Urinary Incontinence; Causes, Symptoms, Diagnosis, Treatment

Urinary incontinence
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Urinary incontinence is the involuntary leakage of urine; in simple terms, it means a person urinates when they do not want to. Control over the urinary sphincter is either lost or weakened.Urinary incontinence is a much more common problem than most people realize.

According to the American Urological Association, one-quarter to one-third of men and women in the United States experience urinary incontinence.Urinary incontinence is more common among women than men. An estimated 30 percent of females aged 30-60 are thought to suffer from it, compared to 1.5-5 percent of men.

Types of Urinary Incontinence

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Urinary incontinence may be caused by alcohol intoxication.

  • Stress incontinence – also known as effort incontinence, is due essentially to insufficient strength of the pelvic floor muscles to prevent the passage of urine, especially during activities that increase intra-abdominal pressure, such as coughing, sneezing, or bearing down.
  • Urge incontinence  – is involuntary loss of urine occurring for no apparent reason while suddenly feeling the need or urge to urinate.
  • Overflow incontinence – Sometimes people find that they cannot stop their bladders from constantly dribbling or continuing to dribble for some time after they have passed urine. It is as if their bladders were constantly overflowing, hence the general name overflow incontinence.
  • Mixed incontinence – is not uncommon in the elderly female population and can sometimes be complicated by urinary retention, which makes it a treatment challenge requiring staged multimodal treatment.
  • Structural incontinence – rarely, structural problems can cause incontinence, usually diagnosed in childhood (for example, an ectopic ureter). Fistulas caused by obstetric and gynecologic trauma or injury are commonly known as obstetric fistulas and can lead to incontinence. These types of vaginal fistulas include, most commonly, vesicovaginal fistula and, more rarely, ureterovaginal fistula. These may be difficult to diagnose. The use of standard techniques along with a vaginogram or radiologically viewing the vaginal vault with instillation of contrast media.
  • Functional incontinence – occurs when a person recognizes the need to urinate but cannot make it to the bathroom. The loss of urine may be large. There are several causes of functional incontinence including confusion, dementia, poor eyesight, mobility or dexterity, unwillingness to toilet because of depression or anxiety or inebriation due to alcohol.Functional incontinence can also occur in certain circumstances where no biological or medical problem is present. For example, a person may recognise the need to urinate but may be in a situation where there is no toilet nearby or access to a toilet is restricted.
  • Nocturnal enuresis – is episodic UI while asleep. It is normal in young children.
  • Transient incontinence – is a temporary incontinence most often seen in pregnant women when it subsequently resolves after the birth of the child.
  • Giggle incontinence  – is an involuntary response to laughter. It usually affects children.
  • Double incontinence -there is also a related condition for defecation known as fecal incontinence. Due to involvement of the same muscle group (levator ani) in bladder and bowel continence, patients with urinary incontinence are more likely to have fecal incontinence in addition. This is sometimes termed “double incontinence”.
  • Post-void dribbling – is the phenomenon where urine remaining in the urethra after voiding the bladder slowly leaks out after urination.
  • Coital incontinence (CI) – is urinary leakage that occurs during either penetration or orgasm and can occur with a sexual partner or with masturbation. It has been reported to occur in 10% to 24% of sexually active women with pelvic floor disorders.

Causes, Symptoms, and Treatment of Urinary Incontinence

Type of Incontinence Common Causes Common Symptoms Treatment Options
Urge urinary incontinence (UUI)
  • Idiopathic detrusor overactivity
Urinary tract infections Urgency and frequency, day or night
  • Anticholinergic drugs

    • Oxybutynin
    • Tolterodine
  • Surgery

    • Intravesical Botox
    • Sacral nerve stimulation
  • Neurogenic detrusor overactivity
  • Neurological disorders

    • Parkinson’s disease
    • Alzheimer’s disease
  • Cerebrovascular accidents (e.g., stroke)

    • Trauma
    • Medications
Stress urinary incontinence (SUI)
  • Stress incontinence (outlet incompetence)
  • Pelvic surgery
  • Parity (childbirth)
  • Constipation
Small volumes of urine loss with coughing or sneezing
  • Weight loss
  • Kegel (pelvic floor) exercises with or without biofeedback
  • Sling procedures
  • Transurethral collagen denaturation (Renessa procedure)
  • Transurethral bulking agents
Mixed urinary incontinence (MUI)
  • Mixed UUI and SUI
  • Pelvic surgery
  • Parity (childbirth)
  • Constipation
Symptoms may include urge and stress features Treatment depends on predominant symptoms
Overflow incontinence (OFI)
  • Overflow incontinence
  • Benign prostatic hyperplasia (BPH)
  • Bladder outlet obstruction
  • Fecal impaction
  • Hypotonic/neurogenic bladder
  • Urethral stricture disease
Poor stream, incomplete emptying, and dribbling
  • Alpha-adrenergic blockers
  • 5-alpha-reductase inhibitors
  • Intermittent catheterization
  • Surgical options
Other types of incontinence
  • Post-prostatectomy incontinence
Disruption or denervation of pelvic floor muscle fibers Stress incontinence and dribbling
  • Kegel pelvic floor exercises
  • Male urethral sling
  • Artificial urinary sphincter
  • Fistula (e.g., colovesical or vesicovaginal)
  • Postsurgical complications
  • Crohn’s disease
  • Diverticulitis
  • Cancer
Continuous, steady incontinence Surgical repair
  • Functional incontinence
  • Limited mobility
  • Change in mental status
Symptoms vary Eliminate causes

Causes of Urinary Incontinence

Urinary incontinence isn’t a disease, it’s a symptom. It can be caused by everyday habits, underlying medical conditions or physical problems. A thorough evaluation by your doctor can help determine what’s behind your incontinence.

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Temporary urinary incontinence

Certain drinks, foods and medications may act as diuretics — stimulating your bladder and increasing your volume of urine. They include:

  • Alcohol
  • Caffeine
  • Carbonated drinks and sparkling water
  • Artificial sweeteners
  • Chocolate
  • Chili peppers
  • Foods that are high in spice, sugar or acid, especially citrus fruits
  • Heart and blood pressure medications, sedatives, and muscle relaxants
  • Large doses of vitamin C

Urinary incontinence may also be caused by an easily treatable medical condition, such as:

  • Urinary tract infection. Infections can irritate your bladder, causing you to have strong urges to urinate, and sometimes incontinence.
  • Constipation. The rectum is located near the bladder and shares many of the same nerves. Hard, compacted stool in your rectum causes these nerves to be overactive and increase urinary frequency.

Persistent urinary incontinence

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Urinary incontinence can also be a persistent condition caused by underlying physical problems or changes, including:

  • Pregnancy. Hormonal changes and the increased weight of the fetus can lead to stress incontinence.
  • Childbirth. Vaginal delivery can weaken muscles needed for bladder control and also damage bladder nerves and supportive tissue, leading to a dropped (prolapsed) pelvic floor. With prolapse, the bladder, uterus, rectum or small intestine can get pushed down from the usual position and protrude into the vagina. Such protrusions can be associated with incontinence.
  • Changes with age. Aging of the bladder muscle can decrease the bladder’s capacity to store urine. Also, involuntary bladder contractions become more frequent as you get older.
  • Menopause. After menopause women produce less estrogen, a hormone that helps keep the lining of the bladder and urethra healthy. Deterioration of these tissues can aggravate incontinence.
  • Hysterectomy. In women, the bladder and uterus are supported by many of the same muscles and ligaments. Any surgery that involves a woman’s reproductive system, including removal of the uterus, may damage the supporting pelvic floor muscles, which can lead to incontinence.
  • Enlarged prostate. Especially in older men, incontinence often stems from enlargement of the prostate gland, a condition known as benign prostatic hyperplasia.
  • Prostate cancer. In men, stress incontinence or urge incontinence can be associated with untreated prostate cancer. But more often, incontinence is a side effect of treatments for prostate cancer.
  • Obstruction. A tumor anywhere along your urinary tract can block the normal flow of urine, leading to overflow incontinence. Urinary stones — hard, stone-like masses that form in the bladder — sometimes cause urine leakage.
  • Neurological disorders. Multiple sclerosis, Parkinson’s disease, a stroke, a brain tumor or a spinal injury can interfere with nerve signals involved in bladder control, causing urinary incontinence.

The following points regarding the clinical presentation should be sought when obtaining the history:

  • Severity and quantity of urine lost and frequency of incontinence episodes
  • Duration of the complaint and whether problems have been worsening
  • Triggering factors or events (eg, cough, sneeze, lifting, bending, feeling of urgency, sound of running water, sexual activity/orgasm)
  • Constant versus intermittent urine loss
  • Associated frequency, urgency, dysuria, pain with a full bladder
  • History of urinary tract infections (UTIs)
  • Concomitant fecal incontinence or pelvic organ prolapse
  • Coexistent complicating or exacerbating medical problems
  • Obstetrical history, including difficult deliveries, grand multiparity, forceps use, obstetrical lacerations, and large babies
  • History of pelvic surgery, especially prior incontinence procedures, hysterectomy, or pelvic floor reconstructive procedures
  • Other urologic procedures
  • Spinal and central nervous system surgery
  • Lifestyle issues, such as smoking, alcohol or caffeine abuse, and occupational and recreational factors causing severe or repetitive increases in intra-abdominal pressure
  • Medications

Relevant complicating or exacerbating medical problems may include the following:

  • Chronic cough
  • Chronic obstructive pulmonary disease (COPD)
  • Congestive heart failure
  • Diabetes mellitus
  • Obesity
  • Connective tissue disorders
  • Postmenopausal hypoestrogenism
  • CNS or spinal cord disorders
  • Chronic UTIs
  • Urinary tract stones
  • Benign prostatic hyperplasia
  • Cancer of pelvic organs

Medications that may be associated with urinary incontinence include the following:

  • Cholinergic or anticholinergic drugs
  • Alpha-blockers
  • Over-the-counter allergy medications
  • Estrogen replacement
  • Beta-mimetics
  • Sedatives
  • Muscle relaxants
  • Diuretics
  • Angiotensin-converting enzyme (ACE) inhibitors

Risk factors

Factors that increase your risk of developing urinary incontinence include:

  • Gender. Women are more likely to have stress incontinence. Pregnancy, childbirth, menopause and normal female anatomy account for this difference. However, men with prostate gland problems are at increased risk of urge and overflow incontinence.
  • Age. As you get older, the muscles in your bladder and urethra lose some of their strength. Changes with age reduce how much your bladder can hold and increase the chances of involuntary urine release.
  • Being overweight. Extra weight increases pressure on your bladder and surrounding muscles, which weakens them and allows urine to leak out when you cough or sneeze.
  • Smoking. Tobacco use may increase your risk of urinary incontinence.
  • Family history. If a close family member has urinary incontinence, especially urge incontinence, your risk of developing the condition is higher.
  • Other diseases. Neurological disease or diabetes may increase your risk of incontinence.

Symptoms of urinary incontinence

The main symptom is the unintentional release (leakage) of urine. When and how this occurs will depend on the type of urinary incontinence.

Stress incontinence

This is the most common kind of urinary incontinence, especially among women who have given birth or gone through the menopause.

In this case stress refers to physical pressure, rather than mental stress. When the bladder and muscles involved in urinary control are placed under sudden extra pressure, the person may urinate involuntarily.

The following actions may trigger stress incontinence:

  • A sudden cough
  • Sneezing
  • Laughing
  • Heavy lifting
  • Exercise

Urge incontinence (effort incontinence)

Also known as reflex incontinence or “overactive bladder,” this is the second most common type of urinary incontinence. There is a sudden, involuntary contraction of the muscular wall of the bladder that causes an urge to urinate that cannot be stopped.

When the urge to urinate comes, the person has a very short time before the urine is released, regardless of what they try to do. The urge to urinate may be caused by:

  • A sudden change in position
  • The sound of running water (for some people)
  • Sex (especially during orgasm)

Bladder muscles can activate involuntarily because of damage to the nerves of the bladder, the nervous system, or to the muscles themselves.

Overflow incontinence

This is more common in men with prostate gland problems, a damaged bladder, or a blocked urethra. An enlarged prostate gland can obstruct the bladder.

The bladder cannot hold as much urine as the body is making and/or the bladder cannot empty completely, causing small amounts of urinary leakage. Often, patients will need to urinate frequently, and they may experience “dribbling” or a constant dripping of urine from the urethra.

Mixed incontinence

This is where a patient experiences both stress and urge incontinence at the same time.

Functional incontinence

With functional incontinence, the person knows there is a need to urinate, but cannot make it to the bathroom in time due to a mobility problem.

Common causes of functional incontinence include:

  • Confusion
  • Dementia
  • Poor eyesight
  • Poor mobility
  • Poor dexterity (cannot unbutton pants in time)
  • Depression, anxiety, or anger (unwilling to go to the toilet)

Functional incontinence is more prevalent among elderly people and is common in nursing homes.

Gross total incontinence

This either means that the person leaks urine continuously, or has periodic uncontrollable leaking of large amounts of urine.

The patient may have a congenital problem (born with a defect), there may be an injury to the spinal cord or urinary system, or there may be a hole (fistula) between the bladder and, for example, the vagina.

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Diagnosis

A careful history taking is essential especially in the pattern of voiding and urine leakage as it suggests the type of incontinence faced. Other important points include straining and discomfort, use of drugs, recent surgery, and illness.

The physical examination will focus on looking for signs of medical conditions causing incontinence, such as tumors that block the urinary tract, stool impaction, and poor reflexes or sensations, which may be evidence of a nerve-related cause.

A test often performed is the measurement of bladder capacity and residual urine for evidence of poorly functioning bladder muscles.

Other tests include:

  • A bladder diary – the doctor may ask the patient to record how much they drink, when urination occurs, how much urine is produced, and the number of episodes of incontinence.
  • Physical exam – the doctor may examine the vagina and check the strength of her pelvic floor muscles. If the patient is male, the doctor may examine his rectum to determine whether the prostate gland is enlarged.
  • Stress test – the patient relaxes, then coughs vigorously as the doctor watches for loss of urine.
  • Urinalysis – urine is tested for evidence of infection, urinary stones, or other contributing causes.
  • Blood tests – blood is taken, sent to a laboratory, and examined for substances related to causes of incontinence.
  • Ultrasound – sound waves are used to visualize the kidneys, ureters, bladder, and urethra.
  • Cystoscopy – a thin tube with a tiny camera is inserted in the urethra and used to see the inside of the urethra and bladder.
  • Urodynamic testing – determines how much pressure the bladder and urinary sphincter muscle can withstand.
  • Cystogram – X-ray procedure to visualize the bladder.
  • Cystoscopy – a cystoscope (a thin tube with a lens at the end) is inserted into the urethra. The doctor can view abnormalities in the urinary tract.

Patients are often asked to keep a diary for a day or more, up to a week, to record the pattern of voiding, noting times and the amounts of urine produced.

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Medical devices for treatment

The following medical devices are designed for females.

  • Urethral inserts – the woman inserts the device before activity and takes it out when she wants to urinate.
  • Pessary – a rigid ring inserted into the vagina. It is worn all day. The device helps hold the bladder up and prevent leakage.
  • Radiofrequency therapy – tissue in the lower urinary tract is heated. When it heals it is usually firmer, often resulting in better urinary control.
  • Botox (botulinum toxin type A) – injected into the bladder muscle, to help those with an overactive bladder.
  • Bulking agents – injected into tissue around the urethra, to help keep it closed.

Factors assessed during medical history

Fluid intake

  • The amount and types of fluid (particularly caffeinated, alcoholic and carbonated)

Urinary frequency

  • Increased frequency is typically >7 micturition episodes during waking hours

Nocturia

  • Interruption of sleep at least once because of the need to micturate; each void is preceded and followed by sleep

Urinary urgency

  • Sudden compelling desire to pass urine that is difficult to defer (as opposed to urge, which is considered normal)

Bladder sensation during filling

  • Increased, reduced or absent

Urinary stream

  • Delay in initiating micturition (hesitancy), a slower stream than expected, intermittent stream that stops and starts on more than one occasion, urinary stream that splits or sprays instead of a single discrete stream

Straining

  • The need to abdominally strain, or provide suprapubic pressure to initiate, maintain or improve stream

Incomplete emptying

  • Bladder does not feel empty after micturition

Need to immediately re-void

  • Further micturition is necessary soon after passing urine

Position-dependent voiding

  • The need to take specific positions to improve emptying

Urinary retention

  • Inability to pass urine despite persistent effort

Dysuria

  • Lower urinary tract or vulval burning or discomfort with micturition

Lower urinary tract pain

  • Suprapubic or retropubic pain, pressure or discomfort in the bladder that increases with filling that persists or is relieved after voiding
  • Pain in the urethra, vulva, vagina, perineum or pelvis

Lower urinary tract infection

  • Microbiological evidence of pathological bacteriuria with bladder storage symptoms or pain

Recurrent urinary tract infection

  • At least three symptomatic, medically diagnosed urinary tract infections in the previous 12 months with evidence of resolution between episodes

Box 3

Common medications that can cause urinary incontinence

α-Adrenergic agonists

  • Increase smooth muscle tone in the urethra
  • Can precipitate urinary retention and related symptoms

α-Adrenergic antagonists

  • Decrease smooth muscle tone in the urethra
  • Can precipitate stress urinary incontinence

Angiotensin-converting enzyme inhibitors

  • Cause a cough that can exacerbate stress urinary incontinence

Anticholinergics

  • Can cause impaired emptying, urinary retention and constipation that can contribute to urinary incontinence
  • Can cause cognitive impairment and reduce effective toileting ability

Calcium channel blockers

  • Can cause impaired emptying, urinary retention and constipation that can contribute to urinary incontinence
  • Can cause dependent oedema that can contribute to nocturnal polyuria

Cholinesterase inhibitors

  • Increase bladder contractility
  • Can precipitate urgency urinary incontinence

Diuretics

  • Cause diuresis and precipitate urinary incontinence

Lithium

  • Causes polyuria via induced diabetes insipidus

Opioid analgesics

  • Can cause urinary retention, constipation, confusion and immobility, all of which can contribute to urinary incontinence

Psychotropic drugs, sedatives, hypnotics, antipsychotics and histamine 1 receptor antagonists

  • Can cause confusion and impaired mobility, and precipitate urinary incontinence

Selective serotonin reuptake inhibitors

  • Increased cholinergic transmission can lead to urgency urinary incontinence

Gabapentin, glitazones and NSAIDs

  • Can cause oedema, which can lead to nocturnal polyuria causing nocturia and nocturnal enuresis

Treatment

Your physician may suggest one or more options to treat an overactive bladder:

  • Bladder training, or urinating according to a timetable (instead of according to urge)
  • Kegel exercises to strengthen pelvic muscles
  • Dietary changes to avoid foods that trigger your symptoms
  • Medications, including hormone replacement therapy and anticholinergics (which prevent bladder spasms)
  • A pessary, a ring inserted into the vagina that helps support the bladder and uterus
  • Sacral nerve stimulation therapy, an electrical device to stimulate nerves, affecting signals to the bladder
  • Acupuncture, yoga and other alternative treatments

Muscarinic Receptor Subtypes and Adverse Effects of Receptor Inhibition

Organ System Receptor Subtype Adverse Effects of Inhibition (Anticholinergic Effects)
Bladder (detrusor muscle) M2, M3 Decreased contractions; urinary retention
Cardiac tissue M2 Tachycardia; palpitations
Central nervous system and brain (cortex and hippocampus) M1, M2, M3, M4, M5 Effects on memory, cognition, and psychomotor speed; confusion; delirium; sedation; hallucinations; sleep disruption
Eyes (ciliary muscle and iris) M3, M5 Dry eyes; blurred vision; mydriasis (dilation of the pupil)
Gastrointestinal tract M1, M2, M3 Slowed transit time; constipation; effects on sphincter tone and gastric acid secretion
Salivary glands M1, M3, M4 Xerostomia (dry mouth)

Anticholinergic Agents Used for Urinary Incontinence

Drug Recommended Adult Dose Pharmacokinetic Properties
Darifenacin (Enablex ER, Novartis) 7.5–15 mg q.d.; swallowed whole with liquid; should not be chewed, divided, or crushed
  • Bioavailability, 17%; peak levels, 7 hours post-dose; protein binding, 98% (alpha1-acid-glycoprotein)
  • Extensively metabolized by CYP2D6/3A4*; half-life, 13–19 hours; elimination: 60% in urine, 40% in feces
  • Dose adjustment for moderate hepatic impairment; poor CYP2D6 metabolizers may have higher drug levels
Fesoterodine (Toviaz ER, Pfizer) 4–8 mg q.d.; swallowed whole with liquid; should not be chewed, divided, or crushed
  • Bioavailability, 52% peak levels, 5 hours post-dose; protein binding, 50%; metabolized by CYP2D6/3A4*; active metabolite, 5-hydroxymethyl-tolterodine (5-HMT)
  • Higher parent drug levels may occur in poor CYP2D6 metabolizers
  • Elimination: 70% renal as 5-HMT; half-life, 7 hours
  • Dose adjustments for moderate hepatic impairment and severe renal impairment (CrCl < 30 mL/minute); not recommended in severe hepatic impairment
Oxybutynin IR (Ditropan, Janssen) 2.5–5 mg b.i.d. or t.i.d.; maximum dosage, 5 mg q.i.d.
  • Rapidly absorbed; peak levels, 1 hour post-dose; dose-dependent, linear pharmacokinetics; bioavailability, approximately 6%; extensively metabolized by CYP3A4*; active metabolite, desethyloxybutynin; half-life, 2–5 hours
  • May have direct smooth muscle-relaxant properties and local anesthetic effects
  • Caution recommended in renal impairment
Oxybutynin gel 10% (Gelnique, Watson)
Oxybutynin gel 3% (Anturol, Antares)
1 g (sachet) applied daily to dry, intact skin; rotate application sites (abdomen, thigh, shoulder, upper arm)
Three pumps (84 mg); applied as above; may rotate site if necessary
  • Enters systemic circulation by passive diffusion across stratum corneum
  • Bypasses first-pass GI and hepatic metabolism, reducing formation of N-desethyl-oxybutynin metabolite
  • Steady state: achieved within 3–7 days of continuous dosing
  • Metabolized primarily by CYP3A4*; half-life: ∼30 hours (3%); ∼70 hours (10%)
  • Kinetic profiles similar to that of transdermal formulation (Oxytrol)
  • After application, wait 1 hour before showering; may apply sunscreen 30 minutes before or after application
Oxybutynin transdermal patch (Oxytrol, Watson) 36-mg patch applied twice weekly (every 3–4 days); delivers 3.9 mg daily; rotate administration sites (abdomen, hip, buttock)
  • Enters systemic circulation by passive diffusion across stratum corneum
  • Bypasses first-pass GI and hepatic metabolism, reducing formation of N-desethyl-oxybutynin metabolite; half-life, approximately 7–8 hours
  • Kinetic profile similar to that of gel formulations
Oxybutynin XR (Ditropan XL, Janssen) 5–10 mg q.d.; may be increased to a maximum of 30 mg/day; swallowed whole; should not be chewed, divided, or crushed
  • Peak levels, 4–6 hours post-dose; consistent plasma concentrations
  • Osmotically active bilayer; released over 24 hours
  • Metabolized by CYP3A4*; half-life, 12–13 hours
Solifenacin (vesicare,Astellas Pharma US) 5–10 mg q.d.; swallowed whole with water
  • Bioavailability, 90%; protein binding, 98%; metabolized by CYP3A4*
  • Elimination: 70% renal (<15% unchanged), 22% feces; half-life, 55 hours
  • Dose adjustments for moderate hepatic impairment and severe renal impairment (CrCl < 30 mL/minute); not recommended for use in severe hepatic impairment
Tolterodine IR (Detrol, Pfizer) 1–2 mg b.i.d.
  • Rapidly absorbed; bioavailability, at least 77%; peak levels, 1–2 hours post-dose; protein binding, 96% (mainly to alpha1-acid glycoprotein)
  • Extensively metabolized by CYP2D6 to active metabolite (5-HMT); metabolized by CYP3A4* in patients devoid of CYP2D6
  • Half-life in extensive/poor metabolizers, 3 hours/9.6 hours
  • Elimination: approximately 77% of dose in urine, 17% in feces (metabolites)
  • Dose adjustments for substantially reduced hepatic or renal function
Tolterodine (Detrol LA, Pfizer) 2–4 mg q.d.; swallowed whole with liquid
  • Rapidly absorbed; bioavailability, at least 77%; peak levels, 2–6 hours post-dose; protein binding, 96% (mainly to alpha1-acid glycoprotein)
  • Extensively metabolized by CYP2D6 to active metabolite (5-HMT); 7% of Caucasians are poor metabolizers of CYP2D6
  • Half life in extensive/poor metabolizers, 7 hours/18 hours
  • Elimination: approximately 77% of dose in urine, 17% in feces (metabolites)
  • Dose adjustments for substantially reduced hepatic or renal function
Trospium IR (Sanctura, Allergan) 20 mg b.i.d., at least 1 hour before meals or on empty stomach
  • Bioavailability: <10%; peak levels, 5–6 hours post-dose
  • Metabolism: ester hydrolysis with subsequent conjugation (minimal CYP450 involvement)
  • Elimination: 85% in feces, 6% in urine (60% unchanged); half-life, approximately 20 hours
  • Dose adjustments or avoid in severe renal impairment; should be used with caution in moderate/severe hepatic impairment
Trospium (Sanctura XR, Allergan) 60 mg q.d. in morning, at least 1 hour before breakfast, with water or on empty stomach
  • Peak levels, 5 hours post-dose; protein binding, 50%– 85%
  • Metabolism: ester hydrolysis with subsequent conjugation (minimal CYP450 involvement)
  • Elimination: 85% in feces, 6% in urine (60% unchanged); half-life, approximately 35 hours
  • Not recommended in severe renal impairment; no information on effect of severe hepatic impairment

Commonly prescribed anticholinergic substances *1

  • Anticholinergics
    • Antiemetics/antivertigo drugs
    • Anti-Parkinson
    • Spasmolytics (gastrointestinal tract)
    • Spasmolytics (urogenital tract)
    • Migraine medication
    • Bronchodilators
    • Preanesthetics
    • Mydriatic drugs
  • Medications with anticholinergic side effects
    • Antiarrhythmic agents
    • Antidiarrheal drugs
    • Antihistamines
    • Muscle relaxants
    • Medication for ulcers
    • Antidepressants
    • Antipsychotic drugs
    • Herbal preparations

*1 modified from ()

This is a non-surgical, low-risk treatment to consider if Kegel exercises and medication have failed to relieve urinary symptoms.

PTNS works by indirectly providing electrical stimulation to the nerves responsible for bladder and pelvic floor function.

During this office procedure, the patient’s foot will be elevated and supported, and a slim needle electrode will be placed near the tibial nerve at the ankle.

A device is then connected to the electrode that sends mild electrical pulses to the tibial nerve. These impulses then travel to the group of nerves at the base of the spine—the sacral nerve plexus—that are responsible for bladder function.

Promo block

This treatment stimulates the nerves through gentle electrical impulses, and this can lead to gradual changes in bladder activity over time.

Typically, patients will undergo a series of 12 weekly, half-hour sessions. Improvements with PTNS are typically noted five to six weeks later. Studies have reported that upwards of 80 percent of patients benefit from the procedure.

• Sacral neuromodulation

InterStim therapy is a proven neuromodulation therapy that targets the communication problem between the brain and the nerves that control the bladder.

Bladder function is regulated by a group of nerves at the base of the spine called the sacral nerve plexus. When those nerves are stimulated through gentle electrical impulses similar to that in a heart pacemaker, bladder overactivity can be calmed or eliminated.

The implantation of the InterStim device sends continuous impulses to the sacral nerve plexus, which inhibits urgency and spontaneous uncontrolled bladder activity.

Autonomic dysreflexia

Autonomic dysreflexia associated with intradetrusor injections of BOTOX® could occur in patients treated for detrusor overactivity associated with a neurologic condition and may require prompt medical therapy. In clinical trials, the incidence of autonomic dysreflexia was greater in patients treated.

Antimuscarinic (antispasomodic) medications 

These medications reduce the number of involuntary bladder contractions by preventing spasm of the detrusor muscle that causes them and increase bladder capacity. In general, these medications can reduce leakage of urine caused by OAB by 60% to 75%. Examples of antimuscarinic medications include:

  • darifenacin
  • oxybutynin
  • solifenacin
  • tolterodine
  • trospium

The most common side effects of antimuscarinic medications are dry mouth, dry eyes, increased pressure inside the eye, and constipation. Be sure to tell your doctor about all of the medications you are taking and all of your medical conditions, as there are some people who should not take antimuscarinic medications. These side effects can be minimized bv starting with a low dose of medication and gradually increasing the dose.

Beta3-agonist

This is a new type of medication for the treatment of OAB. It helps relax the detrusor muscle (in the bladder wall) to prevent unwanted spasms that may cause symptoms of OAB. Currently there is only one drug in this category called “mirabegron”. An uncommon side effect of mirabegron is an increase in blood pressure. Be sure to tell your doctor about all of the medications you are taking and all of your medical conditions, as there are some people who should not take this medication.

Other medications

Medications are known as tricyclic antidepressants (e.g., amitriptyline, imipramine) and calcium channel blockers (e.g., nifedipine, diltiazem) have been used with mixed results in the treatment of OAB. They may be prescribed for urinary incontinence, but this is an “off-label” or unapproved use and is not recommended.

The Complete Nighttime Guide to an Overactive Bladder

If you are part of the approximately 16-18% of the population who suffers from overactive bladder syndrome (OAB), you already know how bad it can interfere with your life. From the embarrassment of an incident to the exhaustion after a poor night’s sleep, anyone experiencing the effects of OAB is likely seeking to remedy them. And that’s exactly what this nighttime guide to overactive bladder will cover!

Overactive Bladder and Sleep

“[OAB] can disrupt sleep completely, and people can be extremely overtired,” said Luis Sanz, MD, director of urogynecology and pelvic surgery at Virginia Hospital Center.

We tend to think of wet sheets as the worst potential effect of nocturia, but endless nights of interrupted sleep and the ensuing days of exhaustion can start to feel just as bad– even if you never wet the bed. Many of us tend to dismiss being “tired” as a common thing in our modern society, or even herald it as a side effect of being busy and successful, but long term sleep deprivation is a serious issue.

Not only can OAB interfere with your general wellbeing, but it can also interfere with your sexual wellbeing too. Losing control of your bladder as an intimate evening starts to unfold can certainly pull the plug on the moment. This is a common experience for people with OAB because the sexual activity itself is irritating to the bladder. Luckily, most of the preventative measures that help with OAB, in general, will also help in regard to sex!

Preventative Measures

When it comes to overactive bladder, your best offense is often a well-prepared defense. Here are some things you can do to help decrease the effects of your condition.

Bladder-Approved Nutrition

As with any health-related issue, it’s best to build the plan of attack on a sound foundation. This sound foundation includes good nutrition and avoiding the foods you shouldn’t eat if you have OAB.

Here are some of the foods and beverages are known to irritate your bladder:

  • Alcohol
  • Artificial sweeteners
  • Caffeine – a diuretic that increases urine output
  • Chocolate
  • Citrus juices – since they are acidic
  • Cranberry juice – a surprising culprit that can be good for bladder health in those not affected, but is actually an irritant for individuals with OAB
  • Honey
  • Tea – if it’s caffeinated or is made with any other potential irritants
  • Tomato juice or sauce

One thing to be especially vigilant about is whether a food is okay for your condition, even if it’s a “healthy” food overall. Options like unsweetened fruit juices, tomatoes, and other acidic foods and drinks may be good for the average person, but are irritants for you and your bladder. It’s always good to do a quick internet search on which foods are acidic and to talk to your doctor about nutrition.

No Smoking, Please!

Another big irritant is nicotine. You likely already know that smoking isn’t good for you, but if you do happen to smoke, this is yet another reason to quit. Remember not to be ashamed if you’ve tried to quit before and have failed. It’s not easy, but you can do it!

We recommend talking to your doctor about quitting methods and giving it another attempt. You never know if this one change will be what cures your OAB; it has definitely made a big difference for some patients in the past.

Keep Up the Kegels

Do Kegel exercises regularly to help control your OAB. As you might already know, Kegels are done by contracting and then releasing the muscles around your urethra’s opening. If you’ve never done one before, try stopping your urine stream next time you use the restroom. This is what a Kegel feels like.

Not only can doing Kegels regularly help you build strength over time, doing one when you have the sudden urge to go can also help you control your bladder as you seek out the next bathroom.

Daytime Hydration

This might be the least predictable tip of them all: drink water! Though hydrating too much at night is of course a bad idea (we will get further into that in the next section), drinking enough over the course of the day is a good idea. Drinking too little water will cause your urine to become more concentrated, which can then actually irritate the bladder from the inside out. Having insufficient amounts of fluid in your body can also promote bacteria growth, which can in turn trigger incontinence.

Your Evening Routine

Now that you have some tips and tricks for day-to-day life, let’s get into evening specifics. There are two simple steps that can make a big difference.

The Double Void Trick

If you’ve just started having bladder troubles, perhaps you haven’t previously thought much about when that last bathroom trip of the evening happens. Maybe it’s before brushing your teeth. Maybe when you turn off the TV or finish the dinner dishes or whatever marks the end of your day and beginning of your “winding down” routine. Perhaps you don’t go again after your nighttime routine.

Now that you are battling OAB, try the double-voiding trick instead of just urinating sometime in the evening. Double-voiding involves urinating twice right before bed. Use the restroom once, then brush your teeth and go through your routine. Use the restroom again right before going to bed, even if you don’t feel like it or your bedtime routine only took five minutes. Even squeezing out a last couple drops can help.

Your Fluid Cut-Off Time

Often, we make the mistake of forgetting to drink water during the day and then trying to catch up at night. It makes sense that people get into this habit; days are filled with work, errands, volunteering, and countless activities, while evenings are more of a time to wind down… and sip some glasses of water.

Try to be aware of your hydration timeline and whether you’ve fallen into this habit. If so, turn that routine on its head! Hydrating during the day but not drinking any liquids after 5 or 6 pm is a good idea for anyone who struggles with nocturia.

This cut-off time is a good rule of thumb for irritants as well as liquids. If you’re like most people, it probably sounds rough to never again drink a fresh squeezed fruit juice, eat pasta with tomato sauce, or enjoy a chocolate bar. On days you want to indulge, try to have that fruit juice in the morning, eat the pasta for lunch, or have your chocolate in the early afternoon. And try not to do all those things in the same day!

OAB “Safety Nets”

Perhaps you’re already taking all of those preventive measures, but still have an overactive bladder. That’s when the safety nets come into play.

OAB sufferer struggling with the urge to urinate

Absorbent Briefs

The technology that goes into absorbent briefs has come a long way, and many look as discreet as regular underwear. Slipping one on at night can do a lot to protect your mattress and ease your mind.

Plastic Sheets

Plastic sheets or vinyl covers aren’t always the most comfortable, but they can be highly effective. These options are affordable, not to mention quick and easy to wipe down.

Mattress Covers

Mattress covers and protectors can be a great option as well. Unlike the plastic options, mattress covers are often made from softer terry material and are less noticeable. They are sometimes also less affordable, but are a good investment to make in your health and hygiene, not to mention that they protect a mattress likely costing far more.

Bed Pads

If you sleep like a rock and are more vulnerable to nighttime voiding than waking up, a bed pad might be your new best friend. Bed pads tend to be an optimal match for people who don’t move much in their sleep. The waterproof pads simply slip underneath your body toward the middle of the mattress (above the sheets). If anything happens, all you need to wash is the pad. If nothing goes wrong, you can store it for the day or simply make your bed over it.

Catheter

This is probably the most extreme-sounding option, but is a great for some people. A catheter doesn’t technically require a prescription, but we do recommend talking to your doctor before trying one out. He or she will be able to advise whether or not a catheter is necessary in your specific case.

Medications Used in the Treatment of Benign Prostatic Hyperplasia (BPH)

Nonselective Alpha-Adrenergic Blockers
General comments
  • Used for both BPH and hypertension
  • Dosing based on patient response
  • Monitor for orthostatic hypotension (first dose)

    • Educate patients to rise slowly from supine position
    • Bedtime dosing for immediate-release formulations
  • Monitor efficacy, e.g., urine flow rates, symptoms
  • Potential for intraoperative floppy iris syndrome (cataract surgery)
  • Use with caution with antihypertensive drugs and other drugs that lower blood pressure (e.g., vardenafil)
  • Hepatic metabolism (primarily by CYP2D6/3A4*)
  • Highly protein-bound
  • Mechanism: nonselective alpha1-receptor blockade in bladder neck and prostate
Doxazosin (Cardura and Cardura XL, Pfizer)
  • Dosage (immediate release): 1–8 mg q.d.
  • Dosage (extended release): 4–8 mg q.d. with breakfast; titrate dose every 3–4 weeks (maximum, 8 mg/day)
  • Elimination: fecal 60%, renal 9%
  • Half-life: 15–20 hours
Prazosin (Minipress, Pfizer)
  • FDA-approved for hypertension; not approved for BPH
  • Dosage: 0.5–1.0 mg b.i.d.; titrate dose every 2–7 days (maximum, 2 mg/day)
  • Half-life: 2.5 hours
Terazosin (Hytrin, Abbott)
  • Dosage: 1–5 mg q.d; titrate dose every 2–7 days (maximum, 20 mg/day)
  • Elimination: fecal 60%, renal 40% (10% unchanged)
  • Half-life: 12–14 hours
Uroselective Alpha-Adrenergic Blockers (Alpha1A Receptors)
General comments
  • Used only for BPH
  • Dosing based on patient response
  • Mechanism: selective alpha1-receptor blockade in bladder neck and prostate; selectively reduce urinary tract alpha1A-receptors
Alfuzosin (Uroxatral, Sanofi)
  • Dosage: 1 extended-release tablet (10 mg) q.d.
  • Contraindication: moderate/severe liver disease
  • Elimination: fecal 70%, renal 25% (10% unchanged)
  • Half-life: 10 hours
Silodosin (Rapaflo, Watson)
  • Dosage: 4–8 mg q.d. with food
  • Elimination: fecal 55%, renal 33%
  • Half-life: 14–24 hours; glucuronide conjugate
  • Contraindication: hepatic Child–Pugh score > 10
Tamsulosin (Flomax, Boehringer Ingelheim)
  • Dosage: 0.4–0.8 mg q.d.
  • Elimination: renal 75% (<10% unchanged), fecal 20%
  • Half-life: 15 hours
  • Associated with intraoperative floppy iris syndrome (cataract surgery)
  • Avoid use in patients with sulfa allergy
5-Alpha-Reductase Inhibitors
General comments
  • Used only for BPH
  • Administered as monotherapy or with alpha-adrenergic blockers
  • Contraindications: pregnancy, including pregnant blood transfusion recipient if donor had dose within 6 months; pediatric patients; cutaneous absorption (avoid capsule handling by pregnant or potentially pregnant women)
  • Monitor PSA and side effects: abnormal ejaculation, reduced libido, signs and symptoms of BPH (urine flow)
Dutasteride (Avodart, Glaxo-SmithKline)
  • Dosage: 0.5 mg q.d.
  • Metabolized by CYP3A4*/3A5; active metabolites
  • Elimination: feces 45%, urine < 1%
  • Half-life: 5 weeks
  • Mechanism: inhibits type-1 and type-2 5-alpha-reductase
  • Possible risk of heart failure
Dutasteride/tamsulosin (Jalyn, GlaxoSmithKline)
  • Dosage: 1 capsule (dutasteride 0.5 mg/tamsulosin 0.4 mg) q.d., taken 30 minutes after same meal each day
  • See comments for dutasteride and tamsulosin on previous page
Finasteride (Proscar, Merck)
  • Dosage: 5 mg q.d.
  • Metabolized by CYP3A4*; active metabolites
  • Elimination: feces 60%, urine 40%
  • Half-life: 6–8 hours
  • Mechanism: inhibits type-2 5-alpha-reductase
  • Minimal drug interactions reported; monitor when used with CYP3A4 inhibitors; caution in patients with hepatic impairment
*CYP3A4 metabolism: use lower dose or avoid if patient is taking a concurrent CYP3A4 inhibitor (e.g., clarithromycin, ketoconazole)

Medications to treat Overactive Bladder

The following list of medications are in some way related to, or used in the treatment of this condition.

Physiotherapy

Pelvic floor muscle exercise

www.rxharun.com/pelvic-floor muscle exercise

Classification of drugs

Most drugs used to treat overactive bladder are muscarinic antagonists.

Comparison of drugs

Comparison of overactive bladder medication
agent traits
Oxybutynin (short-acting)
  • well-known by physicians
  • available in market longer than other drugs for OAB
  • many studies provide support of effectiveness
  • available as generic in places including the United States
  • more side effects than alternatives, including dry mouth and constipation
  • severe dry mouth more often reported
  • user takes 2-3 pills a day
Oxybutynin (extended release)
  • fewer side effects than short-acting Oxybutynin
  • 1 pill per day
Oxybutynin (transdermal patch)
  • no pill
  • patch changed every 3–4 days
  • lower rate of dry mouth as compared to pill form
  • patch commonly causes skin irritation which can be severe
Oxybutynin (Topical medication)
  • fewer side effects than short-acting Oxybutynin
  • topical gel applied to abdomen, arms, or thighs daily
  • new on market
  • little existing research on this drug
Tolterodine (short-acting)
  • fewer side effects than short-acting Oxybutynin
  • 2 pills per day
  • 10% of Caucasians and 19% of black people have a genetic difference which causes them to lack a certain enzyme. Lack of this enzyme makes the drug less effective.
Tolterodine (extended release)
  • fewer side effects than short-acting Oxybutynin
  • 1 pill per day
  • 10% of Caucasians and 19% of black people have a genetic difference which causes them to lack a certain enzyme. Lack of this enzyme makes the drug less effective.
Solifenacin
  • 1 pill per day
  • More effective for some symptoms than Tolterodine
  • higher rates of constipation and dry mouth than tolterodine
  • less researched for safety and efficacy than Tolterodine and Oxybutynin
Trospium (short acting)
  • severe dry mouth less common than with oxybutynin
  • less researched for safety and efficacy than Tolterodine and Oxybutynin
Trospium (extended release)
  • 1 pill per day
  • little existing research on this drug
Darifenacin
  • 1 pill per day
  • less researched for safety and efficacy than Tolterodine and Oxybutynin
Fesoterodine
  • same metabolite as Tolterodine, but does not require that enzyme to be active
  • it may avoid drug interactions of Tolterodine
  • little existing research on this drug

Management Options for Mixed Urinary Incontinence

Men Women
Initial management options (treat most bothersome symptom first)
  • Pelvic floor muscle training with/without biofeedback for post-prostatectomy SUI
  • Scheduled voiding (bladder training)
  • Incontinence products
  • Antimuscarinic drugs for OAB with/without UUI
  • Alpha-adrenergic antagonists for bladder outlet obstruction
  • Pelvic floor muscle training for SUI or OAB
  • Bladder training for UUI or OAB
  • Vaginal cones
  • Electrical stimulation
  • Duloxetine for SUI
  • Antimuscarinic drugs for OAB with/without UUI
Specialized management options (if initial therapy fails)
  • Artificial urinary sphincter
  • Male sling
  • Neuromodulation
  • Bulking agents
  • Tapes and slings
  • Colposuspension (Burch) procedure
  • Artificial urinary sphincter
  • Botulinum toxin
  • Neuromodulation
  • Bladder augmentation

OAB = overactive bladder; SUI = stress urinary incontinence; UUI = urge urinary incontinence.

Data from Thüroff JW, et al. Eur Urol 2011;59:387–400.

Imipramine. The tricyclic antidepressant imipramine (Tofranil) has been used off-label to treat patients with SUI. The alpha-adrenergic and anticholinergic properties of this agent may provide the dual benefit needed in these patients. However, the use of imipramine in patients with SUI, especially elderly patients, is limited by its anticholinergic side-effect profile.,

Duloxetine. The lack of approved drugs for SUI has led to studies of alternative agents, including duloxetine (Cymbalta, Eli Lilly). Although duloxetine, a dual serotonin–norepinephrine reuptake inhibitor (SNRI), is approved for the treatment of SUI in Europe, it is indicated only for the treatment of depression and neuropathic pain in the U.S. Duloxetine is believed to influence neurotransmitters on the pudendal nerve. As a result, urethral sphincter contractions are strengthened, and the increased urethral closure forces prevent urine leakage.,

In clinical trials, duloxetine has reduced incontinence episodes and has increased the quality of life in women with SUI. Side effects leading to discontinuation included dry mouth, fatigue, nausea, constipation, and hyperhidrosis. In one study, treatment-related nausea was noted in 40% of patients; in most of these patients, the nausea occurred early in treatment, was transient, and was mild to moderate in severity.

Duloxetine has also been evaluated as a potential treatment option for men with SUI after radical prostatectomy. The drug reduced incontinence episodes and improved quality of life.

Venlafaxine. Venlafaxine (Effexor, Pfizer), another dual SNRI, has been evaluated for the management of SUI. It was reported to be effective in a double-blind, randomized, placebo-controlled study of women with SUI. N

Darifenacin (Enablex). Darifenacin (Enablex, Novartis) was approved in 2004, providing another daily option for treating UUI . The drug’s pharmacokinetic properties include poor bioavailability and CYP2D6-dependent metabolism. Approximately 7% of Caucasian patients and 2% of African-American patients ae poor CYP2D6 metabolizers and are dependent on the CYP3A4 isoenzyme for metabolism. Dosage adjustments are recommended in patients with hepatic impairment, and caution is suggested in patients with renal disease.,

Darifenacin has a greater affinity for bladder M3 receptors, suggesting increased selectivity and tolerability, although clinical evidence of this advantage is lacking. The adverse effects and contraindications associated with darifenacin are similar to those of the other anticholinergic drugs.

Clinical trials with darifenacin reported efficacy similar to that of other agents in the class, but tolerability was better than that of oxybutynin chloride. Darifenacin provided improvements in micturition variables that were similar to those of other anticholinergics, including nocturnal voids, incontinence episodes, and improved quality of life., A community-based survey found that patients with OAB experienced benefits with darifenacin and were generally satisfied with the drug.

Fesoterodine (Toviaz). Pfizer’s extended-release fesoterodine entered the market in 2009 for the treatment of UUI and OAB . Fesoterodine is well absorbed, is not affected by food, and is metabolized by both the CYP2D6 and CYP3A4 enzyme systems. It is a prodrug, with no activity itself, but it is rapidly and completely metabolized to its active metabolite, 5-hydroxymethyl-tolterodine (5-HMT), which is responsible for all of fesoterodine’s anticholinergic effects. 5-HMT is also the active metabolite of tolterodine. With festerodine, however, the metabolite is the single active moiety; thus, fesoterodine delivers more 5-HMT via esterase metabolism compared with tolterodine.

Excretion is primarily via the kidneys, with approximately 70% excreted as active and inactive metabolites., As with other agents in this class, dose-related increases in anticholinergic adverse events, including dry mouth and constipation, were reported in clinical trials of fesoterodine. However, discontinuation rates associated with these side effects were minimal.

Fesoterodine has the potential to interact with inhibitors of the CYP2D6 and CYP3A4 enzyme systems. When fesoterodine is used concurrently with inhibitors of these enzymes, the dosage of fesoterodine should not exceed 4 mg daily. However, coadministration of fesoterodine with CYP3A4 inducers may result in subtherapeutic levels. Dosage adjustments may be necessary in patients with severe hepatic impairment (Child–Pugh class C) and in those with severe renal impairment (CrCl below 30 mL/minute). The recommended dosage in these patients is 4 mg daily.,,

Sacral nerve stimulation. Sacral nerve stimulation has been used as a second-line therapy for incontinence secondary to OAB since the 1980s. Several reports have demonstrated the efficacy of this treatment in UUI. The underlying principle of neuromodulation for detrusor overactivity is the induction of somatic afferent inhibition of sensory processing in the spinal cord.

Investigational agents. Agents being evaluated for the management of UUI include imidafenacin (Ono/Kyorin), an antimuscarinic agent from Japan, and neurokinin-1 receptor antagonists., The latter agents have been useful in treating OAB but offer no advantages in efficacy compared with tolterodine.

Mirabegron (Astellas), a once-daily, oral selective beta3-adrenoceptor agonist, has been shown to reduce episodes of UI and micturition frequency in patients with OAB. Astellas submitted a New Drug Application for mirabegron to the FDA in August 2011. In July 2011, mirabegron was granted marketing approval in Japan. Researchers continue to develop agents that are effective and better tolerated for the treatment of UUI, especially in more sensitive older adults.

Biofeedback

Biofeedback, in combination with pelvic floor exercises, offers a cost-effective method of reducing SUI. Vaginal or rectal sensors are used to obtain a visual indication of contraction activity and muscle strength. The purpose of biofeedback is to guide women regarding which muscles to contract to maximize the benefits of pelvic floor exercises.

Intravaginal Devices

Weighted cone devices attached to vaginal muscles may also help women with SUI. These devices are designed to help patients improve pelvic-floor tone through active, continuous muscle contractions. The weight of the cone retained by the patient is in direct proportion to the improvement in muscle tone and to subsequent improvement in SUI.

A similar device, the Colpexin Sphere, is placed in the vaginal canal to provide support for pelvic floor muscles. This device improves prolapse defects and the utility of pelvic floor exercises. Proper counseling and training are necessary, and small trials have reported success in motivated patients.

Pessaries

Vaginal continence pessaries are used for the treatment of various pelvic floor disorders, including UI and prolapse., Although these devices may be considered first-line options for the treatment of SUI, they are not used extensively in this setting because of their perceived inconvenience. Specific types of pessaries have effectively treated SUI by providing support for the bladder neck at the urogenital angle. One short-term trial reported greater patient satisfaction and less bothersome incontinence symptoms with behavioral therapy compared with the use of pessaries at 3 months, but these differences were not sustained at 12 months; further, combination therapy was not superior to behavioral therapy alone or the use of pessaries alone.

Electrical Stimulation Units

A rectal or vaginal probe is used to apply electrical stimulation to the pelvic floor, with the aim of inhibiting the micturition reflex and improving contraction of the pelvic floor musculature.,, These units may provide a less invasive alternative to surgery in patients with SUI. However, the devices are time-consuming to use. Kegel exercises may be equally effective and less expensive.,

Other Conservative Approaches

Other minimally invasive options for managing women with less severe symptoms of SUI include the injection of transurethral bulking agents, such as collagen, and transurethral collagen denaturation (the Renessa procedure). Transurethral collagen denaturation uses nonablative radiofrequency to reduce tissue compliance. Both transurethral bulking and transurethral collagen denaturation can be performed in the office, and both provide an option for high-risk surgical candidates and for patients with less severe symptoms of SUI.

References

 

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