eMedicine Specialties > Urology > Incontinence

Urinary Incontinence, Nonsurgical Therapies

Raymond Rackley, MD, Professor of Surgery, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University; Staff Physician, Center for Pelvic Medicine and Pelvic Reconstruction, Glickman Urological Institute, Cleveland Clinic Foundation
Sandip P Vasavada, MD, Physician, Center for Female Pelvic Medicine and Genitourinary Reconstructive Surgery, The Glickman Urological and Kidney Institute; Joint Appointment with Women's Institute, Cleveland Clinic; Michael S Ingber, MD, Clinical Fellow, Glickman Urological and Kidney Institute of the Cleveland Clinic; Farzeen Firoozi, MD, Clinical Fellow, Center for Female Urology and Pelvic Reconstructive Surgery, Glickman Urological and Kidney Institute of the Cleveland Clinic

Updated: May 6, 2009

Introduction

Background

Urinary incontinence is defined by the International Continence Society as the involuntary loss of urine that represents a hygienic or social problem to the individual. The different types of incontinence include stress incontinence, urge incontinence, mixed incontinence, overflow incontinence, and functional incontinence. Successful treatment of urinary incontinence must be tailored to the specific cause of incontinence.

Stress incontinence may be treated with surgery, pelvic floor physiotherapy, and anti-incontinent devices. Urge incontinence may be treated with changes in diet, behavioral modification, pelvic-floor exercises, and/or medications and new forms of surgical intervention. Mixed incontinence often requires anticholinergics and surgery. Overflow incontinence is usually treated with some type of catheter or diversion regimen. Functional incontinence is self-limited when the underlying cause is identified and treated in an appropriate fashion.

In general, the first choice for treatment is the least invasive, with the least number of potential complications for the patient. Examples of noninvasive treatments include medications or exercises; however, the least invasive treatment may not afford the best outcome in certain situations. In specific situations, minimally invasive surgery may be the most effective form of managing urinary incontinence.

Pathophysiology

The differential diagnoses of urinary incontinence are broad, with multiple causes. Sometimes, more than one contributing factor exists, further complicating diagnosis and therapy. Distinguishing these different etiologies is imperative because each condition warrants a different, but often overlapping, therapeutic approach.

Stress incontinence is urinary incontinence coincident with increased intra-abdominal pressure in the absence of uninhibited detrusor contraction. In stress incontinence, the bladder outlet has poor resistance to urinary flow. The most common cause of stress incontinence is urethral hypermobility secondary to poor anatomic pelvic support. A less common cause of stress incontinence is an inherent defect in the urethra known as intrinsic sphincter deficiency.

Urge incontinence is involuntary urine loss due to detrusor overactivity. Urge incontinence may be a result of detrusor myopathy, neuropathy, or a combination of both. When the identifiable cause is unknown, it is termed idiopathic urge incontinence. Symptoms of overactive bladder or urge incontinence in the absence of neurologic causes are known as detrusor instability.

Mixed incontinence is urinary incontinence resulting from a combination of stress and urge incontinence. In mixed incontinence, the bladder outlet is weak and the detrusor is overactive. A classic example of mixed incontinence is a patient with meningomyelocele and an incompetent bladder neck with a hyperreflexic detrusor; however, a combination of urethral hypermobility and detrusor instability is a more common scenario.

Reflex incontinence is due to neurologic impairment of the central nervous system. Common neurologic disorders associated with reflex incontinence include stroke, Parkinson disease, and brain tumors. Reflex incontinence also occurs in patients with spinal cord injuries and multiple sclerosis. When patients with suprapontine or suprasacral spinal cord lesions present with symptoms of urge incontinence, this is known as detrusor hyperreflexia.

Overflow incontinence is due to overdistention of the detrusor muscle. Overflow incontinence may occur as a result of bladder outlet obstruction, detrusor atony, or neurologic impairment of the urinary bladder. Common causes of bladder outlet obstruction in men include benign prostatic hyperplasia (BPH), vesical neck contracture, and urethral strictures. In women, urethral obstruction after anti-incontinence surgery such as a sling or bladder neck suspension can result in iatrogenically induced overflow incontinence.

Some common neurologic causes of overflow incontinence include herniated lumbar disc, diabetic cystopathy, and peripheral neuropathy. Less common causes of overflow incontinence include AIDS, genital herpes affecting the perineal area, and neurosyphilis. A decompensated detrusor resulting from a neurologic disorder is known as an areflexic detrusor.

Frequency

United States

Urinary incontinence affects approximately 13 million people in the United States, predominantly women. This includes 10%-35% of adults and 50% of the 1.5 million nursing homes residents. Up to 60% of nursing home patients are incontinent, while 30% of elderly people living at home are incontinent.

Urinary incontinence is an underdiagnosed and underreported medical problem. An estimated 50%-70% of women with urinary incontinence fail to seek medical evaluation and treatment because of social stigma. Only 5% of incontinent individuals in the community and 2% in nursing homes receive appropriate medical evaluation and treatment. People with incontinence often live with this condition for 6-9 years before seeking medical therapy.

Stress incontinence affects 15%-60% of women. Stress incontinence is a disorder of young and old people alike. More than one fourth of nulliparous young college athletes experience stress incontinence when participating in sports.

Mortality/Morbidity

Chronic urinary incontinence is a major problem in the older population, particularly in patients in nursing homes. Chronic urinary incontinence is a health hazard that affects 10%-35% of adults and 50% of the 1.5 million residents in nursing homes.

Urinary incontinence–related morbidities include prolonged hospital admission (35%), urinary tract infections (UTIs; 2%), contact dermatitis (1.6%), and falls (1%). Costs incurred for treating incontinence-related complications approach $2.8 billion, in contrast to $35 million for diagnostic and treatment costs.

Urinary incontinence is a leading cause of admission to a nursing home when families find it too difficult to care for a relative with incontinence. Of nursing home patients, 60% have been reported to be incontinent, while as many as 30% of the older population living at home are incontinent. Individuals with incontinence may experience the sudden involuntary loss of urine several times a day.

Prolonged contact of urine with the unprotected skin causes contact dermatitis and skin breakdown. If left untreated, these skin disorders may lead to pressure sores and ulcers, possibly resulting in secondary infections. For individuals with a decompensated bladder that does not empty well, the elevated postvoid residual (PVR) urine can lead to overgrowth of bacteria and subsequent UTI.

The treatment of urinary incontinence with catheters also poses potential problems. Indwelling catheters left in the bladder for more than 2 weeks become colonized with bacteria. While asymptomatic bacterial colonization does not cause health hazards, unrecognized bacterial colonization can produce symptomatic bladder infections that can manifest as purulent urine, fever, bladder spasms, and hematuria.

Thus, long-term use of indwelling catheters may cause recurrent bladder infections, bladder stones, ascending pyelonephritis, and urethral erosions. Intermittent catheterization may result in bladder infections or urethral injury. Long-term use of suprapubic tubes may cause bladder spasms, bladder stone formation, and bladder infections. Urinary incontinence will continue to be a significant health care problem if left ignored.

Treatment of bladder infections in catheterized patients involves a combination of catheter changes, irrigation with bacteriostatic/bacteriocidal agents, or use of an antibiotic. To minimize symptomatic bladder infections, change long-term indwelling catheters every 3-4 weeks or when drainage is obstructed by debris or encrustations. Long-term prophylactic antibiotic use is discouraged because of the risk of preferentially selecting resistant organisms.

Catheter-associated UTI is the most common nosocomial infection. The type of urinary catheter used may affect the likelihood of catheter-related UTIs. The literature suggests that the risk with short-term catheterization is 5% per day. However, new urinary catheters impregnated with medications (eg, nitrofurazone or minocycline and rifampin) or coated with a silver alloy-hydrogel significantly reduce the risk of catheter-related UTI for catheterizations not exceeding 2-3 weeks.

Among trials of silver-coated urinary catheters, silver alloy catheters appear to be significantly more effective than silver oxide catheters in preventing UTIs. Although silver alloy catheters cost about $6 more than conventional urinary catheters, they may be worth the extra cost to prevent symptomatic UTIs and urosepsis. This type of catheter especially may be apropos in immunocompromised patients at high risk for infection.

Race

Although data concerning urinary incontinence in people of different races are sparse, reports are emerging that race may play an important role in the prevalence and likelihood of reporting of incontinence. In addition, differences in anatomic morphology of the urinary sphincter mechanism in people of different races may affect the likelihood of developing incontinence.

• Older black women report a lower prevalence of urinary incontinence than white women. Fultz et al (1999) reported that 23.02% of white women reported incontinence, compared with 16.17% of black women.¹
• Freeman et al (2001) reported that black women were significantly more likely than white women to report that they experienced menopausal symptoms (46% vs 30%; P <0.001), urinary incontinence, and vaginal dryness.²
• Howard et al (2000) reported that functional and morphologic differences exist in the urethral sphincteric and support system of nulliparous black and white women. Black women demonstrated a 29% higher average urethral closure pressure during a maximum pelvic muscle contraction. Paradoxically, a 36% greater bladder neck hypermobility was present as measured with the cotton-swab test (black women at 49° vs white women at 36°; P = 0.02).³
• Sears et al (2008) reported that, among patients with incontinence, urge incontinence was more common in black women (51.5%), whereas stress incontinence was statistically significantly more common in white women (66.2%; P <0.05).⁴
• Daneshgari et al (2008) reported that Hispanic women reported stress incontinence (odds ratio, 1.7; P = 0.005) and mixed incontinence (odds ratio, 1.8; P = 0.005) more often than did non-Hispanic white women. However, the increased prevalence of incontinence in Hispanic women is likely due to higher prevalences of obesity, hysterectomy, and parity than in white women.⁵
• Nygaard et al (2008) examined the prevalence of symptomatic pelvic floor disorders in women in the United States. Although they did not differentiate urge from stress incontinence, there was no difference among non-Hispanic whites (16%), Hispanics (15.9%), non-Hispanic blacks (13.8%), and other (15%) races (P = 0.83).⁶

Age

In a cross-sectional analysis of women who participated in the 2005-2006 National Health and Nutrition Examination Survey, Nygaard et al (2008) demonstrated that the prevalence of urinary incontinence increased with age. The prevalence was 6.9% in women aged 20-39 years, 17.2% in those aged 40-59 years, 23.3% in those aged 60-79 years, and 31.7% in women older than 80 years (P <0.001).⁶

Clinical

History

One popular way to classify urinary incontinence is to define it according to symptom presentation. Although symptom classification is helpful in describing bladder and urethra function, the symptoms of urinary incontinence are not always clear markers for a proper diagnosis. Furthermore, the symptom complex alone does not allow accurate localization of the problem site, such as the bladder, urethra, or both.

Classification of urinary incontinence into types allows the clinician to make an educated guess at a particular anatomic abnormality that warrants further investigation. The 5 major types of urinary incontinence are as follows:

• Stress incontinence: In stress incontinence, a variable amount of urine escapes suddenly with an increase in intra-abdominal pressure. Little urine is lost, unless the condition is severe.
  • This type of urinary loss is very predictable.
  • Irritative voiding symptoms and nocturia are typically absent.
• Urge incontinence: Urge incontinence or symptoms of an overactive bladder are uncontrolled urine loss associated with a strong desire to void, which is often a very sudden and rapid event that occurs without any warning. Urge incontinence is a type of uncontrolled urine loss that cannot be prevented. In this situation, the entire contents of the bladder are lost rather than a few drops of urine.
  • Patients with symptoms of an overactive bladder are aware of the intense need to void but are unable to hold back urine. Patients have symptoms of urinary frequency, urgency, nocturia, and urge incontinence.
  • Some examples of situations that precipitate urge incontinence include turning a key in the door, washing dishes, or hearing running water. Urge incontinence may also be triggered by drinking too much water or drinking coffee, tea, or alcohol.
• Mixed incontinence: In this type of incontinence, the symptoms of stress incontinence and urge incontinence coexist. With mixed incontinence, the problem is that the bladder is overactive and the urethra is underactive.
  • Affected patients experience mild-to-moderate urine loss with physical activities (stress incontinence). At other times, they experience acute urine loss without any antecedent warning (urge incontinence). Urinary frequency, urgency, and nocturia complement urge incontinence symptom complex.
  • Most of the time, patients are not able to distinguish these 2 different symptom complexes. The symptoms of urge incontinence may unwittingly be confused with the symptoms of stress incontinence and vice versa. In this situation, the symptom complex most unbearable to the patient is treated first.
• Overflow incontinence: As the term implies, the urine overflows from the bladder. Overflow incontinence is a condition that occurs when the bladder is overdistended and has reached its limit of compliance. At this point, the intravesical pressure is greater than the resting urethral closure pressure. Because the intravesical pressure exceeds the resting urethral closure pressure (when the bladder is overdistended), urinary incontinence occurs despite the absence of detrusor contraction.
  • Overflow incontinence may occur in the setting of infravesical bladder outlet obstruction or nonfunctioning detrusor. Causes of bladder outlet obstruction include benign BPH, urethral stricture, posterior urethral valve obstruction, or urethral obstruction after a pubovaginal sling. Causes of nonfunctioning detrusor include detrusor areflexia (ie, sensory or motor paralytic bladder due to underlying neurologic disease) or atonic bladder that has lost its muscular tone (ie, chronic overdistension resulting in decompensated detrusor) in the absence of a neurologic cause. Patients experience a sense of incomplete emptying, slow-flowing urine, and urinary dribbling.
  • Symptoms of overflow incontinence may mimic those of mixed incontinence. Patients lose a small amount of urine when intra-abdominal pressure is increased. Patients who are affected often experience symptoms of frequency and urgency as the detrusor attempts to expel urine.
  • Unfortunately, no medications effectively treat this condition. The only way to treat overflow incontinence is with a catheter. This is true whether the bladder has become decompensated as a result of a neurologic insult (areflexic detrusor) or from a mechanical source (atonic detrusor).
  • Some patients respond well to temporary continuous Foley catheter drainage. Their bladder capacity returns to normal, and voluntary detrusor pressure improves. Return of spontaneous voiding is more likely for patients without neurologic injury. This usually takes at least 1 week of catheter drainage depending on the degree of bladder muscle injury. If it has not resolved after 4 weeks, then the bladder is unlikely to recover with catheter drainage alone. If the underlying cause of the overflow problem can be treated or eliminated, these patients may be able to return to normal voiding. If this is unsuccessful, intermittent catheterization is usually preferred for long-term therapy if logistically possible. Otherwise, a permanent catheter may need to be considered.

Physical

See Pathophysiology for discussion of physical signs of urinary incontinence.

Causes

The differential diagnosis of urinary incontinence has multiple causes. Sometimes, more than one contributing factor exists; distinguishing these different etiologies is imperative because each condition requires a different, but often overlapping, therapeutic approach.

• The most common cause of stress incontinence in women is urethral hypermobility secondary to poor anatomic pelvic support. Women may lose this pelvic support with age, childbirth, surgery, or certain disease states that affect tissue strength. A less common cause of stress incontinence is an inherent defect in the urethra known as intrinsic sphincter deficiency.
• Men who have undergone radical prostatectomy may have damage to their continence mechanism. Similarly, men who undergo transurethral resection of the prostate may also develop stress incontinence due to injury to the external urethral sphincter.
• Urge incontinence may be a result of detrusor myopathy, neuropathy, or a combination of both.
• Mixed incontinence is urinary incontinence resulting from a combination of stress and urge incontinence. The bladder outlet is weak, and the detrusor is overactive.
• Bladder obstruction may result in urinary incontinence due to overflow of urine. Alternatively, urge incontinence may result from an obstructed outlet, both in men and in women. Common causes of bladder outlet obstruction in men include BPH, vesical neck contracture, and urethral strictures. In women, urethral obstruction may be due to severe pelvic organ prolapse. It rarely occurs after anti-incontinence surgery, such as a sling or bladder neck suspension. Some common neurologic causes of overflow incontinence include herniated lumbar disc, diabetic cystopathy, and peripheral neuropathy. Less common causes of overflow incontinence include AIDS, genital herpes affecting the perineal area, and neurosyphilis.

Differential Diagnoses

Other Problems to Be Considered

Transient incontinence
Ureterovaginal fistula
Vesicovaginal fistula
Urethrovaginal fistula
Ectopic ureter
Normal vaginal secretions
Vaginal voiding

Workup

Laboratory Studies

• Urinalysis and urine culture: Cystitis can produce irritative voiding symptoms and urge incontinence.
• Urine cytology: Patients with carcinoma in situ of the urinary bladder have symptoms of urinary frequency and urgency and show evidence of microscopic hematuria.
• Chemistry 7 profile: These tests are helpful for patients in whom poor renal function, obstructed ureters, or urinary retention is suggested.

Imaging Studies

• Cystogram: A lateral cystogram helps to confirm the presence of stress incontinence, the degree of urethral motion, and the presence of cystocele. These radiographs may also demonstrate intrinsic sphincter deficiency by showing a wide-open urethra on the resting films. Vesicovaginal fistula may also be documented in this fashion.
• Magnetic resonance imaging: MRI provides excellent anatomic detail, particularly in women with pelvic organ prolapse. MRI may be useful in certain situations requiring complex surgical reconstruction. However, the cost-effectiveness of obtaining routine MRI remains controversial.

Other Tests

• Voiding diary: A voiding diary is a daily record of the patient's bladder activity and is a useful supplement to the medical history of the patient.
• Pad test: A pad test is a useful adjunct to the patient's history and physical examination. The pad test is an objective test that determines whether the fluid loss the patient is experiencing is in fact urine. Intravesical methylene blue, oral Pyridium, or Urised may be used as a coloring agent. If the peri-pad changes color, the fluid lost is urine. The pad test may be performed during a 1-hour period or a 24-hour period. The pads may be weighed (1 g = 1 mL) to assess the severity of urine loss.
• Q-tip test: This test is performed by inserting a sterile lubricated cotton swab (Q-tip) into the female urethra. The cotton swab is gently passed into the bladder and then slowly pulled back until the neck of the cotton swab is fit snugly against the bladder neck. The patient then is instructed to perform a Valsalva maneuver or to contract the abdominal muscles. Excessive motion of the urethra and bladder neck (hypermobility) with straining is an important finding for type II stress incontinence. A Q-tip excursion angle greater than 35° indicates urethral hypermobility.
• Cough stress test: A critical part of the pelvic examination is direct observation of urine loss using the cough stress test or Marshall test. The cough stress test is performed by filling the bladder with sterile fluid at least halfway (eg, 250 mL) and instructing the patient to bear down (Valsalva) or cough. Observation of leakage during Valsalva maneuver or cough denotes a positive test result.
• The Marshall test, otherwise known as the Marshall-Bonney test, is performed by placing an index finger and the second finger on either side of the bladder neck. With the bladder relatively full, the patient is instructed to perform Valsalva or cough. The 2 fingers at the bladder neck serve to support the proximal urethra during Valsalva maneuver. The absence of leakage with bladder neck elevation and the presence of leakage with loss of bladder neck support confirms stress urinary incontinence due to urethral hypermobility. However, the Marshall test is neither sensitive nor specific enough to diagnose stress urinary incontinence by today's standards. Thus, the Marshall test is not widely practiced today.
• Standing pelvic examination: A standing pelvic examination is performed if a pelvic examination fails to demonstrate urine loss or if a pelvic organ prolapse is suspected. If the pelvic prolapse is present, push the prolapsed organ up with a pessary or gauze and repeat the cough stress test in the standing position.

Procedures

• Postvoid residual volume: The measurement of PVR volume is a part of the basic evaluation for urinary incontinence. If the PVR volume is high, the bladder may be acontractile or the outlet may be obstructed. To determine the PVR urine, either bladder ultrasonography or a urethral catheter may be used.
• Uroflow: A useful screening test, uroflow is used mainly to evaluate bladder outlet obstruction. Consistently low flow rates generally indicate a bladder outlet obstruction but may also indicate decreased detrusor contractility. To properly diagnose bladder outlet obstruction, perform pressure-flow studies.
• Filling cystometrogram: A filling cystometrogram (CMG) assesses bladder capacity, bladder compliance, and the presence of phasic contractions. This test may be performed using either gas or liquid to fill the bladder, with different interpretive criteria applying to each. Usually, the patient feels the first sensation as the bladder begins to fill with 100-200 mL of water. As the bladder nears capacity, 300-400 mL, the patient may begin to feel uncomfortable. True urge to void occurs when the bladder has been filled to capacity. An average adult bladder holds approximately 450-500 mL of urine.
• Abdominal leak point pressure: An important component of multichannel videourodynamics is the determination of the abdominal leak point pressure (ALPP). ALPP allows stress urinary incontinence in women to be classified into urethral hypermobility, intrinsic sphincter deficiency, or both in combination. In patients with stress incontinence, an ALPP less than 90 cm H₂ O indicates intrinsic sphincter deficiency, whereas ALPP greater than 90 cm H₂ O reflects urethral hypermobility.
  • ALPP (also known as Valsalva leak point pressure) is performed by instilling 250 mL of fluid medium into the urinary bladder. The patient is instructed to bear down (Valsalva) in gradients (ie, mild, moderate, severe) to demonstrate leakage. The lowest abdominal pressure required to generate leakage is recorded as ALPP.
  • Cough leak point pressure (CLPP) is performed by instilling 250 mL of fluid medium into the urinary bladder. The patient is instructed to cough in gradients (ie, mild, moderate, severe) to demonstrate leakage. The lowest abdominal pressure required to generate leakage is recorded as CLPP.
  • Valsalva leak point pressure appears to be more sensitive than CLPP in diagnosing intrinsic sphincter deficiency because coughing and Valsalva seem to result in a different reaction of the pelvic floor. In addition, progressive bladder filling in 50-mL increments (eg, 250 mL, 300 mL, 350 mL) also appears to increase the sensitivity of leak point pressure testing. Leak point pressure testing may be performed with or without video (fluoroscopic) capabilities.
• Voiding cystometrogram (pressure-flow study): A pressure-flow study simultaneously records the voiding detrusor pressure and the rate of urinary flow. Voiding cystometrogram is the only test able to provide information about bladder contractility and the extent of a bladder outlet obstruction.
• Electromyography: Electromyography (EMG) enables documentation of voiding and is used to distinguish coordinated voiding (ie, detrusor sphincter synergia) from uncoordinated voiding (ie, detrusor sphincter dyssynergia).
• Cystoscopy: Cystoscopy allows an anatomical assessment of the bladder and the urethra. Bladder lesions, such as a tumor or carcinoma in situ, which would otherwise remain undiagnosed using urodynamics alone, can be identified. Cystoscopy is also indicated for patients experiencing persistent irritative voiding symptoms or hematuria. In some cases, unexplained persistence of symptoms is due to a stone or foreign body (eg, stitch, mesh material from prior surgery for prolapse or incontinence). Lastly, urethroscopy can be performed to assess the structure and function of the urethral sphincter mechanism.

Treatment

Medical Care

Stress incontinence may be treated with surgical and nonsurgical means. Urge incontinence may be treated with behavioral modification or with bladder-relaxing agents. Mixed incontinence may require medications as well as surgery. Overflow incontinence may be treated with some type of catheter regimen. Functional incontinence may be resolved by treating the underlying cause, such as UTI, constipation, or by simply changing a few drugs.

Do not consider anti-incontinence products to be a cure-all for urinary incontinence; however, judicious use of pads and devices to contain urine loss and maintain skin integrity are extremely useful in selected cases. Absorbent pads and internal and external collecting devices have an important role in the management of chronic incontinence.

The criteria for use of these products are fairly clear-cut, and these products are beneficial for women who meet the following conditions: (1) women whose conditions are not improved by all other treatments and who remain incontinent, (2) women who are too ill or disabled to participate in behavioral programs, (3) women with incontinence disorders that cannot be helped by medications, (4) women with incontinence disorders that cannot be corrected by surgery, and (5) women who are awaiting surgery.

Absorbent products

Absorbent products are pads or garments designed to absorb urine to protect the skin and clothing. Available in both disposable and reusable forms, they are a temporary means of keeping the patient dry until a more permanent solution becomes available. By reducing wetness and odor, they help to keep the patient comfortable and allow her to function in usual activities. They may be used temporarily until a definitive treatment has a chance to work or if the treatment yields less-than-perfect results. Absorbent products are helpful during the initial assessment and workup of urinary incontinence. As an adjunct to behavioral and pharmacologic therapies, they play an important role in the care of persons with intractable incontinence.

• Do not use absorbent products in place of definitive interventions to decrease or eliminate urinary incontinence. Early dependency on absorbent pads may be a deterrent to achieving continence, providing the wearer a false sense of security. Long-term use of absorbent products may lead to inevitable acceptance of the incontinence condition, which removes the motivation to seek evaluation and treatment. In addition, improper use of absorbent products may contribute to skin breakdown and UTIs. Thus, appropriate use, meticulous care, and frequent pad or garment changes are needed when absorbent products are used.
• Absorbent products used include underpads, pant liners (shields and guards), adult diapers (briefs), various washable pants and disposable pad systems, or combinations of these products. More than 50% of the members of the National Association for Continence (NAFC), a national support group for incontinent patients (800-252-3337), use some form of protective garment to remain dry. In addition, 47% of all elderly men and women use some type of absorbent products. In nursing homes, disposable diapers or reusable pad and pant systems are used.
• Unlike sanitary napkins, these absorbent products are specially designed to trap urine, minimize odor, and keep the patient dry. Different types of products with varying degrees of absorbency exist. These products may absorb 20-300 mL, depending on the brand and the absorbent material of the product. Absorbent pads and garments that are available include panty shields, pant guards, undergarments, combination pad-pant systems, adult diaper garments, and special bed pads.
• For occasional minimal urine loss, panty shields (small absorbent inserts) may be used. For light incontinence, guards (close-fitting pads) may be more appropriate. Absorbent guards are attached to the underwear and can be worn under usual clothing. Adult undergarments (full-length pads) are bulkier and more absorbent than guards. They may be held in place by waist straps or snug underwear. Adult briefs are the bulkiest type of protection, they offer the highest level of absorbency, and they are secured in place with self-adhesive tape. Absorbent bed pads also are available to protect the bed sheets and mattresses at night. They are available in different sizes and absorbencies.

Urethral occlusive devices

Urethral occlusive devices are artificial devices that may be inserted into the urethra or placed over the urethral meatus to prevent urinary leakage. These devices are palliative measures to prevent involuntary urine loss. Urethral occlusive devices are more attractive than absorbent pads because they tend to keep the patient drier; however, they may be more difficult and expensive to use than pads. Urethral occlusive devices must be removed after several hours or after each voiding. Unlike pads, these devices may be more difficult to change. With device manipulation, patients may soil their hands. In addition, there is always a risk that a urethral plug may fall into the bladder or fall off the urethra. Urethral occlusive devices, perhaps, are best suited for an active incontinent woman who does not desire surgery.

Various penile-compression devices are available to men with incontinence who have undergone radical prostatectomy. In a very small study (12 men), Moore et al (2004) showed that the Cunningham clamp provided better urinary leakage control and overall patient satisfaction than the C3 and U-Tex. However, the Cunningham clamp did cause reduced systolic velocity in the penis. In many cases, these devices do not eliminate leakage but may be suitable for men who wish to avoid surgery.⁷

Catheters

Urinary diversion, using various catheters, has been one of the mainstays of anti-incontinence therapy. The use of catheters for bladder drainage has withstood the test of time. Bladder catheterization may be a temporary measure or a permanent solution for urinary incontinence.

Some patients respond well to temporary continuous Foley catheter drainage. Their bladder capacity returns to normal, and voluntary detrusor pressure improves. Return of spontaneous voiding is more likely for patients without neurologic injury. This usually takes at least 1 week of catheter drainage depending on the degree of bladder muscle injury. If it has not resolved after 4 weeks, then the bladder is unlikely to recover using catheter drainage alone.

If the underlying cause of the overflow problem is bladder outlet obstruction, these patients may be able to return to normal voiding after relief of obstruction. If this is unsuccessful or not feasible, intermittent catheterization is usually preferred for long-term therapy if logistically possible. Otherwise, a permanent catheter may need to be considered.

Different types of bladder catheterization include indwelling urethral catheters, suprapubic tubes, and intermittent self-catheterization.

• Indwelling urethral catheters: Commonly known as Foley catheters, indwelling urethral catheters historically have been the mainstay of treatment for bladder dysfunction. If urethral catheters are being used for a long-term condition, they need to be changed monthly. These catheters may be changed at an office, a clinic, or at home by a visiting nurse.
• The standard catheter size for treating urinary retention is 16F or 18F, with a 5-mL balloon filled with 5-10 mL of sterile water. Larger catheters (eg, 22F, 24F) with bigger balloons are used for treating grossly bloody urine found in other urologic conditions or diseases. Increasing the balloon size to treat a catheter that leaks is not appropriate. Treat leakage around a catheter by eliminating the cause of the leakage. Change or irrigate the catheter if it is blocked. Empty the drainage bag if it is full. Treat any bladder spasms or uninhibited contractions with appropriate anticholinergic medications. Proper management of indwelling urethral catheters varies somewhat per individual patient.
• The usual practice is to change indwelling catheters once every month. The catheter and bag are replaced on a monthly basis; however, catheters that develop encrustations and problems with urine drainage need to be changed more frequently. All indwelling catheters in the urinary bladder for more than 2 weeks become colonized with bacteria. Bacterial colonization does not mean the patient has a clinical bladder infection.
• Symptoms of bladder infection include foul odor, purulent urine, and hematuria. Fever with flank pain often is present if upper tracts are involved. If a bladder infection occurs, change the catheter and the entire drainage system. The urinary drainage bag does not need to be disinfected routinely to prevent infection. A dilute vinegar solution can be used to dissolve the encrustations that tend to form in the drainage bags. Routine irrigation of catheters is not required. However, some authors favor the use of 0.25% acetic acid irrigation because it is bacteriostatic, minimizes catheter encrustation, and reduces odor. When used, 30 mL is instilled into the bladder and allowed to freely drain twice per day. Similarly, 30 cc of hydrogen peroxide can be added to the drainage bags immediately before connecting them to the Foley catheter. This supposedly reduces odor and bacterial growth by using a safe, nontoxic, and inexpensive agent.
• Patients do not have to be taking continuous antibiotics while using the catheter. In fact, continuous use of antibiotics while a catheter is used is contraindicated. Prolonged use of antibiotics to prevent infection actually may cause paradoxical generation of bacteria that are resistant to common antibiotics. Indwelling use of a Foley catheter in individuals who are homebound requires close supervision by a visiting nurse and additional personal hygiene care.
• In spite of its seeming advantages, the use of a Foley catheter for a prolonged period of time (eg, months or years) is strongly discouraged. Long-term dependence on these catheters is extremely risky because long-term use of urethral catheters poses significant health hazards. Indwelling urethral catheters are a significant cause of UTIs that involve the urethra, bladder, and kidneys. Within 2-4 weeks after catheter insertion, bacteria are present in the bladders of most women. Asymptomatic bacterial colonization is common and does not pose a health hazard. However, untreated symptomatic UTIs may lead to urosepsis and death. The death rate of nursing home residents with urethral catheters has been found to be 3 times higher than for residents without catheters.
• The use of a urethral catheter is contraindicated in the treatment of urge incontinence. Other problems associated with indwelling urethral catheters include encrustation of the catheter, bladder spasms resulting in urinary leakage, hematuria, and urethritis. More severe complications include formation of bladder stones, development of periurethral abscess, renal damage, and urethral erosion.
• Another problem of long-term catheterization is bladder contracture, which occurs with urethral catheters as well as suprapubic tubes. Anticholinergic therapy and intermittent clamping of the catheter in combination have been reported to be beneficial for preserving the bladder integrity with long-term catheter use. Individuals who did not use the medication and daily clamping regimen experienced a decrease in bladder capacity and vesicoureteral reflux. For this reason, some physicians recommend using anticholinergic medications with intermittent clamping of the catheter if lower urinary tract reconstruction is anticipated in the future.
• Foley catheter clamping is not a benign procedure. Potential risks include cystitis, pyelonephritis, urosepsis, and bladder perforation. Thus, Foley catheter clamping is not commonly employed except in those rare occasions where bladder reconstruction is being contemplated. The clamping should be performed under strict supervision by monitoring patient comfort and bladder capacity. Coexisting UTIs must be eradicated prior to proceeding with this endeavor.
• The maximum time limit for Foley clamping to expand the bladder capacity should be tailored to the individual but should not exceed 3-4 hours. Patients with small-capacity bladders do not tolerate Foley clamping for more than 1 hour. The Foley catheter should be unclamped immediately if fever, suprapubic pain, obvious bladder distention, leakage around the Foley catheter, or changes in hemodynamics are noted.
• When long-term use of a urethral catheter is anticipated, a suprapubic catheter is an attractive alternative. Restrict the use of indwelling catheters to the following situations:
  • As comfort measures for terminally ill patients
  • To avoid contamination or to promote healing of severe pressure sores
  • In case of inoperable urethral obstruction that prevents bladder emptying
  • In individuals who are severely impaired for whom alternative interventions are not an option
  • When an individual lives alone and a caregiver is unavailable to provide other supportive measures
  • For acutely ill persons in whom accurate fluid balance must be monitored
  • For severely impaired persons for whom bed and clothing changes are painful or disruptive
• Some type of catheter bag tubing support usually is recommended to prevent inadvertent pressure on the Foley catheter balloon and bladder neck tissue. Adequate slack should be afforded to allow reasonable unimpeded leg motion without stretching the Foley catheter. The authors also recommend the routine use of a water-soluble surgical lubricant on the catheter where it exits the urethra, especially in males because of the soreness that can be produced there. The lubricant affords significant symptomatic relief.
• Suprapubic catheters: A suprapubic tube is an attractive alternative to long-term urethral catheter use. The most common use of a suprapubic catheter is in individuals with spinal cord injuries and a malfunctioning bladder. It also can be used in patients with intractable decompensated bladders or complicated urethral strictures. Both people who are paraplegic and people who are quadriplegic have benefited from this form of urinary diversion. When suprapubic tubes are needed, usually smaller (eg, 14F, 16F) catheters can be placed, although some practitioners prefer a larger tube (eg, 24F-28F), especially if they are concerned about the catheter becoming clogged. As in the urethral catheter, change the suprapubic tube at least once a month on a regular basis.
• Many advantages of suprapubic catheters exist. With a suprapubic catheter, the risk of urethral damage is eliminated. Multiple voiding trials may be performed without having to remove the catheter. Because the catheter comes out of the lower abdomen rather than the vaginal area, a suprapubic tube is more patient-friendly. Bladder spasms occur less often because the suprapubic catheter does not irritate the trigone as the urethral catheter does. In addition, suprapubic tubes are more sanitary for the individual, and bladder infections are minimized because the tube is away from the perineum.
• Suprapubic catheters are changed easily by either a nurse or a doctor. Unlike the urethral catheter, a suprapubic tube is less likely to become dislodged because the exit site is so small. When the tube is removed, the hole in the abdomen quickly seals itself within 1-2 days.
• Indications for suprapubic catheters include short-term use following gynecologic, urologic, and other types of surgery. Suprapubic catheters may be used whenever the clinical situation requires the use of a bladder drainage device; however, suprapubic catheters are contraindicated in persons with chronic unstable bladders or intrinsic sphincter deficiency because involuntary urine loss is not prevented. A suprapubic tube does not prevent bladder spasms from occurring in unstable bladders nor does it improve the urethral closure mechanism in an incompetent urethra.
• Potential complications with long-term suprapubic catheterization are similar to those associated with indwelling urethral catheters, including leakage around the catheter, bladder stone formation, UTI, and catheter obstruction. During the initial placement of a suprapubic tube, a potential for bowel injury exists. Although uncommon, bowel perforation is known to occur with first-time placement of suprapubic tubes. Other potential complications include cellulitis around the tube site and hematoma. If the suprapubic tube falls out inadvertently, the exit hole of the tube seals up and closes quickly within 24 hours if the tube is not replaced with a new one. If tube dislodgment is recognized promptly, a new tube can be reinserted quickly and painlessly as long as the tube site remains patent.
• A suprapubic catheter is an alternative solution to an indwelling urethral catheter in women who require long-term bladder drainage. Potential problems unique to suprapubic catheters include skin infection, hematoma, bowel injury, and problems with catheter reinsertion. Long-term management of a suprapubic tube also may be problematic if the health care provider lacks the knowledge and expertise of suprapubic catheters or if the homebound individual lacks quick access to a medical center in case of an emergency. In the right hands, the suprapubic catheter affords many advantages over long-term urethral catheters.
• Intermittent catheterization: Intermittent catheterization, or self-catheterization, is a mode of draining the bladder at timed intervals, as opposed to continuous bladder drainage. A prerequisite for self-catheterization is the ability of patients to use their hands and arms; however, in a situation in which the patient is physically or mentally impaired, a caregiver or health professional can perform intermittent catheterization for the impaired individual. Of all 3 possible options (ie, urethral catheter, suprapubic tube, intermittent catheterization), intermittent catheterization is the best solution for bladder decompression of a motivated individual who is not physically handicapped or mentally impaired.
• Many studies of young individuals with spinal cord injuries have shown that intermittent catheterization is preferable to indwelling catheters (ie, urethral catheter, suprapubic tube) for men and women. Intermittent catheterization has become a healthy alternative to indwelling catheters for individuals with chronic urinary retention due to an obstructed bladder, a weak bladder, or a nonfunctioning bladder. Young children with myelomeningocele have benefited from the use of intermittent catheterization. In addition, self-catheterization is recommended by some surgeons for women during the acute healing process after anti-incontinence surgery.
• Intermittent catheterization may be performed using a soft red rubber catheter or a short rigid plastic catheter. The use of plastic catheters is preferable to red rubber catheters because they are easier to clean and last longer. The bladder must be drained on a regular basis, either based on a timed interval (eg, on awakening, every 3-6 h during the d, and before bed) or based on bladder volume. Remember that the average adult bladder holds approximately 400-500 mL of urine.
• Ideally, the amount drained each time should not exceed 400-500 mL. This drainage limit may require decreasing the fluid intake or increasing the frequency of catheterizations. So, if catheterization is being performed every 6 hours and the amount drained is 700 mL, increase the frequency of catheterization to, perhaps, every 4 hours to maintain the volume drained at 400-500 mL. The idea is to simulate normal voiding. Usually, the average adult empties the bladder 4-5 times a day. Thus, catheterization should occur 4-5 times a day; however, individual catheterization schedules may vary, depending on the amount of fluid taken in during the day.
• Candidates for intermittent catheterization must have motivation and intact physical and cognitive abilities. Anyone who has good use of the hands and arms can perform self-catheterization. Young children and the older people are able to do this everyday without any problems. For individuals who are impaired, a home caregiver or a visiting nurse can be instructed to perform intermittent catheterization. Self-catheterization may be performed at home, at work, or anywhere. Intermittent catheterization may be performed using either a sterile catheter or a nonsterile clean catheter. Intermittent catheterization, using a clean technique, is recommended for young individuals with a bladder that cannot empty who do not have any other available options. Patients should wash their hands with soap and water. Sterile gloves are not necessary. Clean intermittent catheterization results in lower rates of infection than the rates noted with indwelling catheters.
• Studies show that in patients with spinal cord injuries, the incidence of bacteria in the bladder is 1-3% per catheterization and 1-4 episodes of bacteriuria occur per 100 days of intermittent catheterization (occurring 4 times a d). Furthermore, the infections that do occur usually are managed without complications.
• In general, routine use of long-term suppressive therapy with antibiotics in patients with long-term clean intermittent catheterization is not recommended. The use of long-term suppressive antibiotic therapy in people regularly using clean intermittent catheterization is undesirable because it may result in the emergence of resistant bacterial strains.
• In high-risk populations, such as patients with an internal prosthesis (eg, artificial heart valve, artificial hip) or patients who are immunosuppressed because of age or disease, decide the use of antibiotic therapy for asymptomatic bacteriuria on individual merits. For the older population and individuals with a weak immune system, the sterile technique of intermittent catheterization has been recommended. Older persons are at higher risk than younger people for developing bacteriuria and other complications caused by intermittent catheterization because they do not have a strong defense system against infection. Although the incidence of infection and other complications for patients who are older using sterile versus clean intermittent catheterization is not well established, sterile intermittent catheterization appears to be the safest method for this high-risk population.
• Potential advantages of performing intermittent catheterization include patient autonomy, freedom from indwelling catheter and bags, and unimpeded sexual relations. Potential complications of intermittent catheterization include bladder infection, urethral trauma, urethral inflammation, and stricture. Concurrent use of anticholinergic therapy maintains acceptable intravesical pressures and also prevents bladder contracture. Studies have demonstrated that long-term use of intermittent catheterization appears to be preferable to indwelling catheterization (ie, urethral catheter, suprapubic tube), with respect to UTIs, renal failure, and the development of stones within the bladder or kidneys.

Surgical Care

Surgical care for stress incontinence involves procedures that increase urethral outlet resistance. Operations that increase urethral resistance include bladder neck suspension, periurethral bulking therapy, midurethral slings, and artificial urinary sphincter. Surgical care for urge incontinence involves procedures that improve bladder compliance or bladder capacity. Acceptable operations that increase bladder compliance and/or capacity include sacral nerve modulation, injection of neurotoxins such as botulinum toxin, or bladder augmentation.

For more information, see the article Urinary Incontinence, Surgical Therapies.

Diet

Certain foods in a daily diet can worsen symptoms of urinary frequency and urge incontinence. If a patient's diet contains dietary stimulants, changes in the diet may help in ameliorating incontinence symptoms. Dietary stimulants are substances contained within the food or drink that either cause or exacerbate irritative voiding symptoms. By eliminating or minimizing the intake of dietary stimulants, unwanted bladder symptoms can be improved or possibly cured. Avoidance of dietary stimulants begins with consumer awareness through careful label reading and maintaining a daily diet diary. Experimenting with dietary changes is not appropriate for everyone and should be carried out on an individual basis. Certain food products exacerbate symptoms of urge incontinence.

• Food
  • Foods that contain heavy or hot spices may contribute to urge incontinence. A few medical reports have indicated that the avoidance of spicy foods may have a beneficial effect on urinary incontinence. Some examples of hot spices include curry, chili pepper, cayenne pepper, and dry mustard.
  • A second food group that may worsen irritative voiding symptoms is citrus fruit. Fruits and juices that have an acidic pH worsen preexisting urge incontinence. Examples of fruits that have significant acidity include grapefruits, oranges, limes, and lemons.
  • A third food group that may worsen urinary bladder incontinence is chocolate-containing sweets. Chocolate snacks and treats contain caffeine, which is a bladder-irritating agent. Excessive intake of chocolate confectioneries worsens irritative bladder symptoms.
• Fluids
  • The quantity and quality of refreshments consumed influences urinary voiding symptoms. An average American adult requires a daily allowance of approximately 6-8 glasses of fluids. Fluids refer to all the beverages a person consumes in a day, which include water, soda, and milk. The human body receives fluids from beverages consumed, water contained in the food ingested, and water metabolized from food eaten. The recommended amount of fluids consumed (all types) in 24 hours totals 6-8 glasses. The benefits of adequate fluid intake include prevention of dehydration, constipation, UTI, and kidney stone formation.
  • Some patients tend to drink water to excess. Some women drink water because they enjoy the taste. Others are on medication that makes their mouths dry, so they drink more water. Some women who are trying to lose weight are on a diet that requires consuming abundant amounts of water. Drinking water to excess actually worsens irritative bladder symptoms. The exact amount of fluid needed per day is calculated based on the patient's lean body mass. Thus, the amount of fluid requirement varies per individual. For an average adult woman with symptomatic urinary incontinence, drinking approximately 6 glasses of liquid per day is generally recommended. In contrast, some older women do not drink enough fluids to keep themselves well hydrated. They minimize their fluid intake to unacceptable levels, thinking if they drink less, they will experience less incontinence. Trying to prevent incontinence by restricting fluids to excess may lead to bladder irritation and actually worsen urge incontinence.
  • In addition, dehydration contributes to constipation. If a patient has a problem with constipation, recommend eating a high-fiber diet, receiving adequate hydration, and administering laxatives.
  • Many drinks contain a common ingredient, caffeine. Caffeine is a natural diuretic and has a direct excitatory effect on bladder smooth muscle. Thus, caffeine-containing products produce excessive urine and exacerbate symptoms of urinary frequency and urgency. Caffeine-containing products include coffee, tea, hot chocolate, and colas. Even chocolate milk and many over-the-counter medications contain caffeine. Within this list of caffeine-containing products, coffee contains the most amount of caffeine. Drip coffee contains the most caffeine, followed by percolated coffee and then instant coffee. Even decaffeinated coffee contains a small amount of caffeine, approximately the same amount found in chocolate milk. Persons who consume a large amount of caffeine should slowly decrease the amount of caffeine consumed to avoid significant withdrawal responses, such as headache and depression.
  • Studies have shown that drinking carbonated beverages, citrus fruits drinks, and acidic juices may worsen irritative voiding or urge symptoms. Consumption of artificial sweeteners also has been theorized to contribute to urge incontinence.
• Nighttime voiding and incontinence
  • Nighttime voiding and incontinence are major problems in the older population. Women who have nocturia more than twice a night or experience nighttime bed-wetting may benefit from fluid restriction and the elimination of caffeine-containing beverages from their diet in the evening. Patients should restrict fluids after dinnertime so they can sleep uninterrupted through the night. In some cases, desmopressin (DDAVP) can be used to decrease nighttime urine production and help reduce nocturia.
  • Finally, individuals who develop edema of the lower extremities during the day experience nighttime voiding because excess fluid from lower extremities returns to the heart when the person is in a recumbent position. This problem may be handled with a behavior technique, support hose, and/or medications.
  • Advise these individuals to elevate their lower extremities several hours during the late afternoon or evening to stimulate a natural diuresis and limit the amount of edema present at bedtime. Support hose (Jobst) or intermittent, sequential compression devices (SCDs) used briefly at the end of the day can reduce lower extremity edema and minimize night time diuresis, thus improving sleep.
  • Lastly, the judicious use of diuretics has been associated with a decrease in lower-extremity edema and lower nighttime urine volumes. If patients are already taking diuretics, altering the administration time of the diuretics may decrease nighttime voiding and incontinence. Depending on other medical conditions, changing the time of diuretic administration to the morning may prevent large nighttime urinary volumes.

Activity

Anti-incontinence exercises emphasize rehabilitating and strengthening the pelvic floor muscles that are critical in maintaining urinary continence. Pelvic floor muscles also are known as levator ani muscles. They are named levator muscles because they function to levitate or elevate the pelvic organs into their proper place. When levator muscles weaken and fail, pelvic prolapse and stress incontinence result. An anatomic defect of the levator ani musculature requires physical rehabilitation. If aggressive physical therapy does not work, surgery is warranted.

Pelvic muscle exercises may be used alone, augmented with vaginal cones, reinforced with biofeedback therapy, or enhanced with electrical stimulation. Burgio et al (1998) reported that behavioral treatment is a safe and effective intervention that should be used as a first-line treatment for urge and mixed incontinence.⁸ If the patient is using abdominal muscles or contracting the buttocks, these exercises are being performed improperly. If patients have difficulty identifying the levator muscles, biofeedback therapy may be instituted. For selected individuals, electrical stimulation further enhances pelvic muscle rehabilitation therapy.

• Pelvic floor exercise: Pelvic floor exercise refers to strengthening the levator muscles lining the floor of the bony pelvis. The first step in pelvic muscle rehabilitation is to establish a better awareness of the levator muscle function. Pelvic floor exercises, sometimes called Kegel exercises, are a rehabilitation technique used to tighten and tone the pelvic floor muscles (ie, levator ani) that have become weak over time. These exercises empower the external urinary sphincter to prevent stress incontinence and build up the pelvic floor muscles to avert impending pelvic prolapse. In addition, Kegel exercises may be performed to eliminate urge incontinence. Contraction of the external urinary sphincter induces reflex bladder relaxation. Pelvic floor muscle rehabilitation may be used to reprogram the urinary bladder to decrease the frequency of incontinence episodes.
  • Individuals who benefit the most from pelvic floor exercises tend to be young healthy women who can identify the levator muscles accurately. Older adults with weak pelvic tone or women who have difficulty recognizing the right muscles need adjunct therapy such as biofeedback or electrical stimulation. Pelvic floor exercises work best in mild cases of stress incontinence associated with urethral hypermobility but not intrinsic sphincter deficiency. These rehabilitation exercises may be used for urge incontinence as well as mixed incontinence. They also benefit men who develop urinary incontinence following prostate surgery.
  • Pelvic floor muscle exercises are performed by drawing in or lifting up the levator ani muscles as if to control urination or defecation with minimal contraction of abdominal, buttock, or inner thigh muscles. Patients should be instructed to squeeze their pelvic floor muscles by performing one of the following techniques: (1) stop the flow of urine during micturition, (2) squeeze the anal sphincter as if to prevent passing gas, (3) tighten perivaginal muscles by squeezing a penis during sexual relations or squeezing a finger inserted into the vagina.
  • For stress incontinence, the recommended exercise programs differ. For beginners, the individual should perform the squeezing exercise 5 times, holding each contraction for a count of 5. Five contractions equal 1 set. Patients should do 1 set every hour while they are awake, eg, while driving, reading, or watching television. After a while, the patient becomes proficient at this. After a time, the patient may be able to hold each contraction for at least 10 seconds, followed by an equal period of relaxation. The pelvic floor exercises must be performed daily for at least 3-4 months to be effective.
    • Another regimen is to perform the exercises for 10 minutes twice a day using an audiocassette tape. The audiocassette coaches the patient to contract the levator ani muscles for a count of 10 seconds and then to relax for a count of 10 seconds, performing 25 repetitions in a row. Twenty-five contractions equal 1 set. Perform the first set slowly, followed by a second set performed rapidly. In order to gain the most benefit from this program, patients may need to continue this exercise indefinitely. If patients have not significantly improved after a regimented program of 4-6 months, they may need electrical stimulation.
    • Another alternate regimen is to suggest that the patient repeat a set of 5 exercises each time he or she goes to the bathroom. Again, this ensures that the exercises are performed many times during the day. If patients are unable to perform the exercise for the optimal 5-10 seconds, they may need to start at only 2-3 seconds of contraction until they are able to perform the exercise properly.
  • For urge incontinence, pelvic floor muscle exercises are used to retrain the bladder. When the patient contracts the external urethral sphincter, the bladder automatically relaxes, so the urge to urinate eventually subsides. Strong contractions of the pelvic floor muscles suppress bladder contractions. Whenever patients feel urinary urgency, they may try to stop the feeling by contracting the pelvic floor muscles. These steps provide the patient more time to walk slowly to the bathroom with urinary control.
  • By regularly training the external sphincter, patients can gradually increase the time between urination from 1-3 hours. Patients should start to note improvement in 3-4 weeks. Thus, this technique may be used for stress and urge symptoms—mixed incontinence.
  • When performing these drills, patients should not contract their abdominal muscles. Contracting the abdominal muscles is counterproductive and merely worsens urinary incontinence. In general, tailor a regimented program of exercises and repetitions to each individual so that the muscle strength increases progressively. Some patients may need more intensive training than others.
  • Patients should practice contracting the levator ani muscles immediately before and during situations when leakage may occur. This conditions the external sphincter instinctively to contract with increases in abdominal pressure or when the need to urinate is imminent. This is known as the guarding reflex. Involuntary urine loss is thwarted by tightening the external urinary sphincter just as the patient is about to sneeze. The sensation of impending bladder contraction dissipates by squeezing the levator ani muscles when the patient feels the sense of urgency. By making this maneuver a habit, patients develop a protective mechanism against stress and urge incontinence.
  • The beneficial effects of pelvic floor muscle exercises alone have been well documented in medical literature. Successful reduction in urinary incontinence has been reported to range from 56-95%. Pelvic floor exercises are effective, even after multiple anti-incontinence surgeries.
• Vaginal weights: Vaginal weight training is an effective form of pelvic floor muscle rehabilitation for stress incontinence in women who are premenopausal. Vaginal weights are tamponlike special help aids used to enhance pelvic floor muscle exercises. Shaped like a small cone, vaginal weights (identical shape and volume) are available in a set of 5, with increasing weights (ie, 20 g, 32.5 g, 45 g, 60 g, 75 g). As part of a progressive resistive exercise program, a single weight is inserted into the vagina and held in place by tightening the perivaginal muscles (ie, levator ani muscles) for as long as 15 minutes. As the levator ani muscles become stronger, the exercise duration may be increased to 30 minutes.
  • This exercise is performed twice daily. The intravaginal weight provides the sensory feedback for the desired pelvic muscle contraction. The sustained contraction required to retain the weight within the vagina increases the strength of the pelvic floor muscles.
  • The best results are achieved when standard pelvic muscle exercises (ie, Kegel exercises) are performed with intravaginal weights. In premenopausal women with stress incontinence, the subjective cure or improved continence status is approximately 70-80% after 4-6 weeks of treatment. Vaginal weight training also may be useful for postmenopausal women with stress incontinence; however, vaginal weights are not effective in the treatment of pelvic organ prolapse.
• Biofeedback: Biofeedback therapy is a form of pelvic floor muscle rehabilitation using an electronic device for individuals having difficulty identifying levator ani muscles. Biofeedback therapy is recommended for treatment of stress incontinence, urge incontinence, and mixed incontinence. Biofeedback therapy uses a computer and electronic instruments to relay auditory or visual information to the patient about the status of pelvic muscle activity. These devices allow the patient to receive immediate visual feedback on the activity of the pelvic floor muscles.
  • Biofeedback is intensive therapy, with weekly sessions performed in an office or a hospital by a trained professional, and it often is followed by a regimen of pelvic floor muscle exercises at home. During biofeedback therapy, a special tampon-shaped sensor is inserted in the patient's vagina or rectum and a second sensor is placed on her abdomen. These sensors detect electrical signals from the pelvic floor muscles. The patient then is instructed to contract and relax the pelvic floor muscles upon command. When performed properly, the electric signals from the pelvic floor muscles are registered on a computer screen. Biofeedback, using multimeasurement recording, displays the simultaneous measurement of pelvic and abdominal muscle activity on the computer monitor.
  • Biofeedback allows the patient to correctly identify the pelvic muscles that need rehabilitation. The benefit of biofeedback therapy is that it provides the patient with minute-by-minute feedback on the quality and intensity of her pelvic floor contraction. Combining bladder and urinary sphincter biofeedback allows the patient to regulate the pelvic muscle contraction in response to increasing bladder volumes and to monitor the bladder activity. Biofeedback is best used in conjunction with pelvic floor muscle exercises and bladder training.
  • Studies on biofeedback combined with pelvic floor exercises show a 54-87% improvement with incontinence. The best biofeedback protocol is the one that reinforces levator ani muscle contraction with inhibition of abdominal and bladder contraction. Reports using this method show a 76-82% reduction in urinary incontinence. Biofeedback also has been used successfully in the treatment of men with urge incontinence and intermittent stress incontinence after prostate surgery.
  • Medical studies have demonstrated significant improvement in urinary incontinence in women with neurologic disease and in the frail older population when a combination of biofeedback and bladder training is used. Biofeedback provides a specific reinforcement for pelvic muscle contraction that is isolated from the counterproductive abdominal contraction. Therefore, awareness of levator ani muscle contraction can be achieved more efficiently using biofeedback than vaginal palpation alone.
  • Biofeedback produces a greater reduction in female urinary incontinence, compared to pelvic muscle exercises alone. Overall, the medical literature indicates that pelvic muscle exercises and other behavioral strategies, with or without biofeedback, can cure or reduce incontinence. However, the maximum benefit is derived from any pelvic muscle rehabilitation and education program when ongoing reinforcement and guidance, such as biofeedback therapy, are provided.
• Electrical stimulation: Electrical stimulation is a more sophisticated form of biofeedback used for pelvic floor muscle rehabilitation. This treatment involves stimulation of levator ani muscles using painless electric currents. Electrical stimulation of pelvic floor muscles produces a contraction of the levator ani muscles and external urethral sphincter while inhibiting bladder contraction. This therapy depends on a preserved reflex arc through the intact sacral micturition center. Similar to biofeedback, electrical stimulation can be performed at the office or at home. Electrical stimulation can be used in conjunction with biofeedback or pelvic floor muscle exercises.
  • Electrical stimulation therapy requires a similar type of probe and equipment as those used for biofeedback. This form of muscle rehabilitation is similar to the biofeedback therapy, except small electric currents are used. Nonimplantable pelvic floor electrical stimulation uses vaginal sensors, anal sensors, or surface electrodes. Adverse reactions are minimal.
  • As in biofeedback, pelvic floor muscle electrical stimulation has been shown to be effective in treating female stress incontinence, as well as urge and mixed incontinence. Electrical stimulation may be the most beneficial when stress incontinence and very weak or damaged pelvic floor muscles coexist. A regimented program of electrical stimulation helps these weakened pelvic muscles contract so they can become stronger. For women with urge incontinence, electrical stimulation may help the bladder relax and prevent it from contracting involuntarily.
  • Research indicates that pelvic floor electrical stimulation can reduce urinary incontinence significantly in women with stress incontinence and may be effective in men and women with urge and mixed incontinence. Incidence of urge incontinence secondary to neurologic diseases may be decreased with this therapy. Electrical stimulation appears to be the most effective when augmented with pelvic floor exercises. Long-term data report that the rate of patients cured or improved from electrical stimulation ranged from 54-77%; however, in order to derive significant benefit, stimulation must be performed for a minimum of 4 weeks, and patients must continue pelvic floor exercises after the treatment. Unfortunately, this treatment does not appear to benefit patients who are cognitively impaired.
• Bladder training: Bladder training involves relearning how to urinate. This method of rehabilitation most often is used for active women with urge incontinence and sensory urge symptoms. Often, patients find that when they respond to symptoms of urge and return to the bathroom soon after they have voided, they do not urinate much. In other words, although their bladder is not full, it is signaling for them to void.
  • Bladder training generally consists of self-education, scheduled voiding with conscious delay of voiding, and positive reinforcement. Although bladder training is used primarily for urge incontinence, this program may be used for simple stress incontinence and mixed incontinence. Bladder training requires the patient to resist or inhibit the sensation of urgency and postpone voiding. Patients urinate according to a scheduled timetable rather than the symptoms of urge.
  • Bladder training uses dietary tactics such as adjustment in fluid intake and avoidance of dietary stimulants. In addition, distraction and relaxation techniques allow delayed voiding to help distend the urinary bladder. By using these strategies, patients can induce the bladder to accommodate progressively larger voiding volumes.
    • Initially, the interval goal is determined by the patient's current voiding habits and is not enforced at night. Whatever the voiding pattern is, the first voiding interval may be increased by 15- to 30-minute increments. As the bladder becomes accustomed to this delay in voiding, the interval between mandatory voids is increased progressively, with simultaneous distraction or relaxation techniques and dietary modification. The interval goal between each void usually is set at 2-3 hours and may be set further apart if desired.
    • Another method of bladder training is to maintain the prearranged schedule and disregard the unscheduled voids. However, patients need to continue to maintain the prearranged voiding times. They need to continue this program for several months.
  • Alternatively, bladder ultrasound may be employed. If patients need an objective demonstration that their bladder is relatively empty, a portable bladder scanner may be used. A bladder scanner is a portable ultrasound machine that measures the amount of urine present in a patient's bladder. With this device, patients can void when their bladder fills to a certain volume visible on ultrasound rather than responding to the sensation of needing to go to the bathroom. When patients feel the need to void, they can check the bladder using the scanner to visualize how much urine is present. If the bladder is empty, they should ignore that sensation.
  • Bladder training has been used primarily to manage urge incontinence; however, it also may be used for stress and mixed incontinence. This form of training is useful in young women but is difficult to implement in cognitively impaired persons. Bladder training may not be successful in frail women who are older. Medical reports demonstrate that bladder training is effective in reducing urinary incontinence. With bladder training, the rate of patients with mixed incontinence that have been cured is reported to be 12%, while the improvement rate was 75% after 6 months.

Medication

Stress incontinence results from a weak urinary sphincter. The internal sphincter contains high concentrations of alpha-adrenergic receptors. Activation of the alpha-receptors results in contraction of the internal urethral sphincter and increases the urethral resistance to urinary flow. Sympathomimetic drugs, estrogen, and tricyclic agents increase bladder outlet resistance to improve symptoms of stress urinary incontinence. Medical conditions that cause urge incontinence may be neurologic or nonneurologic. The urethra is healthy, but the bladder is hyperactive or overactive. Pharmacologic therapy for stress incontinence and an overactive bladder may be most effective when combined with a pelvic exercise regimen. The 3 main categories of drugs used to treat urge incontinence include anticholinergic drugs, antispasmodics, and tricyclic antidepressant agents.

All drugs with anticholinergic adverse effects are contraindicated if patients have documented narrow-angle glaucoma. Wide-angle glaucoma is not a contraindication to their use. Urinary retention, bowel obstruction, ulcerative colitis, myasthenia gravis, and severe heart diseases are contraindications to anticholinergic use. These agents may impair the patient's ability to perform hazardous activities, such as driving or operating heavy machinery, because of the potential for drowsiness. Anticholinergic drugs should not be taken in combination with alcohol, sedatives, or hypnotic drugs.

When a single drug treatment does not work, a combination therapy such as oxybutynin (Ditropan) and imipramine (Tofranil) may be used. Although their mechanism of action differs, oxybutynin and imipramine work together to improve urge incontinence. Oxybutynin causes direct smooth muscle relaxation of the urinary bladder and has local anesthetic properties. Imipramine has a direct inhibitory and local anesthetic effect on the bladder smooth muscle, similar to oxybutynin; however, imipramine also increases the bladder outlet resistance at the level of the bladder neck. Thus, the combination of these drugs produces a synergistic effect to relax the unstable bladder and to hold in urine and prevent urge incontinence. Potential anticholinergic adverse effects may be additive because both drugs have similar adverse reactions.

Alpha-adrenergic drugs

The bladder neck contains a high concentration of receptors that are sensitive to alpha-agonists. Alpha-agonists increase bladder outlet resistance by contracting the bladder neck.

Pseudoephedrine hydrochloride (Sudafed)

Helps stress incontinence. The subjective improvement and cure rates are similar to that of phenylpropanolamine (recalled from US market). Stimulates vasoconstriction by directly activating alpha-adrenergic receptors.

Dosing

Adult

Nonextended release: 60 mg PO qid
Extended release: 120 mg PO bid

Pediatric

Not established

Interactions

Propranolol, MAOIs, and sympathomimetic agents may increase toxicity of pseudoephedrine; methyldopa and reserpine may reduce effects of pseudoephedrine

Contraindications

Documented hypersensitivity; severe anemia; postural hypertension or hypotension; closed-angle glaucoma; head trauma; cerebral hemorrhage

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in cardiovascular disease, diabetes mellitus, prostatic hypertrophy, and increased intraocular pressure

Anticholinergic drugs

These agents represent first-line medicinal therapy in women with urge incontinence. These agents are effective in treating urge incontinence because they inhibit involuntary bladder contractions. Useful in treating urinary incontinence associated with urinary frequency, urgency, and nocturnal enuresis. All anticholinergic drugs have a similar performance profile and toxicity. Potential adverse effects of all anticholinergic agents include blurred vision, dry mouth, heart palpitations, drowsiness, and facial flushing. When anticholinergic drugs are used in excess, the bladder may go into acute urinary retention.

Dicyclomine hydrochloride (Bentyl)

Another anticholinergic agent with smooth muscle relaxant properties. Blocks the action of acetylcholine at parasympathetic sites in secretory glands and smooth muscle. In a medical study, subjective improvement was reported by 62% of the subjects while on dicyclomine hydrochloride 10 mg tid. The reported cure rate was 90%.

Dosing

Adult

10-20 mg PO tid

Pediatric

Not established

Interactions

Effects are weakened when administered with anti-Parkinson drugs, haloperidol, and phenothiazines; toxicity increases when administered concurrently with amantadine, antihistamines, type I antiarrhythmics, phenothiazines, TCAs, or narcotic analgesics

Contraindications

Documented hypersensitivity; myasthenia gravis; narrow-angle glaucoma; breastfeeding

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

If an adequate response is not obtained within 3 wk, or if adverse effects are too severe, discontinue the drug; caution when administering to patients with hepatic or renal insufficiency, cardiovascular disease, urinary tract obstruction, ulcerative colitis, GI obstruction, hyperthyroidism, or hypertension

Hyoscyamine sulfate (Levsin/SL, Levsin, Levsinex, Cystospaz-M, Levbid)

Anticholinergic agents with antispasmodic properties used in urologic practice for the treatment of urge incontinence. Blocks action of acetylcholine at parasympathetic sites in smooth muscle, secretory glands, and the CNS, which in turn has antispasmodic effects. Hyoscyamine is absorbed well by the GI tract. Food does not affect absorption of this drug. Hyoscyamine sulfate is available in sublingual form (Levsin SL), conventional tablets (Levsin), extended-release capsules (Levsinex Timecaps, Cystospaz-M), and extended-release tablets (Levbid).

Dosing

Adult

0.125 mg PO q4h; alternatively, 0.375 mg PO bid; for severe symptoms, 0.375 mg PO tid

Pediatric

Not established

Interactions

Effects decrease when used concurrently with antacids; toxicity increases when used concurrently with phenothiazines, amantadine, or haloperidol; MAOIs; TCAs

Contraindications

Documented hypersensitivity; obstructive uropathy; narrow-angle glaucoma; myasthenia gravis; obstructive GI tract disease

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in older patients; some products contain sodium metabisulfite, which can cause allergic-type reactions

Propantheline bromide (Pro-Banthine)

Typical prototype for all anticholinergic agents. Blocks action of acetylcholine at postganglionic parasympathetic receptor sites. In a medical study, propantheline bromide has been shown to decrease incidence of urge incontinence by 13-17% when 30 mg were used qid. When stronger doses were used, 60 mg qid, the cure rate was reported to be over 90%.

Dosing

Adult

15 mg PO tid/qid

Pediatric

Not established

Interactions

Effects decrease when administered concurrently with antacids; toxicity increases when administered concurrently with disopyramide, tricyclic antidepressants, phenothiazines, corticosteroids, and bretylium

Contraindications

Documented hypersensitivity; ulcerative colitis; narrow-angle glaucoma; obstructive disease of the GI or urinary tract

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

In addition to urinary retention, potential adverse effects include visual blurring, dry mouth, nausea, constipation, heart palpitation, drowsiness, and mental confusion; caution in renal or hepatic disease

Antispasmodic drugs

These agents relax the smooth muscles of the urinary bladder. By exerting a direct spasmolytic action on the smooth muscle of the bladder, these medications have been reported to increase bladder capacity and effectively decrease or eliminate urge incontinence. The adverse effect profile of antispasmodic drugs is similar to that of anticholinergic agents. These drugs may impair the ability to perform activities requiring mental alertness and physical coordination. Drinking alcohol and using sedatives in combination with these antispasmodic drugs is contraindicated.

In 2001, Appell et al reported the results of the Overactive Bladder: Judging Effective Control and Treatment (OBJECT) trial. This was a large double-blind, multicenter, prospective, randomized controlled study that compared the efficacy and tolerability of oxybutynin (Ditropan XL) (n = 160) with that of tolterodine (Detrol) (n = 170) in men and women with symptoms of overactive bladder. The study concluded that oxybutynin 10 mg was statistically superior to tolterodine 2 mg bid in terms of efficacy. However, both drugs had similar adverse-effect profiles.⁹

Darifenacin (Enablex)

Extended-release product eliciting competitive muscarinic receptor antagonistic activity. Reduces bladder smooth muscle contractions. Has high affinity for M₃ receptors involved in bladder and GI smooth muscle contraction, saliva production, and iris sphincter function. Indicated for overactive bladder with symptoms of urge incontinence, urgency, and frequency. Swallow whole; do not chew, divide, or crush.

Dosing

Adult

7.5 mg PO qd initially; after 2 wk may increase to 15 mg PO qd based on response
Moderate hepatic impairment (Child-Pugh class B) or potent CYP-450 3A4 inhibitors; not to exceed 7.5 mg PO qd

Pediatric

Not established

Interactions

CYP-450 2D6 and 3A4 substrate; potent CYP-450 3A4 inhibitors (eg, ketoconazole, itraconazole, ritonavir, nelfinavir, clarithromycin, nefazodone) decrease clearance (do not exceed 7.5 mg/d); may cause additive toxicity with other anticholinergics (eg, antihistamines); coadministration with CYP-2D6 substrates that have a narrow therapeutic index (eg, flecainide, thioridazine, TCA [imipramine]) may cause toxicity of these other substrates; may increase midazolam or digoxin levels

Contraindications

Documented hypersensitivity; urinary retention; gastric retention; severe hepatic impairment; uncontrolled narrow-angle glaucoma

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Common adverse effects include xerostomia, constipation, and blurred vision; caution with significant bladder outflow obstruction, decreased GI motility, controlled narrow-angle glaucoma, or moderate hepatic impairment; may cause heat prostration because of decreased ability to sweat

Solifenacin succinate (VESIcare)

Elicits competitive muscarinic receptor antagonist activity, which results in anticholinergic effect and inhibition of bladder smooth muscle contraction. Indicated for overactive bladder with symptoms of urgency, frequency, and urge incontinence. Must be swallowed whole; do not crush or chew.

Dosing

Adult

5 mg PO qd; if tolerated, may be increased to 10 mg PO qd

Pediatric

Not established

Interactions

CYP3A4 substrate; because of decreased clearance do not exceed 5 mg/dose when coadministered with CYP3A4 inhibitors (eg, ketoconazole, erythromycin); CYP3A4 inducers (eg, rifampin, carbamazepine) may increase clearance; may increase risk of QT prolongation when coadministered with drugs known to prolong QT interval (eg, sotalol, thioridazine, moxifloxacin)

Contraindications

Documented hypersensitivity; severe hepatic impairment (Child-Pugh class C); uncontrolled narrow-angle glaucoma; urinary retention, gastric retention

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution with renal or hepatic impairment (do not exceed 5 mg with CrCl <30 mL/min or moderate hepatic impairment [Child-Pugh class B]); caution with controlled narrow-angle glaucoma, history of prolonged QT interval, bladder outflow obstruction, or decreased GI motility

Oxybutynin chloride (Ditropan IR, Ditropan XL)

Both dosage forms, immediate release and extended release, have both an anticholinergic and a direct smooth muscle relaxant effect on the urinary bladder. In addition, it provides a local anesthetic effect on the irritable bladder.
The human detrusor has M2 and M3 muscarinic receptors. The M3 receptor mediates contractile response of human detrusor. Oxybutynin has greater affinity for the M3 receptor. Urodynamic studies have shown oxybutynin increases bladder size, decreases frequency of symptoms, and delays initial desire to void.
Ditropan XL has an innovative drug delivery system—oral osmotic delivery system (OROS). The Ditropan XL tablet has a bilayer core that contains a drug layer and a "push layer" that contains osmotic components. The outer tablet is composed of a semipermeable membrane with a precision laser-drilled hole that allows the drug to be released at a constant rate.
When the drug is ingested, the aqueous environment in the gastrointestinal tract causes water to enter the tablet via semipermeable membrane at a constant rate. The introduction of water inside the tablet liquifies drug and also causes the push layer to swell osmotically. As the push layer swells, it forces the drug suspension out the hole at a constant rate over a 24-h period.
Ditropan XL achieves steady-state levels over a 24-h period. Avoids "first pass metabolism" of liver and upper gastrointestinal tract to avoid cytochrome P450 enzymes. Has excellent efficacy with minimal adverse effects.
Medical studies have shown that oxybutynin chloride reduces incontinence episodes by 83-90%. The total continence rate has been reported to be 41-50%. Mean reduction in urinary frequency was 23%. In clinical trials, only 1% stopped taking Ditropan XL due to dry mouth and less than 1% stopped taking Ditropan XL due to CNS adverse effects.

Dosing

Adult

Ditropan IR: 2.5 mg PO tid, titrate prn to 5 mg bid/tid/qid
Ditropan XL: 5-15 mg PO qd

Pediatric

Not established

Interactions

CNS effects may increase when administered concurrently with other CNS depressants

Contraindications

Documented hypersensitivity; uncontrolled narrow-angle glaucoma; partial or complete GI obstruction; myasthenia gravis; ulcerative colitis; toxic megacolon

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Potential adverse effects include dry skin, blurred vision, confusion, drowsiness, nausea, constipation, and dry mouth; caution in urinary tract obstruction, reflux esophagitis, and heart disease

Tolterodine L-tartrate (Detrol and Detrol LA)

Competitive muscarinic receptor antagonist for overactive bladder. However, it differs from other anticholinergic types in that it has selectivity for urinary bladder over salivary glands. Exhibits a high specificity for muscarinic receptors, has minimal activity or affinity for other neurotransmitter receptors and other potential targets such as calcium channels. In clinical studies, the mean decrease in urge incontinence episodes was 50% and the mean decrease in urinary frequency was 17%. The mean decrease in urge incontinence episodes per wk was 53% for Detrol LA 4 mg qd.

Dosing

Adult

Detrol: 2 mg PO bid
Detrol LA: 4 mg PO qd

Pediatric

Not established

Interactions

Do not administer doses of tolterodine > 1 mg bid to patients being treated with macrolide antibiotics or antifungal agents

Contraindications

Documented hypersensitivity; urinary retention; gastric retention; uncontrolled narrow-angle glaucoma

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Potential adverse effects include dry mouth, headache, drowsiness, upset stomach; do not administer doses > 1 mg bid to patients with significantly reduced hepatic function; caution in renal impairment

Trospium (Sanctura)

Quaternary ammonium compound that elicits antispasmodic and antimuscarinic effects. Antagonizes acetylcholine effect on muscarinic receptors. Parasympathetic effect reduces smooth muscle tone in the bladder. Indicated to treat symptoms of overactive bladder (eg, urinary incontinence, urgency, frequency).

Dosing

Adult

20 mg PO bid; take on empty stomach at least 1 h before meals
CrCl <30 mL/min: 20 mg PO hs
>75 years: May titrate dose downward to 20 mg PO qd based on tolerability

Pediatric

Not established

Interactions

High-fat meals decrease absorption; coadministration with drugs that compete for tubular secretion (eg, digoxin, procainamide, pancuronium, morphine, vancomycin, metformin, tenofovir) may decrease trospium elimination; coadministration with other drugs that elicit anticholinergic effects (eg, antihistamines, antispasmodics) may increase adverse effects

Contraindications

Documented hypersensitivity; urinary retention; gastric retention; uncontrolled narrow-angle glaucoma

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Anticholinergic effects may occur (eg, dry mouth, constipation, dry eyes, blurred vision); increased anticholinergic effects may occur in individuals >75 y; decrease dose with severe renal impairment (ie, CrCl <30 mL/min)

Fesoterodine (Toviaz)

Competitive muscarinic receptor antagonist. Antagonistic effect results in decreased bladder smooth muscle contractions. Indicated for symptoms of overactive bladder (eg, urinary urge incontinence, urgency, and frequency). Available as 4- or 8-mg extended-release tab.

Dosing

Adult

4 mg PO qd; may increase to 8 mg/d; not to exceed 4 mg PO qd in severe renal dysfunction (ie, CrCl <30 mL/min) or with coadministration of drugs that decrease metabolism of fesoterodine (eg, ketoconazole, itraconazole, clarithromycin)

Pediatric

Not established

Interactions

Coadministration with other drugs that cause antimuscarinic or anticholinergic effects may exacerbate adverse effects (eg, xerostomia, constipation); coadministration with strong CYP3A4 inhibitors (eg, ketoconazole, itraconazole, clarithromycin) increases maximum concentration and AUC of fesoterodine

Contraindications

Documented hypersensitivity; urinary or gastric retention; uncontrolled narrow-angle glaucoma; severe liver impairment

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Common adverse effects include xerostomia and constipation; caution in myasthenia gravis, hepatic or renal impairment, controlled narrow-angle glaucoma, and decreased gastrointestinal motility; may cause anticholinergic effects (eg, dry eyes, dry throat, urinary retention); may increase heart rate

Tricyclic antidepressants

Historically, these drugs were used to treat major depression; however, they have an additional use, treatment of bladder dysfunction. They function to increase norepinephrine and serotonin levels. In addition, they exhibit an anticholinergic and direct muscle relaxant effect on the urinary bladder.

Imipramine hydrochloride (Tofranil)

Typical tricyclic antidepressant. Facilitates urine storage by decreasing bladder contractility and increasing outlet resistance. Has alpha-adrenergic effect on the bladder neck and antispasmodic effect on the detrusor muscle. Imipramine hydrochloride has local anesthetic effect on bladder mucosa.

Dosing

Adult

10-50 mg PO qd/tid, range is 25-100 mg qd

Pediatric

Not established

Interactions

Increases toxicity of sympathomimetic agents, such as isoproterenol and epinephrine, by potentiating effects and inhibiting antihypertensive effects of clonidine

Contraindications

Documented hypersensitivity; narrow-angle glaucoma; in acute recovery phase following myocardial infarction; avoid in patients taking MAOIs or fluoxetine or in patients who took them in previous 2 wk

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

May impair mental or physical abilities required for performance of potentially hazardous tasks; caution in cardiovascular disease, conduction disturbances, seizure disorders, urinary retention, hyperthyroidism, or patients receiving thyroid replacement; clinical reports of fetal malformation have been reported with use of imipramine, but a causal relationship has not been established; nursing mothers should not take this medication because it may be excreted via the mother's milk and be harmful to the infant

Amitriptyline hydrochloride (Elavil)

TCA with sedative properties. Increases the circulating levels of norepinephrine and serotonin by blocking their reuptake at nerve endings and is ineffective for use in urge incontinence. However, it is extremely effective in decreasing symptoms of urinary frequency in women with pelvic floor muscle dysfunction. Restores serotonin levels and helps break the cycle of pelvic floor muscle spasms. Well-tolerated and effective in majority of women with urinary frequency.

Dosing

Adult

10 mg/d PO; titrate prn by 10 mg/wk until maximum dose of 150 mg is reached, urinary symptoms disappear, or adverse effects become intolerable

Pediatric

Not established

Interactions

Phenobarbital may decrease effects; coadministration with CYP2D6 enzyme system inhibitors (eg, cimetidine, quinidine) may increase amitriptyline levels; amitriptyline inhibits hypotensive effects of guanethidine; may interact with thyroid medications, alcohol, CNS depressants, barbiturates, and disulfiram

Contraindications

Documented hypersensitivity; patient is taking or has taken MAOIs in past 14 d; history of seizure disorder; cardiac arrhythmias; glaucoma

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in cardiac conduction disturbances and history of hyperthyroidism or renal or hepatic impairment; avoid using in elderly people

Estrogens

Conjugated estrogens increase the tone of urethral muscle by up-regulating the alpha-adrenergic receptors in the surrounding area, and they enhance alpha-adrenergic contractile response to strengthen the pelvic muscles, which is important in urethral support (ie, prevents urethral hypermobility). Mucosal turgor of periurethral tissue from proper nourishment enhances urethral mucosal coaptation. The result is an improved mucosal seal effect, which is important in urethral function (ie, prevents intrinsic sphincter deficiency). Estrogen supplementation appears to be the most effective in postmenopausal women with mild-to-moderate incontinence. Both types of stress incontinence improve with estrogen fortification.

Conjugated estrogen (Premarin, Estrace)

Conjugated estrogen may be used as an adjunctive pharmacologic agent for postmenopausal women with stress or mixed incontinence. Oral or vaginal form of estrogen may be used. The usual oral dose is 0.3-1.25 mg taken qd in a cyclic regimen. When oral estrogens are needed, prescribe 0.625-mg pills. To prevent overstimulation of the uterus, conjugate estrogen is taken once a d for 21 consecutive d, followed by 7 d without the drug (eg, 3 wk on and 1 wk off). Regimen is repeated prn and tapered off or discontinued at 3- to 6-mo intervals.
Conjugated estrogen vaginal cream is available in a package with a plastic applicator and a tube that contains 42.5 g of conjugated estrogens. Each g contains 0.625 mg of conjugated estrogens. When vaginal cream is used, 2-4 g (0.5-1 applicator) of cream may be administered intravaginally qd in the usual cyclic regimen. Estrogen cream is readily absorbed through the skin and mucous membranes. When this cream is used for treatment of atrophic vaginitis, it may be placed intravaginally or applied topically around the vaginal tissues.
When estrogen is used long term, the addition of progestin therapy is recommended to prevent endometrial hyperplasia in women with an intact uterus. Medroxyprogesterone 2.5-10 mg/d is needed for 10-13 d to provide maximum maturation of endometrium and to eliminate any hyperplastic changes. Medroxyprogesterone may be administered continuously or intermittently.
Pharmacologic therapy using estrogen derivatives results in few cures (0-14%) but may cause subjective improvement in 29-66% of women. Limited evidence suggests that oral or vaginal estrogen therapy may benefit some women with stress and mixed urinary incontinence. Other potential beneficial effects of estrogen use include decreased bone loss and resolution of hot flashes during menopause.
Routinely prescribing conjugated estrogens to premenopausal women is not recommended. Use this medication in postmenopausal women who are incontinent and who have had a hysterectomy. For postmenopausal women with an intact uterus, cautiously recommend a short-term low-dose of conjugated estrogen and monitor frequently.

Dosing

Adult

0.625 mg/d PO
0.625 mg/g of cream applied topically to vaginal area

Pediatric

Not established

Interactions

May reduce hypoprothrombinemic effect of anticoagulants; coadministration of barbiturates, rifampin, and other agents that induce hepatic microsomal enzymes may reduce estrogen levels; pharmacologic and toxicologic effects of corticosteroids may occur as a result of estrogen-induced inactivation of hepatic P450 enzyme; loss of seizure control has been noted when administered concurrently with hydantoins

Contraindications

Documented hypersensitivity; known or suspected pregnancy; breast cancer; undiagnosed abnormal genital bleeding; active thrombophlebitis; thromboembolic disorders; history of thrombophlebitis, thrombosis, or thromboembolic disorders associated with previous estrogen use (except when used in treatment of breast or prostatic malignancy)

Precautions

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

Certain patients may develop undesirable manifestations of excessive estrogenic stimulation, eg, abnormal or excessive uterine bleeding or mastodynia; estrogens may cause some degree of fluid retention (exercise caution); prolonged unopposed estrogen therapy may increase risk of endometrial hyperplasia

Follow-up

Further Outpatient Care

• Refer to Catheters in Medical Care.

Complications

• Prolonged contact of urine with the unprotected skin causes contact dermatitis and skin breakdown. If left untreated, these skin disorders may lead to pressure sores and ulcers, possibly resulting in secondary infections. For individuals with a decompensated bladder that does not empty well, the postvoid residual urine can lead to overgrowth of bacteria and subsequent UTI.
• Long-term indwelling catheters may cause recurrent bladder infection, bladder stones, ascending pyelonephritis, and urethral erosion. The use of intermittent catheterization may result in bladder infections or urethral injury. Long-term use of suprapubic tubes may result in bladder spasms, bladder stone formation, and bladder infection.
• Potential problems unique to suprapubic catheters include skin infection, hematoma, bowel injury, and problems with catheter reinsertion.
• Complications of intermittent catheterization include bleeding, infection, and urethral injury.
• Untreated UTIs may lead to urosepsis and death.

Prognosis

• The prognosis of a patient with incontinence is excellent with today's health care. With improvement in information technology, well-trained medical staff, and advances in modern medical knowledge, patients with incontinence should not experience the morbidity and mortality of the past. Although the ultimate well being of a patient with incontinence depends on the underlying condition that has precipitated urinary incontinence, urinary incontinence itself is easily treated and prevented by properly trained health care individuals.

Patient Education

• For excellent patient education resources, visit eMedicine's Kidneys and Urinary System Center. Also, see eMedicine's patient education articles Bladder Control Problems, Understanding Bladder Control Medications, and Foley Catheter.

Miscellaneous

Medicolegal Pitfalls

• Failure to diagnose and treat urinary retention may result in adverse consequences.
• Rule out narrow-angle glaucoma prior to prescribing an anticholinergic agent. Narrow-angle glaucoma may be converted to open-angle glaucoma by an experienced ophthalmologist.
• When a patient is taking an anticholinergic agent, monitor these patients to prevent pharmacologically induced urinary retention.

Multimedia

Media file 1: Urinary incontinence. Normal findings on urodynamic study of a 35-year-old white man. During the filling cystometrogram (CMG), there is absence of uninhibited detrusor contractions. Bladder compliance is normal. His maximum bladder capacity is 435 mL. During the pressure-flow study, his maximum flow rate (Qmax) is 25 mL/s and detrusor pressure at maximum flow rate (Pdet Qmax) is 50 cm H2O. The uroflow pattern is without abnormality, producing a bell-shaped curve without any abdominal straining. He voids to completion, and the postvoid residual urine is negligible.

Media file 2: Urinary incontinence. Urodynamic study revealing detrusor instability in a 75-year-old man with urge incontinence. Note the presence of multiple uninhibited detrusor contractions (phasic contractions) that is generating 40- to 75-cm H2O pressure during the filling cystometrogram (CMG). He also has small bladder capacity (81 mL), which is indicative of poorly compliant bladder.

Media file 3: Urinary incontinence. Urodynamic study revealing detrusor hyperreflexia in a 22-year-old woman with multiple sclerosis. Note the presence of multiple phasic contractions (uninhibited detrusor contractions) generating as much as 100 cm H2O pressure.

Media file 4: Urinary incontinence. Urodynamic recording of bladder outlet obstruction due to benign prostatic hyperplasia (BPH) in a 55-year-old man. Note that during a pressure-flow study, his maximum flow rate (Qmax) is only 6 mL/s and detrusor pressure at maximum flow rate (Pdet Qmax) is very high at 101 cm H2O. He also has a small bladder capacity (50 mL) due to chronic bladder outlet obstruction. His flow curve is flat and "bread-loaf" in pattern, which is consistent with infravesical obstruction.

Media file 5: Urinary incontinence. Urodynamic study revealing detrusor sphincter dyssynergia in a 35-year-old woman with C5 spinal cord injury. Note the absence of uninhibited detrusor contractions during the filling cystometrogram (CMG). Typically, patients with cervical cord lesions manifest detrusor hyperreflexia. However, this patient is taking Ditropan XL. Thus, phasic contractions are suppressed. During the pressure-flow study, note the increase in amplitude of the electromyogram (EMG) coincident with detrusor contraction and voiding. Her uroflow rate is low (1 mL/s), detrusor pressure is high (42 cm H2O), and the EMG recording is elevated.

Media file 6: Urinary incontinence. Video-urodynamic study illustrating type III stress urinary incontinence (intrinsic sphincter deficiency [ISD]) in a 65-year-old woman. Static cystogram reveals obvious contrast leakage via the urethra during Valsalva maneuver. Urodynamic study records abdominal leak point pressure (ALPP) of 55 cm H2O, consistent with ISD.

References

1. Fultz NH, Herzog AR, Raghunathan TE. Prevalence and severity of urinary incontinence in older African American and Caucasian women. J Gerontol A Biol Sci Med Sci. Jun 1999;54(6):M299-303. [Medline].

2. Freeman EW, Grisso JA, Berlin J. Symptom reports from a cohort of African American and white women in the late reproductive years. Menopause. Jan-Feb 2001;8(1):33-42. [Medline].

3. Howard D, Delancey JO, Tunn R. Racial differences in the structure and function of the stress urinary continence mechanism. Obstet Gynecol. May 2000;95(5):713-7. [Medline].

4. Sears CL, Wright J, O'Brien J, Jezior JR, Hernandez SL, Albright TS, et al. The racial distribution of female pelvic floor disorders in an equal access health care system. J Urol. Jan 2009;181(1):187-92. [Medline].

5. Daneshgari F, Imrey PB, Risendal B, Dwyer A, Barber MD, Byers T. Differences in urinary incontinence between Hispanic and non-Hispanic white women: a population-based study. BJU Int. Mar 2008;101(5):575-9. [Medline].

6. Nygaard I, Barber MD, Burgio KL, Kenton K, Meikle S, Schaffer J, et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA. Sep 17 2008;300(11):1311-6. [Medline].

7. Moore KN, Schieman S, Ackerman T, Dzus HY, Metcalfe JB, Voaklander DC. Assessing comfort, safety, and patient satisfaction with three commonly used penile compression devices. Urology. Jan 2004;63(1):150-4. [Medline].

8. Burgio KL, Locher JL, Goode PS. Behavioral vs drug treatment for urge urinary incontinence in older women: a randomized controlled trial. JAMA. Dec 16 1998;280(23):1995-2000. [Medline].

9. Appell RA, Sand P, Dmochowski R, Anderson R, Zinner N, Lama D, et al. Prospective randomized controlled trial of extended-release oxybutynin chloride and tolterodine tartrate in the treatment of overactive bladder: results of the OBJECT Study. Mayo Clin Proc. Apr 2001;76(4):358-63. [Medline].

10. Butler RN, Maby JI, Montella JM. Urinary incontinence: primary care therapies for the older woman. Geriatrics. Nov 1999;54(11):31-4, 39-40, 43-4. [Medline].

11. Comiter CV. Surgery Insight: surgical management of postprostatectomy incontinence--the artificial urinary sphincter and male sling. Nat Clin Pract Urol. Nov 2007;4(11):615-24. [Medline].

12. Foster P. Bladder management post catheter. Nurs BC. Nov-Dec 1998;30(5):28-9. [Medline].

13. Gleason DM, Reilly RJ, Kreuzer F. Apical suspension test. Urology. Sep 1980;16(3):284-5. [Medline].

14. Hijaz A, Moy L, Vasavada SP. The Evaluation and Management of Postpostatectomy Urinary Incontinence. Current Clinical Urology: Management of Prostate Cancer. 2004.

15. Ingber M, Nagaraju P and Diokno A. Incontinence in the Elderly. In: Macias-Nunez J, Cameron J, and Oreopoulus D. The Aging Kidney: In Health and Disease. 1. 1. New York, NY: Springer; 2008:293-306.

16. James M, Jackson S, Shepherd A. Pure stress leakage symptomatology: is it safe to discount detrusor instability?. Br J Obstet Gynaecol. Dec 1999;106(12):1255-8. [Medline].

17. Jones S. Promoting continence in older people. Elder Care. Nov 1999;11(8):34-8; quiz 39. [Medline].

18. Lemack GE. Reversing the tide: emerging options for treating overactive bladder symptoms in women. Tex Med. Nov 1999;95(11):78-81. [Medline].

19. Maki DG, Tambyah PA. Engineering out the risk for infection with urinary catheters. Emerg Infect Dis. Mar-Apr 2001;7(2):342-7. [Medline].

20. Maloney C, Cafiero M. Implementing an incontinence program in long-term care settings. A multidisciplinary approach. J Gerontol Nurs. Jun 1999;25(6):47-52. [Medline].

21. Mersfelder TL. Phenylpropanolamine and stroke: the study, the FDA ruling, the implications. Cleve Clin J Med. Mar 2001;68(3):208-9, 213-9, 223. [Medline].

22. Ouslander JG, Cooper E, Godley D. Estrogen treatment for incontinence in frail older women. J Am Geriatr Soc. Nov 1999;47(11):1383-4. [Medline].

23. Rackley RR. Office Evaluation of Urinary Incontinence. Contemporary Therapy in Obstetrics and Gynecology: Issues and Controversies. 2000.

24. Rackley RR, Abdelmalak JB. Management of Female Urinary Incontinence. Essential Urology: A Guide to Clinical Practice. 2004;8:153-167.

25. Rackley RR, Appell RA. Evaluation and medical management of female urinary incontinence. Cleve Clin J Med. Feb 1997;64(2):83-92. [Medline].

26. Saint S, Elmore JG, Sullivan SD. The efficacy of silver alloy-coated urinary catheters in preventing urinary tract infection: a meta-analysis. Am J Med. Sep 1998;105(3):236-41. [Medline].

27. Saint S, Lipsky BA, Baker PD. Urinary catheters: what type do men and their nurses prefer?. J Am Geriatr Soc. Dec 1999;47(12):1453-7. [Medline].

28. Sander P, Mouritsen L, Andersen JT. Evaluation of a simple, non-surgical concept for management of urinary incontinence (minimal care) in an open-access, interdisciplinary incontinence clinic. Neurourol Urodyn. 2000;19(1):9-17. [Medline].

29. Vasavada SP, Rackley RR. Electrical Stimulation for Storage and Emptying Disorders. Campbell's Urology. 2006.

30. Vasavada SP, Rackley RR. How Effective is Pharmocotherapy for Overactive Bladder. Patient Care. 2006;40(1):40-46.

31. Visco AG, Weidner AC, Cundiff GW. Observed patient compliance with a structured outpatient bladder retraining program. Am J Obstet Gynecol. Dec 1999;181(6):1392-4. [Medline].

32. [Best Evidence] Fink HA, Taylor BC, Tacklind JW, Rutks IR, Wilt TJ. Treatment interventions in nursing home residents with urinary incontinence: a systematic review of randomized trials. Mayo Clin Proc. Dec 2008;83(12):1332-43. [Medline].

33. [Best Evidence] Subak LL, Wing R, West DS, Franklin F, Vittinghoff E, Creasman JM, et al. Weight loss to treat urinary incontinence in overweight and obese women. N Engl J Med. Jan 29 2009;360(5):481-90. [Medline].

Keywords

incontinence, urinary incontinence, functional incontinence, stress incontinence, urge incontinence, overflow incontinence, mixed incontinence, reflex incontinence, Foley catheter, decompensated bladder, detrusor instability, Marshall test, Kegel exercises, detrusor hyperreflexia, overactive bladder, urinary tract infections, UTI, underpads, pant liners, shields and guards, adult diapers, disposable pad systems, urethral occlusive devices, indwelling urethral catheters, suprapubic catheters, intermittent catheterization

Contributor Information and Disclosures

Author

Raymond Rackley, MD, Professor of Surgery, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University; Staff Physician, Center for Pelvic Medicine and Pelvic Reconstruction, Glickman Urological Institute, Cleveland Clinic Foundation
Raymond Rackley, MD is a member of the following medical societies: American Urological Association
Disclosure: Pfizer, Novartis, Proctor & Gamble, Allergan Honoraria None; Pfizer, Novartis, Proctor & Gamble, Allergan Consulting fee Other

Coauthor(s)

Sandip P Vasavada, MD, Physician, Center for Female Pelvic Medicine and Genitourinary Reconstructive Surgery, The Glickman Urological and Kidney Institute; Joint Appointment with Women's Institute, Cleveland Clinic
Sandip P Vasavada, MD is a member of the following medical societies: American Urogynecologic Society, American Urological Association, International Continence Society, and Society for Urology and Engineering
Disclosure: pfizer Honoraria Speaking and teaching; allergan Consulting fee Consulting; ndi medical, LLC Ownership interest Review panel membership; novartis Honoraria Speaking and teaching

Michael S Ingber, MD, Clinical Fellow, Glickman Urological and Kidney Institute of the Cleveland Clinic
Disclosure: Nothing to disclose.

Farzeen Firoozi, MD, Clinical Fellow, Center for Female Urology and Pelvic Reconstructive Surgery, Glickman Urological and Kidney Institute of the Cleveland Clinic
Farzeen Firoozi, MD is a member of the following medical societies: American Medical Association and American Urological Association
Disclosure: Nothing to disclose.

Medical Editor

Martha K Terris, MD, FACS, Professor, Department of Surgery, Medical College of Georgia
Martha K Terris, MD, FACS is a member of the following medical societies: American Cancer Society, American College of Surgeons, American Institute of Ultrasound in Medicine, American Urological Association, New York Academy of Sciences, and Society of University Urologists
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Mark Jeffrey Noble, MD, Consulting Staff, Urologic Institute, Cleveland Clinic Foundation
Mark Jeffrey Noble, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, Kansas Medical Society, Sigma Xi, Society of University Urologists, and Southwest Oncology Group
Disclosure: Nothing to disclose.

CME Editor

J Stuart Wolf Jr, MD, FACS, David A Bloom Professor of Urology, Director of Division of Minimally Invasive Urology, Department of Urology, University of Michigan
J Stuart Wolf Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, Society of University Urologists, and Society of Urologic Oncology
Disclosure: Terumo Corporation Consulting fee Consulting; Omeros Corporation Consulting fee Consulting

Chief Editor

Edward David Kim, MD, FACS, Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center
Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, and Tennessee Medical Association
Disclosure: Lilly Consulting fee Consulting; Astellas Consulting fee Speaking and teaching; Indevus Consulting fee Speaking and teaching

© 1994- by Medscape.
All Rights Reserved
(http://www.medscape.com/public/copyright)