Urinary%20incontinence%20in%20women Treatment
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 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
Non-Pharmacological Therapy
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