Urinary%20incontinence%20in%20women Treatment

• 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
  • Consider extended-release formulations or longer-acting antimuscarinic agents if immediate-release formulations are unsuccessful in patients with urgency urinary incontinence
• Product should be selected on the basis of cost and tolerability
  • If effective and tolerable, reassess after 6 months to ascertain continuing need
  • Early follow-up (<30 days) is encouraged in patients with urgency urinary incontinence
  • If patient did not tolerate or failed therapy, may consider giving a different antimuscarinic agent
    • Patients who have not benefitted from antimuscarinic agents may be offered percutaneous posterior tibial nerve stimulation or sacral nerve modulation for improvement of urgency urinary incontinence

• Clinical effectiveness has been documented in several random controlled trials
• Onset of action is seen by week 2 of therapy

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

• Smooth muscle relaxation of the urinary bladder 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
• Newer agents have been shown to be as efficacious but may have improved dosing schedules or side effect profiles
• Consider transdermal preparation if oral antimuscarinic agents are not tolerated because of dry mouth 

Propiverine

• Shown to have both antimuscarinic and calcium antagonistic actions
  • Importance of calcium antagonist component has not been established
• Has a documented beneficial effect in the treatment of detrusor overactivity (DO) and has an apparent acceptable side effect profile

• Has a well-documented effect in overactive bladder (OAB)/DO and adverse effect profile seems acceptable
• Studies have shown decrease in incontinence episodes, voids per day and urgency episodes along with increase in bladder capacity

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

• Significantly decreases average frequency of toilet voids and urge-incontinent episodes compared to placebo
  • Decreases smooth muscle tone in the bladder
  • Effective for treatment of overactive bladder
•  Consider giving Trospium in patients with cognitive dysfunction

• 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, but incidence is less compared with Oxybutynin

• May be given to patients with urge incontinence
• Improvement of urge incontinence is better than with placebo
• Side effects appear mild and are not clinically significant

• May be offered as a bladder wall injection to:
• Patients with urgency urinary incontinence or overactive bladder who have failed antimuscarinic therapy
• Patients with urodynamic studies showing bladder storage impairment who have failed antimuscarinic therapy

• Patients must be informed of the following:
• Risk of increased postvoid residual urine is high and there may be a need to self-catheterize
• Risk of developing urinary tract infection
• Limited duration of response

• Patients at risk of renal complications should have monitoring of their upper urinary tract

• May be considered for temporary improvement of incontinence symptoms in patients with moderate to severe stress incontinence
• Equally effective in improving stress incontinence symptoms in patients with mixed urinary incontinence

• Should only be used as part of a management plan that includes 2 weeks of pelvic floor muscle exercises
• Therapy should be evaluated after 2-4 weeks for effectiveness and tolerability
• Patients who continue therapy should be reassessed after 12 weeks to assess progress

• Postmenopausal women may be offered vaginal estrogen therapy especially if vulvovaginal atrophy symptoms are present

• May be offered as a 1st-line treatment in urgency urinary incontinence (UI) or mixed UI
• There is some evidence that retraining for an overactive bladder is more effective than no treatment in patients with urge incontinence
• Tends to be more effective if urge symptoms are mild

• Patient should be instructed to:
  
  • Sit down or stand quietly when 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 she can wait before going to the toilet (eg 30 seconds on the 1st time, 1 minute on the next, etc)

• Typically begin with a voiding interval of 1 hour during waking hours
  • Increase by 15-30 minutes per week depending on patient’s tolerance of the schedule until a 2- to 3-hour voiding interval is achieved

• May start with a shorter voiding interval if baseline micturition patterns reveal daytime voiding pattern <1 hour

Pelvic Floor Muscle Exercises

• Currently known as pelvic floor muscle training (PFMT)
• An intensive program where repeated voluntary pelvic floor muscle contraction is taught by a healthcare professional for prevention and treatment of UI
• Should be the 1st line of therapy to be offered for at least 3 months duration in patients suffering stress, urge or mixed incontinence; it can also be offered to elderly and post-natal women
  • Improves the function of the pelvic floor muscles
  • Involves recruitment of pelvic floor muscle strengthening and skill training
    • Contraction of pelvic floor muscle causes inward lift of the muscles, resulting to 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
  • Strengthens the external urinary sphincter, builds up pelvic floor muscles to prevent prolapse and helps retrain the bladder

• Digital assessment of pelvic floor function prior to initiating therapy should be undertaken only by a properly trained clinician

• Program should be individualized but should include exercises for both fast- and slow-twitch muscle fibers
• Usual program consists of 3 sets of 8 repetitions, each sustained for 6 seconds, done 3x per week
• Should be practiced x 15-20 weeks and continued on a maintenance basis