urinary%20incontinence%20in%20women
URINARY INCONTINENCE IN WOMEN
Urinary incontinence is the complaint of involuntary urine leakage.
Stress urinary incontinence is the involuntary urine leakage on effort or exertion or when coughing or sneezing.
Urge urinary incontinence is the one associated with or immediately preceded by urgency.
Mixed urinary incontinence is the involuntary urine leakage associated with both urgency and with exertion, effort, coughing or sneezing.

Pharmacotherapy

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 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
Darifenacin
  • Clinical effectiveness has been documented in several random 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
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
  • 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
Solifenacin
  • 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
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 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
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 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
Serotonin and Norepinephrine Reuptake Inhibitor
Duloxetine
  • 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
Estrogen
  • Postmenopausal women may be offered vaginal estrogen therapy especially if vulvovaginal atrophy symptoms are present

Non-Pharmacological Therapy

Bladder Retraining
  • 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
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 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
Developing Pelvic Floor Muscle Exercise Routines
  • 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
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