Selecting Medications For The Treatment Of Urinary Incontinence
BARRY D. WEISS, M.D., University of Arizona College of Medicine, Tucson, Arizona
Am Fam Physician. 2005 Jan 15 71:315-322.
In response to the growing population of older patients with incontinence, pharmaceutical companies are developing new drugs to treat the condition. Before prescribing medications for incontinence, however, physicians should determine the nature and cause of the patients incontinence. The evaluation should rule out reversible conditions, conditions requiring special evaluation, and overflow bladder. The best treatment for urge incontinence is behavior therapy in the form of pelvic floor muscle exercises. Medications, used as an adjunct to behavior therapy, can provide additional benefit. Many therapies are available for patients with stress incontinence, including pelvic floor muscle exercise, surgery, intravaginal support devices, pessaries, periurethral injections, magnetic chairs, and intraurethral inserts. No medication has been approved for the treatment of stress incontinence, although medications are under development.
Urinary incontinence is one of the most common chronic medical conditions seen in primary care practice. It is more prevalent than diabetes, Alzheimers disease, and many other conditions that receive considerably more attention. Incontinence is an expensive problem, generating more costs each year than coronary artery bypass surgery and renal dialysis combined.1,2
Strength of Recommendations
Other Therapies For Urge Urinary Incontinence
Botulinum toxin. Botulinum toxin A , a powerful neurotoxin produced by the bacterium Clostridium botulinum, has been studied as therapy for idiopathic detrusor overactivity in a variety of patients, including those who did not respond to anti-cholinergic drugs. BTX-A prevents the release of acetylcholine at the neuromuscular junction. This effect, in turn, inhibits depolarization of the detrusor muscle, resulting in chemical denervation of the bladder. BTX-A is administered via a cystoscopic technique that is reported to be safe and well tolerated. The toxin is injected directly into the detrusor muscle. In clinical trials, the duration of response was typically 3 to 6 months. Intravesical injections of BTX-A in patients with OAB resulted in increased bladder capacity, increased bladder compliance, and improved quality of life.,
A study of onabotulinumtoxinA in patients with idiopathic UUI or OAB indicated that doses ranging from 100 U to 150 U were effective in managing the disorder. Adverse effects included UTIs and urinary retention.
Although clinical trials with BTX-A have not been robust, they suggest that this agent may offer potential benefits for patients with UUI. Further research is necessary to substantiate the usefulness of BTX-A in this population.
Who Is At Risk For Urinary Incontinence
In adults, you are at higher risk of developing UI if you:
- Are female, especially after going through pregnancy, childbirth, and/or menopause
- Are older. As you age, your urinary tract muscles weaken, making it harder to hold in urine.
- Are a man with prostate problems
- Have certain health problems, such as diabetes, obesity, or long-lasting constipation
- Are a smoker
- Have a birth defect that affects the structure of your urinary tract
In children, bedwetting is more common in younger children, boys, and those whose parents wet the bed when they were children.
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Behavioral Modification And Bladder Training
Bladder training is a conservative behavioral treatment for urinary incontinence that primary care physicians can teach. It is primarily used for urgency urinary incontinence but can also be useful in stress urinary incontinence.
After completing a bladder diary and gaining awareness of their daily voiding patterns, patients can learn scheduled voiding to train the bladder, gradually extending the urges to longer intervals.
Clinicians should instruct patients on how to train the bladder, using methods first described by Wyman and Fantl.
There is evidence that bladder training improves urinary incontinence compared with usual care.,
The ACP recommends bladder training for women who have urgency urinary incontinence, but grades this recommendation as weak with low-quality evidence.
Pessaries And Other Devices
Pessaries are commonly used to treat pelvic organ prolapse but can also be designed to help correct the anatomic defect responsible for stress urinary incontinence. Continence pessaries support the bladder neck so that the urethrovesicular junction is stabilized rather than hypermobile during the increased intra-abdominal pressure that occurs with coughing, sneezing, or physical exertion . In theory, this should decrease leakage.
A ring pessary in place.
A systematic review concluded that the value of pessaries in the management of incontinence remains uncertain. However, there are inherent challenges in conducting trials of such devices. A pessary needs to be fitted by an appropriately trained healthcare provider. The Ambulatory Treatments for Leakage Associated With Stress Incontinence trial reported that behavioral therapy was more effective than a pessary at 3 months, but the treatments were equivalent at 12 months.
The FDA has approved a disposable, over-the-counter silicone intravaginal device for treating stress urinary incontinence. Patients initially purchase a sizing kit and subsequently insert the nonabsorbent temporary intravaginal bladder supportive device, which is worn for up to 8 hours.
Women may elect to use regular tampons to do the job of a pessary, as they are easy to use and low in cost. No large randomized trials have compared tampons and pessaries, and currently no one device is known to be superior to another.
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What Are The Symptoms Of Incontinence
The main symptom of incontinence is a leakage of urine. This could be a constant dripping of urine or an occasional experience of leakage. If you have incontinence, you might have large amounts or small amounts of leaked urine. You might experience leakage for a wide variety of reasons often depending on the type of incontinence you have.
You might leak urine when you:
- Have an urge to urinate, but cant make it to the toilet on time.
- Have to get up in the middle of night to urinate .
Incontinence Associated With Benign Prostatic Hyperplasia
Chronic bladder outlet obstruction leads to functional changes, such as decreased bladder compliance and detrusor overactivity. In turn, this may result in frequency, urgency and urgency incontinence.10Detrusor overactivity, mediated by M2 and M3 muscarinic receptors, contributes to lower urinary tract symptoms in approximately 15% of men.11
In patients with overactive bladder syndrome secondary to bladder outlet obstruction, treatment varies from watchful waiting to drug therapy and various surgical options depending on the severity of symptoms and indications for intervention.11The mainstay of drug treatment includes alpha adrenergic receptor blockers and 5-alpha-reductase inhibitors. If the overactive bladder syndrome is secondary to bladder outlet obstruction there may be a role for combinations of these drugs. Although there is a risk of acute urinary retention with alpha adrenergic receptor blockers and antimuscarinic drugs in combination, the rate is low.12
With 5-alpha-reductase inhibitors, common adverse effects include fatigue, loss of libido and ejaculatory and/or erectile dysfunction. Long-term use at the end of four years shows an absolute reduction in the overall risk of developing prostate cancer.13The alpha blockers can cause hypotension. As the elderly are more susceptible to orthostatic hypotension, they may have an increased risk of falls.
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How Do Doctors Diagnose Urinary Incontinence
The treatments for different types of urinary incontinence are varied, so its important for us as doctors to make a distinction and ask patients the right questions about their symptoms. Their answers help us determine a diagnosis and formulate a treatment plan.
Some common questions we ask about urine leakage include:
- When did you start leaking urine?
- Do you leak urine with activity?
- Do you experience a sense of urgency to urinate?
- If so, do you leak urine if you cant get to the bathroom right away?
- How many times per day and night do you go to the bathroom?
- Do you use pads to protect against urine leakage?
- If so, how many times per day do you change your pad?
Once we have a solid, overall view of a patients symptoms, we can determine whether she has stress or urge urinary incontinence, or a combination of both.
“The treatments for different types of urinary incontinence are varied, so its important to make a distinction and ask patients the right questions about their symptoms. Their answers help us determine a diagnosis and formulate a treatment plan.”
Maria Florian-Rodriguez, M.D.
Two Types Of Urinary Incontinence
Stress urinary incontinence
Stress urinary incontinence is due to the weakening of the pelvic floor and is most commonly associated with childbirth. The pelvic floor is the term for the muscles and ligaments that support the bladder, uterus, rectum, and vagina. Women with this condition often leak urine when coughing, laughing, sneezing, exercising, or, in severe cases, just walking.
At UT Southwestern, we start with the most conservative treatment then work our way toward more advanced techniques. Based on a patients symptoms, we can take one of three approaches to managing urinary incontinence:
Urge urinary incontinence
Overactive bladder or urinary urgency is the feeling of a sudden urge to urinate that is difficult to control and can lead to leakage if you dont go to the bathroom right away. Symptoms also include going to the bathroom more than eight times a day or waking up multiple times at night to go to the bathroom.
The condition is associated with aging, obesity, menopause, and smoking. But what women eat and drink also can cause bladder irritation. Spicy, acidic, or citrusy foods and artificial sweeteners can cause problems, as can alcohol and caffeinated drinks such as coffee, tea, or soda.
Medication is the gold-standard treatment for urge urinary incontinence. These drugs allow the bladder to fill up with more urine before giving the signal that a patient needs to use the bathroom.
To schedule an appointment, call orrequest an appointment online.
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Can Incontinence Be Prevented
Different events throughout your life can lead to many of the things that cause incontinence. The muscles that support your pelvic organs can weaken over time. For women, these muscles can also be weakened by big life events like pregnancy and childbirth. However, in the same way you work out to build strength in your legs or arms, you can do exercises to strengthen your pelvic floor muscles. Doing exercises to strengthen your pelvic muscles may not prevent you from having any issues with incontinence, but it can help you regain control of your bladder. Maintaining a healthy body weight can also help with bladder control. Talk to your healthcare provider about the best ways to maintain strong pelvic floor muscles throughout your life.
What Your Treatment Will Involve
Your healthcare providers recommended treatment plan will depend on the cause of your incontinence. An underlying medical condition may require medication, surgery, or other treatments.
In certain situations, your healthcare provider may not be able to cure your bladder incontinence. In these cases, there are steps you can take to manage your condition.
For example, your healthcare provider may advise you to:
- adjust your diet or fluid intake
- maintain a clear and well-lit path to the bathroom
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How Do I Do Kegel Exercises
Kegel exercises are a simple way to build strength in your pelvic floor muscles. These exercises are done by lifting, holding and then relaxing your pelvic floor muscles. You can find these muscles by stopping the flow of urine mid-stream while youre urinating. Only do this until you learn how to find the muscles stopping the flow of urine mid-stream isnt healthy over a long period of time.
When youre doing Kegel exercises, start small. Only hold it for a few second. Over time you can slowly work your way up to longer and longer stretches of holding the muscles tight.
Unlike other types of workouts, no one can tell when youre doing Kegel exercises. Aim to do several sets of Kegel exercises twice a day.
Percutaneous Tibial Nerve Stimulation
Normal voiding depends not only on the normal function of organs and muscles, but also on nerves that deliver appropriate signals regarding urination. In urge incontinence, the nerves regulating the bladder can become hyper-reactive, sending strong signals to empty before the bladder is full. Nerve stimulation therapies “jam” the pathways that transmit these abnormal messages.
In PTNS, a small acupuncture needle is placed in the ankle along the tibial nerve. A handheld device connects to the needle to deliver mild electrical impulses to the nerve. These travel up the tibial nerve to the sacral nerve plexus, which regulates the bladder. PTNS sessions are painless, last 30 minutes and are repeated weekly for 12 weeks. All sessions take place in a medical office.
Medicine For Stress Incontinence
If stress incontinence does not significantly improve with lifestyle changes or exercises, surgery will usually be recommended as the next step.
However, if you’re unsuitable for surgery or want to avoid an operation, you may benefit from an antidepressant medicine called duloxetine. This can help increase the muscle tone of the urethra, to help keep it closed.
You’ll need to take duloxetine tablets twice a day and will be assessed after 2 to 4 weeks to see if the medicine is beneficial or causing any side effects.
Possible side effects of duloxetine can include:
Do not suddenly stop taking duloxetine, as this can also cause unpleasant side effects. A GP will reduce your dose gradually.
Duloxetine is not suitable for everyone, however, so a GP will discuss any other medical conditions you have to determine if you can take it.
Urinary Stress Incontinence Treatment
Urinary incontinence is a condition where an individual passes urine involuntarily. It affects approximately 200 million people worldwide. Though it is more common in women than men. Dr. Amal Al Qedrah specializes in advanced urinary stress incontinence treatment for women based on focused and individualized patient care.
Our specialists help patients effectively manage the symptoms of UI with the goal of enabling them to enjoy a better quality of life. Its important to determine the type of urinary incontinence that you have, and your symptoms often tell your doctor which type you have. So you need to take care of your health by visiting and consulting doctors periodically.
Childbirth incontinence may occur as a result of pressure, overweight, or other medical conditions that tighten the pelvic floor muscles. When the pelvic floor muscles are unable to support the bladder properly, the bladder descends and presses the vaginal walls. The muscles surrounding the urethra cannot be strengthened. Urine may leak due to excess pressure on the bladder caused by coughing, sneezing, laughing, exercising, or various other movements.
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Electrical And Magnetic Stimulation
Electrical stimulation of the pelvic floor muscles with a vaginal or anal electrode can be used in women who cannot voluntarily contract pelvic floor muscles.13 This can be done at home and typically consists of two 15-minute sessions daily for 12 weeks. Medicare has approved its use in patients who have incontinence that does not respond to structured pelvic floor muscle exercise programs.
Extracorporeal magnetic innervation involves a series of treatments in which the patient sits, fully clothed, on a chair that generates a low-power magnetic field. Patients typically undergo two or three treatments per week for six to eight weeks. One early study showed this method to be most effective for women who have mild stress incontinence .39 A more recent study found it to be more effective than sham treatment for women who are unable to generate adequate pelvic floor muscle contractions.40
What Are Kegel Exercises
Kegel exercises, also called Kegels or pelvic floor muscle training, are exercises for your pelvic floor muscles to help prevent or reduce stress urinary incontinence. Your pelvic floor muscles support your uterus, bladder, small intestine, and rectum.
Four in 10 women improved their symptoms after trying Kegels.9 Kegels can be done daily and may be especially helpful during pregnancy. They can help prevent the weakening of pelvic floor muscles, which often happens during pregnancy and childbirth. Your pelvic floor muscles may also weaken with age and less physical activity.
Some women have urinary symptoms because the pelvic floor muscles are always tightened. In this situation, Kegel exercises will not help your urinary symptoms and may cause more problems. Talk to your doctor or nurse about your urinary symptoms before doing Kegel exercises.
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Guidance For Industry And Fda Staffclinical Investigations Of Devices Indicated For The Treatment Of Urinary Incontinence
This guidance represents the Food and Drug Administrations current thinking on this topic. It does not create or confer any rights for or on any person and does not operate to bind FDA or the public. You can use an alternative approach if the approach satisfies the requirements of the applicable statutes and regulations. If you want to discuss an alternative approach, contact the FDA staff responsible for implementing this guidance. If you cannot identify the appropriate FDA staff, call the appropriate number listed on the title page of this guidance.
Why Does Pregnancy Cause Incontinence
During pregnancy, your body goes through a lot of physical changes. As your uterus stretches to hold the growing baby, a few things happen. Your bladder can be squished by the expanding baby, making your bladder hold less than before. You might experience an increased urgency to pee during pregnancy because your bladder cannot hold as much as before. This might become even more challenging towards the end of pregnancy when the baby is at its largest.
Another reason for incontinence during pregnancy is the weakening of your pelvic floor muscles. These muscles are the support structures for all of the organs in your pelvis. During pregnancy, they can be stretched and weakened as your uterus expands.
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