Treatment for UI can include behavioral, pharmacologic, and device or surgical intervention. With all types of incontinence, it is important to maximize treatment for comorbid conditions that can exacerbate urinary symptoms. Medications that contribute to bladder dysfunction and polyuria should be modified if possible (Table 39–3). In some people, reducing dietary diuretics, such as caffeine and alcohol, and bladder irritants, such as spicy foods or acidic fruits, can reduce urinary symptoms. Cautious avoidance of excess liquid intake at certain times of the day may be useful.
Table 39–3.Medications that can contribute to urinary incontinence. ||Download (.pdf) Table 39–3. Medications that can contribute to urinary incontinence.
|Medication/Class ||Mechanism |
| ||Anticholinergic effects on bladder wall/sphincter |
| ||Increased urinary volume and diuresis |
|Sedation; impaired cognition |
|Opioids ||Opioid receptor-induced bladder dysfunction |
|α-Adrenergic agonists ||Urethral sphincter constriction |
Behavioral modification utilizes lifestyle and environmental modifications to reduce episodes of UI.
Habit training identifies UI triggers and employs situational bladder emptying to prevent incontinence episodes. Examples include toileting after meals, prior to bedtime, or before vigorous physical exercise if these events are regularly associated with incontinence.
Scheduled (Timed) Voiding
Scheduled voiding utilizes regularly timed attempts to void, regardless of urge or sensation to urinate. This approach minimizes large bladder volumes that may result in incontinent episodes. The interval between voids can be increased or decreased based on success in staying dry. This is especially useful in cognitively impaired or nursing home populations where caregivers can plan interval toileting, for example, every 2 hours, to reduce incontinence episodes.
This technique can also be used for bladder retraining in cognitively intact individuals with urge type incontinence. Scheduled voids are first performed at an interval that allows for maximal dryness. The interval is then increased by 30–60 minutes every few days to “train” the bladder to accommodate an increasing volume of urine. With success, time between voiding can reach 3–4 hours without urgency symptoms or leakage.
Prompted voiding employs frequent inquiry about the need to pass urine and assistance to the toilet when the response is “yes.” This is generally used by caregivers of cognitively impaired adults with functional or urge incontinence.
Pelvic muscle training (a.k.a. Kegel exercises) strengthens the urinary sphincter and pelvic floor by exercising the pelvic floor muscles which are under voluntary control. This is most useful in women with stress-type incontinence. The pelvic muscles are contracted for 8–10 repetitions of 6–8 seconds each. To ensure the proper muscles are being used, instruct women to “hold back” the urine flow while voiding on the toilet. Hold these muscles contracted for progressively longer times, up to 10 seconds if possible. Three sets of these contractions should be performed 3–4 times daily to augment the closing pressure of the pelvic floor–urethral sphincter mechanism. Some women have difficulty localizing the pelvic floor muscles, which are used for continence control. Specially trained gynecologic physical therapists can assist women in isolating and appropriately exercising these muscles. Techniques, such as biofeedback, electrical stimulation, and the insertion of weighted vaginal cones, can be used to improve pelvic floor strength.
SH Urinary incontinence: behavioral modification therapy in older adult. Clin Geriatr Med
N Pelvic floor exercise for urinary incontinence: a systematic literature review. Maturitas
Pharmacotherapy can be effective for all forms of UI, but medication must be carefully selected to target the underlying etiology of the incontinence (Table 39–4). In many cases, medications modulate bladder wall and sphincter function through antimuscarinic or anticholinergic effects on sympathetic or parasympathetic pathways. Because many older adults have mixed type of incontinence, medications must be used cautiously, as improvement in one type of incontinence (eg, urge type) may worsen another form (eg, overflow type).
Table 39–4.Medications used to treat urinary incontinence.
A meta-analysis has shown that topical estrogen can improve incontinence in women with both stress- and urge-type symptoms. Topical estrogen is usually supplied through vaginal suppositories and creams. For some women, however, ring devices impregnated with estrogen that are placed in the vagina for up to 3 months can be more practical than daily estrogen administration. Systemic (oral) estrogen is not beneficial for control of UI, and, in fact, may worsen urinary symptoms.
et al Oestrogen therapy for urinary incontinence in post-menopausal women. Cochrane Database Syst Rev
The mainstay of pharmacotherapy for urge incontinence is the use of medications with anticholinergic effects through inhibition of muscarinic postganglionic cholinergic sites on the bladder wall. This reduces bladder wall contraction and thus increases bladder capacity. Numerous medications are now available in this category. These medications may be available in sustained-release oral and transdermal formulations, which are generally better tolerated; however, efficacy is not superior to the immediate-release formulations. Given the heterogeneity in studies and variety of clinical outcomes measured, it is difficult to say with certainty, even with meta-analysis data, that any one medication is truly superior to another. The anticholinergic side effects of these medications can be troublesome to older adults and include dry eyes and mouth, constipation, headache, dizziness, orthostatic blood pressure changes, and confusion.
EJ Which anticholinergic drug for overactive bladder symptoms in adults. Cochrane Database Syst Rev
The prostate, bladder neck, and urethral tissue contract under the stimulation of α-adrenergic receptors. Alpha blockade allows relaxation of these tissues to improve urine flow and is used most frequently in men with bladder outlet obstruction caused by BPH. The literature clearly demonstrates the benefit of α blockers in reducing urinary retention in this population. A number of α blockers are available. Most of these medications are “nonselective” for urinary tract tissue and also block the α receptors on the vascular system, causing vasodilation and hypotension. Tamsulosin and silodosin are “selective” α1A blockers, with minimal binding to nonurinary tissues and thus less potential to cause hypotension. These medications are considered preferential for older men because of their more favorable side-effect profile.
Because α blockade allows for urethral relaxation, these medications have potential for use in non-BPH overflow incontinence from neurogenic bladder, urethral obstruction, or urethral noncompliance. Studies show benefit in urinary symptoms and flow rates with use of α-blocker in these conditions. Alpha blockers have also been shown to improve the success in removing an indwelling urinary catheter after placement for urinary retention. Studies suggest that as little as 48 hours of α-blockade treatment may be needed prior to successful catheter removal. There is growing interest in using α blockers for women with bladder outlet obstruction. Recent studies demonstrate improvement in urinary flow and urinary symptoms in women with bladder outlet obstruction or neurogenic bladder, but not with overactive bladder.
5α-Reductase inhibitors (5αRI) block the conversion of testosterone to the active metabolite, dihydrotestosterone, reduce prostate tissue volume and thus reduce bladder outflow obstruction. Both finasteride and dutasteride have been well studied and demonstrate improvement in overflow incontinence and LUTS in men with BPH (see Chapter 40, “Benign Prostatic Hyperplasia & Prostate Cancer,” for more on treatment of benign prostatic hypertrophy).
Bethanechol is a muscarinic agonist at smooth muscle cholinergic receptors. Although it generally is used to stimulate gastric motility it has the pharmacologic potential to increase detrusor tone and improve bladder emptying in the setting of neurogenic bladder. There is no evidence that bethanechol is clinically efficacious for managing urinary symptoms and the side effects of dizziness, hypotension, nausea, and abdominal cramping make this medication a poor choice for older adults.
Because of the anticholinergic properties, tricyclic antidepressants (TCAs) may improve symptoms of detrusor hyperactivity. A few studies have been done to demonstrate efficacy of this class of medication for UI, but most have looked at imipramine. Side effects of TCAs limit use in many older adults.
Nocturia occurs in many older adults as a result of increased nocturnal mobilization of peripheral edema and increased levels of atrial natriuretic peptide. This can lead to nocturnal UI. Studies indicate desmopressin can effectively reduce nocturia and bothersome urinary symptoms; however, significant hyponatremia developed in some older subjects. Routine use of desmopressin for nocturnal UI is not recommended in older adults.
Incontinence pads, adult diapers, and incontinence garments are regularly used to manage incontinence episodes. An estimated 4.4 billion dollars are spent annually in United States nursing homes alone for incontinence products, laundry service and continence care.
Urinary collection devices for management of transient or chronic urinary retention include intermittent or indwelling catheters. For the cognitively intact and motivated person (or caregiver), intermittent catheterization is preferable as it is less likely to result in urinary tract infection when compared to other forms of urinary catheterization. External (condom-type) catheters are not appropriate for management of urinary retention but may be desirable for men who want to avoid urinary leakage from other types of UI. These devices also increase the risk of urinary tract infection, and can cause skin irritation or infection, so should be used cautiously.
Women with GU organ prolapse can experience overflow urinary incontinence from obstruction or worsening of stress urinary incontinence. Those who do not desire, or are not appropriate surgical candidates, can benefit from placement of a pessary. Pessaries are plastic or silicone devices that are inserted into the vagina to physically prevent the prolapse of surrounding tissues into the vaginal canal. These devices come in a variety of sizes and shapes including ring, cube, and Gellhorn types. Some devices must be removed regularly and require dexterity and motivation for use. Other types can remain in place for several weeks and can be changed for cleaning and inspection by medical providers.
DE Practicalities and pitfalls of pessaries in older women. Clin Obstet Gynecol
Temporary urethral blockade may be attained by using internal urethral plugs or external adhesive seals or patches (foam pads). Plugs function like a balloon and must be inserted into the urethra and inflated when continence is desired. These devices are generally used for stress type incontinence. Permanently placed balloon devices can be implanted with adjustable inflation/deflation mechanisms to control continence. These are generally used in men with postprostatectomy destruction of the urethral sphincter. Complete continence is achieved in approximately 30% of men, and complication rates average between 20% and 30%.
Urethral bulking procedures involved the injection of collagen around the bladder neck, external to the urethral sphincter, to increase the urethral impedance to urinary flow. This may be done in women with stress or urge incontinence or in men after prostate surgery. Unfortunately improvement in symptoms is often modest, with low cure rates and deterioration in benefit over time.
An artificial urethral sphincter can be surgically implanted for control of stress-type incontinence. This is usually performed in men after prostate surgery and has been shown to have significant benefit on control of UI. Unfortunately, up to 25% of devices must be revised or replaced within 5 years of implantation because of erosion or mechanical failure of the device.
Surgical suspension options—
Five major types of surgical suspension procedures are used for management of UI in women and are generally performed for stress-type incontinence: anterior repair, suburethral sling, colposuspension, long-needle suspension, and tension-free vaginal tape (TVT). Anterior repair (colporrhaphy) utilizes sutures or support material to elevate the urethra and/or bladder neck and reconstruct the pubocervical fascia. Cure rates and effectiveness deteriorate substantially with time and this procedure is losing favor for treatment of UI. Needle-suspension procedures are more minimally invasive means of supporting the bladder neck by placing sutures through a transcutaneous approach. This procedure has significantly less success and higher complications than other techniques and is generally not being recommended for the routine treatment of UI. Open colposuspension (also referred to as Burch procedure) uses sutures to elevate the periurethral fascia toward the Cooper ligament. A systematic review of more than 4000 women demonstrated a cure rate of 80% with this procedure, and 60% remained continent at 5 years. Open colposuspension has largely been replaced by the less-invasive suburethral sling or TVT procedures. The sling procedure uses a band of either synthetic or autologous fascial material. The band is guided under the bladder neck and both ends are anchored into the pelvic tissue to approximate normal bladder position. TVT uses a similar suspension technique, but at the midurethra and without anchoring of the material. The evidence suggests that TVT is equally effective as traditional fascial sling operations. TVT is more effective than open colposuspension.
R Committee 13: surgical treatment of urinary incontinence in men. In: Abrams P, Cardozo L, Khoury S, Wein A, eds. Incontinence. 4th ed. Paris, France: Health Publication Ltd 2009:1121-–1190. Available at: http://www.icsoffice.org/Publications/ICI_4/files-book/comite-13.pdf