Selecting Medications For The Treatment Of Urinary Incontinence
BARRY D. WEISS, M.D., University of Arizona College of Medicine, Tucson, Arizona
Am Fam Physician. 2005 Jan 15 71:315-322.
In response to the growing population of older patients with incontinence, pharmaceutical companies are developing new drugs to treat the condition. Before prescribing medications for incontinence, however, physicians should determine the nature and cause of the patients incontinence. The evaluation should rule out reversible conditions, conditions requiring special evaluation, and overflow bladder. The best treatment for urge incontinence is behavior therapy in the form of pelvic floor muscle exercises. Medications, used as an adjunct to behavior therapy, can provide additional benefit. Many therapies are available for patients with stress incontinence, including pelvic floor muscle exercise, surgery, intravaginal support devices, pessaries, periurethral injections, magnetic chairs, and intraurethral inserts. No medication has been approved for the treatment of stress incontinence, although medications are under development.
Urinary incontinence is one of the most common chronic medical conditions seen in primary care practice. It is more prevalent than diabetes, Alzheimers disease, and many other conditions that receive considerably more attention. Incontinence is an expensive problem, generating more costs each year than coronary artery bypass surgery and renal dialysis combined.1,2
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Causes Of Stress Incontinence
- Chronic coughing
An easy way to imagine stress incontinence is to picture yourself holding a water balloon. Imagine the narrow part of the balloon is squeezed shut by your fingers to stop the water trickling out. If your fingers arent holding tight enough and you press the balloon, water will leak out.
The balloon represents your bladder, your fingers represent your pelvic floor muscles, and the pressure on the balloon represents an external physical force.
Prevention Of Urinary Incontinence
Being overweight, being constipated, lifting heavy weights and drinking a lot of caffeine all make incontinence more likely. So, if youre worried about incontinence, try to maintain a healthy weight, eat and drink healthily and to reduce the amount of strenuous exercise you do.
You may be able to prevent incontinence during pregnancy and in the first few months after by doing pelvic floor exercises while youre pregnant. Ask your midwife for more information.
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Where To Go For Urinary Incontinence Treatment
For urinary incontinence treatment, start with your primary care doctor. Tell them you are having problems with bladder control. If your primary care doctor is unable to help, ask for a referral to a specialist. Doctors who specialize in treating urinary incontinence include urogynecologists, gynecologists with extra training in urinary incontinence, or urologists, doctors who specialize in problems of the urinary tract system in men and women.
Treatment Of Urge Incontinence
The anticholinergic agents oxybutynin and tolterodine are used widely to treat urge incontinence. These medications are not, however, the most effective therapies. Behavior therapies are more effective, and theynot medicationsshould be first-line treatment.
Behavior therapies for urge incontinence include bladder training and pelvic floor muscle exercises. Bladder training is more effective than oxybutynin and improves incontinence in more than 50 percent of patients.6 Kegel exercises are even more effective. In a randomized controlled trial 7 comparing Kegel exercises with oxybutynin in patients with urge incontinence, patients performing Kegel exercises had an 81 percent reduction in incontinence episodes compared with a 69 percent decrease in oxybutynin-treated patients, a statistically significant difference.
Although biofeedback commonly is used to help patients learn effective Kegel technique, evidence suggests that biofeedback training does not result in decreased frequency of incontinence episodes compared with Kegel exercises alone.8 Physicians should keep in mind that successful use of Kegel exercises is dependent on a patients motivation and ability to cooperate with the exercise routine.
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Stress Urinary Incontinence In Women
Stress Urinary Incontinence is when pressure placed on the bladder causes urinary leakage. This often happens with physical movement. If you’ve ever wondered why you pee when you laugh, pee when you cough, or pee when you exercise – that’s stress urinary incontinence.
In order to understand why Stress Urinary Incontinence occurs, a quick refresher course on the female urinary anatomy might be helpful. The bladder has two functions. The first is to store urine produced by the kidneys and the second is to contract and push the urine through the urethra. Controlling the flow of urine out of the bladder is the sphincter muscle. The nervous system detects when the bladder is ready to be emptied and tells the sphincter to relax, allowing you to pee. When there is any sort of abdominal stress on the pelvic organsthe bladder, vagina, uterus, and rectumSUI can occur.
Female Urinary Anatomy
Specifically, there are two types of stress incontinence: urethral hypermobility and intrinsic sphincteric deficiency .
What Causes Female Urinary Stress Incontinence
Female urinary stress incontinence occurs when your pelvic muscles weaken. These muscles form a bowl that lines your pelvis. They support your bladder and control the release of your urine. As you age these pelvic muscles grow weak. Childbirth, pelvic surgery, and injury to your pelvis can weaken the muscles. Increased age and a history of pregnancy are also big risk factors.
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How Is Incontinence Treated
There are many different factors that your healthcare provider will consider when creating a treatment plan for your incontinence. The type of incontinence and the ways it affects your life are both big considerations. Your provider will also talk to you about the type of treatment you are most comfortable with. There are three main types of treatment you can explore for incontinence medications, lifestyle changes and surgery. Each option has pros and cons that your provider will discuss with you.
Medications to treat incontinence
There are quite a few medications that can reduce leakage. Some of these drugs stabilize the muscle contractions that cause problems with an overactive bladder. Other medications actually do the opposite thing relaxing muscles to allow your bladder to empty completely. Hormone replacement therapies can often involving replacing estrogen thats decreased during menopause may also help restore normal bladder function.
In many cases, medications can work very well to return normal function to the bladder. Your provider will carefully select a medication that matches your specific needs. Often, your provider will start you on a low dose of the medication and then increase it slowly. This is done to try and reduce your risks of side effects and to keep track of how well the medication is working to treat your incontinence.
Common medications that can be used to treat incontinence include:
Lifestyle changes to manage incontinence
Stress Urinary Incontinence Treatments
Your treatment for stress urinary incontinence will depend on the severity of your symptoms. Many people find that introducing pelvic floor muscles can make a significant difference. If your symptoms are still troublesome, your GP can prescribe medication along with the exercises. As a final resort there are surgical treatments available, these will only be considered if your condition is severe and is causing an impact on your daily life. Your GP or Healthcare Practitioner will be able to advise on the best route of treatment for you.
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How Is Urinary Incontinence Treated
The kind of treatment you have will depend on:
- the type of urinary incontinence you have
- how severe it is
- your age, health and medical history.
Your doctor may refer you to a womens health physiotherapist or a doctor who specialises in womens pelvic floor problems . They may recommend one or more of these treatment options:
- Lifestyle changes such as losing weight, quitting smoking, eating more fibre, drinking more water or lifting less.
- Medication to help relax the bladder muscles, which play an important role in urge incontinence.
- Physiotherapy to strengthen the pelvic floor, which supports your bladder. A physiotherapist can design a special pelvic exercise program for you.
- Surgery to support or hold up your bladder or urethra . Surgery is usually only considered if medication or physiotherapy have not been successful.
- The success of treatment can vary. While treatment may not cure your incontinence, it can still help you live more comfortably with it.
How Successful Is Treatment For Urinary Incontinence
The outlook is promising for urinary incontinence treatment. About 80% of people with urinary incontinence can improve or even be cured. The best outcome depends, of course, on getting the correct diagnosis and following your doctor’s advice to help improve your condition.
American Academy of Family Physicians: “Urinary Incontinence: Embarrassing but Treatable.”
Jennifer Anger, MD, MPH, urologist, Cedars-Sinai Medical Center, Los Angeles.
Amy Rosenman, MD, co-author, The Incontinence Solution, urogynecologist, Santa Monica, CA, associate clinical professor, UCLA.
National Library of Medicine MedlinePlus Medical Encyclopedia: “Urge Incontinence.”
Halina Zynczynski, MD, director, division of Urogynecology and Reconstructive Pelvic Surgery, Magee-Women’s Hospital, associate professor of obstetrics and gynecology, University of Pittsburgh School of Medicine, Pittsburgh, PA.
American Family Physician: “Selecting Medications for the Treatment of Urinary Incontinence.”
National Association for Continence: “Treatment Options for Incontinence.”
American Urological Association: “Diagnosis and Treatment of Overactive Bladder in Adults: AUA/SUFU Guideline.”
Global Library of Women’s Medicine.
Rovner, E. Rev Urol., 2004
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How Does Stress Urinary Incontinence Affect Your Life
Stress urinary incontinence can have a huge effect on your quality of life. The physical and emotional demands created by stress incontinence can leave you feeling exhausted, embarrassed and even depressed. Some of the common byproducts of SUI are:
Depression. Many people with SUI are deeply ashamed of their condition and live in constant fear of having an accident. This can lead to them avoiding things they once loved, like hanging out with friends or family, attending social events or even working out. This restrictive nature of SUI can lead to isolation, loneliness and depression in many if left untreated.
Skin care issues. Constant moisture, especially urine, can cause your skin to be irritated and sore. Its important to use proper protection for incontinence to avoid this from happening. Absorbent pads with wicking materials help keep moisture away from the body and avoid irritation, while moisture barrier creams can help protect skin from coming into contact with urine.
Will Urinary Incontinence Go Away On Its Own
There’s no doubt that urinary incontinence affects your quality of life. Leakages can not only irritate your skin and cause embarrassment, but constantly worrying about when one might happen next can keep you from living your life. So much so that you might plan everything you do around whether there’s a bathroom nearby.
It’s a very common problem affecting up to one in three women. If you’re experiencing urinary incontinence, you’re likely looking for answers. Specifically, what can you do to stop it?
“Urinary incontinence is a loss of urine when you’re not actively trying to urinate,” explains Dr. Fiona Lindo, urogynecologist at Houston Methodist. “It can happen without you being aware or with physical exertion, such as exercise or even when simply standing up, coughing or laughing.”
“Unfortunately, urinary incontinence isn’t likely to go away on its own. The good news, however, is that there are things that you can do on your own to improve it, and there are plenty of options for treating it,” adds Dr. Lindo.
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How Do I Cope With My Fecal Incontinence
Doing the following can help you cope with your fecal incontinence:
- using the toilet before leaving home
- carrying a bag with cleanup supplies and a change of clothes when leaving the house
- finding public restrooms before one is needed
- wearing absorbent pads inside your underwear
- wearing disposable underwear
The Link Between Running And Urine Leaks
First, lets learn more about incontinence.
Leaking, or urinary incontinence, is a medical condition that refers to the involuntary loss of urine triggered by increased pressure or abrupt muscle contraction of the bladder.
In other words, its when youre unable to control your bladder.
Incontinence can be nothing but a minor nuisance to a complete loss of bladder control.
Surveys show that incontinence affects twice as many women as men.
This may be blamed on hormonal changes and delivery history .
At least one in three female runners over 30 may experience bladder leaks while running, research reports.
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What Causes Bladder Leaks
There are two main types of urinary incontinence:
If you have this type, activities that raise the pressure inside your abdomen cause urine to leak through the ring of muscle in your bladder that normally holds it in. Coughing, sneezing, jumping and lifting heavy objects could lead to a leak.
Going through childbirth, smoking or being overweight can raise the risk of stress incontinence for women, Wright says. Stress incontinence in men is rare, and when it arises, its often due to prostate cancer treatment, such as radiation or surgery.
With this type, your brain, spinal cord and bladder dont work together properly to allow you to hold and release urine at the right time. Your bladder may suddenly empty itself without warning. Or you may feel like you need to urinate frequently, a problem called overactive bladder.
Some diseases that affect the nervous system, such as multiple sclerosis or stroke, can cause this kind of incontinence, says Wright. In men, an enlarged prostate may be the culprit. But in many cases, doctors dont know what causes urge incontinence.
It is possible to have both types of incontinence at the same time.
TRY IT: Keep Records
Your doctor will want to know as much as possible about your bladder leakswhen they occur, how much urine comes out, and what youre doing when leaks happen. Consider keeping a diary of when you urinate and when you have leaks, recommends Wright.
What Causes Stress Incontinence
Stress incontinence is caused by a weakening of the muscles and sphincters in and around the bladder. The sphincters are ring-like structures at the bottom of the bladder and urethra that close to stop the flow of urine.
Some of these muscles are voluntary and can be controlled , while others deep inside are involuntary and cannot be consciously controlled.
Image: A bladder with internal and external sphincters.
When these structures and muscles weaken or do not receive the proper nerve impulses, they don’t close all the way and allow urine to flow through them .
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Daily Pelvic Floor Exercises
These can be really effective at reducing leakage, but it’s important to do the exercises properly.
You can feel your pelvic floor muscles if you try to stop the flow of urine when you go to the toilet. To strengthen your pelvic floor muscles, sit comfortably and squeeze the muscles 10 to 15 times in a row. Avoid holding your breath, or tightening your stomach, buttock, or thigh muscles at the same time.
When you get used to doing pelvic floor exercises, you can try holding each squeeze for a few seconds. Every week, you can add more squeezes, but be careful not to overdo it, and always have a rest in between sets of squeezes.
You may have to do these exercises for 3 months before you see any benefits.
Pelvic floor exercises are most effective when tailored to the person. Continence and women’s health or pelvic floor physiotherapists can assess your pelvic floor function and design an exercise program to meet your needs. Ask your GP for a referral.
The Continence Foundation of Australia has produced this video on how to do pelvic floor exercises:
The Continence Foundation of Australia has produced these videos to help explain the function and role of the pelvic floor muscles:
What Should I Do About Anal Discomfort
Fecal incontinence can cause anal discomfort such as irritation, pain, or itching. You can help relieve anal discomfort by
- washing the anal area after a bowel movement
- changing soiled underwear as soon as possible
- keeping the anal area dry
- using a moisture-barrier cream in the area around your anus
- using nonmedicated powders
- using wicking pads or disposable underwear
- wearing clothes and underwear that let air pass through easily
Talk with your doctor or a health care professional about which moisture-barrier creams and nonmedicated powders are right for you.
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What Treatment Options Are Available If Urinary Incontinence Still Won’t Go Away
Seeing a urogynecologist as early as possible can help ensure that you have a complete understanding of your condition and treatments options.
“Both stress and urgency incontinence typically respond well to behavioral modifications, but if things are not improving, it’s best to get evaluated,” says Dr. Lindo. “This is why I always recommend seeing a specialist about your condition right away. You never want to play the guessing game with your health, especially when your condition affects your quality of life.”
In addition, your doctor can recommend a pelvic floor physical therapy program. While Kegels can play an important role in alleviating urinary incontinence, Dr. Lindo says they’re performed incorrectly more than 80 percent of the time.
“An incorrect Kegel will not help correct urinary incontinence,” warns Dr. Lindo. “Seeing a physical therapist who specializes in pelvic floor exercises can help ensure you’re performing Kegels and other exercises correctly and truly strengthening your pelvic floor.”
And if your condition continues to progress or worsen, your urogynecologist has expertise to perform testing and recommend a range of urinary incontinence treatment options and procedures that can help to correct your condition and address your specific situation.
Causes Of Urinary Incontinence
The cause of urinary incontinence depends on the type of incontinence you have.
Urge incontinence occurs when the muscle of your bladder wall contracts when you dont want it to. This causes you to feel the need to pass urine urgently. This can develop as you get older or be caused by neurological conditions such as a stroke or multiple sclerosis.
Some things which make having stress incontinence more likely include the following.
- Being pregnant and giving birth. This stretches and weakens your pelvic floor muscles, which can lead to incontinence. Having a vaginal birth, having a cut to your perineum during childbirth or having more than one pregnancy are all linked to stress incontinence.
- Being overweight.
- Being constipated.
- Getting older the older you are the more likely you are to have any type of incontinence.
- Other members of your close family having stress incontinence.
- Having a prolapse this is when one or more of the organs in your pelvis slip down from the normal position and bulge into your vagina.
Other causes of incontinence include:
- a urine infection
- strenuous activity such as weight lifting
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