Conservative measures are surprisingly effective. If they fail, drugs often help. A urologist outlines these and other steps primary-care clinicians can take.
Mrs. B has been experiencing urinary incontinence (UI) for the past two years, especially when she lifts grocery bags and other heavy objects. Lately she has given up tennis because she worries about leakage while on the court. Occasional sudden urges to urinate have had her rushing to find a bathroom and led to several embarrassing accidents. Her four children were delivered vaginally.
UI affects over 12 million adults in the United States, the majority of them women. Although UI has received more attention recently, most women still go undiagnosed and untreated. Because UI is a symptom of several other problems, rather than a condition with a single cause, it may not be preventable. But once it develops, there are numerous ways to keep UI from crippling patients’ lives.
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Types of UI
The four categories of UI are as follows:
• Stress UI is leakage triggered by such activities as coughing, sneezing, and lifting. Causes include weak pelvic muscles, often resulting from childbirth; thinning and drying of the skin in the vagina or urethra, especially after menopause; and, in some cases, connective tissue disorders.
• Urge UI, frequently called overactive bladder (OAB), is a sudden, compelling desire to urinate. It is associated with diminished bladder capacity and OAB contractions, which may be due to such factors as aging or infection of the kidneys or bladder.• Overflow UI is a constant leakage of urine resulting from an overfilled bladder, which can be caused by certain medications, diabetic neuropathy, and urethral occlusion.
• Mixed UI. Women with symptoms of both stress and urge UI are said to have mixed UI.
The history and physical exam often provide the basis for diagnosis and treatment. Initial therapy is aimed at treating the underlying cause. Stress, urge, and mixed UI can often be successfully treated by the primary-care clinician. Recalcitrant cases and patients with neurologic problems and serious disorders, such as Parkinson’s disease and multiple sclerosis, should generally be referred to a urologist.
Keeping stress UI in check
Many cases of stress UI can be alleviated by simple pelvic-floor contractions (PFCs), or Kegel exercises, which involve contracting and holding the muscles used to stop the flow of urine. Kegel exercises can be taught by instructing the patient to perform a PFC during pelvic examination or by asking her to utilize the muscles she would use to terminate urine flow in midstream. An effective regimen typically involves performing a set of 10 Kegel exercises, holding each contraction for 5-10 seconds, and repeating sets of 10 three to five times a day.
Patients with stress UI that does not improve after faithfully practicing Kegel exercises for several weeks may want to add biofeedback, sometimes using weighted vaginal cones. This is a more intense form of Kegel exercise that is often taught by a physical therapist or specialized nurse.
No medications for treating stress UI are currently available in the United States. Vaginal estrogen has been proposed as a treatment for both stress and urge UI, but studies show that estrogen offers no consistent improvement and may actually exacerbate existing UI.
Women whose stress UI is not effectively controlled with Kegel exercises but who wish to avoid surgery may want to try office-administered injections to bulk up the urethral sphincter so it closes more forcefully. FDA-approved periurethral bulking agents include bovine dermal glutaraldehyde cross-linked collagen, carbon-coated zirconium beads, ethylene vinyl alcohol, and calcium hydroxyapatite.
Urge UI strategies
Conservative approaches for urge UI include Kegel exercises, dietary modification, urge suppression, and timed voiding.
Bladder-irritating foods and beverages that have been associated with urge UI include caffeinated drinks, alcohol (especially some wines), spicy foods, and acidic/citrus fruits. Tobacco, a potent bladder carcinogen, is also a strong bladder irritant; eliminating tobacco may also reduce urge UI.
Urge suppression is just what its name suggests. Patients who feel a sudden, strong urge to urinate often go rushing for a bathroom, which can open the bladder neck and increase the likelihood of leakage. Instead, a woman who feels the urge to urinate should perform a Kegel exercise, which will help stop bladder contractions. After the urge passes, she should be able to proceed to the bathroom without leaking en route.
Timed voiding involves having the patient fill in a chart of her voiding and leaking times for several days. From the patterns that appear, the patient can plan to urinate at regular intervals, before she would otherwise leak, gradually increasing the time between trips to the bathroom.
If conservative measures for treating urge UI fail, medication can often help. FDA-approved agents include regular and extended-release formulations of tolterodine (Detrol and Detrol LA) and regular and extended-release forms of oxybutynin (Ditropan and Ditropan XL). Newer medications include a topical form of oxybutynin (Oxytrol), trospium chloride (Sanctura), solifenacin (Vesicare), and darifenacin (Enablex). Of these, oxybutynin has the longest track record; but it also has a relatively high incidence of side effects, such as dry mouth, constipation, and cognitive dysfunction, which may limit its extended use by some patients.
The surgical option
If lifestyle changes and medication are not effective for treating stress or urge UI, consider one of several so-called surgical vaginal sling procedures. All sling procedures involve placing a band of material directly under the bladder neck or midurethra; this acts as a support to prevent bladder neck and urethral descent during physical activity. Up to 90% of women who undergo such procedures experience cure or vast improvement. Sling surgery is performed by urologists or urogynecologists, often on an outpatient basis.
Mrs. B was diagnosed with mixed UI and, after six weeks of Kegel exercises and a course of solifenacin, is now back on the tennis court, working to perfect her serve.
