Less-intensive treatments also decrease incontinence episodes. In a randomized trial, the guidance of a simple self-help booklet was only somewhat less effective in reducing leakage (mean reduction in leakage episodes 43%) than behavioral training (mean reduction 69%) or behavioral training plus electrical stimulation (mean reduction 72%) (53).
Vaginal devices (pessaries) and urethral inserts are available for treating stress urinary incontinence. In a tertiary care population, approximately two-thirds of women with stress urinary incontinence offered a trial of vaginal devices chose to undergo pessary fitting (54). Most (89%) achieved a successful fit. Of those who took a pessary home to manage their stress urinary incontinence, approximately one-half used it for more than 6 months. Women who stopped using the pessary generally did so within the first month. In an intent-to-treat analysis of a recent large multisite randomized trial, 3 months after beginning either pessary or behavioral therapy, 40% of those randomized to pessary and 49% of those doing behavioral therapy were “very much” or “much” better. By 12 months there were no group differences in outcomes and patient satisfaction was greater than 50% for each group (55). Some women are pleased to be able to avoid surgery or to use a “crutch” while waiting for the effect of pelvic muscle training; others prefer a treatment option (like surgery) that does not require daily intervention. Examples of some vaginal devices are shown in Figure 26.9.
Urethral inserts are sterile inserts placed into the urethra by the patient and removed before a void, after which a new sterile insert is placed. Such inserts are appropriate for women with
Figure 26.9 Vaginal incontinence pessaries: (clockwise from top): A: Suarez ring (Cook Urological, Spencer, IN), B: PelvX ring (DesChutes Medical Products, Bend, OR), C: Incontinence dish (Milex Inc., Chicago, IL), D: Incontinence dish with support (Mentor Corp., Santa Barbara, CA), E: Introl prosthesis (was Johnson and Johnson; currently not available), F: Incontinence ring with support (Milex Inc., Chicago, IL), (middle): G: Incontinence dish with support (Milex Inc., Chicago, IL).
relatively pure stress incontinence, no history of recurrent urinary tract infections, and no serious contraindications to bacteriuria (e.g., artificial heart valves). The FemSoft device was U.S. Food and Drug Administration (FDA) approved in 1997 and is the only urethral insert that is available in the United States. Several other urethral inserts and urethral occlusion devices were marketed with good effectiveness but were withdrawn from the market. In a 5-year, multicenter trial involving 150 women with a mean follow-up of 15 months, a statistically significant reduction in incontinence episodes and pad weight were observed with 93% of the women having a negative pad test at 12 months. However, urinary tract infections were common and found in 31.3% of the subjects (56). Urethral inserts have not developed a widespread acceptance but may offer a viable treatment option for some select patients.