urinary%20incontinence
URINARY INCONTINENCE
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 & increasing bladder capacity
  • All available antimuscarinic agents decrease the frequency of urgency & incontinence episodes effectively
  • Product should be selected on the basis of cost & tolerability
  • Antimuscarinic therapy should be tried for 4-12 wk to assess benefits & side effects
    • If effective & tolerable, reassess after 6 mth to ascertain continuing need
    • If patient did not tolerate or failed therapy, may consider giving a different antimuscarinic agent

Considerations Regarding Antimuscarinic Therapy in Men

  • If Over Active Bladder (OAB) exists w/o evidence of bladder outlet obstruction, then 1st line therapy w/ antimuscarinics can be considered
  • In men w/ concomitant bladder outlet obstruction, bladder outlet resistance should be appropriately treated before considering the addition of antimuscarinics for OAB

Listed in alphabetical order:

Darifenacin

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

Fesoterodine

  • The 8-mg daily dose has been shown to be more effective than the 4-mg daily dose of Tolterodine ER in treating & 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 & 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

Propiverine

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

Solifenacin

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

Tolterodine

  • Has selectivity for urinary bladder
  • Several studies have documented significant reduction in micturition frequency & in the number of incontinence episodes
  • Reduction in wkly urge incontinence & total incontinence in women are similar between extended-release products of Oxybutynin & Tolterodine; tolerability is also comparable
  • Long-acting formulations have improved tolerability w/o impairing effectiveness

Trospium

  • Significantly decreases average frequency of toilet voids & urge-incontinent episodes compared to placebo
    • Decreases smooth muscle tone in the bladder
    • Effective for treatment of OAB
  • Consider to give in patients w/ cognitive dysfunction
  • Effects occur by wk 1 of therapy & nocturnal frequency decreases significantly by wk 4
  • Dry mouth appears to occur in comparable frequency as Tolterodine

Beta-adrenoceptor Agonist

Mirabegron

  • May be given to patients w/ urge incontinence
  • Improvement of urge incontinence is better than w/ placebo
  • Side effects appear mild & are not clinically significant
Peripherally-Acting Muscle Relaxant

Botulinum toxin A

  • May be offered as a bladder wall injection to:
    • Patients w/ urgency urinary incontinence or overactive bladder who have failed antimuscarinic therapy
    • Patients w/ 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 & there may be a need to self-catheterize
    • Risk of developing urinary tract infection
    • Long-term side effects are still uncertain
  • Patients at risk of renal complications should have monitoring of their upper urinary tract

Serotonin & Norepinephrine Reuptake Inhibitor

Duloxetine

  • May be considered in patients w/ moderate to severe stress incontinence
    • Equally effective in improving stress incontinence symptoms in patients w/ mixed urinary incontinence
  • Should only be used as part of a management plan that includes 2 wk pelvic floor muscle exercises
  • Therapy should be evaluated after 2-4 wk for effectiveness & tolerability
  • Patients who continue therapy should be reassessed after 12 wk 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 urge UI or mixed UI
  • There is some evidence that retraining for an overactive bladder is more effective than no treatment in patients w/ urge incontinence
  • Tends to be more effective if urge symptoms are mild

Urge Suppression Training

  • Patient should be instructed to:
    • Sit down, if possible, or stand quietly when urge occurs
    • To perform Kegel exercises (squeeze pelvic floor muscles) quickly several times w/o relaxing fully between squeezes
    • Relax rest of body & focus on another task for distraction
    • Once the urge subsides, patient should see how long he/she can wait before going to the toilet (eg 30 sec the 1st time, 1 min the next, etc)

Outpatient Bladder Training Protocol

  • Typically begin w/ a voiding interval of 1 hr during waking hr
    • Increase by 15-30 min per wk depending on patient tolerance of the schedule until a 2- to 3-hr voiding interval is achieved
    • May start w/ a shorter voiding interval if baseline micturition patterns reveal daytime voiding pattern <1 hr

Pelvic Floor Muscle Exercises

  • Currently known as pelvic floor muscle training (PFMT)
  • A program where repeated voluntary pelvic floor muscle contraction is taught by a healthcare professional for prevention & treatment of UI
  • Should be the 1st line of therapy to be offered for at least 3 mth duration in patients suffering from stress or mixed incontinence, it can also be offered to elderly & post-natal women
    • Improves the function of the pelvic floor muscles
    • Involves recruitment of pelvic floor muscle strengthening & skill training
      • Contraction of pelvic floor muscle causes inward lift of the muscles, resulting to increase in urethral closure pressure, stabilization & 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 & 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 & helps retrain the bladder
    • However, more good-quality evidence is needed to prove the clinical & cost effectiveness of these conservative therapies for UI
  • Digital assessment of pelvic floor function prior to initiating therapy should be undertaken only by a properly trained clinician
  • Pelvic floor exercises should be considered for male patients following radical prostate surgery as there seems to be of some benefit
  • In men w/ complaints of post-micturition dribble, both pelvic floor muscle exercises & urethral milking appear to be effective

Developing Pelvic Floor Muscle Exercise Routines

  • Program should be individualized but should include exercises for both fast- & slow-twitch muscle fibers
  • Perform until the muscle fatigues, several times a day
  • Usual program consists of 3 sets of 8 repetitions, each sustained for 6 seconds, done 3 times per wk
  • Should be practiced for 15-20 wk & continued on a maintenance basis
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