Stress Urinary Incontinence: A Review of Treatment Options

Transcription

1 Stress Urinary Incontinence: A Review of Treatment Options DEAUN A. CARPENTER, RN, BSN, CNOR; CONSTANCE VISOVSKY, PhD, RN, ACNP-BC 1.7 ABSTRACT Stress urinary incontinence occurs when the support structures of the pelvic floor and the urinary system are stretched, damaged, or defective. This condition is common in women of all ages, and billions of dollars are spent each year to correct the condition and improve quality of life. This article reviews three current treatments for stress urinary incontinence: the Burch colposuspension procedure, urethral slings, and radiofrequency treatments. In one study, researchers reported that patient satisfaction rates were higher for the Burch procedure than for urethral sling procedures. Other researchers found that urethral sling procedures had high rates of success but that adverse events were more common. Adverse events for both types of procedures include voiding difficulties, postoperative urge incontinence, and urinary tract infections. Radiofrequency interventions can improve the quality of life for many patients and can provide a short-term intervention for many patients who later may require a more-invasive surgical procedure. AORN J 91 (April 2010) AORN, Inc, doi: /j.aorn Key words: female stress urinary incontinence, pelvic floor dysfunction, Burch colposuspension, pubovaginal sling, radiofrequency bladder neck suspension. indicates that continuing education contact hours are available for this activity. Earn the contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evaluation at The contact hours for this article expire April 30, Urinary incontinence (UI) is the inability to voluntarily control bladder function. 1 Stress UI (SUI) is the involuntary leakage of urine on effort, such as exertion 2 ; this condition is common among women of all ages. 3,4 The cost of care associated with managing UI is rising, and billions of dollars are spent annually in the United States for treatment of UI. 5 A claims data analysis shows that the average direct medical cost to treat SUI in 1998 was $5, Data from the Healthcare Cost and Utilization Project show that physician visits by women specifically for the treatment of UI increased from 845 per 100,000 visits in 1992 to 1,845 per 100,000 visits in This article reviews the current literature for procedural management of SUI. doi: /j.aorn AORN, Inc, 2010 April 2010 Vol 91 No 4 AORN Journal 471

2 April 2010 Vol 91 No 4 CARPENTER VISOVSKY Figure 1. Anatomy of the urinary support system. SEARCH STRATEGY We reviewed articles on three types of procedures performed to treat SUI, the Burch colposuspension, urethral sling procedures, and laparoscopic treatment by using radiofrequency (RF) energy, after conducting a literature search in Medline, CINAHL, the Cochrane Library, and PubMed. The search terms we used were urinary incontinence, incontinence, women, intravaginal, urgency, surgical, retropubic, suburethral slings, transobturator, Burch colposuspension, pelvic floor dysfunction, radio frequency, transurethral, fascia, and epidemiology. We included all publications, studies published between January 2000 and August 2008, and studies with female study participants (ie, studies that included both men and women or women only). We reviewed articles that were systematic reviews and accounts of clinical trials, multicenter studies, and prospective studies. ANATOMY OF SUI Knowledge of the anatomy of the urinary support system facilitates understanding about how continence is achieved. The system can be divided into two parts: the bladder neck support system and the sphincter system. 8 Support for the urethra is maintained by the anterior vagina; the endopelvic fascia; the arcus tendineus fascia of the pelvis; and the levator ani muscles, which are divided into three parts: the puborectalis, iliococcygeus, and pubococcygeus muscles (Figure 1). These structures provide a hammock-like support system for the urethra on the anterior wall of the vagina. When the support tissues are stretched (eg, during childbirth) the urethra rotates to a downward and backward facing position. Defects or alterations in this support system contribute to the symptoms of SUI, as evidenced by leakage of bladder contents. Possible risk factors for developing these defects include birthrelated injuries, pregnancy, smoking, obesity, and aging. 9 Defects that result in SUI can be repaired surgically with techniques such as a retropubic colposuspension or pubovaginal sling or via minimally invasive RF bladder neck suspension. 10,11 The 472 AORN Journal

3 STRESS URINARY INCONTINENCE nursing plan of care will be similar no matter which surgical technique is used (Table 1). RETROPUBIC COLPOSUSPENSION Surgeons use this surgical technique to lift the tissues near the patient s bladder neck and proximal urethra and to attach them with sutures to either the ileopectineal line or the obturator shelf. 12 Three variations of this procedure are the Burch approach, the Marshall-Marchetti-Krantz approach, and the paravaginal defect repair. 12 Traditionally, the Burch procedure has been the gold standard for surgical treatment of SUI because of its long-term success rate. 13 Dainer et al 13 conducted a systematic review of 85 articles and the outcomes of approximately 3,500 surgical procedures, and concluded that the Burch procedure, when performed as a primary procedure, has a success rate of 69% to 90%. During a Burch procedure, the surgeon elevates and fixes the patient s anterior vaginal wall and paravesical tissues to the ileopectineal line of the pelvic side wall. 12,14 The Burch technique can be performed through a minimally invasive laparoscopic approach or through an open abdominal incision. When the procedure is performed successfully, the patient s vagina and associated structures become a broad sling that supports and elevates the bladder neck, thus preventing leakage of bladder contents. 13 Moore et al 15 found that, in those women who had recurrent SUI after retropubic incontinence surgery, the Burch procedure had a success rate of 90%. Complications of the laparoscopic Burch technique are cited as detrusor instability, cystotomy, ureteral injury, infection, hemorrhage, and voiding dysfunction. 13,15,16 Voiding dysfunction has been identified as delayed voiding or urinary retention, 15 the use of any postoperative bladder catheter after six weeks, or re-operation for the takedown of a pubovaginal sling or Burch colposuspension. 14,17 Rates of complications for the Burch colposuspension vary from 10% 14 to 41.2%. 16 In 2007, Albo et al 14 reported that the most commonly cited adverse event associated with the Burch procedure was urinary tract infection (UTI), which they believed was related to a delay in the return to normal voiding patterns and a prolonged need for catheterization. A study by Speights et al 18 indicated injury to the lower urinary tract associated with Burch procedures to be about 2.3%, which is much less than the 10% noted in previous reports. Since the Burch procedure was first described in 1961, many new approaches have been introduced to address the challenges and embarrassment of SUI. PUBOVAGINAL SLING By using this technique, the surgeon creates artificial support for the urethra through the use of a narrow band of either autologous or synthetic material, which suspends the patient s urethra and helps to prevent leakage of bladder contents. The tension-free vaginal tape (TVT) procedure and the transobturator suburethral tape (TOT) procedure are techniques in which the surgeon uses a sling of synthetic material for the urethral suspension. The surgeon inserts the TVT through a vaginal incision and creates a sling via a retropubic approach. 19 Methods that use a TOT are similar to the TVT in principle; however, the surgeon uses the inside-out approach, in which he or she passes a needle with the tape attached from an incision inside of the vagina through the obturator foramen to the outside of the body in the groin area. This approach avoids blind entry into the retropubic space, thereby minimizing the risk of injury to the patient s internal structures. 20 Both techniques are successful in treating SUI and, in one study, had an objective cure rate of 90% in the group that underwent TOT and 84.3% in the group that underwent TVT. 21 Patients were considered objectively cured if they had no complaints of SUI and demonstrated a negative stress test. In a study by Daneshgari et al, 22 AORN Journal 473

4 April 2010 Vol 91 No 4 CARPENTER VISOVSKY TABLE 1. Nursing Care Plan for a Patient Undergoing Surgery for Stress Urinary Incontinence Diagnosis Nursing interventions Interim outcome statement Outcome statement Risk for perioperative positioning injury Assesses baseline skin condition. Identifies baseline tissue perfusion. Identifies baseline musculoskeletal status. Identifies physical alterations that require additional precautions for procedure-specific positioning. Verifies presence of prosthetics or corrective devices. Positions the patient. Implements protective measures to prevent skin or tissue injury from mechanical sources. Applies safety devices. Evaluates tissue perfusion. Evaluates musculoskeletal status. Evaluates for signs and symptoms of physical injury to skin or tissue. The patient is free from pain or numbness associated with surgical positioning. The patient is free from signs and symptoms of injury related to positioning. Risk for imbalanced fluid volume Identifies baseline genitourinary status. Verifies the presence of prosthetics or corrective devices (eg, pessary device). Identifies physiological status. Reports deviation in diagnostic study results. Identifies factors associated with an increased risk for hemorrhage or fluid and electrolyte imbalance. Monitors physiological parameters. Evaluates genitourinary status. The patient s urinary output is within expected range at discharge from the OR, procedure room, or postanesthesia care unit. The patient s genitourinary status is maintained at or improved from baseline levels. Risk for imbalanced body temperature Assesses risk for normothermia regulation. Assesses risk for inadvertent hypothermia. Identifies physiological status. Reports deviation in diagnostic study results. Monitors body temperature. Monitors physiological parameters. Evaluates response to thermoregulation measures. The patient s temperature is higher than 36 C (96.8 F) at the time of discharge from the OR or procedure room. The patient is at or returning to normothermia at the conclusion of the immediate postoperative period. (table continued) however, the associated operative complications are noted to be significant for midurethral slings. Daneshgari et al 22 also cite anatomical evidence (eg, nerve damage to the neurovascular bundles of the urethral sphincter) and clinical evidence (eg, low leak-point pressures) for postoperative 474 AORN Journal

5 STRESS URINARY INCONTINENCE TABLE 1. (continued) Nursing Care Plan for a Patient Undergoing Surgery for Stress Urinary Incontinence Diagnosis Nursing interventions Interim outcome statement Outcome statement Deficient knowledge and anxiety Assesses baseline neurological status. Identifies sensory impairments. Identifies barriers to communication. Identifies patient and designated support person s educational needs. Determines knowledge level. Assesses readiness to learn. Identifies psychosocial status. Elicits perceptions of surgery. Assesses coping mechanisms. Implements measures to provide psychological support. Includes patient or designated support persons in perioperative teaching. Explains expected sequence of events. Provides status reports to designated support person. Evaluates response to instructions. The patient verbalizes the sequence of events to expect before and immediately after surgery. The patient states realistic expectations regarding recovery from the procedure. The patient and his or her family members identify signs and symptoms to report to the surgeon or health care provider. The patient and his or her family members describe the prescribed postoperative regimen accurately. The patient or designated support person demonstrates knowledge of the expected responses to the operative or invasive procedure. alterations in continence mechanisms that contribute to SUI. They reported that complications rates for the group that underwent TVT ranged from 4.3% to 75.1% and that complications for the group that underwent TOT ranged from 10.5% to 31.3%. 22 They identified complications from the suburethral synthetic tapes as bladder outlet obstruction, bladder and bowel perforation, UTI, hemorrhage, and groin and thigh pain. 22 Abdel- Fatteh et al 23 cited tape erosion as a common adverse effect of this procedure. Surgeons also can place slings made from a harvested strip of the patient s rectus fascia around the urethrovesical junction and secure the slings with permanent sutures to the rectus fascia. 24,25 This creates the support required for the urethra to maintain continence. RF BLADDER NECK SUSPENSION Tissue that is targeted with RF thermal energy becomes denatured and remodeled. This remodeling causes a decrease in the dynamic compliance of the anatomic region targeted. For SUI, RF treatment stops the inappropriate opening of the bladder neck and the resulting urine leakage. 26 After RF treatment, elastic fascia is replaced at a histologic level by stiff fibrotic tissue that improves support for the bladder neck. 27 Anatomically, RF does not cause tissue necrosis or scarring of structures, so it does not interfere with the possibility of future, more-invasive surgical interventions, if they are needed. 26 Radiofrequency also may provide some patients with the option of delaying incontinence surgery until more-invasive types of incontinence surgery are required. Radiofrequency treatments for SUI can be AORN Journal 475

6 April 2010 Vol 91 No 4 CARPENTER VISOVSKY PATIENT EDUCATION Surgery for Stress Urinary Incontinence What causes stress urinary incontinence (SUI)? The lower urinary tract consists of the urinary bladder (the organ that stores urine) and the urethra (the channel through which urine exits the body). A sphincter muscle opens and closes to allow urine to leave the bladder. Ligaments, tendons, and muscles support the bladder and urethra and help the urethra remain closed during exercise, coughing, and straining. These structures can be injured or weakened by childbirth; pelvic surgery; obesity; frequent prolonged straining; and strenuous exercise. The urethra then drops and opens during physical stress or straining, which causes urine to leak out of the bladder involuntarily. What are my treatment options? Options for treating stress incontinence include lifestyle changes, physical therapy, devices placed in the vagina or urethra, medications, and surgery. Your doctor may first suggest nonsurgical treatment. Often, several treatments are used together for the best effect. If nonsurgical treatments do not improve the problem, surgery may help. Three common types of surgery for stress urinary incontinence are retropubic suspension, pubovaginal sling, and radiofrequency bladder neck suspension. You and your doctor will choose which type of surgery is right for you. How do I get ready for the procedure? It is important to arrive on time for the procedure. Your doctor may tell you not to eat or drink anything after a certain time, depending on what time of day your surgery is scheduled. Be sure to tell your doctor if you feel like you have a cold or a fever or are urinating bright red blood before the procedure. What happens during the procedure? After cleaning your genital area, the surgeon puts a catheter into your bladder. During a retropubic suspension, the doctor places a few stitches in the wall of your vagina and through pelvic tissue to raise the bladder neck back to the correct position and help support the urethra. During a pubovaginal sling procedure, the doctor places a sling under your urethra and holds it in place with stitches or by friction between the sling and surrounding tissues. The sling is a narrow strap made of your own tissues or man-made materials. During radiofrequency bladder neck suspension, the doctor uses radiofrequency energy to remodel the bladder neck, which stops the inappropriate opening of the bladder neck and the resulting urine leakage. A small amount of blood in your urine is normal, but tell your doctor if the bleeding continues or is heavy. Prolonged or heavy bleeding may signal a problem. It may take awhile for the bladder to adapt to the new position after surgery. Bladder spasms can occur during recovery. As the bladder heals, the spasms usually stop, but some women may develop long-term spasms after surgery. Medication can help control the spasms. Some women get bladder infections after surgery. If this occurs, then it can be treated with antibiotics. To speed up the recovery, you should avoid activities that put stress on the surgical area, such as: straining with bowel movements; strenuous exercises; heavy lifting; and placing anything in your vagina for six weeks, including tampons and douches. Ask your doctor about when you can resume driving, exercise, sexual intercourse, and daily activities. What are the risks of surgery? All surgery has some risk. There may be problems with the anesthesia used. Infection or damage to the pelvic organs, urethra, bladder, bowel, blood vessels, or surrounding nerves also could occur. In rare cases, the body may reject the sling, or the stitches can get infected or may wear away. In rare situations, a woman may not be able to void on her own so the stitches or the sling may have to be removed. Call your doctor immediately if you experience any of the following complications: vomiting or fainting, urgent and frequent urination, inability to urinate, heavy bleeding or blood clots in your urine, severe abdominal pain or cramping, redness or discharge from incisions, abnormal discharge from your vagina, fever or chills, or shortness of breath or chest pain. Patient Resources Urinary incontinence. Mayo Clinic. urinary-incontinence/surgery.html. Accessed January 23, Urinary incontinence. MedlinePlus. medlineplus/urinaryincontinence.html. Accessed January 23, What should I do after surgery? The time needed to recover varies. It is longer for abdominal surgery and shorter for laparoscopic or vaginal surgery. After surgery, discomfort may last for a few days or weeks. The doctor may prescribe pain medicine. Take the medicine according to your doctor s instructions. You may have difficulty voiding for awhile. During this time, you may need to use a tube to empty your bladder a few times each day. Drink plenty of fluids to help decrease the soreness when you urinate. 476 AORN Journal

7 STRESS URINARY INCONTINENCE performed transvaginally, transurethrally, or laparoscopically, and all have been shown to be safe and effective. 11,26-28 In a three-year retrospective study conducted by Appell et al 29 in 2007, results from the Incontinence Quality of Life survey showed improvement in SUI after RF treatment. In contrast, a 2008 study by Ismail 30 indicated that RF procedures are not an effective means for treating SUI. The hospital data of the 24 women studied by Ismail 30 indicated that RF treatment for SUI had a success rate of only 45.8% at one year after surgery. 30 COMPARISON OF RESULTS In a 2007 study of 655 women that compared the fascial sling to the Burch procedure, Albo et al 14 reported that the fascial sling had a higher rate of surgical success but also a higher rate of adverse events. Both procedures are reported to have adverse events that include voiding difficulties, postoperative urge incontinence, and UTIs, with UTIs being most common in the group of patients having a sling procedure. 14 In a 2008, large, randomized controlled trial that compared the Burch colposuspension with the fascial sling procedure, Tennstedt et al 31 reported that the Burch procedure was associated with greater satisfaction in quality of life for patients during a 24-month period. Use of synthetic slings appears to be effective and is less expensive and is associated with a faster recovery time; however, Dean et al 32 indicate that longer-term data are needed to determine the outcomes of these procedures. Radiofrequency techniques show promise by providing fast, safe, and well-tolerated results; but the studies reviewed here also indicate a need for more longterm data collection and analysis ,31 CONCLUSION Although all the procedures in this review had some measure of success, failure, and complications, it is important to understand the reason for the satisfaction experienced by the women who undertook the interventions. In 2008, Tennstedt et al 31 identified differences between the subjective and objective opinions of success. Women reported that improvement in UI symptoms was more important to them than the type of surgery performed or its success rate. Ultimately, the goal is to return the woman to a quality of life that she considers acceptable. Surgeons must weigh the patient s goal against how the success of a procedure may be viewed by medical personnel. Editor s note: CINAHL, the Cumulative Index to Nursing and Allied Health Literature, is a registered trademark of EBSCO Industries, Birmingham, AL. PubMed and Medline are registered trademarks of the National Library of Medicine, National Institutes of Health, Washington, DC. References 1. Abrams P, Cardozo L, Fall M, et al. The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourol Urodyn. 2002;21(2): Coyne KS, Zhou Z, Thompson C, Versi E. The impact on health-related quality of life of stress, urge and mixed urinary incontinence. BJU Int. 2003;92(7): Nyggard IE, Thompson FL, Svengalis SL, Albright JP. Urinary incontinence in elite nulliparous athletes. Obstet Gynecol. 1994;84(2): Diokno AC, Sampselle CM, Herzog AR, et al. Prevention of urinary incontinence by behavioral modification program: a randomized, controlled trial among older women in the community. J Urol. 2004;171(3): Wilson L, Brown JS, Shin GP, Luc KO, Subak LL. Annual direct cost of urinary incontinence. Obstet Gynecol. 2001;98(3): Birnbaum HG, Leong SA, Oster EF, Kinchen K, Sun P. Cost of stress urinary incontinence: a claims data analysis. Pharmacoeconomics. 2004;22(2): 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(4): Ashton-Miller JA, Howard D, Delancey JO. The functional anatomy of the female pelvic floor and stress continence control system. Scand J Urol Nephrol. 2001;207(Suppl): Luber KM. The definition, prevalence, and risk factors for stress urinary incontinence. Rev Urol. 2004;6(Suppl 3):S3-S9. AORN Journal 477

8 April 2010 Vol 91 No 4 CARPENTER VISOVSKY 10. Thakar R, Stanton S. Regular review: management of urinary incontinence in women. BMJ. 2000;321(7272): Fulmer BR, Sakamoto K, Turk MT, et al. Acute and long-term outcomes of radio-frequency bladder neck suspension. J Urol. 2002;167(1): Lapitan MC, Cody DJ, Grant AM. Open retropubic colposuspension for urinary incontinence in women. Cochrane Database Syst Rev. 2009;15(2):CD Dainer M, Hall CD, Choe J, Bhatia NN. The Burch procedure: a comprehensive review. Obstet Gynecol Surv. 1999;54(1): Albo ME, Richter HE, Brubaker L, et al. Urinary Continence Treatment Network. Burch colposuspension versus fascial sling to reduce urinary stress incontinence. N Engl J Med. 2007;365(21): Moore RD, Speights SE, Miklos JR. Laparoscopic Burch colposuspension for recurrent stress urinary incontinence. J Am Assoc Gynecol Laparosc. 2001;8(3): Wang AC. Burch culposuspension vs. Stamey bladder neck suspension. A comparison of complications with special emphasis on detrussor instability and voiding dysfunction. J Reprod Med. 1996;41(7): Lemack GE, Krauss S, Litman H, et al. Normal preoperative urodynamic testing does not predict voiding dysfunction after Burch colposuspension versus pubovaginal sling. J Urol. 2008;180(5): Speights SE, Moore RD, Miklos JR. Frequency of lower urinary tract injury at laparoscopic Burch and paravaginal repair. J Am Assoc Gynecol Laparosc. 2000;7(4): Saini J, Neeraj K, Miklos JR, Moore R. Nonsurgical and minimally invasive outpatient treatments for stress urinary incontinence and pelvic organ prolapse. Female Patient. 2004;29(5): Reisenauer C, Kirschniak A, Drews U, Wallwiener D. Transobturator vaginal tape inside-out. A minimally invasive treatment of stress urinary incontinence: surgical procedure and anatomical conditions. Eur J Obstet Gynecol Reprod Biol. 2006;127(1): detayrac R, Deffieux X, Droupy S, Chauveaud- Lambling A, Calvanese-Benamour L, Fernandez H. A prospective randomized trial comparing tension-free vaginal tape and transobturator suburethral tape for surgical treatment of stress urinary incontinence. Am J Obstet Gynecol. 2004;190(3): Daneshgari F, Kong W, Swartz M. Complications of mid urethral slings: important outcomes for future clinical trials. J Urol. 2008;180(5): Abdel-Fattah M, Sivanesan K, Ramsay I, Pringle S, Bjornsson S. How common are tape erosions? A comparison of two versions of the transobturator tensionfree vaginal tape procedure. BJU Int. 2006;98(3): McGuire EJ, Lytton B. Pubovaginal sling procedure for stress incontinence. J Urol. 2002;67(2 pt 2): Chaikin DC, Rosenthal J, Blaivas JG. Pubovaginal sling for all types of stress urinary incontinence: long-term analysis. J Urol. 1998;160(4): Appell RA, Juma S, Wells WG, et al. Transurethral radiofrequency energy collagen micro-remodeling for the treatment of female stress urinary incontinence. Neurourol Urodyn. 2006;25(4): Dmochowski RR, Avon M, Ross J, et al. Transvaginal radio-frequency treatment of the endopelvic fascia: a prospective evaluation for the treatment of genuine stress urinary incontinence. J Urol. 2003;169(3): Lenihan JP. Comparison of the quality of life after nonsurgical radiofrequency energy tissue micro-remodeling in premenopausal and postmenopausal women with moderate-to-severe stress urinary incontinence. Am J Obstet Gynecol. 2005;192(6): Appell RA, Singh G, Klimberg IW, et al. Nonsurgical, radiofrequency collagen denaturation for stress urinary incontinence: retrospective 3-year evaluation. Expert Rev Med Devices. 2007;4(4): Ismail SI. Radiofrequency remodelling of the endopelvic fascia is not an effective procedure for urodynamic stress incontinence in women. Int Urogynecol J Pelvic Floor Dysfunct. 2008;19(12): Tennstedt SL, Litman HJ, Zimmern P, et al. Quality of life after surgery for stress incontinence. Int Urogynecol J Pelvic Floor Dysfunct. 2008;19(12): Dean NM, Ellis G, Wilson PD, Herbison GP. Laparoscopic colposuspension for urinary incontinence in women. Cochrane Database Syst Rev. 2006;19(3): CD Deaun A. Carpenter, RN, BSN, CNOR, is an RN first assistant at Yuma District Hospital, Yuma, CO. Ms Carpenter has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. Constance Visovsky, PhD, RN, ACNP-BC, is an associate professor at the University of Nebraska Medical Center College of Nursing, Nebraska Medical Center, Omaha. Dr Visovsky has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. 478 AORN Journal

9 EXAMINATION CONTINUING EDUCATION PROGRAM Stress Urinary Incontinence: A Review of Treatment Options 1.7 PURPOSE/GOAL To educate perioperative nurses about surgical treatment options for stress urinary incontinence (SUI) and their outcomes. OBJECTIVES 1. Explain the anatomic reasons SUI occurs in women. 2. Identify risks for developing SUI. 3. Describe current treatment options for SUI. 4. Identify adverse events that can occur with SUI surgical treatment options. The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the Examination and Learner Evaluation online at QUESTIONS 1. Stress urinary incontinence in women occurs when the pelvic floor muscles, vagina, and ligaments that support the urethra are a. too tight as a result of postsurgical scarring. b. stretched or damaged as in childbirth. c. damaged by radiofrequency treatments. d. surgically shortened. 2. Risk factors for SUI include 1. aging. 2. nulliparity. 3. obesity. 4. pregnancy. 5. smoking. a. 1 and 2 b. 3, 4, and 5 c. 1, 3, 4, and 5 d. 1, 2, 3, and 5 3. Stress urinary incontinence can be repaired by 1. retropubic colposuspension. 2. pubovaginal sling. 3. radiofrequency bladder neck suspension. 4. suprapubic cystostomy. a. 1 and 3 b. 2 and 4 c. 1, 2, and 3 d. 1, 2, 3, and 4 4. In a review of 3,500 surgical procedures, the Burch procedure, when performed as a primary procedure, had a success rate of a. 27% to 39%. b. 45% to 67%. c. 54% to 72%. d. 69% to 90%. 5. The Burch procedure can be performed laparoscopically or through an open abdominal incision. a. true b. false 6. During a pubovaginal sling procedure, the surgeon a. creates a constricting band around the neck of the bladder to prevent urine leakage. AORN, Inc, 2010 April 2010 Vol 91 No 4 AORN Journal 479

10 April 2010 Vol 91 No 4 CE EXAMINATION b. tightens the muscles that have been stretched or damaged so that they provide better support for the urethra. c. creates artificial support for the urethra by using a narrow band of autologous or synthetic material. d. injects silicone around the urethral meatus to prevent urine leakage. 7. When using the transobturator suburethral tape technique, the surgeon passes a needle from an incision inside the vagina through the obturator foramen to avoid blind entry into the retropubic space. a. true b. false 8. Complications from the use of suburethral synthetic tapes can include 1. bladder outlet obstruction. 2. urinary tract infection. 3. hemorrhage. 4. groin and thigh pain. 5. tape erosion. a. 1 and 2 b. 3 and 5 c. 1, 2, 4, and 5 d. 1, 2, 3, 4, and 5 9. Bladder neck suspension using radiofrequency thermal energy to treat SUI a. causes elastic fascia to be replaced by stiff fibrotic tissue that increases support for the bladder neck. b. causes tissue necrosis that interferes with bladder neck function. c. scars the surrounding tissue, which causes tightening and thus reduces urine leakage. d. relaxes surrounding musculature, which decreases urine leakage. 10. In comparisons of Burch colposuspension and the fascial sling procedure, the Burch procedure was associated with 1. greater satisfaction in quality of life during a 24-month period. 2. a higher rate of surgical success. 3. lower rates of adverse events. a. 1 and 2 b. 1 and 3 c. 2 and 3 d. 1, 2, and 3 The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, BC, director, Center for Perioperative Education. Ms Holm and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article. 480 AORN Journal

11 LEARNER EVALUATION CONTINUING EDUCATION PROGRAM Stress Urinary Incontinence: A Review of Treatment Options 1.7 This evaluation is used to determine the extent to which this continuing education program met your learning needs. Rate the items as described below. OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Explain the anatomic reasons stress urinary incontinence (SUI) occurs in women. Low High 2. Identify risks for developing SUI. Low High 3. Describe current treatment options for SUI. Low High 4. Identify adverse events that can occur with SUI surgical treatment options. Low High CONTENT 5. To what extent did this article increase your knowledge of the subject matter? Low High 6. To what extent were your individual objectives met? Low High 7. Will you be able to use the information from this article in your work setting? 1. Yes 2. No 8. Will you change your practice as a result of reading this article? (If yes, answer question #8A. If no, answer question #8B.) 8A. How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other: 8B. If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time to teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: 9. Our accrediting body requires that we verify the time you needed to complete the 1.7 continuing education contact hour (102-minute) program: This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements. AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. AORN recognizes these activities as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP Check with your state board of nursing for acceptance of this activity for relicensure. Event: #10016; Session: #4007 Fee: Members $8.50, Nonmembers $17 The deadline for this program is April 30, A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program will be able to print a certificate of completion. AORN, Inc, 2010 April 2010 Vol 91 No 4 AORN Journal 481