Urinary Incontinence For Health Professionals: Treatment Options

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Treatment Options

Adapted and reproduced with permission from The Foundation for Medical Practice Education, www.fmpe.org

General considerations

Although referral to specialists is required for UI patients with complex histories, family doctors can often develop an effective managment strategy based on history, physical examination, basic laboratory investigations, and possibly a PVR test.

A multifactorial, stepped approach designed to relieve the most bothersome aspects of UI is the cornerstone of successful therapy. It is appropriate to initiate lifestyle strategies and physical therapy even before definitive determination of the type of UI.

Patients with large (second or third degree) cystoceles or rectoceles will likely require either surgical repair or a pesssary, although pelvic floor exercises and pharmacotherapy have successfully helped some of these patients.

The bottom line

  • Because of the stigma associated with UI, physicians need to take a proactive approach in discussing and identifying the problem.
  • A multifaceted approach involving lifestyle modifications, pelvic muscle exercises, bladder retraining, and (in some cases) medication or surgery the cornerstone of successful UI treatment.

Lifestyle changes

Intake of adequate fluid (1.5 to 2 liters a day) may improve symptoms of UI, while reduction or elimination of caffeine intake may improve lower urinary tract symptoms [Level II Evidence].

Moderate physical activity may prevent or reduce lower urinary symptoms [Level III Evidence], and obese women can significantly improve urine retention by losing weight [Level I Evidence].

Coughing associated with cigarette smoking can trigger or exacerbate the urge to urinate; for this and other health reasons, smokers with UI should be encouraged to quit.

Patients taking drugs known to affect bladder function may benefit from reducing their dose or switching to another drug.

Pelvic muscle exercises

Pelvic muscle exercises (PME) also called Kegel or pelvic floor muscle training exercises, offer a suitable conservative first-line treatment for patients with urgency, stress or mixed UI [Level I Evidence].

PMEs are most effective in patients who participate in a supervised PME program for at least 3 months with a physiotherapist.

PME involves strengthening pelvic floor muscles.

  1. Digital assessment of pelvic floor muscle function is advised prior to initiation of PME, to ensure that the patient is contracting the correct muscle. It can be done visually during the examination by asking the woman to contract the muscles in her vagina and observing the response.
  2. Some studies suggest that patients can perform these exercises adequately with verbal instructions, while other experts (including Kegel himself) argue that correct PME requires digital confirmation.

PME has a poor long-term adherence rate, so instructions should be kept simple and daily requirements realistic.

Biofeedback may help women perform these exercises properly. Women experiencing difficulty should be referred to a physiotherapist.

Bladder retraining

Bladder retraining is recommended for management of urge and mixed UI [Level I Evidence]. This strategy, which involves gradually increasing the interval between voids until the patient is able to void every 3-4 hours while awake, usually takes several weeks to yield results.

Pharmacotherapy

A number of drugs are used to treat urgency UI. It may be appropriate to initiate drug therapy if lifestyle measures and physical therapy have not yielded satisfactory results.

Drugs used to treat UI

Evidence for the use of estrogen to treat stress UI in postmenopausal women is conflicting and increasingly weak, with recent data suggesting a lack of objective benefit.

 

ANTICHOLINERGIC AGENTS

 

 

Recommended:

To be avoided/use with caution in:

Trospium chloride

20 mg po bid

 

A good first choice in the elderly, especially for patients at risk of cognitive impairment; studies suggest that its large molecular size and hydrophilic properties reduce the likelihood that trospium will cross the BBB and cause confusion.

 

Trospium is not metabolized by the liver, thereby reducing the risk of CYP450 drug-drug interactions.

Not recommended in patients with severe renal impairment (as trospium is primarily excreted unchanged by the kidneys), patients with clinically significant bladder outflow obstruction; and patients unable or unwilling to take the medication twice daily on an empty stomach (~1 hour prior to eating)

Darifenacin

7.5-15 mg po qd

 

A good choice in older adults at risk for cognitive impairment. Studies show no effect on memory.

Administer with caution to patients with clinically significant bladder outflow obstruction or risk for urinary retention

 

Due to its low bioavailability and cytochrome CYP2D6 and CYP3A4 metabolism, patients are more susceptible to toxicity and/or hepatic drug-drug interactions

 

Darifenacin is associated with high rates of constipation

Solifenacin

5-10 mg po qd

 

Also a good choice in older adults, as studies show no impairment in cognition.

Administer with caution to patients with clinically significant bladder outflow obstruction, decreased GI motility, reduced hepatic or renal function, and patients taking other drugs that are metabolized by cytochrome CYP3A4.

 

The muscarinic selectivity of solifenacin makes it likely to cause or exacerbate constipation

Tolterodine

immediate release 1-2- mg po bid or long-acting (LA) 2-4 mg po qd

Widely used but is being replaced by fesoterodine.  Reports of confusion and prolonged QT interval/tachycardia in cardiovascular patients have diminished its enthusiastic use in the elderly.

 

In men, combined use of tolterodine and tamsulosin has been shown to be effective for the treatment of OAB.

Administer with caution to: patients with increased risk of experiencing torsade de pointes / taking medications that can prolong the QT interval; patients with myasthenia gravis, reduced hepatic or renal function (dose ≤1 mg bid), clinically significant bladder outflow obstruction, and GI obstructive disorders; patients at risk of decreased GI motility; and patients taking other medications metabolized by CYP2D6 and CYP3A4.

Fesoterodine

4 or 8 mg po qd

A good choice in older adults. Studies show no impairment in cognition and no cardiovascular side effects.

Avoid in patients with lactose intolerance. Administer with caution to patients with clinically significant bladder outflow obstruction or risk for urinary retention.  Less cytochrome metabolism than tolterodine, leading to more stable drug levels. Still requires CYP3A4 metabolism to be excreted.

Oxybutynin immediate release 2.5-5 mg po bid-tid or extended release 10-15 mg po qd

The immediate release form of oxybutynin at doses greater than 5 mg per day is not recommended in the elderly due to a high risk of cognitive impairment and intolerance secondary to dry mouth.

Oxybutynin readily crosses the blood brain barrier, and is associated with CNS side effects, including memory impairment, confusion, sedation, and hallucinations.

• Administer with caution to patients with severe GI obstructive disorders, clinically significant bladder obstruction, hepatic or renal disease, and in patients taking other medications metabolized by CYP3A4.

 

Dry mouth is the most significant (occurs in 71%); the incidence is dose-dependent and reduced with use of the extended-release form (29% at 10 mg qd)

Oxybutynin transdermal patch

twice per week  or daily gel

Patients who cannot tolerate dry mouth as the patch and gel have the lowest incidence of dry mouth (5-7%).

 

The patch provides more stable serum concentrations than oral delivery and avoids presystemic metabolism.

Patients with a dry skin condition cannot tolerate the patch as 15% of users develop a local skin irritation.

 

BETA – 3 AGONIST DRUGS

 

 

Recommended:

To be avoided/use with caution in:

Mirabegron

25 – 50 mg daily

A new class of medication whose mechanism of action is via beta-3 agonism, which relaxes the detrusor muscle during the bladder storage phase.

 

At the time of publication (2013), there were no published studies on sub-group analyses in the elderly.

 

Studies in the general population, of which 30% of participants were over age 65 suggest that the rate of dry mouth and constipation is the same as placebo.

Contraindicated in patients with uncontrolled hypertension.

 

Use with caution in patients with digoxin.

 

Potential for drug-drug interactions in patients on other drugs metabolized by CYP2D6 (i.e. metoprolol) and CYP3A4.

 

Surgery

Surgery, which involves improving the urethral/bladder support mechanisms or changing the angle at which the urethra and bladder meet, is a treatment option for stress UI and can be considered as a first-line treatment in select situations when compliance with nonsurgical treatments is poor. Types of surgery most commonly involve minimally invasive TVT or TOT. While short-term success rates of surgery can approach 90%, data on long-term effectiveness (>5-10 years) are limited. Surgery may also be needed to remove obstructions that cause or exacerbate UI.

Assistive devices

Pessaries are recommended for women who have symptomatic organ prolapse [Level III Evidence]. For women with atrophic changes, local estrogen therapy prior to and after pessary insertion may help prevent vaginal infection and ulceration.

Continence products such as absorbent pads may be useful as an adjunct to other therapy or for long-term care of patients with chronic, intractable UI [Level III Evidence]

 

We are pleased to house this series of FAQs for health professionals, supervised by Cara Tannenbaum, from the Centre de recherche de l’Institut universitaire de gériatrie de Montréal.

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The production of this content was supported by a Knowledge-to-Action partnership grant between the CWHN and the Canadian Institutes of Health Research and supervised by Dr Cara Tannenbaum from the Centre de Recherche de l'Institut Universitaire de Gériatrie de Montréal.