Urinary Incontinence Naturopathic Treatment
Up to 41 of patients with urogynecologic pelvic floor disorders also have fecal incontinence therefore, Kelvin et al4 and others have recommended a complete pelvic floor evaluation prior to extensive operative intervention. Alternatively, repair of an anterior enterocele or rec-tocele may uncover previously occult urinary incontinence. Clearly, a careful history and thorough evaluation are necessary prior to planning an intervention for patients at risk for both urog-ynecologic and anorectal disorders (generally postmenopausal multiparous women).
Interestingly, the impetus for studying duloxetine was for discovering a treatment of urinary urge incontinence and overactive bladder. Insertion of EMG electrodes into the rhabdosphincter was a compulsion instilled in me during my dissertation studies to obtain as much data as practical from every experiment conducted. Even after seeing pronounced effects on the rhabdosphincter, I was still more impressed with the effects on the bladder and anticipated clinical benefits for urge incontinence and overactive bladder to supersede clinical benefit for SUI. Fortunately we did have the preclinical data regarding enhancement of sphincter activity or we might not have included SUI patients in the initial trials and we might not have been as aggressive in post hoc analyses of the initial low-dose clinical trial results that supported additional trials at higher doses. Interestingly, there are some indications for benefit by duloxetine in urge incontinence and overactive bladder. The first is...
Pharmacologic agents may be given empirically to women with symptoms of overactive bladder. Tolterodine (Detrol) and extended-release oxybutynin chloride (Ditropan XL) have largely replaced generic oxybutynin as a first-line treatment option for overactive bladder because of favorable side effect profiles. Oxybutynin transdermal may cause less dry mouth than the oral formulation. 3. ERT is also an effective treatment for women with overactive bladder. Even in patients taking systemic estrogen, localized ERT (ie, estradiol-impregnated vaginal ring) may increase inadequate estrogen levels and decrease the symptoms associated with overactive bladder. 4. Pelvic floor electrical stimulation is also effective in treating women with overactive bladder. Pelvic floor electrical stimulation results in a 50 percent cure rate of detrusor instability.
Since its first descriptions in the early 1960s, normal pressure hydrocephalus (NPH) has been difficult to recognize, and conclusive diagnosis relied on response to cerebrospinal fluid shunting. The clinical manifestations classically consist of the triad of gait apraxia, urinary incontinence, and dementia.
Some research suggests that biofeedback may be helpful for people with urinary incontinence, a problem that may occur in MS. Medications and pelvic exercises are available for incontinence. These approaches may not be fully effective, however, and the medications may have undesirable side effects. Studies for biofeedback treatment of urinary incontinence have reported mixed results. Biofeedback may be especially effective for people who have difficulty knowing which muscles to contract during the performance of pelvic exercises. Studies must be done to more fully evaluate biofeedback therapy for urinary incontinence, specifically for MS-related urinary incontinence.
Berghmans LCM, Hendriks HJM, Hay-Smith EJ, et al. Conservative treatment of stress urinary incontinence in women a systematic review of randomized clinical trials. Br J Urol 1998 82 181-191. de Kruif YP, van Wegen Erwin EH. Pelvic floor muscle exercise therapy with myofeedback for women with stress urinary incontinence a meta-analysis. Physiotherapy 1996 82 107-113.
Several other dietary factors should be kept in mind. Alcohol may, over the short-term, produce or worsen fatigue, bladder problems, walking difficulty, or clumsiness in the arms and legs. Grapefruit juice may increase the effects of many medications, including some that are commonly used for MS diazepam (Valium), clonazepam (Klonopin), carbamazepine (Tegretol), sildenafil (Viagra), and sertraline (Zoloft).
In the first series of experiments testing duloxetine's effects on lower urinary tract function,27 I chose to use the cat as the experimental species because most of the preceding experiments with 5HT and norepinephrine had been conducted in cat and thus provided benchmarks upon which to interpret the effects of duloxetine. I also chose to use a model of bladder irritation, i.e., infusion of dilute acetic acid into the bladder, to induce 'overactive bladder' because the importance of nociceptive (i.e., C fiber primary afferent neurons) stimuli in the etiology of overactive bladder was just beginning to emerge. As luck would have it, both of these choices were critical because subsequent studies showed that duloxetine has very little effects on normal (i.e., saline infused - unirritated) bladder activity, presumably because 5HT and or norepinephrine have greater effects on 'irritative,' C fiber-mediated bladder activity than normal bladder primary afferent fibers. Subsequent studies...
In the early 1990s, therapy for stress urinary incontinence relied on pelvic floor exercises and surgery. Bringing the first drug forward to treat any indication provided a number of challenges, such as extent of medical need and clinical trial design. Unique to duloxetine's trials in incontinence were (1) the fact that urologic thought leaders' prevailing opinion at that time was that stress incontinence was 'an anatomical defect' that would be only amenable to surgery and not pharmacological therapy, and (2) doubts about whether a CNS approach to a urological problem was tenable.
A preliminary diagnosis of urinary incontinence can be made on the basis of a history, physical examination and a few simple office and laboratory tests. C. Because fecal impaction has been linked to urinary incontinence, a history that includes frequency of bowel movements, length of time to evacuate and whether the patient must splint her vagina or perineum during defecation should be obtained. Patients should be questioned about fecal incontinence. D. A complete list of all prescription and nonprescrip-tion drugs should be obtained. When appropriate, discontinuation of these medications associated with incontinence or substitution of appropriate alternative medications will often cure or significantly improve urinary incontinence.
Some patients feel they need to have daily bowel movements and resort to laxative and enema misuse. Some patients may make several daily attempts straining to evacuate, while others may postpone the urge or make hurried attempts for convenience. Another frequently observed behavioral pattern, common among elderly women with symptoms of urinary incontinence, is the restriction of fluid intake to avoid leakage in fact, this may worsen symptoms of constipation as well as symptoms of urinary incontinence. Reviewing a daily record of bowel habits guides the clinician to tailor education specifically to the underlying functional disorder.
Unfortunately, clinicians taught Kegel exercises without the use of instrumentation. Bump et al18 showed that verbal or written instructions alone are not adequate, concluding that 50 of patients performed Kegel exercises incorrectly. There are disadvantages to teaching Kegel exercises without specific feedback from muscle contractions. There is a strong tendency to substitute abdominal and gluteal contractions for weak pelvic floor muscles. This incorrect manner of performing Kegel exercises is reinforced by sensory proprioceptive sensations, giving faulty feedback for the desired contraction, and, in effect, rendering the Kegel exercise useless.9 For patients with fecal or urinary incontinence, abdominal contractions raise intraabdominal pressure, thereby increasing the probability of an accident. For patients to begin performing isolated pelvic muscle contractions, they are instructed to contract their pelvic floor muscles without contracting abdominal, gluteal, or leg muscles, and...
Inability to store urine is termed urinary incontinence. There are three primary forms of urinary incontinence. 1. Stress urinary incontinence (SUI) is urine leakage resulting from abdominal pressure exceeding urethral resistance during physical 'stress' (i.e., coughing, laughing, or sneezing) and is primarily seen in women. 2. Urge urinary incontinence (UUI) is urine leakage resulting from involuntary activation of the micturition reflex, which in certain circumstances is due to emergence of a pathological spinal reflex (i.e., a 'short circuit' reflex not routed through the brain stem and considerably less influenced by higher levels of the CNS) that is initiated by bladder 'nociceptive' (C fiber) primary afferent (i.e., sensory) fibers. 3. Often, involuntary bladder contractions can occur without leakage of urine but produce symptoms of urinary frequency, urgency, and nocturia. This condition is often referred to as overactive bladder (OAB).
Another classic form of incontinence known as urinary urge incontinence (UUI), which is a complaint of involuntary leakage of urine accompanied by or immediately preceded by urgency, is more common in males than females, accounting for 40-80 of male cases.73 UUI is usually caused by detrusor overactivity in men. It is thought that obstruction caused by BPH can affect the local or ventral detrusor control, which results in overactivity, and this explains the higher prevalence in males. The presence of detrusor overactivity can also affect bladder contraction strength, and greater bladder contractions can lead to higher urge severity. It is possible that both UUI and overactive bladder can have similar underlying mechanisms to those observed in BPH patients with detrusor overactivity, which leads some authors to question whether BPH is part of a larger syndrome involving prostatitis (inflammatory), intersititial cystitis, UUI, and overactive bladder.
It is important in the initial examination to determine if PROM actually occurred. Often, urinary incontinence, loss of the mucous plug, and increased leukorrhea, which are common occurrences during the third trimester, are mistaken for PROM. Inspect the perineum and vaginal vault for presence of fluid, noting the color, consistency, and any foul odor. Normally, amniotic fluid is clear or sometimes blood-tinged with small white particles of vernix. Meconium-stained fluid, which results from the fetus passing stool in utero, can be stained from a light tan to thick green, resembling split pea soup. Take the patient's vital signs. An elevated temperature and tachycardia are signs that infection is present as a result of PROM. Auscultate the lungs bilaterally. Palpate the uterus for tenderness, which is often present if infection is present. Check the patient's reflexes, and inspect all extremities for edema.
The commercial applications of motor prostheses for the restoration of biological function are focused on the restoration of bladder and bowel function and in the restoration of respiratory function in those individuals with a high cervical level spinal cord injury. Four systems have been identified for use in bladder control and or bladder continence Brindley-Finetech system, marketed by NeuroControl Corp. LEVATOR Turbo CS200 Continence Stimulator, marketed by Ferraris Medical, Ltd. Interstim, marketed by Medtronic, The Brindley-Finetech Bladder Controller, also known as the VOCARE system in the United States,79,80 consists of two electrode pairs and a stimulator implanted within the body and an external control unit worn around the waist. The electrodes are implanted near the second through fourth sacral nerves bilaterally in the sacral canal after they have been exposed by a laminectomy. The stimulating electrodes provide for the contraction of the bladder wall to induce urine...
Radical prostatectomy has been the recommended treatment option for men with middle-stage disease because of high cure rates. This procedure removes the entire prostate gland, including the prostatic capsule, the seminal vesicles, and a portion of the bladder neck. Two common side effects of prostatectomy are urinary incontinence and impotence. The urinary incontinence usually resolves with time and after performing Kegel exercises, although 10 to 15 of men continue to experience incontinence 6 months after surgery. Impotence occurs in 85 to 90 of patients. All men who undergo radical prostatectomy lack emission and ejaculation because of the removal of the seminal vesicles and transection of the vas deferens. Newer surgical techniques (nerve-sparing prostatectomy) preserves continence in most men, and erectile function in selected cases. Antispasmodics may be ordered for bladder spasms. Anticholinergic and antispasmodic drugs may also be prescribed to help relieve urinary...
The Praxis-24 system being developed by Neopraxis Pty., Ltd.96,97 is an implanted system that provides for up to 22 channels of electrical stimulation. This system is designed to provide for upright standing and walking for individuals with sustained paraplegia, in addition to providing for bladder control. Electrodes placed adjacent to the motor nerves in the quadriceps,
It is important to undergo a medical evaluation for urinary incontinence. Because CAM therapies have not been extensively studied, it is important to consider conventional therapy first in this area. Multiple CAM therapies have produced promising results for urinary incontinence
The cause of death is the injury or disease which begins the train of events that ultimately leads to death. The cause of death may be separated into a proximate cause and an immediate cause. The proximate cause is the initial event and the immediate cause is the last event prior to death. For example, a beam falls on the back of a man working at a construction site and he becomes paralyzed. As a result of the paralysis, he loses bladder control and becomes prone to develop urinary tract infections. Years after the accident he develops a particularly severe kidney infection, becomes quite sick, and dies. In this case, the proximate cause of his death is the injury which left him paralyzed. The immediate cause is the infection of the kidney (pyelonephritis).
Prostate surgery can contribute to transient, short- or long-term incontinence. Radical retropubic prostatectomy is a surgical procedure used in prostate cancer, which involves the removal of adenomatous tissue via an incision in the surgical capsule of the prostate. However, this technique can result in refractory incontinence. One study of 146 prostate cancer patients showed that stress urinary incontinence was evident in the majority of patients (95 ) after surgery, with the main cause of incontinence being intrinsic sphincter deficiency.65 Another study in 120 prostate cancer patients showed that radical prostatectomy had a significant impact on nocturia and voiding frequency in a small proportion of patients.66
Incontinence.13 Patients with fecal incontinence may complain of multiple daily bowel movements and a feeling of incomplete evacuation resulting in postdefecation seepage.9 Many patients who present with constipation frequently have symptoms of urinary incontinence. Due to the coexistence of concomitant multifac-torial PFM dysfunction associated with weak PFM and outlet obstruction, it is difficult to offer a specific standard biofeedback therapy protocol that is beneficial for all patients. Therefore, the clinician must address all bowel and bladder symptoms and develop an individualized program for each patient with progressive realistic goals. The behavioral component is aimed toward systematic changes in the patient's behavior to influence bowel and bladder function. Operant conditioning utilizing trial and error as an essential part of learning is merely one aspect of the learning process. Treatment is aimed at shaping the patient's responses toward a normal model by gradually...
Multiple sclerosis patients present with a broad array of symptoms including reduced or abnormal sensations, weakness, vision changes, clumsiness, and loss of bladder control. The diversity of initial symptoms is a reflection of the focal nature of the disease and makes accurate diagnosis a challenge. A number of signs can be assessed to help in making the diagnosis including abnormal eye movements or pupillary response, altered reflex responses, impaired coordination or sensation, and evidence of spasticity or weakness in the arms or legs. Definitive diagnosis is made by a number of tests including blood tests to rule out other possible diagnoses (e.g., Lyme disease), an examination of cerebrospinal fluid to assess the presence of elevated immunoglobulin G (IgG), and oligoclonal banding, a visual evoked potential test to determine if there is a slowing in signal conduction, and a magnetic resonance imaging (MRI) scan to assess the presence of periventricular lesions. Multiple...
Selective stimulation of neural tissue is a great challenge for biomedical engineering. A typical example in bladder control is activation of the detru-sor muscle without activation of the urethral sphincter and afferent fibers when stimulating sacral roots with tripolar cuff electrodes. Analysis with the activating function is of help for finding the polarized and hyperpo-larized regions but nonlinear membrane current modeling has to be included to quantify cathodic and anodic block or anodic break phenomena in selected target fibers and to determine the stimulus pulse parameters for an operating window.14,83,84
Action Kinetics Atropine blocks the action of acetylcholine on post-ganglionic cholinergic receptors in smooth muscle, cardiac muscle, exocrine glands, urinary bladder, and the AV and SA nodes in the heart. Ophthalmologically, atropine blocks the effect of acetylcholine on the sphincter muscle of the iris and the accommodative muscle of the ciliary body. This results in dilation of the pupil (mydriasis) and paralysis of the muscles required to accommodate for close vision (cycloplegia). Peak effect Mydriasis, 30-40 min cycloplegia, 1-3 hr. Recovery Up to 12 days. Duration, PO 4-6 hr. tV2 2.5 hr. Metabolized by the liver although 30 -50 is excreted through the kidneys unchanged. Uses PO Adjunct in peptic ulcer treatment. Irritable bowel syndrome. Adjunct in treatment of spastic disorders of the biliary tract. Urologic disorders, urinary incontinence. During anesthesia to control salivation and bronchial secretions. Has been used for parkinsonism but more effective drugs are available.
Without any historical pharmaceutical sales data for an indication, the market potential is difficult to predict because most financial models are based on sales of competitors' products. Since there were no well-marketed products for stress urinary incontinence, it was difficult to develop a financial model. In 1992, even sales of urge incontinence products were remarkably small for example, the top UUI medicine was Ditropan, which only had 92 million days of therapy prescribed in the USA, and there were virtually no drug sales in the USA for SUI. This absence of therapy highlighted the need for new therapy with a mechanism of action that was different from previous therapy and was emphasized in 1992 by the Agency for Health Care Policy and Research (AHCPR) which released its first guideline on urinary incontinence and reported 1 in 4 women ages 30-59 have experienced an episode of urinary incontinence
In 1998, the US-FDA approved the Finetech-Brindley bladder controller for commercial use, and the first totally integrated cochlear amplifier (TICA) was implanted in Europe. In 2000 alone, the US-FDA approved the first middle ear implant, the auditory brainstem implant, and the Interstim implant for bladder control for use in humans. Also, a fully implantable hearing aid, the Implex AG Hearing Technology from Germany, was approved for European use. Prostheses for restoration of vision began to make significant progress with large-scale human trials of prostheses located in the visual cortex (1995), epiretinal space (1998), and subretinal space (2000). The results of the US-FDA-authorized subretinal trial were presented in 2002 (see Chapter 11 for details). Implantation of the Abio Cor, a permanent, self-contained heart replacement proceeded in 2001, along with Phase II studies on a totally implantable MEIHD. Also in 2001, the US-FDA approved the first contactless middle-ear implant...
This trial34 was the first to show efficacy in neurogenic bladder (and is the only trial published for any overactive bladder condition to date). This important trial also supported the early positive results for duloxetine in SUI. This study showed a reduction from 1.7 to 0.3 incontinence episodes per day in neurogenic bladder patients at 20 mg (but no effect at 10 mg) and a reduction from 3 to 1 incontinence episodes day at both 10 and 20 mg doses in SUI patients. Although the trial was a single-blinded study and contained no placebo group (which was traditional in Japan at that time to ensure all patients were treated with something), these results added to the early suggestions of duloxetine's efficacy.
Dr Thor received his PhD in Pharmacology from the University of Pittsburgh School of Medicine where he trained under William (Chet) de Groat, PhD and was supported by a PhARMA predoctoral fellowship. He held a National Research Service Award postdoctoral fellowship from the NIH at Uniformed Services University of the Health Sciences in Bethesda, Maryland, and was a Senior Staff Fellow in the Laboratory of Neurophysiology at the NIH. He joined Eli Lilly in the Neuroscience Division in 1990, where he discovered duloxetine (Yentreve) as a treatment for stress urinary incontinence. In 1998, he formed PPD GenuPro as a subsidiary of PPD Inc., where he discovered the clinical potential of dapoxetine as a therapy for premature ejaculation. These two drugs are the first agents to be submitted to regulatory agencies for their respective indications. In 2002, he founded Dynogen Pharmaceuticals Inc., a neurosci-ence-based drug discovery and development company targeting genitourinary and...
Involuntary loss of urine preceded by a strong urge to void, whether or not the bladder is full, is a symptom of the condition commonly referred to as urge incontinence. Other commonly used terms such as detrusor instability and detrusor hyperreflexia refer to involuntary detrusor contractions observed during urodynamic studies.
Disorders involving bladder dysfunction are captured under the acronym LUTS lower urinary tract symptoms. These disorders include benign prostatic hyperplasia or hypertrophy (hyperplasia being an increase in the number of the prostate cells and hypertrophy an increase in cell size), incontinence or overactive bladder, and bladder outlet obstruction.1'2
The loss of bladder control presents an individual with a medical problem that also has serious social implications. Regaining control of the bladder allows these individuals to improve their health and participate and contribute to society without fear of embarrassment. Commercial neuropros-thetic bladders (for example, the Vocare system made by Neurocontrol Corp. remote-ability.com) provide the patient with an external unit to control when the bladder will empty. These units generate signals that are transmitted to an implanted receiver, which uses pacemaker-like technology to activate appropriate nerves. Future challenges in neuroprosthetic bladder development center on device design to make the devices smaller and less obtrusive and to perhaps develop approaches that allow the user control of the device without the need for an external triggering unit.