Injections for Stress Incontinence an Option When Surgery Isn't

WASHINGTON – Urethral bulking with injectable therapy is an option to consider for the treatment of stress incontinence in elderly women who aren’t candidates for a sling procedure, according to Dr. Richard D. Cespedes.

It’s a good option for, say, the 83-year-old woman with no prior urologic history, stage 1 prolapse and urethral hypermobility, and comorbidities requiring anticoagulant therapy, said Dr. Cespedes of the comprehensive continence and pelvic health center at the Shore Health System in Easton, Md.

"The elderly generally have a greater risk of retention with a sling procedure," he said. "And I never have to have my patients come off their [anticoagulant] medications for injection therapy. ... I’ve never had any significant bleeding."

Patients are more satisfied with injectable therapy when they appreciate that lasting continence can be achieved through multiple injections spaced about a month apart, with periodic reinjections after that.

"Think of it as a process for tissue expansion ... [that’s] best performed slowly," with only one to two syringes injected per visit and 4-6 weeks between visits to allow for tissue incorporation or encapsulation, Dr. Cespedes said. "Injections may be repeated for essentially any length of time with continued good results in most cases. I’ve injected patients once a year for 10 years with no loss in efficacy."

Bovine collagen (Contigen) is no longer available, he said, but the three newer injectables that are currently available – calcium hydroxylapatite particles (Coaptite), polydimethylsiloxane (Macroplastique), and carbon-coated beads (Durasphere EXP) – all have better durability than collagen, he said during a discussion of office-based therapy for stress urinary incontinence at the annual meeting of the American Urological Association.

The bulking agents are injected in the submucosa of the bladder neck or the midurethra.

Elderly females who aren’t good candidates for open procedures and who have significant incontinence symptoms are "by far ... the largest group I inject," he said, but young women who aren’t candidates for a sling procedure may also benefit from the injectables.

Dr. Saad Juma of the Incontinence Research Institute in Encinitas, Calif., said that the 83-year-old patient would also be a candidate for radiotherapy of the bladder neck and proximal urethra using controlled, low-level radiofrequency energy. The therapy, known as transurethral radiofrequency collagen remodeling, is a Food and Drug Administration–approved, office-based, minimally invasive procedure for management of female stress urinary incontinence due to bladder neck hypermobility.

The therapy results in microscopic collagen denaturation and subsequent reduced tissue compliance. "Urethral resistance increases ... and mucosa and deeper urethral tissues are preserved," he explained.

Dr. Cespedes reported having no relevant financial disclosures, and Dr. Juma reported that he is a consultant/adviser to American Medical Systems, Coloplast, and Contura, as well as an investigator with Bioform, Contura, and Solace Therapeutics.

WASHINGTON – Urethral bulking with injectable therapy is an option to consider for the treatment of stress incontinence in elderly women who aren’t candidates for a sling procedure, according to Dr. Richard D. Cespedes.

It’s a good option for, say, the 83-year-old woman with no prior urologic history, stage 1 prolapse and urethral hypermobility, and comorbidities requiring anticoagulant therapy, said Dr. Cespedes of the comprehensive continence and pelvic health center at the Shore Health System in Easton, Md.

"The elderly generally have a greater risk of retention with a sling procedure," he said. "And I never have to have my patients come off their [anticoagulant] medications for injection therapy. ... I’ve never had any significant bleeding."

Patients are more satisfied with injectable therapy when they appreciate that lasting continence can be achieved through multiple injections spaced about a month apart, with periodic reinjections after that.

"Think of it as a process for tissue expansion ... [that’s] best performed slowly," with only one to two syringes injected per visit and 4-6 weeks between visits to allow for tissue incorporation or encapsulation, Dr. Cespedes said. "Injections may be repeated for essentially any length of time with continued good results in most cases. I’ve injected patients once a year for 10 years with no loss in efficacy."

Bovine collagen (Contigen) is no longer available, he said, but the three newer injectables that are currently available – calcium hydroxylapatite particles (Coaptite), polydimethylsiloxane (Macroplastique), and carbon-coated beads (Durasphere EXP) – all have better durability than collagen, he said during a discussion of office-based therapy for stress urinary incontinence at the annual meeting of the American Urological Association.

The bulking agents are injected in the submucosa of the bladder neck or the midurethra.

Elderly females who aren’t good candidates for open procedures and who have significant incontinence symptoms are "by far ... the largest group I inject," he said, but young women who aren’t candidates for a sling procedure may also benefit from the injectables.

Dr. Saad Juma of the Incontinence Research Institute in Encinitas, Calif., said that the 83-year-old patient would also be a candidate for radiotherapy of the bladder neck and proximal urethra using controlled, low-level radiofrequency energy. The therapy, known as transurethral radiofrequency collagen remodeling, is a Food and Drug Administration–approved, office-based, minimally invasive procedure for management of female stress urinary incontinence due to bladder neck hypermobility.

The therapy results in microscopic collagen denaturation and subsequent reduced tissue compliance. "Urethral resistance increases ... and mucosa and deeper urethral tissues are preserved," he explained.

Dr. Cespedes reported having no relevant financial disclosures, and Dr. Juma reported that he is a consultant/adviser to American Medical Systems, Coloplast, and Contura, as well as an investigator with Bioform, Contura, and Solace Therapeutics.

WASHINGTON – Urethral bulking with injectable therapy is an option to consider for the treatment of stress incontinence in elderly women who aren’t candidates for a sling procedure, according to Dr. Richard D. Cespedes.

It’s a good option for, say, the 83-year-old woman with no prior urologic history, stage 1 prolapse and urethral hypermobility, and comorbidities requiring anticoagulant therapy, said Dr. Cespedes of the comprehensive continence and pelvic health center at the Shore Health System in Easton, Md.

"The elderly generally have a greater risk of retention with a sling procedure," he said. "And I never have to have my patients come off their [anticoagulant] medications for injection therapy. ... I’ve never had any significant bleeding."

Patients are more satisfied with injectable therapy when they appreciate that lasting continence can be achieved through multiple injections spaced about a month apart, with periodic reinjections after that.

"Think of it as a process for tissue expansion ... [that’s] best performed slowly," with only one to two syringes injected per visit and 4-6 weeks between visits to allow for tissue incorporation or encapsulation, Dr. Cespedes said. "Injections may be repeated for essentially any length of time with continued good results in most cases. I’ve injected patients once a year for 10 years with no loss in efficacy."

Bovine collagen (Contigen) is no longer available, he said, but the three newer injectables that are currently available – calcium hydroxylapatite particles (Coaptite), polydimethylsiloxane (Macroplastique), and carbon-coated beads (Durasphere EXP) – all have better durability than collagen, he said during a discussion of office-based therapy for stress urinary incontinence at the annual meeting of the American Urological Association.

The bulking agents are injected in the submucosa of the bladder neck or the midurethra.

Elderly females who aren’t good candidates for open procedures and who have significant incontinence symptoms are "by far ... the largest group I inject," he said, but young women who aren’t candidates for a sling procedure may also benefit from the injectables.

Dr. Saad Juma of the Incontinence Research Institute in Encinitas, Calif., said that the 83-year-old patient would also be a candidate for radiotherapy of the bladder neck and proximal urethra using controlled, low-level radiofrequency energy. The therapy, known as transurethral radiofrequency collagen remodeling, is a Food and Drug Administration–approved, office-based, minimally invasive procedure for management of female stress urinary incontinence due to bladder neck hypermobility.

The therapy results in microscopic collagen denaturation and subsequent reduced tissue compliance. "Urethral resistance increases ... and mucosa and deeper urethral tissues are preserved," he explained.

Dr. Cespedes reported having no relevant financial disclosures, and Dr. Juma reported that he is a consultant/adviser to American Medical Systems, Coloplast, and Contura, as well as an investigator with Bioform, Contura, and Solace Therapeutics.