The most extensively studied medications for the treatment of nocturnal enuresis are tricyclic antidepressants, particularly imipramine. These agents may work by altering the sleep mechanism, by providing anticholinergic or antidepressant effects, or by affecting antidiuretic hormone excretion. The typical starting dose of imipramine is 25 mg at bedtime, which may be increased to as high as 75 mg. In the elderly, imipramine should be used cautiously because it increases the risk of hip fracture, presumably related to the potential side effect of orthostatic hypertension (64).
In a randomized, placebo-controlled study comparing nighttime doses of placebo and 1 mg of bumetanide (a loop diuretic), bumetanide decreased nocturia episodes by 25% compared with placebo (65). Patients who produce half of their total urine at night often benefit from the use of a diuretic (e.g., 20 mg furosemide) in the late afternoon to move ﬂuid through the system and decrease their nighttime urine production.
Historically, the body of literature concerning surgical therapy for stress urinary incontinence, while large, is hampered by poor methods, short follow-up, biased outcome observations, and little attention paid to the patients’ perceptions of symptoms and quality of life (66). Over the past decade, scientific research in this area evolved; while much of the literature continues to reﬂect small short-term case series, randomized trials with rigorous follow-up are becoming more common.
Several shifts occurred in recommendations regarding surgical therapy in the past generation. In 1997, the American Urological Association convened a clinical guidelines panel to analyze published outcomes data on surgical procedures to treat female stress urinary incontinence and to produce practice recommendations to guide surgical decision making (67). The panel concluded that colposuspension (e.g., Burch, Marshall-Marchetti-Krantz [MMK]) and slings were more effective than transvaginal needle suspensions or anterior repairs for longterm success (48-month cure/dry rates). The median probability estimates for cure/dry rates at 48 months and longer were 84% (95% confidence interval [CI], 79%–88%) for colposuspension and 83% (95% CI, 75%–88%) for sling procedures, compared with 67% (95% CI, 53%–79%) for transvaginal needle suspensions and 61% (95% CI, 47%–72%) for anterior repairs. Thus, the latter two procedures are no longer recommended as adequate treatments for stress urinary incontinence.