Patient information: Urinary incontinence treatments for women

URINARY INCONTINENCE OVERVIEW

Leaking urine is never a normal or expected part of aging, and you should not just "learn to live with it". In most cases, treatments are available to reduce or eliminate leaking. Your healthcare provider 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, urge and stress incontinence. Information about the different types of urinary incontinence and the causes, symptoms, and diagnosis of urinary incontinence is available separately. (See "Patient information: Urinary incontinence in women".)

More detailed information about incontinence is available by subscription. (See "Clinical presentation and diagnosis of urinary incontinence" and "Treatment of urinary incontinence".)

TREATMENTS FOR STRESS AND URGE INCONTINENCE

The following treatments may be helpful for women with stress and/or urge incontinence. Information about the different types of urinary incontinence can be found in the more general topic. (See "Patient information: Urinary incontinence in women".)

Fluid management — If you drink large amounts of fluids, you may find that cutting back on fluids will reduce your leakage. Between 32 and 64 ounces of fluid per day (from both food and fluids) is sufficient for most people; you may need more fluid when you are active and sweating or if it is hot.

One recommendation is to drink a small amount of fluid at regular intervals throughout the day (rather than drinking larger amounts all at once). If you get up frequently during the night to urinate, stop drinking fluids 3 to 4 hours before you go to bed.

Treat other health conditions — Certain health conditions can worsen urine leakage. Treating these conditions may help to reduce or eliminate your leakage.

• Avoid taking diuretics at a time when it will be difficult to get to the bathroom for several hours.
• If you have swelling in your feet, elevate your feet for several hours in the afternoon or evening and consider wearing compression stockings. Your healthcare provider may suggest that you take a diuretic (fluid pill) in the afternoon. These measures can help reduce nighttime trips to the toilet.
• Ask your healthcare provider if any of your medications (prescription and non-prescription) could be causing or worsening your leakage.
• If you have diabetes and your blood sugar levels are high, talk with your healthcare provider. Having high blood sugar causes your kidneys to produce more urine.
• In people who are obese or overweight, losing weight can help to reduce urine leakage.

TREATMENTS FOR URGE INCONTINENCE AND OVERACTIVE BLADDER

Bladder irritants — Some people find that certain foods and drinks cause them to go to the bathroom more frequently. This includes drinks with caffeine (including soda), alcohol, spicy foods, and acidic foods or beverages, and artificial sweeteners. It is reasonable to see if temporarily eliminating one or more of these items reduces your need to go urgently and frequently.

Bladder training — Bladder training can help you learn to go to the bathroom less frequently by "retraining" your bladder to hold more urine (table 1).

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 sooner, try to suppress the urge by standing or sitting still, performing a pelvic muscle exercise, and think of the urge as a wave that is fading away.
• After one to two weeks, you can increase the time between bathroom trips by 15 to 30 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.

For people with dementia or memory impairment, a different approach is used, called prompted voiding. This involves reminding the person to use the toilet regularly (usually every two to three hours).

Prevent constipation — Constipation can worsen frequency and urgency. Increasing the amount of fiber in your diet to between 20 and 30 grams per day can prevent constipation. Treatment of constipation is discussed in a separate topic review. (See "Patient information: Constipation in adults".)

Medications — In some people, urge incontinence is severe and a medicine is needed to get symptoms under control. Examples of these medications include oxybutinin (Ditropan®), tolterodine (Detrol®), fesoterodine (Toviaz®), trospium (Sanctura®), solifenacin (VESIcare®) and darifenacin (Enablex®). These medications may work best when combined with bladder training.

If you do not respond to one medicine, you may respond to another. 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.
• If you take one of these medications for long periods of time you need to brush your teeth regularly and see a dentist every 6 months because dry mouth can increase the risk of cavities.
• There is a small risk of urinary retention (not emptying the bladder completely) with these medications, especially in older people.

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 severe urge incontinence, with most studies reporting a decrease in the frequency of leakage [1].

There is a risk that Botox® 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 effects of Botox® are temporary, on average lasting only three to six months.

The role of Botox in the treatment of urinary incontinence is not yet clear. The treatment holds promise for people with severe symptoms who have not responded to other treatments. Botox is not approved for the treatment or urinary incontinence. Further trials are needed to determine the best dose and if Botox is safe for people with less severe symptoms.

Electric stimulation — There are several types of electric stimulation available to treat urge incontinence, including an office-based procedure and a surgically implanted device.

Office treatment — Office electrical stimulation involves placing a hair-thin needle 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. It may help to reduce the need to frequently rush to the bathroom. This treatment is performed in a healthcare provider's office one to three times per week for six to eight weeks.

Surgically implanted stimulator — 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 urge incontinence, urgency and frequency, or urinary retention who have not improved with more conservative treatments. It is not clear how the treatment works, although studies show good results in most patients.

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 information: Treatment of painful bladder syndrome and interstitial cystitis", in the section on "Electrical stimulation").

TREATMENTS FOR STRESS INCONTINENCE

Pelvic muscle exercises — Pelvic muscle exercises, also known as pelvic floor muscle exercises or Kegel exercises, strengthen the muscles involved in controlling urine leakage (table 2) and (see "Patient information: Pelvic floor muscle exercises".

• Practicing these exercises on a regular basis may help to reduce urine leakage caused by stress incontinence.
• If you have sudden urges to urinate, you can perform these exercises to help temporarily control the urge.

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 (picture 1). A pessary is a reasonable treatment if you want to delay or avoid surgery. When fit properly, you will not feel the pessary.

The pessary must be removed and cleaned with soap and water periodically. In addition, there is a small risk that the pessary can cause irritation inside the vagina. Most women who use a pessary see their healthcare provider every three to six months for an examination. Some women, especially those who are sexually active, are able to learn how to insert and remove the pessary on their own.

Surgical treatments — 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 treatment of stress urinary incontinence in women".)

In general, surgery is not recommended until you are finished having children because pregnancy and childbirth can cause damage, potentially allowing leakage to recur.

OTHER MEASURES

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 recommended.

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. 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.

Catheters — A catheter may be necessary if you cannot empty your bladder completely or at all. Because catheters increase the risk of urinary tract infections and other serious complications, especially when left in place for long periods, they are usually a treatment of last resort.

A catheter may be inserted and left in the bladder, or may be inserted intermittently to drain the bladder, and then removed. A healthcare provider can teach you or a family member how to perform intermittent catheterization at home.

Portable toilet — If you have difficulty walking, talk to your healthcare provider. 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 provider is the best source of information for questions and concerns related to your medical problem. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Patient Level Information:
Patient information: Pelvic floor muscle exercises
Patient information: Urinary incontinence in women
Patient information: Constipation in adults
Patient information: Treatment of painful bladder syndrome and interstitial cystitis

Professional Level Information:
Clinical presentation and diagnosis of urinary incontinence
Epidemiology, risk factors, and pathogenesis of urinary incontinence
Evaluation and management of women with persistent/recurrent stress incontinence
Lower urinary tract symptoms in men
Midurethral slings for treatment of stress urinary incontinence in women
Pelvic floor disorders associated with pregnancy and childbirth
Surgical treatment of stress urinary incontinence in women
Treatment of urinary incontinence
Vaginal pessary treatment of prolapse and incontinence

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.

• National Library of Medicine

      (www.nlm.nih.gov/medlineplus/healthtopics.html)

• National Institute on Aging

      (www.nia.nih.gov/)

• The American Urogynecology Association

      (http://augs.org)

• National Association for Continence

      1-800-BLADDER
      (www.nafc.org)

• Simon Foundation

      (www.simonfoundation.org)

• National Institute of Diabetes & Digestive & Kidney Diseases

      (www.niddk.nih.gov/)

• American Urological Association Foundation

      (www.urologyhealth.org)

• For continence resources in other countries, go to Continence Worldwide

      (www.continenceworldwide.com)

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