Urinary Incontinence: Treatment

In general, patient and/or caregiver education is an important part of the treatment strategies for urinary incontinence. Urinary incontinence is not considered a normal part of aging--and some causes are reversible. Patients and/or caregivers should be informed of the treatment options available and the recommended pathway to explore these options.

 

Stress incontinence Conservative: behavioral therapy, exercises to strengthen pelvic muscles, weight loss if overweight, electrical stimulation, Absorbent pads and catheters   Urge incontinence Conservative: behavioral therapy, exercises, weight loss Absorbent pads and catheters   Mixed: treatment as above focusing on dominant   symptoms

The type of urinary incontinence determines the types of treatment and management that may be prescribed. The categories of treatment are generally conservative, pharmacologic, and surgical. These generally start with the least invasive treatment options with an escalation to the more invasive options, if needed. The review of medications may allow for some changes to reduce the risk for incontinence. Substances, such as caffeine and alcohol, should be avoided if they contribute to incontinence. Generally, during end-of-life care, urinary incontinence can create a burden for the patient and their caregivers and are handled according to the individual patient's needs and wishes. Maximizing comfort may suggest the use of an indwelling or condom catheter. Behavioral treatments may include instruction on fully emptying the bladder more completely using double voiding techniques to urinate again a few moments after initial urination. Fluid and diet management may include education about avoiding alcohol, caffeine, acidic foods that may irritate the bladder. In some cases, reducing fluid consumption and/or the changing the types of fluids consumed, losing excessive weight, and/or increasing physical activity may help to reduce symptoms.

Stress incontinence management begins with conservative treatments that include behavioral therapy, exercises to strengthen pelvic floor muscles, and weight loss if the patient is overweight. For now, let’s concentrate on behavioral therapy as a first line of treatment. It should be noted that improvements don’t necessarily mean staying completely dry, but reducing the frequency and amount of urine leakage.

Behavioral therapy is a first line of treatment options for stress and urge incontinence and is generally considered for first because of the level of safety, absence of side effects, patient comfort, and high levels of patient satisfaction. Between 57% to 86% reduction in the frequency of incontinence has been achieved through behavioral therapies. Bladder drills and bladder training were among the earliest forms of treatments for urge incontinence. Bladder drills impose longer intervals between urination to help in establishing a more normal frequency of urination. Bladder training is similar, but uses a more gradual fashion of training in an outpatient setting. Bladder training in outpatient settings have achieved cure rates of between 44% and 90%.  

Multicomponent behavior therapy includes the behavioral therapy we described, but focuses on pelvic floor muscle rehabilitation, which has yielded a 76% to 86% reduction in incontinence. Exercises were designed to teach patients how to control and exercise periurethral muscles. The goal is to use voluntary contraction of these muscles to block the urethra during activities that may lead to leakage in stress incontinence. These exercises were considered effective with rates of improvement or cure that ranged from 38% to 100% in trials. It should be noted that trials were typically done in older women, who are at greatest risk for urinary incontinence, and several were combined with estrogen therapy or electrical stimulation.

Electrical stimulation involves electrodes that are temporarily inserted into the vagina or rectum to strengthen pelvic muscles and may include multiple treatments over several months. Biofeedback may also be included during the instruction phase to assure that patients are correctly conducting the exercises. Pelvic floor exercises are generally considered an effective treatment in both men and women. The addition of electrical stimulation to better identify and strengthen muscles involved and shows a trend toward improvement, but not significant contribution to improvement rates.

Pelvic floor exercises were originally used for stress incontinence. But more recent study suggests that voluntary pelvic muscle contraction can inhibit detrusor contraction, making it viable as a treatment for urge incontinence. For patients with urge incontinence, this involves behavioral training to resist rushing to the toilet by pausing, sitting, relaxing the body, and contracting pelvic floor muscles multiple times to reduce urgency, inhibit detrusor contraction, and prevent leakage. Once the urgency subsides the patient can proceed to the toilet at a normal pace.

Supervised pelvic floor muscle training, or PFMT, has been studied for performance in stress, urge, and mixed incontinence. Nearly 60% of women were able to maintain adequate symptom control at the 12-month mark and 78% maintained the same result at the 6-month mark in stress incontinence cases. Between 24% and 35% of men maintained adequate control at the 12-month mark in cases of urge incontinence. Finally, about 28% of women and 47% of men were able to maintain control at the six-month mark for mixed urinary incontinence.

And it is interesting to note that exactly how behavioral therapy works has not been clearly established. Improvement in urinary incontinence frequency has been seen even without improvements in the risk factors of bladder capacity and detrusor muscle instability. While it may seem counterintuitive, it seems that improved bladder function may not be fully necessary to achieve clinical improvements with behavioral therapy.

Absorbent pads and catheters may also be used if medical treatments don’t adequately reduce incontinence. Pads and protective garments these days are often no more bulky than normal underwear. Men who experience urine dribbles can use a drip collector, which is a small pocket of absorbent padding sorn over the penis and held in place by tighter-fitting underwear. Catheters may be used and patients can be instructed on inserting a soft tube catheter into the urethra several times a day for urination. It will be important to also provide instruction on how to clean these reusable catheters to use safely.

We should note patient satisfaction as an important outcome for treatment. Behavioral treatment studies suggest that improvements in patient satisfaction are seen at a fairly high rate, but complete continence may be achieved at a much lower rate. Patient reports of being “much better” or “completely satisfied” were typically higher than for the rates of continence achievement. It is important to consider patient satisfaction and the impact that behavioral treatment can have on patient quality of life. Quality of life survey instruments are routinely used in studies of incontinence, recognizing the value of patient perspective on changes in symptoms and quality of life dimensions.