Urinary incontinence is a condition that presents in many forms and is a consequence of many etiologic events.
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In general, medical conditions such as urinary infections and diabetes should be properly treated and controlled to help with incontinence. Additional measures can include:
- Losing weight if the patient is obese or overweight
- Cutting down the use of alcohol and caffeine
- Taking in adequate fluids while preventing overhydration
Stress incontinence
Urinary incontinence is a common condition, especially in women after childbirth, during which urine escapes in situations such as coughing, sneezing, or laughing. The most common ways to treat this condition include Kegel's exercises as well as a wide range of medical device-based treatment approaches.
Kegel's exercises
Kegel’s exercises, or pelvic floor muscle training, with or without biofeedback, can be prescribed for treating urinary incontinence in women. Typically, this treatment modality will require the patient to learn how to squeeze the pelvic floor muscles. Once these movements are learned, patients are advised to perform them regularly several times a minute until they can work up to sessions of 5 or more minutes. Taken together, urinary incontinence patients should complete pelvic floor music training sessions 3 or more times a day, for 3 months or more.
Medical device-based treatment
Electric stimulation treatment for urinary incontinence typically involves the insertion of a soft silicone tube resembling a tampon into the vagina. Through this tube, 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.
Another type of device-based treatment includes magnetic stimulation. In this treatment modality, which is done in a doctor’s office, the patient is seated in a special chair that is equipped to create a magnetic field that leads to contraction-relaxation cycles of the pelvic muscles.
Vaginal cones, which are a set of small cones graduated in weight, can also be used to correct urinary incontinence. More specifically, vaginal cones are retained in the vagina against the pull of gravity, which is achieved by the woman tightening the vagina. Once the patient finds it easy to retain one cone, she is advised to move on to the next heavier one. As the weight of the cone gradually increases, the patient is able to better train the pelvic floor muscles to remain toned rather than lax.
Stress Incontinence - Dr. Ralph Turner
Medication-based treatment
Estrogen-based formulations including topical creams, vaginal tablets, or rings release estrogen, which firms up the vagina. These estrogen-based treatment options are particularly useful in postmenopausal women with lax pelvic floors.
Another type of medication-based treatment that can be used to correct urinary incontinence includes fuloxetine, which is a serotonin-norepinephrine reuptake inhibitor, that can be given as an add-on medication.
Surgical methods
Several different surgical methods are available to correct urinary incontinence, which include tape and sling procedures, the injection of urethral bulking agents, and artificial urinary sphincter placement.
Tape and sling procedures
Tape and sling procedures are used to correct the position of the urethra and prevent urine leakage. These procedures reduce the pressure exerted on the bladder and strengthen the pelvic supports.
Some of the adverse effects that can occur 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. Despite the potential adverse effects that can occur, these procedures are often highly effective in most women.
Urethral bulking agents
Substances like collagen can be used as urethral bulking agents. During this type of procedure, the selected agent is injected into the tissue around the urethra to make the tissue more solid and help to close off the urethra. Typically, these substances degrade over time and eventually decrease in their effectiveness. However, the injection of urethral bulking agents does not require an incision to be performed.
Artificial urinary sphincter
The placement of an artificial urinary sphincter is more commonly used to control stress incontinence in men rather than women. This procedure involves the use of a small pump, a fluid reservoir, and a circular part that fits around the urethra.
The patient may operate the pump themselves to close off the urethra and release it when necessary. In some cases, the sphincter may stop working properly and require surgical removal.
Urge incontinence
Individuals struggling with urge incontinence may find that urine escapes immediately after a strong and uncontrollable urge to urinate. The best treatments for urge incontinence include bladder training or certain medications.
Bladder training
Bladder training typically relies upon the ability of the patient to train their bladder to hold urine for slightly longer periods each time until they are eventually able to control the passage of urine. Starting with a timed schedule, the patient is advised to visit the restroom and empty their bladder, whether or not they feel the need to. Once the patient is accustomed to this schedule, the belief is that their bladder will be trained to retain the urine until the next scheduled time arrives.
Over time, this type of training modality will increase the stability of the bladder. It is generally recommended that patients undergo at least 6 weeks of bladder training to experience the beneficial results of this treatment modality.
Medications
In order to reduce the frequency or amount of urinary leakage, or even eliminate this issue from altogether, antimuscarinic drugs may be prescribed. Antimuscarinic agents function by inhibiting the nerve impulses which are responsible for the sudden bladder contractions that ultimately cause urge incontinence. Typically, these drugs are taken orally and are started at a low dosage. Careful follow-up is mandatory with these drugs.
Some of the different types of antimuscarinic drugs that might be prescribed to a patient to resolve their urinary leakage include:
- Oxybutynin
- Tolterodine
- Darifenacin
- Solifenacin
- Fesoterodine
- Trospium
Despite their utility, many muscarinic drugs can cause undesirable side effects, some of which include;
- Dry mouth
- Constipation
- Fatigue
- Blurring of vision
- Glaucoma in a few cases
An alternative that is sometimes used to treat urge incontinence is mirabegron, which is a beta-3 receptor antagonist that relaxes the bladder muscle to help patients retain urine. Mirabegron is associated with some potentially serious side effects such as a rise in blood pressure and heart rate, as well as a higher risk of urinary infections; therefore, its use should be monitored carefully.
Surgery
Several surgical procedures can be used to resolve urge incontinence, which include the injection of botulinum toxin, sacral neuromodulation, percutaneous tibial nerve stimulation, augmentation cystoplasty and urinary diversion.
Botulinum toxin injection
The administration of botulinum toxin relaxes the detrusor muscle of the bladder wall and can sustain this effect for several months. If this procedure results in incomplete bladder emptying, self-catheterization may be taught to empty the bladder fully.
Sacral neuromodulation
During a sacral neuromodulation procedure, a small electrical signal generator is implanted near the sacrum, which is the lowest part of the back, usually in one of the gluteal muscles. The generator sends a signal to the brain to interfere with the abnormal frequent impulses from the detrusor muscle of the bladder, which travel through the same nerve.
By interfering with this neurological process, the bladder urges are inhibited. Notwithstanding the face that many people are cured of their urge incontinence by this procedure, some people may not tolerate the procedure well.
Percutaneous tibial nerve stimulation
This form of therapy involves the stimulation of the the tibial nerve by a very thin needle electrode near the ankle. As the nerve impulses travel up the nerve, it blocks other impulses from arising within the bladder muscles, thus reducing the urge to urinate. Percutaneous tibial nerve stimulation is performed in a doctor’s office and typically requires a toal of 12 sessions that last for 30 minutes each session.
Augmentation cystoplasty
Augmentation cystoplasty begins with taking tissue from the intestinal wall and moving it to to the bladder to enlarge bladder capacity. However, lifelong use of a catheter may be necessary following this procedure. Additionally, the freuqency of urinary tract infections (UTIs) follownig this procedure may also increase.
Urinary diversion
During a urinary diversion procedure, urine is directed outside the body instead of flowing into the bladder.
Mixed incontinence
Mixed incontinence is typically described as a mixture of both stress and urge incontinences that occur at different times. Typically, mixed incontinence can be treated using a combination of treatment approaches. In cases that do not respond to any of these, treatment options, absorbent pads or hand-held urine collection bottles may be needed to help the patient manage the condition.
Overflow incontinence
Overflow incontinence, which is otherwise known as chronic urinary retention, can be treated by clean intermittent catheterization or indewelling catheterization.
During clean intermittent catheterization, the patient is taught by a trained advisor on how to remove urine from the bladder by inserting a clean thin tube into the bladder through the urethra. Some of the risks associated with this procedure include a higher rate of urinary infections. Additionally, the number of catheterizations required varies from person to person.
Comparatively, indwelling catheterization is often prescribed for those whose overflow incontinence cannot be managed by clean intermittent catheterization. Rather, these individuals may opt to have a permanent catheter inserted into the bladder that allows urine to draining into a bag, which is emptied regularly.
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