Urinary Incontinence: Treatment (continued)

Trials of behavioral therapy may be followed by pharmacologic therapies and ultimately (and only as needed), surgical therapies. Common medications include anticholinergics to help in calming an overactive bladder in cases of urge incontinence. Examples of this type of therapy includes oxybutynin (Ditropan XL), tolterodine (Detrol), darifenacin (Enablex), fesoterodine (Toviaz), solifenacin (Vesicare), and tospium chloride.

Mirabegron (Myrbetriq) relaxes bladder muscles for cases of urge incontinence and can increase bladder capacity to hold more urine. It may also increase the amount urine that can be released during urination for more complete bladder emptying.

Alpha blockers, such as tamsulosin (Flomax), alfuzosin (Uroxatral), silodosin (Rapaflo), and doxazosin (Cardura), may be used in men who have urge or overflow incontinence. These medications relax bladder neck muscles and the muscle fibers in the prostate to make it easier to empty the bladder.

For women, topical low-dose estrogen, which come in forms of a cream, ring, or patch, may help to rejuvenate and tone tissues in the urethra and vaginal areas.

Medical devices to treat women include urethral inserts and pessary. Urethral inserts are small, tampon-like disposable plugs that can block urination during specific activities that may be associated with urinary incontinence. A pessary is a flexible silicone ring inserted into the vagina to wear during active times of the day. This device helps to support the urethra to prevent leakage and is used in women with vaginal prolapse.

Other therapies may include injections of bulking materials, botox injections, and nerve stimulators. Synthetic bulking materials may be injected around the urethra in cases of stress incontinence to help to keep it closed and prevent leakage. These injections are seen as less effective than more invasive surgical methods. Botox may be injected into the bladder muscle for overactive bladder and urge incontinence. Botox is generally reserved for those who have failed other therapies. Botox injections have shown between 16% and 51% symptom control in women at the three-month mark. Nerve stimulators include use of painless electrical pulses to stimulate the sacral nerves that are involved in bladder control in overactive bladder and urge incontinence. This therapy may be used if other therapies fail. Neurological treatments for women with urge incontinence have maintained adequate symptom control about 17% after 10 years. The two types of nerve stimulator devices include one that is inserted under the skin in the buttocks area and connected to wires on the lower back. The other is a removable plug inserted into the vagina.

Surgeries may be indicated if other treatments fail. At 12 months, about 84% of women who received surgical intervention for stress incontinence and 82% of women surgically treated for mixed incontinence maintained satisfactory symptom control. This rate was about 53% after three years for men who received sling surgeries. 

Surgeries may include sling procedures, bladder neck suspension, prolapse surgery, and artificial urinary sphincter placement. Slings are used to treat stress incontinence by placing synthetic mesh or strips of body tissues under the urethra and bladder neck to help keep the urethra closed. A bladder neck suspension provide support to the bladder neck and urethra with sutures that connect the neck of the bladder (where bladder and urethra meet) to ligaments near the pubic bone. Prolapse surgery may be used for women who have pelvic organ prolapse and mixed incontinence. It may include the combination of a sling procedure and prolapse surgery because the repair of prolapse alone doesn’t usually improve incontinence symptoms. Artificial urinary sphincters are small, fluid-filled rings that are surgically placed around the bladder neck to keep the urinary sphincter shut until there is a need to urinate. In this case, in order to urinate, the patient must press a valve impacted under the skin that allows the ring to deflate to let urine flow from the bladder.

Overflow Incontinence

As in stress and urge incontinence, overflow incontinence treatment may involve bladder training and scheduled toileting, double voiding to ensure bladder emptying, and fluid and diet management.

Additional treatment may include intermittent catheterization that involves patient and/or caregiver instruction on the placement of a soft-tube catheter to allow urination several times in a day. Alternatively, an indwelling catheter may be placed to allow urination. Obstructions can be identified and proper treatment applied to remove these barriers. Medical devices used in stress, urge, and mixed incontinence may also be applied, such as a pessary or urethral insert.

Pharmacologic treatments for overflow incontinence are mostly used in men and may include 5a reductase inhibitors that treat enlarged prostates. Alpha-blockers, as used in treatment of urge incontinence in men, may also be used for overflow incontinence treatment.

Surgical options may include similar treatments for stress and urge incontinence, such as sling procedures, bladder neck suspension, prolapse surgery for women, and artificial urinary sphincters.

Treatment for functional incontinence is based on treating the underlying causes as well as accommodating patient limitations. In cases of cognitive deficits, there are a number of strategies that can help to maintain toileting functions as much as possible, such as improving access and identification of the bathroom, removing obstacles, and providing respectful support for instructions and hygiene.