Skip to main content
SpringerLink
Log in

Pharmacological Management of Women with Mixed Urinary Incontinence

  • Therapy in Practice
  • Published:
Drugs Aims and scope Submit manuscript

Abstract

Mixed urinary incontinence (MUI) is a symptomatic diagnosis. It is defined by the International Continence Society as the complaint of involuntary leakage associated with urgency and also with exertion, effort, sneezing and coughing. A search of medical databases revealed that only a small number of limited studies that assess the prevalence, epidemiology and treatment of MUI have been conducted. Most studies have looked separately at either stress urinary incontinence or urgency urinary incontinence. Thus, management of MUI involves a combination of treatments for both stress and urgency incontinence, but should concentrate initially on the most bothersome and/or predominant symptom. Initial management includes an accurate history and examination, which is supplemented by a bladder diary and quality-of-life questionnaire. Once a preliminary diagnosis is established, first-line therapy includes patient education and lifestyle interventions, such as weight loss. This is supplemented by pelvic floor muscle training and bladder training, which help with both components of MUI. Oral pharmacotherapy often acts synergistically with the previous treatments; however, only very few randomised, placebo-controlled trials have looked at the effects of pharmacotherapy on MUI. The two main classes of drugs are the antimuscarinics, which are effective in urgency incontinence, and the serotonin-norepinephrine re-uptake inhibitors, which are effective in stress incontinence. Combination of these two drug classes is a feasible option but has not been tested in any trials to date. Should these treatments fail, then patients should be referred for cystometry to confirm the diagnosis. Treatment options available following urodynamics include invasive minor and major surgical procedures, which either treat the stress or urgency component of MUI but not both. Surgical procedures carry the risk of infection, haemorrhage and failure.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

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): 167–78

    Article  PubMed  Google Scholar 

  2. Hunskaar S, Burgio K, Clark A, et al. Epidemiology of urinary (UI) and faecal (FI) incontinence and pelvic organ prolapse (POP). In: Abrams P, Cardozo L, Khoury S, et al., editors. Incontinence. Paris: Health Publication Ltd, 2005: 255–312

    Google Scholar 

  3. Stewart WF, Van Rooyen JB, Cundiff GW, et al. Prevalence and burden of overactive bladder in the United States. World J Urol 2003 May; 20(6): 327–36

    PubMed  CAS  Google Scholar 

  4. Hannestad YS, Rortveit G, Sandvik H, et al. A community-based epidemiological survey of female urinary incontinence: the Norwegian EPINCONT study. Epidemiology of Incontinence in the County of Nord-Trondelag. J Clin Epidemiol 2000 Nov; 53(ll): 1150–7

    Article  PubMed  CAS  Google Scholar 

  5. Hashim H, Abrams P. Is the bladder a reliable witness for predicting detrusor overactivity? J Urol 2006 Jan; 175(1): 191–5

    Article  PubMed  CAS  Google Scholar 

  6. Brading AF. A myogenic basis for the overactive bladder. Urology 1997 Dec; 50 (6A Suppl.): 57–67

    Article  PubMed  CAS  Google Scholar 

  7. de Groat WC. A neurologic basis for the overactive bladder. Urology 1997 Dec; 50 (6A Suppl.): 36–52

    Article  PubMed  Google Scholar 

  8. Mostwin J, Bourcier A, Haab F, et al. Pathophysiology of urinary incontinence, fecal incontinence and pelvic organ prolapse. In: Abrams P, Cardozo L, Khoury S, et al., editors. Incontinence. Paris: Health Publication Ltd, 2005: 423–84

    Google Scholar 

  9. Rortveit G, Daltveit AK, Hannestad YS, et al. Vaginal delivery parameters and urinary incontinence: the Norwegian EPINCONT study. Am J Obstet Gynecol 2003 Nov; 189(5): 1268–74

    Article  PubMed  Google Scholar 

  10. Mostwin JL. Pathophysiology: the varieties of bladder overactivity. Urology 2002 Nov; 60 (5 Suppl. 1): 22–6

    Article  PubMed  Google Scholar 

  11. Takazawa K, Arisawa K. Relationship between the type of urinary incontinence and falls among frail elderly women in Japan. J Med Invest 2005 Aug; 52(3–4): 165–71

    Article  PubMed  Google Scholar 

  12. Wilson L, Brown JS, Shin GP, et al. Annual direct cost of urinary incontinence. Obstet Gynecol 2001 Sep; 98(3): 398–406

    Article  PubMed  CAS  Google Scholar 

  13. Hu TW, Wagner TH, Bentkover JD, et al. Costs of urinary incontinence and overactive bladder in the United States: a comparative study. Urology 2004 Mar; 63(3): 461–5

    Article  PubMed  Google Scholar 

  14. Turner DA, Shaw C, McGrother CW, et al. The cost of clinically significant urinary storage symptoms for community dwelling adults in the UK. BJU Int 2004 Jun; 93(9): 1246–52

    Article  PubMed  CAS  Google Scholar 

  15. Coyne KS, Zhou Z, Thompson C, et al. The impact on health-related quality of life of stress, urge and mixed urinary incontinence. BJU Int 2003 Nov; 92(7): 731–5

    Article  PubMed  CAS  Google Scholar 

  16. Monz B, Pons ME, Hampel C, et al. Patient-reported impact of urinary incontinence-Results from treatment seeking women in 14 European countries. Maturitas 2005 Nov; 52 Suppl. 2: 24–34

    Article  Google Scholar 

  17. Yip SK, Chan A, Pang S, et al. The impact of urodynamic stress incontinence and detrusor overactivity on marital relationship and sexual function. Am J Obstet Gynecol 2003 May; 188(5): 1244–8

    Article  PubMed  Google Scholar 

  18. Abrams P, Andersson KE, Brubaker L, et al. Recommendations of the International Scientific Committee: evaluation and treatment of urinary incontinence, pelvic organ prolapse and faecal incontinence. In: Abrams P, Cardozo L, Khoury S, et al., editors. Incontinence. Paris: Health Publication Ltd, 2005: 1589–630

    Google Scholar 

  19. Bent AE, Gousse AE, Hendrix SL, et al. Validation of a two-item quantitative questionnaire for the triage of women with urinary incontinence. Obstet Gynecol 2005 Oct; 106(4): 767–73

    Article  PubMed  Google Scholar 

  20. Steele AC, Kohli N, Mallipeddi P, et al. Pharmacologic causes of female incontinence. Int Urogynecol J Pelvic Floor Dysfunct 1999; 10(2): 106–10

    Article  PubMed  CAS  Google Scholar 

  21. Bump RC, McClish DK. Cigarette smoking and urinary incontinence in women. Am J Obstet Gynecol 1992; 167: 1213–8

    PubMed  CAS  Google Scholar 

  22. Bump RC, McClish DK. Cigarette smoking and pure genuine stress incontinence of urine: a comparison of risk factors and determinants between smokers and nonsmokers. Am J Obstet Gynecol 1994 Feb; 170: 579–82

    PubMed  CAS  Google Scholar 

  23. Mushkat Y, Bukovsky I, Langer R. Female urinary stress incontinence: does it have familial prevalence? Am J Obstet Gynecol 1996 Feb; 174(2): 617–9

    Article  PubMed  CAS  Google Scholar 

  24. Bai SW, Kang JY, Rha KH, et al. Relationship of urodynamic parameters and obesity in women with stress urinary incontinence. J Reprod Med 2002 Jul; 47(7): 559–63

    PubMed  Google Scholar 

  25. Bump RC, Mattiasson A, Bo K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996 Jul; 175(1): 10–7

    Article  PubMed  CAS  Google Scholar 

  26. Staskin D, Hilton P, Emmanuel A, et al. Initial assessment of incontinence. In: Abrams P, Cardozo L, Khoury S, et al., editors. Incontinence. Paris: Health Publication Ltd, 2005

    Google Scholar 

  27. Schick E, Jolivet-Tremblay M, Dupont C, et al. Frequency-volume chart: the minimum number of days required to obtain reliable results. Neurourol Urodyn 2003; 22(2): 92–6

    Article  PubMed  Google Scholar 

  28. Avery K, Donovan J, Peters TJ, et al. ICIQ: a brief and robust measure for evaluating the symptoms and impact of urinary incontinence. Neurourol Urodyn 2004; 23(4): 322–30

    Article  PubMed  Google Scholar 

  29. Abrams P, Blaivas JG, Stanton SL, et al. The standardisation of terminology of lower urinary tract function. The International Continence Society Committee on Standardisation of Terminology. Scand J Urol Nephrol Suppl 1988; 114: 5–19

    CAS  Google Scholar 

  30. Hannestad YS, Rortveit G, Daltveit AK, et al. Are smoking and other lifestyle factors associated with female urinary incontinence? The Norwegian EPINCONT Study. BJOG 2003 Mar; 110(3): 247–54

    Article  PubMed  Google Scholar 

  31. Subak LL, Whitcomb E, Shen H, et al. Weight loss: a novel and effective treatment for urinary incontinence. J Urol 2005 Jul; 174(1): 190–5

    Article  PubMed  Google Scholar 

  32. Bo K, Borgen JS. Prevalence of stress and urge urinary incontinence in elite athletes and controls. Med Sci Sports Exerc 2001 Nov; 33(11): 1797–802

    Article  PubMed  CAS  Google Scholar 

  33. Swithinbank L, Hashim H, Abrams P. The effect of fluid intake on urinary symptoms in women. J Urol 2005 Jul; 174(1): 187–9

    Article  PubMed  CAS  Google Scholar 

  34. Dallosso HM, McGrother CW, Matthews RJ, et al. Nutrient composition of the diet and the development of overactive bladder: a longitudinal study in women. Neurourol Urodyn 2004; 23(3): 204–10

    Article  PubMed  Google Scholar 

  35. Dallosso HM, McGrother CW, Matthews RJ, et al. The association of diet and other lifestyle factors with overactive bladder and stress incontinence: a longitudinal study in women. BJU Int 2003 Jul; 92(1): 69–77

    Article  PubMed  CAS  Google Scholar 

  36. Hisayama T, Shinkai M, Takayanagi I, et al. Mechanism of action of nicotine in isolated urinary bladder of guinea-pig: involvement of tachykinin(s) released by nicotine in the drug’s sympathomimetic effect. Arch Int Pharmacodyn Ther 1989 Sep; 301: 277–84

    PubMed  CAS  Google Scholar 

  37. Koley B, Koley J, Saha JK. The effects of nicotine on spontaneous contractions of cat urinary bladder in situ. Br J Pharmacol 1984 Oct; 83(2): 347–55

    Article  PubMed  CAS  Google Scholar 

  38. Wilson PD, Berghmans B, Hagen S, et al. Adult conservative management. In: Abrams P, Cardozo L, Khoury S, et al., editors. Incontinence. Paris: Health Publication Ltd, 2005: 855–964

    Google Scholar 

  39. Millard RJ. Clinical efficacy of tolterodine with or without a simplified pelvic floor exercise regimen. Neurourol Urodyn 2004; 23(1): 48–53

    Article  PubMed  CAS  Google Scholar 

  40. Nygaard IE, Kreder KJ, Lepic MM, et al. Efficacy of pelvic floor muscle exercises in women with stress, urge, and mixed urinary incontinence. Am J Obstet Gynecol 1996 Jan; 174(1 Pt 1): 120–5

    Article  PubMed  CAS  Google Scholar 

  41. Publicover C, Bear M. The effect of bladder training on urinary incontinence in community-dwelling older women. J Wound Ostomy Continence Nurs 1997 Nov; 24(6): 319–24

    PubMed  CAS  Google Scholar 

  42. Roe B, Williams K, Palmer M. Bladder training for urinary incontinence in adults. Cochrane Database Syst Rev 2000; (2): CD001308

  43. Yoon HS, Song HH, Ro YJ. A comparison of effectiveness of bladder training and pelvic muscle exercise on female urinary incontinence. Int J Nurs Stud 2003 Jan; 40(1): 45–50

    Article  PubMed  Google Scholar 

  44. Burgio KL, Robinson JC, Engel BT. The role of biofeedback in Kegel exercise training for stress urinary incontinence. Am J Obstet Gynecol 1986 Jan; 154(1): 58–64

    PubMed  CAS  Google Scholar 

  45. Bo K, Talseth T, Holme I. Single blind, randomised controlled trial of pelvic floor exercises, electrical stimulation, vaginal cones, and no treatment in management of genuine stress incontinence in women. BMJ 1999 Feb; 318(7182): 487–93

    Article  PubMed  CAS  Google Scholar 

  46. Alhasso A, Glazener C, Pickard R, et al. Adrenergic drugs for urinary incontinence in adults. Cochrane Database Syst Rev 2005; (3): CD001842

  47. Weil EH, Eerdmans PH, Dijkman GA, et al. Randomized double-blind placebo-controlled multicenter evaluation of efficacy and dose finding of midodrine hydrochloride in women with mild to moderate stress urinary incontinence: a phase II study. Int Urogynecol J Pelvic Floor Dysfunct 1998; 9(3): 145–50

    Article  PubMed  CAS  Google Scholar 

  48. Ishiko O, Ushiroyama T, Saji F, et al. beta(2)-adrenergic agonists and pelvic floor exercises for female stress incontinence. Int J Gynaecol Obstet 2000 Oct; 71(1): 39–44

    Article  PubMed  CAS  Google Scholar 

  49. Gruneberger A. Treatment of motor urge incontinence with clenbuterol and flavoxate hydrochloride. Br J Obstet Gynaecol 1984 Mar; 91(3): 275–8

    Article  PubMed  CAS  Google Scholar 

  50. Hunsballe JM, Djurhuus JC. Clinical options for imipramine in the management of urinary incontinence. Urol Res 2001 Apr; 29(2): 118–25

    Article  PubMed  CAS  Google Scholar 

  51. Lin HH, Sheu BC, Lo MC, et al. Comparison of treatment outcomes for imipramine for female genuine stress incontinence. Br J Obstet Gynaecol 1999 Oct; 106(10): 1089–92

    Article  PubMed  CAS  Google Scholar 

  52. Thor KB. Targeting serotonin and norepinephrine receptors in stress urinary incontinence. Int J Gynaecol Obstet 2004 Jul; 86 Suppl. 1: S38–52

    Article  PubMed  CAS  Google Scholar 

  53. Michel MC, Peters SL. Role of serotonin and noradrenaline in stress urinary incontinence. BJU Int 2004 Jul; 94 Suppl. 1: 23–30

    Article  Google Scholar 

  54. Thor KB. Serotonin and norepinephrine involvement in efferent pathways to the urethral rhabdosphincter: implications for treating stress urinary incontinence. Urology 2003 Oct; 62 (4 Suppl. 1): 3–9

    Article  PubMed  Google Scholar 

  55. Mariappan P, Ballantyne Z, N’dow J, et al. Serotonin and noradrenaline reuptake inhibitors (SNRI) for stress urinary incontinence in adults. Cochrane Database Syst Rev 2005; (3): CD004742

  56. Dmochowski RR, Miklos JR, Norton PA, et al. Duloxetine versus placebo for the treatment of North American women with stress urinary incontinence. J Urol 2003 Oct; 170(4 Pt 1): 1259–63

    Article  PubMed  CAS  Google Scholar 

  57. Millard RJ, Moore K, Rencken R, et al. Duloxetine vs placebo in the treatment of stress urinary incontinence: a four-continent randomized clinical trial. BJU Int 2004 Feb; 93(3): 311–8

    Article  PubMed  CAS  Google Scholar 

  58. Norton PA, Zinner NR, Yalcin I, et al. Duloxetine versus placebo in the treatment of stress urinary incontinence. Am J Obstet Gynecol 2002 Jul; 187(1): 40–8

    Article  PubMed  CAS  Google Scholar 

  59. Van KP, Abrams P, Lange R, et al. Duloxetine versus placebo in the treatment of European and Canadian women with stress urinary incontinence. BJOG 2004 Mar; 111(3): 249–57

    Article  Google Scholar 

  60. Yalcin I, Bump RC. Validation of two global impression questionnaires for incontinence. Am J Obstet Gynecol 2003 Jul; 189(1): 98–101

    Article  PubMed  Google Scholar 

  61. Bump R, Yalcin I, Voss S. The effect of duloxetine dose escalation and tapering on the incidence of adverse events (AE) in women with stress urinary incontinence (SUI) [abstract no. 116]. Neurourol Urodyn 2005 Sep; 24(5/6): 582–3

    Google Scholar 

  62. Burt VK, Wohlreich MM, Mallinckrodt CH, et al. Duloxetine for the treatment of major depressive disorder in women ages 40 to 55 years. Psychosomatics 2005 Jul; 46(4): 345–54

    Article  PubMed  CAS  Google Scholar 

  63. Ghoniem GM, Van Leeuwen JS, Elser DM, et al. A randomized controlled trial of duloxetine alone, pelvic floor muscle training alone, combined treatment and no active treatment in women with stress urinary incontinence. J Urol 2005 May; 173(5): 1647–53

    Article  PubMed  CAS  Google Scholar 

  64. Bump RC, Norton PA, Zinner NR, et al. Mixed urinary incontinence symptoms: urodynamic findings, incontinence severity, and treatment response. Obstet Gynecol 2003 Jul; 102(1): 76–83

    Article  PubMed  Google Scholar 

  65. Hashim H, Abrams P. Drag treatment of overactive bladder: efficacy, cost and quality-of-life considerations. Drugs 2004; 64(15): 1643–56

    Article  PubMed  CAS  Google Scholar 

  66. Sellers DJ, Yamanishi T, Chappie CR, et al. M3 muscarinic receptors but not M2 mediate contraction of the porcine detrusor muscle in vitro. J Auton Pharmacol 2000 Jun; 20(3): 171–6

    Article  PubMed  CAS  Google Scholar 

  67. Andersson KE, Appell R, Cardozo L, et al. Pharmacological treatment of urinary incontinence. In: Abrams P, Cardozo L, Khoury S, Wein A, editors. Incontinence. Paris: Health Publication Ltd, 2005: 809–54

    Google Scholar 

  68. Khullar V, Hill S, Laval KU, et al. Treatment of urge-predominant mixed urinary incontinence with tolterodine extended release: a randomized, placebo-controlled trial. Urology 2004 Aug; 64(2): 269–74

    Article  PubMed  Google Scholar 

  69. Abrams P, Avery K, Gardener N, et al. ICIQ Advisory Board. The International Consultation on Incontinence modular questionnaire: www.iciq.net. J Urol 2006 Mar; 175(3 Pt 1): 1063–6; discussion 1066

    Article  PubMed  Google Scholar 

  70. Kreder KJ, Brabaker L, Mainprize T. Tolterodine is equally effective in patients with mixed incontinence and those with urge incontinence alone. BJU Int 2003 Sep; 92(4): 418–21

    Article  PubMed  CAS  Google Scholar 

  71. Karram MM, Bhatia NN. Management of coexistent stress and urge urinary incontinence. Obstet Gynecol 1989 Jan; 73(1): 4–7

    PubMed  CAS  Google Scholar 

  72. Dmochowski RR, Davila GW, Zinner NR, et al. Efficacy and safety of transdermal oxybutynin in patients with urge and mixed urinary incontinence. J Urol 2002 Aug; 168(2): 580–6

    Article  PubMed  CAS  Google Scholar 

  73. Dmochowski RR, Sand PK, Zinner NR, et al. Comparative efficacy and safety of transdermal oxybutynin and oral tolterodine versus placebo in previously treated patients with urge and mixed urinary incontinence. Urology 2003 Aug; 62(2): 237–42

    Article  PubMed  Google Scholar 

  74. Kelleher C, Cardozo L, Kobashi K, et al. Solifenacin: as effective in mixed urinary incontinence as in urge urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunt 2005 Nov; 8: 1–7

    Google Scholar 

  75. Moehrer B, Hextall A, Jackson S. Oestrogens for urinary incontinence in women. Cochrane Database Syst Rev 2003; (2): CD001405

  76. Fantl JA, Cardozo L, McClish DK. Estrogen therapy in the management of urinary incontinence in postmenopausal women: a meta-analysis: First report of the Hormones and Urogenital Therapy Committee. Obstet Gynecol 1994 Jan; 83(1): 12–8

    PubMed  CAS  Google Scholar 

  77. Cardozo L, Lose G, McClish D, et al. A systematic review of the effects of estrogens for symptoms suggestive of overactive bladder. Acta Obstet Gynecol Scand 2004 Oct; 83(10): 892–7

    PubMed  Google Scholar 

  78. Robinson D, Cardozo L. Oestrogens and the lower urinary tract. BJOG 2004 Dec; 111 Suppl. 1: 10–4

    Article  Google Scholar 

  79. Robinson D, Cardozo L, Akeson M, et al. Antidiuresis: a new concept in managing female daytime urinary incontinence. BJU Int 2004 May; 93(7): 996–1000

    Article  PubMed  CAS  Google Scholar 

  80. Dwyer PL. Differentiating stress urinary incontinence from urge urinary incontinence. Int J Gynaecol Obstet 2004 Jul; 86 Suppl. 1: S17–24

    Article  PubMed  Google Scholar 

  81. Balmforth J, Cardozo LD. Trends toward less invasive treatment of female stress urinary incontinence. Urology 2003 Oct; 62 (4 Suppl. 1): 52–60

    Article  PubMed  Google Scholar 

  82. Colombo M, Zanetta G, Vitobello D, et al. The Burch colposus-pension for women with and without detrasor overactivity. Br J Obstet Gynaecol 1996 Mar; 103(3): 255–60

    Article  PubMed  CAS  Google Scholar 

  83. Osman T. Stress incontinence surgery for patients presenting with mixed incontinence and a normal cystometrogram. BJU Int 2003 Dec; 92(9): 964–8

    Article  PubMed  CAS  Google Scholar 

  84. Segal JL, Vassallo B, Kleeman S, et al. Prevalence of persistent and de novo overactive bladder symptoms after the tension-free vaginal tape. Obstet Gynecol 2004 Dec; 104(6): 1263–9

    Article  PubMed  Google Scholar 

  85. Rezapour M, Ulmsten U. Tension-free vaginal tape (TVT) in women with mixed urinary incontinence: a long-term follow-up. Int Urogynecol J Pelvic Floor Dysfunct 2001; 12 Suppl. 2: S15–18

    PubMed  Google Scholar 

  86. Scotti RJ, Angell G, Flora R, et al. Antecedent history as a predictor of surgical cure of urgency symptoms in mixed incontinence. Obstet Gynecol 1998 Jan; 91(1): 51–4

    Article  PubMed  CAS  Google Scholar 

  87. Holmgren C, Nilsson S, Lanner L, et al. Long-term results with tension-free vaginal tape on mixed and stress urinary incontinence. Obstet Gynecol 2005 Jul; 106(1): 38–43

    Article  PubMed  Google Scholar 

  88. Sand PK, Hill RC, Ostergard DR. Incontinence history as a predictor of detrasor stability. Obstet Gynecol 1988 Feb; 71(2): 257–60

    PubMed  CAS  Google Scholar 

  89. Weidner AC, Myers ER, Visco AG, et al. Which women with stress incontinence require urodynamic evaluation? Am J Obstet Gynecol 2001 Jan; 184(2): 20–7

    Article  PubMed  CAS  Google Scholar 

Download references

Acknowledgements

Dr Hashim Hashim is or has been an investigator, lecturer and consultant for many pharmaceutical companies producing or developing drugs for lower urinary tract symptoms.

Professor Paul Abrams is or has been an investigator, lecturer and consultant for many pharmaceutical companies producing or developing drugs for lower urinary tract symptoms.

No sources of funding were used in the preparation of this article.

Author information

Authors and Affiliations

  1. Bristol Urological Institute, Southmead Hospital, Westbury-on-Trym, Bristol, BS10 5NB, UK

    Hashim Hashim & Paul Abrams

Authors
  1. Hashim Hashim
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Paul Abrams
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Hashim Hashim.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Hashim, H., Abrams, P. Pharmacological Management of Women with Mixed Urinary Incontinence. Drugs 66, 591–606 (2006). https://doi.org/10.2165/00003495-200666050-00002

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.2165/00003495-200666050-00002

Keywords

Search

Navigation