Urinary%20incontinence%20in%20women Treatment

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
  • Consider extended-release formulations or longer-acting antimuscarinic agents if immediate-release formulations are unsuccessful in patients with urge UI
• 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
  • Assess patient 4 weeks after starting therapy, earlier if with adverse events
  • If effective and tolerable, reassess after 6 months to ascertain continuing need
  • Early follow-up (<30 days) is encouraged in patients with urge UI
  • Assess patient on long-term treatment every 12 months, every 6 months for those >75 years old
  • If patient did not tolerate or failed therapy, may consider giving a different antimuscarinic agent
• Consider the following when giving antimuscarinics with strong anticholinergic properties to patients: Presence of coexisting conditions (eg dementia or cognitive impairment, poor bladder emptying), risk of adverse events (eg cognitive impairment) and use of other medicines which affect total anticholinergic load
• Consider transdermal preparation if oral antimuscarinic agents are not tolerated

Darifenacin 

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

Fesoterodine 

• 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

Imidafenacin

• Has well-documented effect in  overactive bladder (OAB)/DO with acceptable tolerability  
• Shows higher inhibitory effect on urinary bladder contraction than on the salivary gland

Oxybutynin 

• 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
  • 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 

• 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 DO and has an apparent acceptable side effect profile

Solifenacin 

• Has a well-documented effect in 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

Tolterodine 

• 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

Trospium 

• 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 OAB
• 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

Beta-adrenoceptor Agonist

Mirabegron 

• 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

Peripherally-Acting Muscle Relaxant

Botulinum toxin A 

• May be offered as a bladder wall injection to:
  • Patients with urge UI or OAB caused by DO who have failed antimuscarinic therapy and non-surgical management
  • 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 or use a temporary indwelling catheter
  • Risk of adverse effects including developing UTI
  • Limited duration of response and long-term risks
• Patients at risk of renal complications should have monitoring of their upper urinary tract

Serotonin and Norepinephrine Reuptake Inhibitor

Duloxetine 

• May be considered for temporary improvement of incontinence symptoms in patients with moderate to severe stress incontinence or who are unsuitable for surgical treatment 
  • Equally effective in improving stress incontinence symptoms in patients with mixed UI
• Should only be used as part of a management plan that includes 2-week pelvic floor muscle exercises
• Therapy should be evaluated after 2-4 weeks for effectiveness, tolerability and adverse effects
• Patients who continue therapy should be reassessed after 12 weeks to assess progress

Estrogen 

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

Bladder Training 

• May be offered as a 1st-line treatment for a minimum of 6 weeks in urge or mixed UI
• There is some evidence that retraining for an OAB is more effective than no treatment in patients with urge incontinence
• Tends to be more effective if urge symptoms are mild

Urge Suppression Training 

• 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)

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 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 postnatal 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
  • Strengthens the external urinary sphincter, builds up pelvic floor muscles to prevent prolapse and helps retrain the bladder
• Adjunctive pelvic floor muscle therapies should be individualized as added benefit is presently unclear
  • 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
• Digital assessment of pelvic floor function prior to initiating therapy should be undertaken only by a properly trained clinician

Developing Pelvic Floor Muscle Exercise Routines 

• Should be implemented after appropriate patient evaluation and adequate training  
• 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/contractions, each sustained for 6 seconds, done 3x per week
• Should be practiced for 15-20 weeks and continued on a maintenance basis

Other Procedures for OAB 

Augmentation Cystoplasty 

• May be given to women with idiopathic DO who are unresponsive to non-surgical management and are willing and able to self-catheterize
• Advise patient regarding the small risk of malignancy in the augmented bladder and need for long-term follow-up

Percutaneous Sacral Nerve Stimulation

• Patients who have not benefited from antimuscarinic agents and non-surgical management may be offered percutaneous sacral or posterior tibial nerve stimulation for improvement of OAB 
• May also be offered to patients whose symptoms have not responded to treatment with Botulinum toxin type A 

Urinary Diversion 

• Should be considered in patients with OAB who have failed non-surgical management and wherein treatment with Botulinum toxin type A, percutaneous sacral nerve stimulation and augmentation cystoplasty are inappropriate or unacceptable
• Advise patient on need for long-term follow-up