor
b.2. Vaginal infection
b.3. Ulceration and erosions
b.4. Bleeding
b.5. Itching and irritation
b.6. Etc.
A.5. Interventional therapies 
Dr, Flanagan L, in the study of Systematic review of care intervention studies for the management of incontinence and promotion of continence in older people in care homes with urinary incontinence as the primary focus (1966-2010), showed that care interventions for the management and promotion of continence, with urinary incontinence as the primary focus, in older care home residents, incontinence is a prevalent and serious problem amongst older people in care homes, with an increasing international focus. MEDLINE and CINAHL searches via OVID (January 1966 to May 2010) were carried out, with studies limited to English language publications only. Included in this search were studies investigating urinary and fecal incontinence in people aged 65 years or older in care homes. Studies on surgical or pharmacological interventions or fecal incontinence alone were excluded. A total of 33 interventional studies were identified. Toileting programs and incontinence pads are the mainstays of treatment, with some studies implying significant economic and labor costs. Drug therapy as an adjunct to toileting programs has so far shown only moderate benefits. Combined physical therapy/behavioral therapies have shown effective short-term improvements. Adaptations to physical environment and staff training techniques might also be paramount. Exercise and Functional Incidental Training programs, although expensive, might provide additional benefit by reducing wetness rates and improving appropriate toileting rates. Combined complex behavioral interventions are now a common feature and their effectiveness for the management of urinary incontinence should be determined in future studies. Studies including long-term effectiveness on maintaining continence with full economic evaluation are also warranted in this population(40). Other direct intervention therapies include
1. Perianal injectable bulking agents 
In the assessment to determine the effectiveness of perianal injection of bulking agents for the treatment of faecal incontinence in adults, showed that Four eligible randomised trials were identified with a total of 176 patients. All trials but one were at an uncertain or high risk of bias. Most trials reported a short term benefit from injections regardless of the material used as outcome measures improved over time. A silicone biomaterial (PTQ), was shown to provide some advantages and was safer in treating faecal incontinence than carbon-coated beads (Durasphere(R)) in the short term. Similarly, there were short term benefits from injections delivered under ultrasound guidance compared with digital guidance. However, PTQ did not demonstrate obvious clinical benefit compared to control injection of normal saline. No long term evidence on outcomes was available and further conclusions were not warranted from the available data(41).
2. Botulinum toxin type A
Botulinum toxin type A is a type of interventional therapy to benefit people with Urinary Incontinence as a result of an overactive bladder.
3. Nerve stimulators
Dr. Findlay JM and Dr. Maxwell-Armstrong C. at the Royal Berkshire Hospital, in the study ofPosterior tibial nerve stimulation and faecal incontinence: a review found that eight studies are discussed in the context of the methodology and underlying neurophysiology of peripheral neuromodulation, as are thus far unanswered questions. The eight studies include a total of 129 patients with faecal incontinence (of variable aetiology), all of whom had failed conservative management. One study was prospective and controlled, six were uncontrolled and one was retrospective and uncontrolled. Five different neuromodulatory protocols were used over six different study periods. Outcome measures varied, but short term primary endpoint success ranged from 30.0% to 83.3%. The limitations to this early evidence, whilst encouraging, are significant, and it remains to be seen whether this novel treatment modality represents the minimally invasive, well-tolerated, cost-effective and flexible panacea hoped for this common and debilitating disease(42).
4. Etc.
A.6. Surgical treatments
Dr. Bergman A and the research team at the University of Southern California Medical Cente, in the study of one hundred seven consecutive patients with clinical and urodynamic findings of genuine stress incontinence not previously treated were prospectively allocated in a randomized manner to one of three surgical procedures: anterior colporrhaphy, revised Pereyra procedure, or Burch retropubic urethropexy, showed that at the 1 year postoperative evaluation Burch procedure stabilized the urethrovesical junction and prevented its descent during straining (evaluated by a postoperative Q-tip test) more effectively than either the Pereyra or anterior colporrhaphy. No procedure resulted in severe postoperative voiding difficulties. The present prospective randomized study demonstrates that in our hands the abdominal retropubic operation for genuine stress incontinence in patients not previously operated on results in a higher cure rate when compared with anterior colporrhaphy or Pereyra procedure(43).
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Sources
(28) http://www.ncbi.nlm.nih.gov/pubmed/12121581 
(29) http://www.ncbi.nlm.nih.gov/pubmed/22069999
(30) http://www.ncbi.nlm.nih.gov/pubmed/20945064
(31) http://www.ncbi.nlm.nih.gov/pubmed/11421517
(32) http://www.ncbi.nlm.nih.gov/pubmed/901858   
(33) http://www.ncbi.nlm.nih.gov/pubmed/15116061
 (34) http://www.ncbi.nlm.nih.gov/pubmed/19259853
(35) http://www.ncbi.nlm.nih.gov/pubmed/19821277  
(36)  http://www.ncbi.nlm.nih.gov/pubmed/7009892
(37 http://www.ncbi.nlm.nih.gov/pubmed/19503763
(38) http://www.ncbi.nlm.nih.gov/pubmed/12054188  
(39) http://www.ncbi.nlm.nih.gov/pubmed/20508777
(40) http://www.ncbi.nlm.nih.gov/pubmed/22672329
(41) http://www.ncbi.nlm.nih.gov/pubmed/20464759 
(42) http://www.ncbi.nlm.nih.gov/pubmed/21069357
(43) http://www.ncbi.nlm.nih.gov/pubmed/2729386