Urinary%20incontinence Treatment

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

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

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