Urinary Incontinence Management

Pharmacological therapy

Antimuscarinic Agents  

Antimuscarinic agents act mainly during the urinary storage phase, decreasing urge and increasing bladder capacity. All available antimuscarinic agents decrease the frequency of urgency and incontinence episodes effectively. The product should be selected on the basis of cost and tolerability. Antimuscarinic therapy should be tried for 4-12 weeks to assess benefits and side effects. If effective and tolerable, reassess after 6 months to ascertain continuing need. If the patient did not tolerate or failed therapy, consider giving a different antimuscarinic agent.  

The following should be considered regarding antimuscarinic therapy in men: If OAB exists without evidence of bladder outlet obstruction, then first-line therapy with antimuscarinics can be considered. In men with concomitant bladder outlet obstruction, bladder outlet resistance should be appropriately treated before considering the addition of antimuscarinics for OAB.  

Darifenacin  

The clinical effectiveness of Darifenacin has been documented in several randomized controlled trials. Its onset of action is seen by week 2 of therapy.  

Fesoterodine  

The 8-mg daily dose of Fesoterodine has been shown to be more effective than the 4-mg daily dose of Tolterodine ER in treating and improving urge incontinence but the risk of side effects is higher.  

Oxybutynin  

Oxybutynin causes smooth muscle relaxation of the urinary bladder which occurs by inhibiting the action of acetylcholine paralyzing the smooth muscles. The immediate-release form of Oxybutynin is recognized for its efficacy and newer agents are compared to it once efficacy over placebo has been determined. Older women who may be at higher risk of sudden physical or mental health deterioration should not be offered immediate-release Oxybutynin. Newer agents have been shown to be as efficacious but may have improved dosing schedules or side effect profiles.  

Propiverine  

Propiverine has been shown to have both antimuscarinic and calcium antagonistic actions (the importance of the calcium antagonist component has not been established). This has a documented beneficial effect in the treatment of detrusor overactivity (DO) and has an apparently acceptable side effect profile.  

Solifenacin  

Solifenacin has a well-documented effect in OAB/DO and its adverse effect profile seems acceptable. Studies have shown a decrease in incontinence episodes, voids per day and urgency episodes along with an increase in bladder capacity.  

Tolterodine  

Tolterodine has selectivity for the urinary bladder. Several studies have documented significant reduction in micturition frequency and in the number of incontinence episodes. A reduction in weekly urge incontinence and total incontinence in women is similar between extended-release products of Oxybutynin and Tolterodine; tolerability is also comparable. Long-acting formulations have improved tolerability without impairing effectiveness.  

Trospium  

Trospium significantly decreases the average frequency of toilet voids and urge-incontinent episodes compared to placebo. It decreases smooth muscle tone in the bladder. Trospium is effective for the treatment of OAB. Consider giving Trospium to patients with cognitive dysfunction. The effects occur by week 1 of therapy and nocturnal frequency decreases significantly by week 4. Dry mouth appears to occur in comparable frequency as Tolterodine.

Urinary Incontinence_Management

Nonpharmacological

Lifestyle Interventions  

Fluid Intake  

The average amount of fluid needed per day is calculated based on the patient’s lean body mass. Encourage patients to modify their fluid intake to produce a 24-hour urinary output between 1-2 L. A very large or small urine volume output can contribute to UI.  

Diet  

Certain foods contain stimulants that may exacerbate symptoms of incontinence such as heavy or hot spices, fruits or juices with acidic pH and corn syrup, sugar, or honey. The use of artificial sweeteners may also contribute to urge incontinence.  

Caffeine  

Examples of caffeinated drinks include coffee, tea, carbonated drinks and hot chocolate. Studies suggest that decreasing caffeine may improve frequency and urgency.

Weight Loss  

In morbidly obese women, massive (surgically induced) weight loss has been shown to significantly decrease incontinence. This should be considered as a first-line treatment. Moderate weight loss may also decrease incontinence.  

Smoking Cessation  

Smoking >20 cigarettes per day is considered to reinforce UI.  

Use of Anti-incontinence Products  

Pads and products that help contain urine loss may be beneficial. Absorbent products are temporary means to absorb urine and help protect skin and clothing. This may also be used as an adjunct to behavioral and pharmacological treatment. Patients may be assessed yearly for efficacy of the absorbent product and evaluation of skin integrity and quality of life.  

Urethral occlusive products are artificial devices inserted into or placed over the urethral meatus. These products keep patients drier but are more difficult and expensive to use compared to absorbent products.  

Catheters such as indwelling urethral catheters, suprapubic tubes and intermittent self-catheterization may be used. Discuss with the patient the risks and benefits of catheterization. Some patients improve with temporary continuous Foley catheterization wherein bladder capacity returns to normal and voluntary detrusor function improves. Intermittent catheterization is the best form of bladder draining for those who are not physically or mentally handicapped. Other anti-incontinence products such as penile clamps for men and intravaginal devices for women, may be considered.  

Bladder Retraining  

Bladder retraining may be offered as a first-line treatment in urge UI or mixed UI. There is some evidence that retraining for an OAB is more effective than no treatment in patients with urge incontinence. This tends to be more effective if urge symptoms are mild.  

Urge Suppression Training  

The patient should be instructed to sit down, if possible, or stand quietly when the urge occurs. Perform Kegel exercises (squeeze pelvic floor muscles) quickly several times without relaxing fully between squeezes. Relax the rest of the body and focus on another task for distraction. Once the urge subsides, the patient should see how long he/she can wait before going to the toilet (eg 30 seconds the first time, 1 minute the next, etc).  

Outpatient Bladder Training Protocol  

Outpatient bladder training protocol typically begins with a voiding interval of 1 hour during waking hours. Increase by 15-30 minutes per week depending on the patient’s tolerance of the schedule until a 2- to 3-hour voiding interval is achieved. The patient may start with a shorter voiding interval if baseline micturition patterns reveal a daytime voiding pattern of <1 hour.  

Pelvic Floor Muscle Exercises  

Pelvic floor muscle exercises are currently known as pelvic floor muscle training (PFMT). It is a program where repeated voluntary pelvic floor muscle contraction is taught by a healthcare professional for prevention and treatment of UI. This should be the first-line therapy to be offered for at least 3 months’ duration in patients suffering from stress or mixed incontinence; it can also be offered to elderly and post-natal women. This improves the function of the pelvic floor muscles. It involves recruitment of pelvic floor muscle strengthening and skill training. The contraction of pelvic floor muscles causes an inward lift of the muscles, resulting in an increase in urethral closure pressure, stabilization and resistance to downward movement.  

Biofeedback may promote awareness of the physiological action of pelvic floor muscles by visual, tactile or auditory means. Weighted vaginal cones are used to facilitate strengthening of pelvic floor muscles through passive and active contraction of the muscles which prevents the cones from slipping out of the vagina. Electrical stimulation uses electrical current to stimulate the pelvic floor muscles or to normalize reflex activity. This strengthens the external urinary sphincter; builds up pelvic floor muscles to prevent prolapse and helps retrain the bladder. However, better-quality evidence is needed to prove the clinical and cost-effectiveness of these conservative therapies for UI.  

Digital assessment of pelvic floor function prior to initiating therapy should be undertaken only by a properly trained clinician. Pelvic floor exercises should be considered for male patients following radical prostate surgery as there seems to be some benefit. In men with complaints of post-micturition dribble, both pelvic floor muscle exercises and urethral milking appear to be effective.  

Developing Pelvic Floor Muscle Exercise Routines  

The program should be individualized but should include exercises for both fast- and slow-twitch muscle fibers. This may be performed several times a day until the muscle fatigues. The usual program consists of three sets of 8-12 contractions, sustained for 8-10 seconds each, done three times per day. It should be practiced for 15-20 weeks and continued on a maintenance basis.