Urinary incontinence is a condition that presents in many forms and is a consequence of many etiologic events. In general, medical conditions such as urinary infections and diabetes should be properly treated and controlled to help with incontinence. Other measures are:
- Losing weight if you are obese or overweight
- Cutting down on the use of alcohol and caffeine
- Taking in adequate fluids but preventing over-hydration
This is a common condition, especially in women after childbirth, in which urine escapes in situations such as coughing, sneezing or laughing. The best ways of treating it are summarized below:
- Kegel’s exercises or pelvic floor muscle training, with or without biofeedback: this consists of learning to squeeze the pelvic floor muscles regularly several times a minute, working up to sessions of 5 or more minutes 3 or more times a day, for 3 months or more.
- Medical device-based treatment:
- Electric stimulation: a soft silicone tube resembling a tampon is inserted into the vagina. Through it, electric signals are sent to the pelvic muscles to contract them. The strength of the signal is set to cause contractions which are strong but not uncomfortable. While the feeling is still not pleasant, this procedure may be useful for individuals who cannot learn how to feel or squeeze their pelvic muscles otherwise.
- Magnetic stimulation: in this treatment modality, which is done in a doctor’s office, the patient is seated in a special chair which is equipped to create a magnetic field which leads to contraction-relaxation cycles of the pelvic muscles.
- Vaginal cones: these are a set of small cones graduated in weight, which must be retained in the vagina against the pull of gravity. This is done by the woman tightening the vagina. Once she finds it easy to retain one cone, she moves on to the next heavier one. These help to train the pelvic floor muscles to remain toned rather than lax.
- Topical creams, vaginal tablets or rings containing estrogen: these release estrogen which firms up the vagina, and are especially useful in postmenopausal women with lax pelvic floors
- Duloxetine (a serotonin-norepinephrine reuptake inhibitor that is given as an add-on medication)
- Tape and sling procedures are used to correct the position of the urethra and prevent urine leakage. They reduce the pressure exerted on the bladder and strengthen the pelvic supports. Adverse effects following the procedures include not being able to empty the bladder completely, having recurrent urinary infections, developing urge incontinence, erosion of the vaginal mucosa overlying the tape or sling, having problems with sexual intercourse or having to revise the surgery later to tighten or loosen the tape or sling. These are effective in many women, however.
- Urethral bulking agents: substances like collagen are usually injected into the tissue around the urethra to make them more solid and help to close off the urethra. They usually wear down with time and become less effective. They do not require an incision, however.
- Artificial urinary sphincter: this is more commonly used to control stress incontinence in men rather than women, and consists of a small pump, a fluid reservoir, and a circular part that fits around the urethra. The patient may operate the pump to close off the urethra, and release it when necessary. It may stop working properly in some cases and require to be removed surgically.
In this situation you may find that urine escapes immediately after a strong and uncontrollable urge to urinate. The best treatments are given below:
- Bladder training: this depends on training the bladder to hold urine for slightly longer periods each time, until you are able to control the passage of urine. Starting with a timed schedule, you visit the toilet and empty your bladder on the dot, whether or not you feel the need to. Once you are used to this, your bladder is trained to hold in the urine till the next set time arrives. Eventually this leads to your bladder becoming stable. At least 6 weeks of training are usually recommended.
- Medications: in order to reduce the frequency or amount of urinary leakage (or even prevent it altogether), antimuscarinic drugs which inhibit the nerve impulses that are responsible for the sudden bladder contractions that cause urge incontinence are given. Most are taken orally, and are started at a low dosage. Careful follow-up is mandatory with these drugs.
Side effects of these drugs include:
- dry mouth
- blurring of vision
- glaucoma in a few cases
An alternative sometimes used for urge incontinence is mirabegron, a beta-3 receptor antagonist which relaxes the bladder muscle, and thus helps to retain urine. It has potentially serious side effects such as a rise in blood pressure and heart rate, as well as a higher risk of urinary infections. Its use should be monitored carefully.
- Botulinum toxin injection: this relaxes the detrusor muscle of the bladder wall. The effect lasts for several months. If this results in incomplete bladder emptying, self-catheterization may be taught to empty the bladder fully.
- Sacral neuromodulation: here a small electrical signal generator is implanted near the sacrum, at the lowest part of the back, usually in one of the gluteal muscles. The signals it sends to the brain interfere with the abnormal frequent impulses from the detrusor muscle of the bladder, which travel via the same nerve. Thus the bladder urges are inhibited. Some people may not tolerate this technique, but others report that they are cured by it.
- Percutaneous tibial nerve stimulation: in this therapy, the tibial nerve is stimulated by a very thin needle electrode near the ankle, and the nerve impulses travel up the nerve to block other impulses arising from the bladder muscles, and reduce the urge to urinate. It is done in a doctor’s office for 30 minutes at a time and requires 12 sessions.
- Augmentation cystoplasty: in this approach the tissue from the intestinal wall is added to the bladder to enlarge bladder capacity. However, lifelong use of a catheter may be necessary following this procedure. Urinary infections may also become more common.
- Urinary diversion: Here urine is directed outside the body instead of flowing into the bladder.
This is usually a mixture of stress and urge incontinence occurring at different times, which is treated by selecting from the above methods for each. In cases which do not respond to any of these, absorbent pads or hand-held urine collection bottles may be needed to help you manage the condition.
This is also called chronic urinary retention and is treated by:
- Clean intermittent catheterization: here the patient is taught, by a trained advisor, how to remove urine from the bladder by a clean thin tube inserted into the bladder through the urethra. Risks include a higher rate of urinary infections. The number of catheterizations required varies from person to person.
- Indwelling catheterization: people who are not managed by clean intermittent catheterization may opt to have a permanent catheter inserted into the bladder, draining into a bag, which is emptied regularly.
Reviewed by: Dr Tomislav Meštrović, MD, PhD