eMedicine Specialties > Urology > Incontinence

Urinary Incontinence, Nonsurgical Therapies: Treatment & Medication

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
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; 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
Contributor Information and Disclosures

Updated: May 6, 2009

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.

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%.

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).

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%.

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.

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.

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.

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.

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).

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.

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.

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.

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.

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