Patient education: Urinary incontinence treatments for women (Beyond the Basics)
- Emily S Lukacz, MD, MAS
Emily S Lukacz, MD, MAS
- Professor of Clinical Reproductive Medicine
- UC San Diego Heath System
URINARY INCONTINENCE OVERVIEW
Many women suffer from urinary leakage. Treatments are available to reduce or eliminate leaking. Your healthcare clinician can help you with treatment if you are bothered by leaking urine, having to rush to the toilet frequently or getting up from sleeping to go to the toilet.
This article discusses treatments for the two main types of leakage in women, stress and urgency incontinence. These treatments also apply to women who have a combination of urge and stress incontinence, called mixed incontinence. Information about the different types of urinary incontinence and the causes, symptoms, and diagnosis of urinary incontinence is available separately. (See "Patient education: Urinary incontinence in women (Beyond the Basics)".)
More detailed information about incontinence in women as well as information about lower urinary tract symptoms in men is available by subscription. (See "Evaluation of women with urinary incontinence" and "Treatment of urinary incontinence in women" and "Lower urinary tract symptoms in men".)
BEFORE STARTING TREATMENT
Certain health conditions can worsen urine leakage. You should talk to your healthcare provider about treating these conditions and any medications that might be worsening your urinary leakage.
The following treatments may be helpful for women with stress and/or urgency incontinence.
Lifestyle modification — Some changes in your lifestyle may help symptoms of urinary leakage.
●Weight loss – If you are overweight or obese, talk to your healthcare provider about strategies to lose weight. In people who are obese or overweight, losing weight can help to reduce urine leakage.
●Fluid management – If you drink large amounts of fluids, you may find that cutting back on fluids will reduce your leakage. A total of 64 ounces of all liquids (water, juice, milk, etc) fluid per day is sufficient for most people; you may need more fluid when you are active and sweating or if it is hot. If you drink too little fluid, your urine may become very concentrated and darker than usual. One recommendation is to drink a small amount of fluid at regular intervals throughout the day (rather than drinking larger amounts all at once).
We also suggest reducing the amount of alcoholic, caffeinated, and carbonated beverages you drink. This may help decrease urinary urgency and leakage.
If you get up frequently during the night to urinate, stop drinking fluids 3 to 4 hours before you go to bed.
●Avoiding constipation – Constipation can make urinary leakage worse. Increasing the amount of fiber in your diet to 30 grams per day can prevent constipation. Treatment of constipation is discussed in a separate topic review. (See "Patient education: Constipation in adults (Beyond the Basics)".)
Pelvic muscle exercises — Pelvic muscle exercises, also known as Kegel exercises, strengthen the muscles involved in controlling urine leakage. This is explained in a table (table 1). (see "Patient education: Pelvic floor muscle exercises (Beyond the Basics)").
Practicing these exercises on a regular basis helps to strengthen the muscles used to support the urethra and prevent leakage caused by stress incontinence (ie, coughing, laughing, sneezing). If you have sudden urges to urinate, you can also perform these exercises to help temporarily control the urge. To do this, you need to stop what you are doing and do three quick pelvic floor contractions until the urgency subsides. Using this “freeze and squeeze” technique can reduce bladder contractions and give you more time to get to the toilet. If you have difficulty doing these exercises, talk to your healthcare provider to see what options are available to help you do the exercises better.
Bladder training — Bladder training can help you learn to go to the bathroom less frequently by "retraining" your bladder to hold more urine (table 2).
Bladder training has two components: going to the bathroom on a schedule while you are awake and using strategies to control sudden urges.
●You begin by going to the bathroom at specific intervals during the day, starting with a small time interval. For example, if you currently go to the bathroom every 30 to 45 minutes, you would start by going every 45 minutes, whether you feel the need to go or not. Many people can start by going every 1 to 2 hours.
●If you have an urgent need to go before it is time to go the bathroom again, try to suppress the urge by standing or sitting still, performing pelvic muscle exercise “freeze and squeeze," and thinking of the urge as a wave that is fading away.
●When your urine control improves, increase the time between bathroom trips by 30 to 60 minutes.
●Your goal is to slowly increase this time up to a more normal interval. It is normal to urinate approximately every three to four hours during the day and for older adults to wake from sleeping up to once per night.
Topical vaginal estrogen — Vaginal estrogen may be helpful for peri- or post-menopausal women with urinary incontinence and vaginal atrophy.
TREATMENTS FOR STRESS INCONTINENCE
If you continue to have symptoms despite the initial treatments for stress urinary incontinence, you can discuss other options with your healthcare provider.
●Vaginal pessaries - A vaginal pessary is a flexible device made of silicone that can be worn in the vagina. A pessary can help to reduce or eliminate stress incontinence. A pessary is a reasonable treatment if you want to delay or avoid surgery. When fit properly, you will not feel any discomfort with the pessary.
The pessary must be removed and cleaned with soap and water periodically. Many women can learn to do this on their own and are advised to remove it overnight once every week or two. For those women who cannot remove the device, the pessary can be monitored, cleaned, and replaced by a healthcare provider every three to six months. There is a small risk that the pessary can cause irritation or an erosion of the skin inside the vagina. If this occurs, vaginal estrogen and/or more frequent removal can resolve the problem.
●Medications - In the United States, there are no medications that have been approved for stress incontinence. Multiple medications have been evaluated for stress incontinence. You should talk to your healthcare provider about whether or not there are any medication options that are appropriate for you.
●Surgery - Surgery offers the highest cure rate of any treatment for stress urinary incontinence, even in elderly women. There are several surgical procedures for the treatment of stress incontinence. Each procedure has its own risks, benefits, complications, and chance of failure. These issues should be discussed in detail with a surgeon who is experienced in performing procedures to treat incontinence. (See "Surgical management of stress urinary incontinence in women: Choosing a primary surgical procedure".)
In general, surgery is not recommended until you are finished having children because pregnancy and childbirth can cause damage, potentially allowing leakage to recur.
TREATMENTS FOR URGENCY INCONTINENCE AND OVERACTIVE BLADDER
If you continue to have symptoms despite initial treatments for urgency incontinence, you can discuss other options, such as medication, with your healthcare provider.
Medications — In some people, urgency incontinence is more severe and a medicine is needed to get symptoms under control. Examples of these medications include darifenacin (Enablex), fesoterodine (Toviaz), mirabegron, oxybutynin (Ditropan), solifenacin (VESIcare), tolterodine (Detrol), and trospium (Sanctura).
Some people take medicine temporarily, until symptoms improve, while others take medication indefinitely.
●The most common side effects of these medications are dry mouth, constipation, and heartburn. The Oxytrol patch is associated with the least amount of these side effects and is available over the counter without a prescription. The other medications require a prescription. Mirabegron may raise blood pressure, so you should have your blood pressure monitored carefully while taking this medication.
●There are several strategies to prevent and treat dry mouth and constipation. These include sucking on sugar-free candy or chewing gum and using over-the-counter oral lubricants. Constipation can be managed typically with fiber supplementation and dietary options such as prunes and prune juice. It is important to not drink more water to combat these symptoms, as excessive fluid intake can result in more urine leakage.
●There is a small risk of urinary retention (not emptying the bladder completely) with these medications, especially in older people. If you develop difficulty urinating or feel like you are not completely emptying your bladder, you should follow up with your provider for evaluation.
Other therapies — If medications are not enough to improve your symptoms, there are other options for treatment that you can discuss with your healthcare provider.
●Acupuncture – Acupuncture might improve urinary incontinence in some women.
●Botox - Botulinum toxin A, also known as Botox, is a toxin produced by a bacteria that temporarily paralyzes muscles. Studies have examined using injections of Botox into the bladder as a treatment for urgency incontinence, for people who have not responded to other treatments. Botulinum toxin A is as effective as oral medication in decreasing leakage and more effective in eliminating leakage altogether .
However, there is a risk that botulinum toxin A will prevent the bladder from emptying. If this happened, you would need to insert a catheter (a thin tube) into your bladder several times per day to empty. However, the side effects are usually temporary. The decrease in leakage with botulinum toxin A injection can last six months or longer.
●Percutaneous tibial nerve stimulation – This treatment involves placing a hair-thin needle (like acupuncture) into a nerve near the ankle. This nerve is connected to nerves in the lower back that affect your bladder. The needle is connected to a small device that sends electrical pulses to the nerve. The treatment is not painful. This treatment is performed in a healthcare clinician's office once per week for 12 weeks and, if needed, can be continued monthly for maintenance.
●Sacral neuromodulation – A sacral nerve stimulator (SNS) is a device, about the size of a pacemaker, which can be surgically implanted. The device is placed under the skin in the upper buttock, and is connected with wires to a nerve (the sacral nerve) in the lower back. The device sends electrical pulses to the sacral nerve, which seems to help people with severe symptoms of urgency incontinence, urgency and frequency, or urinary retention who have not improved with other treatments.
Potential risks of the surgery include pain at the site where the unit is implanted (in the buttocks), movement of the device over time, infection, and others. More detailed information about sacral nerve stimulation is available separately. (See "Patient education: Treatment of interstitial cystitis/bladder pain syndrome (Beyond the Basics)", section on 'Electrical stimulation for painful bladder'.)
Pads — While pads are not a recommended treatment for incontinence, they are necessary in some cases. Pads and protective undergarments are available in a variety of sizes and absorbencies, depending upon how much you leak. Pads designed for menstrual bleeding are usually not typically adequate.
Information on pad varieties and other urinary incontinence supplies is available from medical supply companies and urinary incontinence advocacy groups (see 'Where to get more information' below). The US National Association for Continence has an online tool that can help you to choose a protective garment (http://nafc.org).
Whatever pad you choose, it is important to keep your skin dry and to control urine odor. If your skin is exposed to urine for long periods, it can become irritated and can potentially develop skin burns or infection. Use of zinc-based barrier products can help protect the skin (ie, zinc oxide). Protective products for the bed or other furniture may also be needed.
Pads are expensive and are not usually covered by insurance; in the United States, some state Medicaid plans cover the cost of pads for people with very limited incomes. In other countries, pads may be obtained for no or little cost through continence advisor nurses.
Portable toilet — If you have difficulty walking, talk to your healthcare clinician. You may benefit from a portable toilet that can be placed close to your bed or living area. In addition, move electrical cords, throw rugs, or furniture out of hallways and walkways so that you do not trip or fall on the way to the bathroom.
WHERE TO GET MORE INFORMATION
Your healthcare clinician is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient education: Urinary incontinence (The Basics)
Patient education: Pelvic muscle (Kegel) exercises (The Basics)
Patient education: Urinary incontinence in men (The Basics)
Patient education: Neurogenic bladder in adults (The Basics)
Patient education: Surgery to treat stress urinary incontinence in women (The Basics)
Patient education: Treatments for urgency incontinence in women (The Basics)
Patient education: Using a catheter to empty the bladder (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: Urinary incontinence in women (Beyond the Basics)
Patient education: Pelvic floor muscle exercises (Beyond the Basics)
Patient education: Constipation in adults (Beyond the Basics)
Patient education: Treatment of interstitial cystitis/bladder pain syndrome (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Evaluation of women with urinary incontinence
Lower urinary tract symptoms in men
Urinary incontinence and pelvic organ prolapse associated with pregnancy and childbirth
Pelvic organ prolapse and stress urinary incontinence in women: Combined surgical treatment
Stress urinary incontinence in women: Persistent/recurrent symptoms after surgical treatment
Treatment of urinary incontinence in women
Vaginal pessary treatment of prolapse and incontinence
Surgical management of stress urinary incontinence in women: Choosing a primary surgical procedure
Surgical management of stress urinary incontinence in women: Choosing a type of midurethral sling
Surgical management of stress urinary incontinence in women: Retropubic midurethral slings
Surgical management of stress urinary incontinence in women: Transobturator midurethral slings
The following organizations also provide reliable health information.
●National Library of Medicine
●National Institute on Aging
●The American Urogynecology Association
●Pelvic Floor Disorders Research Foundation
●National Association for Continence
●National Institute of Diabetes & Digestive & Kidney Diseases
●American Urological Association Foundation
●For continence resources in other countries, go to Continence Worldwide
- Visco AG, Brubaker L, Richter HE, et al. Anticholinergic therapy vs. onabotulinumtoxina for urgency urinary incontinence. N Engl J Med 2012; 367:1803.
- Schurch B, de Sèze M, Denys P, et al. Botulinum toxin type a is a safe and effective treatment for neurogenic urinary incontinence: results of a single treatment, randomized, placebo controlled 6-month study. J Urol 2005; 174:196.
- Janknegt RA, Hassouna MM, Siegel SW, et al. Long-term effectiveness of sacral nerve stimulation for refractory urge incontinence. Eur Urol 2001; 39:101.
- Hassouna MM, Siegel SW, Nÿeholt AA, et al. Sacral neuromodulation in the treatment of urgency-frequency symptoms: a multicenter study on efficacy and safety. J Urol 2000; 163:1849.
- Burgio KL, Goode PS, Locher JL, et al. Behavioral training with and without biofeedback in the treatment of urge incontinence in older women: a randomized controlled trial. JAMA 2002; 288:2293.
- Herbison P, Hay-Smith J, Ellis G, Moore K. Effectiveness of anticholinergic drugs compared with placebo in the treatment of overactive bladder: systematic review. BMJ 2003; 326:841.
- Moehrer B, Hextall A, Jackson S. Oestrogens for urinary incontinence in women. Cochrane Database Syst Rev 2003; :CD001405.
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.