Advances toward tissue engineering for the treatment of stress urinary incontinence

Suburethral pubovaginal sling placement is a common surgical procedure for the treatment of stress urinary incontinence. A wide variety of graft materials is available, each associated with inherent desirable and undesirable characteristics and complications. In this article, we discuss the rationale for and application of small intestinal submucosa (SIS) in lower urinary tract tissue engineering, with emphasis on the use of SIS as a suitable and biologically compatible sling material. In addition, we discuss exciting research regarding the engineering of true functional sphincter reconstruction using this biologic scaffold and pre-seeded muscle cells.     

Pads and pants for urinary incontinence.

Fifty-one female patients, incontinent of urine, were asked to compared two different combinations of pants and pads used in the ambulatory management of their incontinence. They were offered the Kanga pant with a Kanga pad and the Sandra pant with a Bambi pad. Each patient tried both pants and pads and thus comparisons could be made on a within-patient basis. Both systems kept a similar proportion of patients dry during the day and night. In terms of comfort, however, the Kanga pant was quite clearly preferred to the Sandra. The Bambi pad was rated more highly than the Kanga pad, although the difference between the two pads was not so pronounced as that between pants.     

Prevalence of urinary incontinence.

The prevalence of urinary incontinence was investigated by determining the number of incontinent patients under the care of various health and social service agencies in two London boroughs and by a postal survey of the 22 430 people aged 5 years and over on the practice lists of 12 general practitioners in different parts of the country. The prevalence of incontinence known to the health and social service agencies was 0.2% in women and 0.1% in men aged 15-64 and 2.5% in women and 1.3% in men aged 65 and over. The postal survey, to which 89% of the people whose correct address was known replied, showed a prevalence of urinary incontinence of 8.5% in women and 1.6% in men aged 15-64 and 11.6% in women and 6.9% in men aged 65 and over. Nulliparous women had a lower prevalence than those who had had one, two, or three babies, but within the parity range of one to three there were no differences in prevalence. The prevalence was appreciably increased in women who had had four or more babies. Incontinence was moderate or severe in a fifth of those who reported it in the postal survey, of whom less than a third were receiving health or social services for the condition. Incontinence is a common symptom, and many unrecognised cases appear to exist. There may be considerable scope for improving its management.     

Pharmacotherapy for stress urinary incontinence

The purpose of this review article is to highlight new pharmacotherapies on the horizon for the treatment of stress urinary incontinence. Although behavioral and surgical therapies are currently the mainstay of treatment for this condition, we are hopeful that pharmacotherapy will one day take center stage of the various treatment options. Currently, there are no medications approved by the US Food and Drug Administration for the treatment of stress urinary incontinence. However, exciting clinical data are becoming available about an oral medication for the treatment of stress urinary incontinence that appears to be clinically safe and efficacious. In addition to discussing medications currently under development, this article also discusses pharmacologic targets that could be suitable future targets to treat stress urinary incontinence.     

Algorithmic method for assessing urinary incontinence in elderly women.

In young patients the assessment of urinary incontinence is based increasingly on the results of complex urodynamic investigations. The value of such techniques in the elderly, however, is as yet unproved. Based on the clinical and urodynamic findings in 100 incontinent elderly women an algorithmic method for managing such patients was devised. A retrospective study comparing the algorithmic outcome with the results of standard urodynamic assessment showed that 60% of invasive investigations could be avoided by this method with minimal loss of diagnostic accuracy.     

Advances in the understanding of sress urinary incontinence and the promise of stem-cell therapy

The middle urethra and external urethral sphincter are the focus in management of stress urinary incontinence, and recent cellular-therapy research suggests a new paradigm in treatment. Cell-based therapies are most often described as using autologous multipotent stem cells procured from bone marrow in procedures that may be painful, require anesthesia, and yield low numbers of mesenchymal stem cells upon processing. In contrast, muscleand adipose-derived stem cells can be obtained easily in large quantities under local anesthesia. Instead of lifting the urethra with a sling or bulking up the urethral sphincter with collagen, we now have the potential to restore function with the use of autologous stem cells.     

Treatment options for stress urinary incontinence

Treatment options for stress urinary incontinence (SUI) in women are designed to prevent the involuntary loss of urine from the urethra during increases in intraabdominal pressure that occur during physical activity, coughing, or sneezing. Effective nonsurgical therapies include behavioral therapy (eg, bladder training, fluid and dietary modification) and drug therapy. Surgical therapy for this condition has existed for well over 100 years. Currently, approximately 200 different surgical procedures have been described. Because of the physiologic risks inherent in surgical procedures, the cost of hospitalization, and the loss of productivity during convalescence, surgeons continue to modify their techniques to improve efficacy, safety, and cost-effectiveness, and to minimize invasiveness. No single procedure or intervention is optimal for all patients. Having a variety of treatment options offers the possibility of tailoring therapy to the desires and needs of the individual patient. The key to an optimal therapeutic outcome is an accurate diagnosis combined with the selection of an appropriate intervention that is acceptable to the patient after balancing multiple factors.     

Behavioural treatment of urinary incontinence in geriatric patients.

Urinary incontinence and a program to treat it were studied in a geriatric hospital. Of 161 men, 58 (36%) were incontinent. The most common probable causes were cerebrovascular accident and organic brain syndrome. Evaluation by cystometry (after treatment of infections) in 30 patients showed 24 (80%) to have detrusor hyperreflexia. Twenty patients with hyperreflexia completed a timed-voiding routine, which benefited 17 of them (85%).     

Evaluating the effectiveness of therapies for urinary incontinence

Subjective criteria, behavioral/emotional factors, and quality-of-life assessments are necessary components in evaluating incontinence therapies. Behavioral regimens often yield a response that lasts beyond the end of therapy and, when combined with pharmacologic therapy, are likely to extend duration of response. In addition to objective efficacy criteria, a number of instruments evaluate quality-of-life issues. Shortened forms of these will likely overcome limitations on patient compliance and completion. New instruments continue to be developed, but until one or more are universally accepted, variations in reported outcomes can be expected.     

The prevalence of urinary incontinence

Urinary incontinence is a significant health problem with considerable social and economic impact. It is important to distinguish between prevalence and incidence with regard to incontinence, and prevalence-the probability of having incontinence within a defined population at a defined point in time-is the more important when considering its impact and the utilization of healthcare resources. There are large variations in the severity and impact of incontinence, and its severity, frequency, and predictability all need to be considered when evaluating its effects on patients, The degree of bother is particularly significant when determining who will need treatment. Incontinence may be a result of bladder dysfunction, sphincter dysfunction, or a combination of both, but large-scale studies are not designed to determine the etiology. In young women, the prevalence of incontinence is usually low, but prevalence peaks around menopause, with a steady rise there-after into later life. Although the prevalence of stress and mixed (stress and urge) incontinence is higher than urge incontinence, the latter is more likely to require treatment. In women, moderate and severe bother have a prevalence ranging from about 3% to 17%. Severe incontinence has a low prevalence in young women, but rapidly increases at ages 70 through 80. In men, the prevalence of incontinence is much lower than in women, about 3% to 11% overall, with urge incontinence accounting for 40% to 80% of all male patients. Stress incontinence accounts for less than 10% of cases and is attributable to prostate surgery, trauma, or neurological injury. Incontinence in men also increases with age, but severe incontinence in 70- to 80-year-old men is about half of that in women. The most effective therapy for incontinence will rely on targeting the correct populations to be treated, which depends on how data is collected on prevalence and severity.     

Neurophysiology of stress urinary incontinence

Stress urinary incontinence (SUI) involves involuntary leakage of urine in response to abdominal pressure caused by activities such as sneezing and coughing. The condition affects millions of women worldwide, causing physical discomfort as well as social distress and even social isolation. Until recently, SUI was approached by clinicians as a purely anatomic problem requiring behavioral or surgical therapy. Over the past several years, extensive basic and clinical research in the field of neurourology has enhanced our understanding of the complex neural circuitry regulating normal function of the lower urinary tract. As a result, novel concepts have emerged regarding possible neurologic dysfunctions that might underlie the development of SUI, as well as potential novel strategies for pharmacologic therapy. This article reviews the normal neurophysiologic control of lower urinary tract function and considers potential pharmacologic approaches to correcting SUI.