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©2014 MFMER | slide-1 Female Urinary Incontinence; Tips for Taming the Tinkles Felecia Fick, CRTT, PA-C
©2014 MFMER | slide-2 Disclosures None
©2014 MFMER | slide-3 Objectives Describe the evaluation of patients with urinary incontinence Discuss how to diagnose different types of urinary incontinence List treatment considerations for different types of urinary incontinence Describe when to refer patients with urinary incontinence
©2014 MFMER | slide-4 Normal Micturition Cycle
©2014 MFMER | slide-5 What is normal? Diurnal frequency- 8 voids Nocturia- 0-1 void Bladder capacity cc Normal voids cc Daily fluid intake ounces
©2014 MFMER | slide-6 What is urinary incontinence? Any involuntary loss of urine (International Continence Society/ICS and American Urological Association/AUA) The symptom is the patient’s complaint The sign is the objective demonstration of urine loss Loss of bladder control (Mayo Clinic)
©2014 MFMER | slide-7 Prevalence At least 50% of patients do not report urinary incontinence  25-51% of the population Around 13 million in the United States [6,7] More commonly seen caucasians, multiple childbirths , aging , living in a nursing home 
©2014 MFMER | slide-8 Types of urinary incontinence Stress Urge Mixed Overflow Functional Neurogenic Transient
©2014 MFMER | slide-9 Stress Incontinence Involuntary loss of urine occurring when the intravesical pressure exceeds the maximum urethral pressure in the absence of a detrusor contraction (ICS) Loss of urine with exertion -coughing, sneezing Risk factors- pregnancy, vaginal deliveries, heredity, obesity Norton’s test
©2014 MFMER | slide-10 Urge incontinence (Overactive Bladder) Involuntary loss of urine associated with a strong desire to void/urgency (ICS) Risk factors- aging, obesity, genetics, though usually idiopathic ***Urinary tract infection
©2014 MFMER | slide-11 Mixed incontinence Combination of stress AND urinary urge incontinence
©2014 MFMER | slide-12 Overflow incontinence Bladder is not emptying and overflows Frequent small urinations Constant dribbling Causes- Weak detrusor contraction (neurological) Outlet obstruction (pelvic prolapse, surgical procedures)
©2014 MFMER | slide-13 Functional incontinence Incontinence due to a physical or cognitive impairment in the setting of a normal functioning urinary tract Causes- Mobility- (arthritis, orthopedic surgery) Cognition- (Alzheimer's disease)
©2014 MFMER | slide-14 Neurogenic Bladders (incontinence) Incontinence due to a neurogenic cause Examples- (multiple sclerosis, spinal cord injuries, parkinsons, stroke) May present as urge, stress, overflow, or retention Requires a subspecialty appointment with a neurourologist so refer them
©2014 MFMER | slide-15 Transient incontinence Temporary incontinence Occurs in 33% of community dwelling elderly and 50% of acutely hospitalized patients Secondary to “DIAPPERS” D elirium I nfection A trophic vaginitis P harmacological P sychological E ndocrine R estricted mobility S tool impaction [1,2,3]
©2014 MFMER | slide-16 Don’t ask, don’t tell-patient perspective Patient embarrassment Belief that symptoms are normal Belief that symptoms will subside Patient is unaware of treatment options or that treatment will be successful Afraid of invasive, costly procedures - specifically the CATHETER….
©2014 MFMER | slide-17 Reasons incontinence is not addressed from a provider perspective Many other important symptoms take precedence Perception that patient is not bothered Unaware of the significant impact on the patient’s quality of life Unaware of treatment options or positive benefit of treatment
©2014 MFMER | slide-18 Reasons to address incontinence Quality of life improvement Morbidity and Mortality Cost
©2014 MFMER | slide-19 Quality of Life Physical Limitations or cessation of physical activity Psychological Guilt/depressi on Loss of self- respect/dignity Fear Social Reduction in social activity Alteration of travel plans Institutionaliz ation Domestic Special precautions with clothing Specialized underwear, bedding Occupational Absence from work Decreased productivity Sexual Avoidance of sexual contact and intimacy
©2014 MFMER | slide-20 Morbidity and Mortality Infections UTIs, urosepsis, candida, cellulitis, pressure ulcers Falls and fractures Sleep deprivation Psychological Impact Poor self-esteem, depression, social withdrawal, sexual dysfunction Caregiver burden [11,13,20]
©2014 MFMER | slide-21 Cost Billions! $20 billion in 2000 for total urinary incontinence costs to society  56 percent consequence costs (i.e., nursing home admissions) and loss of productivity [15,16] $65.9B in 2007 for OAB Projected $76.2B $82.6B-2020
©2014 MFMER | slide-22 Patient evaluation History Questionnaires Voiding Diary Physical exam Additional testing - urines - post void residual - urodynamics test - cystoscopy
©2014 MFMER | slide-23 History
©2014 MFMER | slide-24 Patient history Review Questionnaire (UDI=urogenital distress inventory, IIQ=incontinence impact questionnarie…) OBGYN - number of pregnancies - delivery method (vaginal, cesarean) - instruments used (forceps, suction) - degree of tearing, episiotomy Pelvic Surgery
©2014 MFMER | slide-25 Patient history Storage symptoms Urgency Frequency Nocturia Incontinence Pain Voiding symptoms Hesitancy Weak slow stream Incomplete emptying Post void dribbling Pain Bladder symptoms ( LUTS =lower urinary tract symptoms)
©2014 MFMER | slide-26 Bladder diary
©2014 MFMER | slide-27 Patient history “Incontinence” When do you leak urine? What triggers your leakage episodes? How often does it happen? Do you wear pads? What kind of pad? How many per day? Are they soaked or damp?
©2014 MFMER | slide-28 Patient history Vaginal symptoms Itching, dryness, burning, discharge, bleeding, infection, history of skin conditions such as atrophic vaginitis or lichen sclerosus Can be seen with pelvic prolapse and/or Incontinence
©2014 MFMER | slide-29 Patient history Sexual history Sexually active or not Dyspareunia Penetration, movement, orgasm, anorgasmic Vaginal dryness-lubricants used Post coital bleeding ?sexually transmitted infection Abuse
©2014 MFMER | slide-30 Patient history Bowel symptoms Constipation Fecal incontinence Splinting Incomplete emptying
©2014 MFMER | slide-31 Patient history Neurological Pulmonary Medical Diagnosis Physical Mobility Mental Status including psychiatric history Obesity
©2014 MFMER | slide-32 Patient history Medication review-diuretics, lithium, etc.. Social Smoking, alcohol, recreational drugs Family history Gynecological, urological, colorectal malignancy
©2014 MFMER | slide-33 Physical Exam General Abdominal /Back(scars, masses, CVA tenderness on the back) Urologic/gynecologic Visual inspection Skin conditions, rashes, atrophy, vaginal discharge Perineal sensation, reflexes (soft touch/sharp) Cough stress test Kegels or pelvic floor myalgia Prolapse Masses-(bartholins, urethral, skenes, diverticulum, bimanual, rectal exam included in this evaluation)
©2014 MFMER | slide-34 Kegels Squeezing and releasing the pelvic floor muscles which includes the vagina, urethra, rectum. Same muscle used to stop the urinary stream. Graded as absent, weak, moderate, strong. Can be taught through pelvic floor physical therapy. Used as a treatment option for urinary incontinence.
©2014 MFMER | slide-35 Squirting Sue 40 yo c/o urinary incontinence only with running (no other urogynecological symptoms) G4, P4 (vaginal, forceps with first 2, 3 rd degree tearing with 3 rd, largest birth weight 10 lbs) BMI 22 PMH/PSH-Healthy. No surgeries. Medications/allergies-None. Bladder diary, urines, post void residual-normal Physical exam is normal with strong kegels.
©2014 MFMER | slide-36 Squirting Sue What is her diagnosis? 1)Transient incontinence 2)Overflow incontinence 3)Urge incontinence 4)Stress incontinence 5)Mixed incontinence
©2014 MFMER | slide-37 Squirting Sue Answer 1)Transient incontinence 2)Overflow incontinence 3)Urge incontinence 4)Stress incontinence 5)Mixed incontinence
©2014 MFMER | slide-38 Squirting Sue First LineTreatment 1) Urethral insert (Femsoft) 2) Pessary 3) Kegels on her own 4) Pelvic floor physical therapy/biofeedback 5) Surgery 6) Tell her to wear a pad
©2014 MFMER | slide-39 All are potential options, depending on how aggressive the patient wants to be with treatment
©2014 MFMER | slide-40 Squirting Sue First LineTreatment 1) Urethral insert (Femsoft) 2) Pessary 3) Kegels on her own 4) Pelvic floor physical therapy/biofeedback 5) Surgery 6) Tell her to wear a pad
©2014 MFMER | slide-41 Answer 1) Urethral insert (Femsoft)
©2014 MFMER | slide-42 Urgency Ursula 70 yo c/o urinary incontinence with a strong urge, urgency, frequency. No incontinence with cough or stress manuevers. G0. PMH/PSH-Healthy. No surgeries. BMI 30. Medications/allergies-None. Labs-Urines and post void residual are normal.
©2014 MFMER | slide-43 Urgency Ursula’s Physical Exam
©2014 MFMER | slide-44 Urgency Ursula’s Physical Exam
©2014 MFMER | slide-45 Urgency Ursula’s Physical Exam No prolapse or incontinence. Weak kegels. Otherwise, unremarkable.
©2014 MFMER | slide-46 Bladder diary
©2014 MFMER | slide-47 Bladder diary
©2014 MFMER | slide-48 Bladder diary
©2014 MFMER | slide-49 Bladder diary
©2014 MFMER | slide-50 Urgency Ursula What is her diagnosis? 1) Stress incontinence 2) Urge incontinence 3) Mixed incontinence and atrophic vaginitis 4) Overflow incontinence 5) Urge incontinence and atrophic vaginitis
©2014 MFMER | slide-51 Urgency Ursula Answer 1) Stress incontinence 2) Urge incontinence 3) Mixed incontinence and atrophic vaginitis 4) Overflow incontinence 5) Urge incontinence and atrophic vaginitis
©2014 MFMER | slide-52 Urgency Ursula Treatment 1) Pelvic floor physical therapy 2) Vaginal estrogen 3) Dietary irritant avoidance 4) Weight loss 5) All of the above
©2014 MFMER | slide-53 Urgency Ursula’s Treatment Answer 1) Pelvic floor physical therapy 2) Vaginal estrogen 3) Dietary irritant avoidance 4) Weight loss 5) All of the above
©2014 MFMER | slide-54 Treatment Overactive Bladder Behavioral Modification Fluid management Avoid Bladder Irritants Pelvic Floor Muscle Strengthening (Consider PT) Urge Suppression/ Awareness Of Triggers Bladder Retraining/ Timed Voiding Improve Mobility and Coexisting Health Issues Improve Bowel Habits/ Regularity Behavioral Modification Fluid management Avoid Bladder Irritants Improve Mobility and Coexisting Health Issues Improve Bowel Habits/ Regularity
©2014 MFMER | slide-55 What are dietary irritants? The 6 C’s C affeine C itrus C arbonation Vitamin C Al c ohol ( C ocktails) C igarettes
©2014 MFMER | slide-56 Urgency Ursula returns 3 months later Overactive bladder symptoms are no better. She has faithfully followed all recommendations. Vaginal tissue – improved Normal BMI. 4 sessions PT completed. Moderate kegel. Bladder diary-same except for no longer taking in dietary irritants.
©2014 MFMER | slide-57 Urgency Ursula’s return treatment? 1) Anticholinergics 2) Surgery 3) Continue with conservative therapy as the treatment risks outweigh the benefits 4) Pessary
©2014 MFMER | slide-58 Urgency Ursula’s return treatment answer 1) Anticholinergics 2) Surgery 3) Continue with conservative therapy as the above treatments risks outweigh the benefits 4) Pessary
©2014 MFMER | slide-59 Abrams P, Wein AJ. (1998). The Overactive Bladder: A Widespread and Treatable Condition. Erik Sparre Medical AB. Iris/Ciliary Body = Blurred Vision Lacrimal Gland = Dry Eyes Salivary Glands = Dry Mouth Heart = Tachycardia Gall Bladder Stomach = Dyspepsia Colon = Constipation Bladder (detrusor muscle) CNS Distribution of Muscarinic Receptors in Target Organs of the Parasympathetic Nervous System Dizziness Somnolence Impaired Memory & Cognition
©2014 MFMER | slide-60 Available anticholinergics Oxybutynin tablet (Ditropan IR, ER) transdermal patch (Oxytrol)-which is OTC transdermal gel (Gelnique) Tolterodine tartrate (Detrol, IR, ER) Trospium chloride (Sanctura, IR, XR) Fesoterodine fumarate (Toviaz) Darifenacin (Enablex) Solifenacin succinate (Vesicare) Mirabegron (Myrbetriq)
©2014 MFMER | slide-61 Which one to chose? In general, you could start with any one. OBJECT trial, Mayo Clinic Proceedings, 2001 Oxybutynin ER/ Ditropan XL 10mg daily Good efficacy, reasonable cost If not effective or side effects Try another
©2014 MFMER | slide-62 Frequent Francis 50 yo G0 c/o urinary frequency. Failed Tolterodine tartrate (Detrol LA), Fesoterodine fumarate (Toviaz), and Solifenacin succinate (Vesicare). Not interested in trying another medication. No dietary irritants. BMI 23. PMH/PSH- healthy. No meds/allergies. Labs-urines normal. Exam-normal with strong kegels.
©2014 MFMER | slide-63
©2014 MFMER | slide-64 Frequent Francis’s diagnosis 1)Urinary urgency 2)Urinary frequency 3)Obstructive voiding symptoms 4)Urge incontinence
©2014 MFMER | slide-65 Frequent Francis’s diagnosis 1)Urinary urgency 2)Urinary frequency 3)Obstructive voiding symptoms 4)Urge incontinence
©2014 MFMER | slide-66 Frequent Francis’s Treatment 1) Oxybutynin ER 10mg daily 2) Botox 3) Sacral Nerve Stimulator 4) Augmentation Cystoplasty 5) Refer
©2014 MFMER | slide-67 Frequent Francis’s Treatment 1) Oxybutynin ER 10mg daily 2) Botox 3) Sacral Nerve Stimulator 4) Augmentation Cystoplasty 5) Refer
©2014 MFMER | slide-68 Botulinum Toxin Many uses in the medical field today Outpatient surgery injected cystoscopically Effective within 2 weeks Effective for 6-12 months Around 80% success Small chance of urinary retention $$$$ so we always ask pt to get insurance pre- approval
©2014 MFMER | slide-69 Treatment Urinary Urge Incontinence Surgical Options: Sacral Neuromodulation (Interstim) Uses a small device (battery) which sends electrical impulses through a lead positioned close to S3 sacral nerve Modulates the nervous signals to the bladder
©2014 MFMER | slide-70 Wet Wanda 57 yo c/o urinary incontinence with urgency (larger volume leakage) and stress activities (small drops). She has constipation. No other complaints. G2, P2 (forceps with first, largest birth weight 9lbs). BMI 28 PMH/PSH- Hysterectomy, DM2, HTN Medications- Estradiol TD (Vivelle Dot), Metformin, HCTZ Allergies-NKDA SH: Drinks 1 pot of coffee daily and has 3 sodas. Smokes 1 pack of cigarettes daily x 25 years. Urines and post void residual are normal.
©2014 MFMER | slide-71 Wet Wanda Physical exam- Normal external genitalia. Normal vaginal mucosa. Weak kegels. No prolapse. With cough, leaks small amount. While getting off the exam table, she had a strong urge and gushed a larger amount of urine.
©2014 MFMER | slide-72 Wet Wanda’s diagnosis 1) Stress incontinence 2) Urge incontinence 3) Mixed incontinence 4) Overflow incontinence
©2014 MFMER | slide-73 Wet Wanda diagnosis answer 1) Stress incontinence 2) Urge incontinence 3) Mixed incontinence 4) Overflow incontinence
©2014 MFMER | slide-74 How do you treat mixed incontinence? Do you treat the stress or urge first? Ask the patient what bothers her most Treat the most bothersome symptom first For Wet Wanda, she is most bothered by her urinary urge incontinence
©2014 MFMER | slide-75 Wet Wanda’s first treatment 1) Take her off the HCTZ and do a sling surgery 2) Pessary 3) Anticholinergics 4) Conservative management- avoid constipation, lose weight, avoid dietary/social irritants-smoking, soda, coffee.. 5) Who knows?
©2014 MFMER | slide-76 Wet Wanda’s answer 1) Take her off the HCTZ and do a sling surgery 2) Pessary 3) Anticholinergics 4) Conservative management- avoid constipation, lose weight, avoid dietary/social irritants-smoking, soda, coffee.. 5) Who knows?.
©2014 MFMER | slide-77 Obesity
©2014 MFMER | slide-78 Does weight loss help incontinence? Program to Reduce Incontinence by Diet and Exercise (PRIDE) January New England Journal of Medicine women 30 and older with a BMI of greater than 3 months incontinence leaking at least 10 times/week 6 month weight loss program and followed for 18 months [18,19]
©2014 MFMER | slide-79 PRIDE, continued.. Group 1-”intensive” weight loss group had diet, exercise, behavioral modification with coaches, classes, etc.. And a follow up 12 month weight maintenance program Group 2-received information on diet and exercise with NO direct training to help them change habits [18,19]
©2014 MFMER | slide-80 PRIDE, continued… Group 1- Lost an average of 8% (about 17lbs) of their body weight Investigators reported a 47% mean reduction of weekly incontinent episodes Group 2- Lost an average of 1.6% (about 3lbs) of their body weight Investigators reported a 28% mean reduction in weekly incontinent episodes 
©2014 MFMER | slide-81 Wet Wanda returns 3 months later… She is 50% improved from her urge incontinence, has stopped smoking, lost weight to now a normal BMI, no more constipation. She is interested in more aggressive treatment options.
©2014 MFMER | slide-82 Wet Wanda returns 3 months later… Treatment options.. 1) Haven’t we fixed her yet? She’s still leaking? 2) Anticholinergics 3) Pessary 4) Surgery
©2014 MFMER | slide-83 Wet Wanda returns 3 months later… Treatment options.. 1) Haven’t we fixed her yet? She’s still leaking? 2) Anticholinergics 3) Pessary 4) Surgery
©2014 MFMER | slide-84 Wet Wanda returns 2 months later.. Good news! You fixed Wanda’s urge incontinence! It is gone! She has now joined a Crossfit class and has had to stop it due to her bothersome incontinence with these Crossfit exercises. She has been so pleased with your care of fixing her urge incontinence, that she is confident in your ability to fix her stress urinary incontinence.
©2014 MFMER | slide-85 Wet Wanda’s treatment for stress incontinence 1) Urethral insert (Femsoft) 2) Pessary 3) Surgery
©2014 MFMER | slide-86 Answer Any option is reasonable. I would present all options to the patient and let her decide as there is no wrong answer.
©2014 MFMER | slide-87 Treatment Stress Urinary Incontinence Ring with a Knob Pessary Marland Pessary
©2014 MFMER | slide-88 Pessary care Patient self maintenance preferred Removed twice weekly to clean with soap/water Some use only with activity Inserted with a water based lubricant Removed before intercourse Last usually around 10 years Around $80 each
©2014 MFMER | slide-89 Leaking Liz 37 yo G2, P2 (NSVD) female who leaks with plyometrics which incorporates a lot of jumping. Femsoft worked for her intermittent incontinence (early 20s). Continent pessary worked well from 36-37yo. Now interested in a more permanent fix. Healthy. Normal BMI. No meds/allergies. Unremarkable PMH/PSH. Normal exam with strong kegels.
©2014 MFMER | slide-90 Leaking Liz treatments 1) Bulking agent 2) Slings
©2014 MFMER | slide-91 Leaking Liz treatments 1) Bulking agent 2) Slings *** Pt to talk with surgeon to decide correct procedure for her. One size does not fit all.
©2014 MFMER | slide-92 Surgical treatment for stress incontinence Outpatient surgery Bulking agents Periurethral injection of material (collagen, macroplastique, etc..) to increase tissue bulk. Slings Piece of material (like a hammock) inserted transvaginally supporting the urethra. Goal is to reduce stress incontinence without causing obstructive voiding symptoms or urinary retention.
©2014 MFMER | slide-93 References 1. Resnick NM, Yalla SV: Geriatric incontinence and voiding dysfunction. In: Campbell-Walsh Urology (9th Edition). Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (Eds). Saunders Elsevier, PA, USA, 2305– 2321 (2005). 2. Herzog AR, Fultz NH: Prevalence and incidence of urinary incontinence in community-dwelling populations. J. Am. Geriatr. Soc. 38(3), 273–281 (1990). 3. Resnick NM: Urinary incontinence in the elderly. Med. Grand Rounds 3, 281–290 (1984). Original article suggesting 'delirium, infection, atrophy, pharmaceuticals, excess urine output, restricted mobility, stool impaction' (DIAPERS) mnemonic for transient causes of urinary incontinence in the elderly. 4. Matthews CA, Whitehead WE, Townsend MK, Grodstein F: Risk factors for urinary, fecal, or dual incontinence in the Nurses' Health Study. Obstet Gynecol. 2013;122(3): Branch LG, Walker LA, Wetle TT, DuBeau CE, Resnick NM: Urinary incontinence knowledge among community-dwelling people 65 years of age and older. J Am Geriatr Soc. 1994;42(12): Buckley BS, Lapitan MC: Epidemiology Committee of the Fourth International Consultation on Incontinence, Paris, 2008: Prevalence of urinary incontinence in men, women, and children--current evidence: findings of the Fourth International Consultation on Incontinence. Urology. 2010;76(2): Markland AD, Richter HE, Fwu CW, Eggers P, Kusek JW: Prevalence and trends of urinary incontinence in adults in the United States, 2001 to J Urol. 2011;186(2):589.
©2014 MFMER | slide-94 References continued 8. Nygaard I, et. al. Pelvic Floor Disorders Network: Prevalence of symptomatic pelvic floor disorders in US women. JAMA. 2008;300(11): Offermans MP et al. Prevalence of urinary incontinence and associated risk factors in nursing home residents: a systematic review. Neurourol Urodyn 2009; 28: Offermans MP et al. Prevalence of urinary incontinence and associated risk factors in nursing home residents: a systematic review. Neurourol Urodyn 2009; 28: Burgio KL, Zyczynski H, Locher JL, et al. Urinary incontinence in the 12-month postpartum period. Obstet Gynecol 2003; 102:1291.Burgio KL, Zyczynski H, Locher JL, et al. Urinary incontinence in the 12-month postpartum period. Obstet Gynecol 2003; 102: Brown JS, Vittinghoff E, Wyman JF, et al. Urinary incontinence: does it increase risk for falls and fractures? Study of Osteoporotic Fractures Research Group. J Am Geriatr Soc 2000; 48:721.Brown JS, Vittinghoff E, Wyman JF, et al. Urinary incontinence: does it increase risk for falls and fractures? Study of Osteoporotic Fractures Research Group. J Am Geriatr Soc 2000; 48: DuBeau CE, Kuchel GA, Johnson T, et al.. Incontinence in the frail elderly. In: Incontinence, 4th ed., Abrams P, Cardozo L, Khoury S, Wein A. (Eds), Health Publications Ltd, Paris p Herzog AR, Diokno AC, Brown MB, et al. Urinary incontinence as a risk factor for mortality. J Am Geriatr Soc 1994; 42:264Herzog AR, Diokno AC, Brown MB, et al. Urinary incontinence as a risk factor for mortality. J Am Geriatr Soc 1994; 42: Hu TW, Wagner TH, Bentkover JD, et al. Costs of urinary incontinence and overactive bladder in the United States: a comparative study. Urology 2004; 63:461.Hu TW, Wagner TH, Bentkover JD, et al. Costs of urinary incontinence and overactive bladder in the United States: a comparative study. Urology 2004; 63: Stothers L, Thom D, Calhoun E. Urologic diseases in America project: urinary incontinence in males-- demographics and economic burden. J Urol 2005; 173: Stothers L, Thom D, Calhoun E. Urologic diseases in America project: urinary incontinence in males-- demographics and economic burden. J Urol 2005; 173: Thom DH, Nygaard IE, Calhoun EA. Urologic diseases in America project: urinary incontinence in women- national trends in hospitalizations, office visits, treatment and economic impact. J Urol 2005; 173: Thom DH, Nygaard IE, Calhoun EA. Urologic diseases in America project: urinary incontinence in women- national trends in hospitalizations, office visits, treatment and economic impact. J Urol 2005; 173:1295.
©2014 MFMER | slide-95 References continued Coyne KS 1, Economic burden of urgency urinary incontinence in the United States: a systematic review. J Manag Care Pharm Feb;20(2): Coyne KSJ Manag Care Pharm. 18. Subak LL, et. al. Weight loss to treat urinary incontinence in overweight and obese women. N Engl J Med Jan 29;360(5): Subak LL Engl J Med. 19. Wing RR, et. Al. Effect of weight loss on urinary incontinence in overweight and obese women:results at 12 and 18 months. Journal of Urology 2010 Sept;18(3): Wing RR., et. Al. Improving urinary incontinence in overweight and obese women through modest weight loss. Obstetrics & Gynecology 2010 Aug;116(2 Pt 1): Coyne KS, Sexton CC, Irwin DE, et al. The impact of overactive bladder, incontinence and other lower urinary tract symptoms on quality of life, work productivity, sexuality and emotional well-being in men and women: results from the EPIC study. BJU Int 2008; 101: Coyne KS, Sexton CC, Irwin DE, et al. The impact of overactive bladder, incontinence and other lower urinary tract symptoms on quality of life, work productivity, sexuality and emotional well-being in men and women: results from the EPIC study. BJU Int 2008; 101:
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