Treatment is keyed to the type of incontinence. The usual approaches are as follows:
Stress incontinence - Surgery, pelvic floor physiotherapy, anti-incontinence devices, and medication
Urge incontinence - Changes in diet, behavioral modification, pelvic-floor exercises, and/or medications and new forms of surgical intervention
Mixed incontinence - Anticholinergic drugs and surgery
Overflow incontinence - Catheterization regimen or diversion
Functional incontinence - Treatment of the underlying cause
Some experts recommend a trial of medical therapy before considering surgical treatment. Others believe that if the incontinence is severe and correctable by surgical means, a trial of medical therapy is not mandatory and does not need to be performed if the informed patient chooses to proceed directly to surgery.
Treatment of comorbid disease may minimize incontinence episodes. Measures such as smoking cessation, control of asthma, and relief chronic constipation may be beneficial.
Absorbent products are pads or garments designed to absorb urine to protect the skin and clothing. Both disposable and reusable forms are available. By reducing wetness and odor, these products help to keep patients comfortable and allow them to function in usual activities.
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 patients who meet the following conditions:
Persistent incontinence despite all appropriate treatments
Inability to participate in behavioral programs, due to illness or disability
Presence of an incontinence disorder that cannot be helped by medications
Presence of an incontinence disorder that cannot be corrected by surgery
Absorbent products may also be used temporarily until a definitive treatment has a chance to work, in patients awaiting surgery, or long-term if treatment has yielded 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.
More than 50% of the members of the National Association for Continence (NAFC), a national support group for incontinent patients, 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.
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 urinary tract infections (UTIs). Thus, appropriate use, meticulous care, and frequent pad or garment changes are needed when absorbent products are used.
Different types of products with varying degrees of absorbency exist. Unlike sanitary napkins, these absorbent products are specially designed to trap urine, minimize odor, and keep the patient dry. These products may absorb 20-300 mL, depending on the brand and the absorbent material of the product. Absorbent products used include underpads, panty shields, pant guards, adult diapers (briefs), various washable pants and disposable pad systems, or combinations of these products.
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 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 may be best suited for an active incontinent woman who does not desire surgery.
The Impress Softpatch (UroMed Corporation, Needham, Mass.) is an adhesive foam patch designed for a single use. A hydrogel adhesive anchors the patch over the urethral meatus. In one study, 52% of women with mild-to-moderate stress incontinence were dry, and 82% were improved with the use of this device.
The Reliance Urinary Control Insert (UroMed Corporation, Needham, Mass.) is a small catheterlike device that is inserted into the urethra. The balloon is inflated with air. The single-use device is removed before voiding by pulling on an attached thread. Approximately 80% of patients are dry with the use of this insert, with an additional 12% greatly improved. Complications such as migration into the bladder and UTI have been reported.
The FemAssist (Insight Medical Corporation, Boston, Mass.) and CapSure Shield (Bard Urological, Covington, Ga.) are silicon devices that seal the urethral meatus with an action similar to a suction cup. These devices can decrease significantly the urine loss in short-term pad test studies.
In a more extended study of the device, only 2 of 31 women finished a 6-month trial. Reasons cited for dropout were lack of efficacy, poor adhesion, discomfort, and difficulty placing the device. This study points out that short-term results in highly motivated individuals may not be generalized to longer-term use under real-life circumstances.
The Introl Bladder Neck Support Prosthesis (UroMed Corporation, Needham, Mass.) is an insertable vaginal device with arms that provide support on each side of the bladder neck. If properly fitted, the prosthesis can achieve cure rates of approximately 80% for stress incontinence.
Incontinence pessaries also are available for use in mild stress incontinence. These ring- or dish-shaped devices usually are reinforced in the area that sits under the bladder neck/proximal urethra. A modicum of success has been achieved with these specially designed pessaries.
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 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. 
For patients undergoing robot-assisted radical prostatectomy (RARP), a study by Lee et al found that the bladder plication stitch is an effective technical modification for lessening the period of recovery of urinary continence. 
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 overflow incontinence. The use of a urethral catheter is contraindicated in the treatment of urge incontinence.
Catheterization is the only way to treat overflow incontinence. 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).
Self-catheterization is the preferred approach if the patient is able to perform it. Indwelling Foley catheters or a suprapubic tube is considered if a patient is not able to perform self-catheterization.
Some patients with overflow incontinence respond well to temporary continuous 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 overflow incontinence 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.
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. Indwelling use of a Foley catheter in individuals who are homebound requires close supervision by a visiting nurse and additional personal hygiene care.
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. 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.
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. After more than 2 weeks in the urinary bladder, all indwelling catheters 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 mL 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.
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 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.
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, with monitoring of 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 catheterization is anticipated, a suprapubic catheter is an attractive alternative to a urethral catheter. 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
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 paraplegic and quadriplegic patients have benefited from this form of urinary diversion.
Other 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.
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.
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 with urethral catheters, the suprapubic tubes should be changed at least once a month on a regular basis.
Suprapubic catheters have many advantages, as follows:
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
Suprapubic tubes are more sanitary for the individual; 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.
Some of the 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. Potential problems unique to suprapubic catheters include cellulitis around the tube site, hematoma, bowel injury, and difficulties with catheter reinsertion.
The potential for bowel injury exists during the initial placement of a suprapubic tube. Although uncommon, bowel perforation is known to occur in this circumstance.
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.
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. Nevertheless, in the right hands, the suprapubic catheter affords many advantages over long-term urethral catheters.
Intermittent catheterization, or self-catheterization, is a mode of draining the bladder at timed intervals, as opposed to continuous bladder drainage. 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.
Intermittent catheterization is most appropriate for patients with detrusor hyperreflexia and functional obstruction. Many of these patients have detrusor-sphincter dyssynergia and are at risk for pyelonephritis and upper tract injury.
Some patients with urge incontinence and coexisting hypofunctioning detrusors may benefit from self-catheterization. For example, some diabetic patients with bladder neuropathy may have instability requiring bladder-relaxing pharmacotherapy but, at the same time, may have intermittent detrusor hypofunctioning with poor emptying. The addition of bladder-relaxing drugs may worsen the baseline poor detrusor function, resulting in retention and overflow incontinence. In some cases, the solution may be to combine bladder-relaxing medical therapy with intermittent self-catheterization.
The ability of patients to use their hands and arms is usually a prerequisite for self-catheterization. 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.
Many studies of young persons (both male and female) with spinal cord injuries have shown that intermittent catheterization is preferable to indwelling catheters (ie, urethral catheter, suprapubic tube). Intermittent catheterization has become a valuable alternative to indwelling catheters for individuals with chronic urinary retention due to an obstructed, weak, or 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 short rigid plastic catheter or a soft red rubber catheter. Plastic catheters are 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 hours during the day, and before bed) or based on bladder volume. The average adult bladder holds approximately 400-500 mL of urine, and 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. For example, 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 or 5 times a day; however, individual catheterization schedules may vary, depending on the amount of fluid taken in during the day.
Candidates for self-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 older people have proved capable of doing this every day 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 other sites. In young, immunocompetent patients, intermittent catheterization may be performed using either a sterile catheter or a nonsterile clean catheter. 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 (when drainage is performed 4 times daily). 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, whether to use antibiotic therapy for asymptomatic bacteriuria depends on individual merits.
For the older population and individuals with an impaired 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 with sterile versus clean intermittent catheterization is not well established for older patients, 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.
Medicated and silver-coated catheters
The type of urinary catheter used may affect the likelihood of catheter-related UTIs. 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.
In 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.
Medication may have some benefit in stress and urge urinary incontinence. These agents are not uniformly effective, and adverse effects may limit their long-term use. Medications used for treatment of urinary incontinence include the following:
Alpha agonists, such as midodrine (Pro-Amatine) or pseudoephedrine (Sudafed), may improve symptoms of mild stress incontinence by increasing intrinsic urethral tone due to these agents’ effects on the urethral sphincter. Phenylpropanolamine hydrochloride (Entex LA, Ornade) was the first-line pharmacologic therapy for women with stress incontinence; however, it has been recalled from the US market.
The subjective improvement and cure rates with pseudoephedrine are similar to those conferred by phenylpropanolamine, which resulted in few cures or dryness (0-14%) but provided subjective improvement in 20-60% of women. In adults, pseudoephedrine dosing is 60 mg qid, or 120 mg bid with the extended-release form. Pediatric dosing has not been established. Pseudoephedrine is also a pregnancy category C drug.
TCAs have historically been used to treat major depression, but their pharmacological effects also make these drugs good choices for mixed incontinence, nocturia, and nocturnal enuresis. TCAs have also been used in the treatment of stress incontinence.
TCAs have complicated direct and indirect effects on the lower genitourinary tract. They possess both a central and peripheral anticholinergic effect, as well as being alpha-adrenergic agonists and central sedatives. The resultant clinical effect is bladder muscle relaxation and increased urethral sphincter tone. High pretreatment urethral closure pressure has served as a predictor of success.
Imipramine (Tofranil) is the most widely used tricyclic for urologic indications. It facilitates urine storage by decreasing bladder contractility and increasing outlet resistance. It has an alpha-adrenergic effect on the bladder neck, an antispasmodic effect on the detrusor muscle, and a local anesthetic effect on the bladder mucosa. (Note FDA black box warning: In short-term studies, antidepressants increased the risk of suicidal thinking and behavior in children, adolescents, and young adults (< 24 y) taking antidepressants for major depressive disorders and other psychiatric illnesses.)
Adult dosing is 10-50 mg 1 to 3 times daily, with a range of 25-100 mg qd. Pediatric dosing is not established. Imipramine is a pregnancy category D drug.
The combination of imipramine and oxybutynin (Ditropan) produces a synergistic effect to relax the unstable bladder, allowing it to better hold urine and preventing urge incontinence.
Amitriptyline (Elavil) is a tricyclic antidepressant with sedative properties that increases circulating levels of norepinephrine and serotonin by blocking their reuptake at nerve endings. It is ineffective for use in urge incontinence but extremely effective in decreasing symptoms of urinary frequency in women with pelvic floor muscle dysfunction. It restores serotonin levels and helps break cycle of pelvic floor muscle spasms.
Amitriptyline is well tolerated and effective in most women with urinary frequency. Adult dosing is 10 mg qd; titrate if necessary by 10 mg/wk until a maximum dose of 150 mg is reached, urinary symptoms disappear, or adverse effects become intolerable. Pediatric dosing is not established. Amitriptyline is also a pregnancy category D drug.
In addition to anticholinergic adverse effects, serious allergic reactions have been reported with TCAs, although rarely. Cardiotoxicity rarely is problematic at the low doses used for treatment of urinary incontinence. Central effects, such as sedation and tremor, may be troublesome to some patients. On occasion, prescribing imipramine at bedtime and a musculotropic agent in the daytime may be helpful.
The serotonin/norepinephrine reuptake inhibitor duloxetine is the first drug developed and marketed specifically for stress urinary incontinence. Duloxetine has been approved for the treatment of stress incontinence in Europe, but is not approved for this indication by the US Food and Drug Administration.
In animal models, duloxetine seems to increase pudendal motor nerve output via increased levels of serotonin and norepinephrine in the pudendal motor nucleus of the sacral spinal segments. As a result, urethral muscular tone and closure pressure is augmented. Similarly, studies in humans suggest that duloxetine enhances urethral closure through neuromodulation of the external urethral sphincter. 
A number of clinical trials have demonstrated the efficacy of duloxetine compared with placebo in the treatment of mild and moderate stress incontinence. A small, prospective, double-blind, randomized, placebo-controlled trial demonstrated modest efficacy in patients with severe stress urinary incontinence. 
In this study, patients with pure, urodynamically confirmed stress incontinence who were awaiting surgery were treated with duloxetine for 8 weeks. All participants had, on average, 14 or more episodes of stress incontinence per week. Significant improvement was observed in the quality of life indices and in frequency of incontinence episodes and use of protective pads in the patients treated with duloxetine compared with placebo. All positive clinical responses were observed within 2 weeks after initiation of therapy–some as early as 5 days.
The most common side effect was nausea, which tended to decrease with continued use. Discontinuation of therapy was significantly more common in the treatment group, with equal numbers of patients withdrawing because of nausea, vomiting, worsening of hypertension, and headache. Other common side effects included constipation and dry mouth. At the end of the 8-week trial, 20% of the treatment group patients were no longer interested in surgical therapy, versus 0% in the placebo arm.
Another small study demonstrated similar results, with 24% of the patients who received duloxetine declining their planned surgical therapy. Of note, 48% of the patients stopped the medication due to side effects at the 40 mg twice-daily dose schedule used in this study. 
A multicenter, double-blind, randomized, placebo-controlled study in 2,758 women with predominant stress incontinence found that after 6 weeks, the decrease in weekly incontinence episode frequency was significantly greater with duloxetine compared with placebo (-50 vs -29.9%). In an uncontrolled, open-label, 72-week extension of the study in 2,290 patients, 21.5% of patients discontinued the drug because of adverse effects. However, the efficacy of duloxetine was maintained in those women who remained on therapy. 
The clinical and urodynamic effects of blocking cholinergic receptors in the bladder are an increase in bladder capacity, an increase in the volume threshold for initiation of an involuntary contraction, and a decrease in the strength of involuntary contractions.
Propantheline bromide is an anticholinergic agent that has been used to treat detrusor overactivity. Propantheline commonly is prescribed in dosages of 15-30 mg every 4-6 hours. In one study, propantheline bromide decreased the rate 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%. Because gastrointestinal absorption is poor, it is often recommended that propantheline be taken on an empty stomach.
Typical anticholinergic adverse effects can be expected, including dry mouth, constipation, dry eyes, blurred vision, orthostatic hypotension, and increased heart rate. This agent probably should be avoided by patients with heart disease and closed-angle glaucoma. Improvement rates in various studies generally have been approximately 50%. Propantheline is no longer considered a first-line drug for detrusor instability due to relatively poor efficacy and a high incidence of adverse effects.
Oxybutynin (Ditropan XL), which has both antimuscarinic and antispasmodic effects, 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 the drug because of dry mouth and less than 1% stopped taking it due to CNS adverse effects.
Tolterodine (Detrol) is a potent antimuscarinic agent for treating detrusor overactivity. In animal models, the drug has shown selectivity for the urinary tract over the salivary glands. Tolterodine has performed well in clinical trials, showing comparable efficacy to oxybutynin with lower discontinuance rates. The dosage range is 1-2 mg twice daily.
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 week was 53% for long-acting tolterodine (Detrol LA) 4 mg qd.
In the Overactive Bladder: Judging Effective Control and Treatment (OBJECT) trial, extended-release oxybutynin 10 mg was statistically superior to tolterodine 2 mg bid in controlling urge incontinence, total incontinence, and micturition frequency. Both drugs had similar adverse-effect profiles.  OBJECT was a large double-blind, multicenter, prospective, randomized controlled study in 276 women and 56 men with symptoms of overactive bladder.
Two small studies examining the use of transdermal scopolamine in the treatment of detrusor overactivity have been reported. The results of these studies are conflicting in terms of both efficacy and tolerability of adverse effects.
Trospium (Sanctura) elicits antispasmodic and antimuscarinic effects. It acts by antagonizing acetylcholine effect on muscarinic receptors. Parasympathetic effect reduces smooth muscle tone in the bladder.
Trospium is indicated to treat urinary incontinence, urgency, and frequency. The typical dose is 20 mg bid taken on an empty stomach at least 1 h before meals. The dose is reduced to 20 mg hs in patients with renal insufficiency (ie, creatinine clearance [CrCl] < 30 mL/min). Elderly individuals (ie, >75 y) may require a similar dose reduction to avoid adverse effects. Mild anticholinergic effects (eg, dry mouth, constipation, dry eyes, blurred vision) may occur.
Solifenacin (VESIcare) is a competitive muscarinic receptor antagonist that causes anticholinergic effects and inhibits bladder smooth muscle contraction. The initial dose is 5 mg qd, which may be increased to 10 mg/d if tolerated and warranted.
Precautions include renal or hepatic impairment (do not exceed 5 mg with CrCl < 30 mL/min or moderate hepatic impairment [Child-Pugh class B]), controlled narrow-angle glaucoma, history of prolonged QT interval, bladder outflow obstruction, or decreased GI motility. The tablet must be swallowed whole (not crushed) with liquid.
Another anticholinergic agent is the extended-release product darifenacin (Enablex). It has high affinity for M3 receptors involved in bladder and GI smooth muscle contraction, saliva production, and iris sphincter function. A prospective, randomized, placebo-controlled, double-blind study demonstrated the efficacy of extended-release darifenacin with regard to reductions in incontinence episodes, decreases in frequency and urgency, and improved bladder capacity.
The initial dose is 7.5 mg PO qd. After 2 weeks, the dose may be increased to 15 mg/d based on response.  Do not exceed 7.5 mg/d if moderate hepatic impairment (Child-Pugh class B) is present or the patient is also taking potent CYP-450 3A4 inhibitors.
Additive toxicity may occur if administered with other anticholinergics (eg, antihistamines). Coadministration with CYP-2D6 substrates that have a narrow therapeutic index (eg, flecainide, thioridazine, TCAs) may cause toxicity of these other 2D6 substrates. Coadministration may also increase midazolam or digoxin levels.
Increasingly, prolongation of the QT interval has been recognized as a potential problem in antimuscarinic drugs as well as medications of many different classes. Individuals with pharmacologic prolongation of the QT interval may be at increased risk for potentially fatal polymorphic ventricular tachyarrhythmia. Additional risk factors for this problem include female gender, advanced age, hypokalemia, and polypharmacy.
No direct studies compare the incidence of prolonged QT intervals or clinically concerning tachyarrhythmias among commonly prescribed antimuscarinic agents. However, in a study of 188 healthy volunteers receiving therapeutic (15 mg) and supratherapeutic doses of darifenacin, no prolongation of the corrected QT interval could be documented. 
More commonly observed adverse effects include xerostomia, constipation, and blurred vision. Darifenacin must be swallowed whole; do not chew, divide, or crush.
Fesoterodine (Toviaz) has been FDA approved for symptoms of overactive bladder (eg, urinary urge incontinence, urgency, frequency). It is a competitive muscarinic receptor antagonist and administered once daily.
Rule out narrow-angle glaucoma prior to prescribing an anticholinergic agent. Experienced ophthalmologists can convert narrow-angle glaucoma to open-angle glaucoma. Patients who are taking an anticholinergic agent should be monitored to prevent pharmacologically induced urinary retention.
Musculotropic relaxants depress smooth muscle activity directly but at a site distal to the cholinergic receptor. Relaxants also may work in part due to anticholinergic and local anesthetic properties at the level of the bladder. Oxybutynin is the prototype drug in this class. The typical dosage is 5 mg 2-4 times per day. Adverse effects are related mostly to the anticholinergic effects. Lower dosages, such as 2.5 mg 2-3 times a day, may be more appropriate for elderly patients.
Good-to-excellent results have been obtained in clinical trials, with improvement rates ranging from 61-86%. Oxybutynin is available in syrup and extended-release formulations. The extended release form is dosed 5-15 mg once daily and is of comparable efficacy to the parent drug.
One study that used specially prepared oxybutynin suppositories in patients who were intolerant of anticholinergic adverse effects when taking the oral form found that adverse effects via this route of administration were less, but the overall symptomatic improvement rate was only 48%.  Most of these patients were elderly.
Flavoxate is a direct smooth muscle relaxant with very weak anticholinergic properties. Few adverse effects are associated with its administration, but efficacy has been questionable. An observational study of flavoxate use in clinical practice described good results in decreasing daytime and nighttime urgency and the number of voids, but urge incontinence was not examined.  The usual dosage is 100-200 mg 3-4 times per day. This agent is not in common use in current practice.
Dicyclomine is a smooth muscle relaxant that has been used most commonly to treat irritable bowel syndrome. Moderate efficacy has been reported with a dosage of 10-20 mg taken orally 3 times daily. Adverse effects mostly are anticholinergic.
Calcium channel blockers
Terodiline was once a very popular drug for the treatment of detrusor overactivity in Europe but has since been withdrawn from the market due to a potential for serious adverse cardiac effects. In a small study, verapamil was no more effective than placebo and less effective than oxybutynin. However, verapamil combined with oxybutynin was more effective than oxybutynin alone.
A small study showed magnesium hydroxide to be beneficial for some patients with sensory urgency and detrusor overactivity. The presumed mechanism of action is through calcium antagonism. More work is needed before this treatment is recommended.
These agents relax beta-adrenergic receptors that are contained in smooth muscle, such as the bladder. Studies of terbutaline and clenbuterol have yielded mixed results. The role of these drugs as adjuncts to other pharmacologic therapies has not been explored.
Mirabegron (Myrbetriq), a beta-3 adrenergic receptor agonist, causes relaxation of the detrusor miuscle and increases bladder capacity. It is indicated for overactive bladder with symptoms of urge urinary incontinence, urgency, and urinary frequency. A guideline from the American Urological Association recommends beta-3-adrenergic receptor agonists as second-line therapy in patients with an inadequate response to behavioral therapy. 
The agent 1-desamino-8-D-arginine vasopressin (DDAVP) has been used in children with nocturnal enuresis, with good results. The hormone causes water to be reabsorbed from the renal collecting system. Reduction in nighttime urine production may be beneficial in patients with detrusor overactivity and a significant degree of nocturia. Caution is needed when using this drug in elderly patients. Do not use in patients with significant heart failure or in children younger than 5 years (eg, water intoxication).
Estrogen therapy may have several positive effects in patients with stress incontinence who are estrogen deficient. Estrogen may increase the density of alpha-receptors in the urethra. In addition, the vascularity of the urethral mucosa is increased and the coaptive abilities of the urethral mucosa may be augmented. In theory, these effects would seem to translate into improved continence; however, several studies stand in opposition of these assumptions.
A number of small studies show oral estrogen therapy to be of no clinical benefit to women with stress incontinence or detrusor overactivity. In a subgroup analysis of postmenopausal women enrolled in the Heart and Estrogen/Progestin Replacement Study (HERS), worsening of incontinence occurred in 39% of patients in the hormone treatment group compared with 27% of patients in the placebo group. 
In the Women's Health Initiative Study, women with baseline incontinence being treated with combined or unopposed estrogen oral therapy also showed exacerbation of symptoms significantly more often than women in the placebo group. In addition, women in the hormone-exposed groups with no baseline incontinence developed symptoms more often than those in the placebo group. 
Both of these trials present level 1 evidence against oral hormone therapy to treat incontinence. No adequate studies of local estrogen therapy exist. A meta-analysis found some evidence that local estrogen may improve incontinence, but there was little evidence on post-treatment results and none on long-term effects.  Local urogenital treatment provides more rapid and reliable effects in treating genitourinary atrophy and deserves study as a preoperative adjunct.
Pharmacologic therapy using estrogen derivatives results in few cures (0-14%) but may cause subjective improvement in 29-66% of women. It may be useful in postmenopausal women with atrophic vaginitis or intrinsic sphincter deficiency.
A neurotoxin produced by Clostridium botulinum, onabotulinumtoxinA (Botox) prevents acetylcholine release from presynaptic membrane. Therapy for urinary incontinence consists of 30 intradetrusor injections via cystoscopy.
In August 2011, onabotulinumtoxinA was approved by the US Food and Drug Administration (FDA) for urinary incontinence in patients with neurologic conditions (eg, spinal cord injury, multiple sclerosis) who have overactive bladder. Trials have shown patients who received onabotulinumtoxinA had significant reduction in urinary incontinence episodes and improved urodynamics compared with placebo at 12 weeks. [72, 73, 74]
In January 2013, the FDA expanded the approved use of onabotulinumtoxinA to treat adults with overactive bladder who cannot use or do not adequately respond to anticholinergic drugs. The new indication was based on results of two placebo-controlled clinical trials in 1105 patients with symptoms of overactive bladder. After 12 weeks, patients who received injections of 100 units of onabotulinumtoxinA (20 injections of 5 units each) experienced urinary incontinence an average of 1.6 to 1.9 times less per day than patients treated with placebo. Treatment with onabotulinumtoxinA can be repeated if necessary, but at least 12 weeks should elapse between treatments. 
The ABC trial (Anticholinergic therapy vs onabotulinum toxinA for urgency incontinence) shed some light on the utility of 100 units of onabotulinum toxinA in the setting of overactive bladder. The data have shown comparable efficacy of 100 units of onabotulinum toxinA to anticholinergic medications with reduced systemic side effects in the onabotulinum toxinA-injected group, yet higher rates of retention and urinary tract infections. Patients receiving onabotulinum toxinA were more likely to be dry, however. Patients who received anticholinergic drugs were more likely to suffer from dry mouth and other systemic side effects. 
In a study that compared sacral neuromodulation and onabotulinumtoxinA in 364 women with refractory urge urinary incontinence, treatment with onabotulinumtoxinA resulted in a greater reduction in 6-month mean number of daily episodes of urge incontinence. However, the authors note that although the difference was statistically significant, is of uncertain clinical importance. In addition, treatment with onabotulinumtoxinA resulted in a higher risk of urinary tract infections and need for transient self-catheterizations. 
Intravesical capsaicin, the main pungent ingredient of hot peppers, has been evaluated for the treatment of detrusor overactivity and neurogenic detrusor overactivity.  The proposed mechanism is through desensitization of capsaicin-sensitive unmyelinated afferents. Neuronal damage through osmotic swelling also may occur.
Improvement rates of 40-100% have been reported. Observation has ranged from 1-60 months. In the largest of these series, 44% of patients with neurogenic detrusor overactivity secondary to multiple sclerosis were dry.
Positive findings from an ice water test indicating bladder hypersensitivity have been suggested as a method of selecting patients for capsaicin therapy. Lidocaine, 1%, is administered intravesically 5-15 minutes before capsaicin is administered. Approximately 50-100 mL of 1-2 mmol capsaicin is mixed in 30% ethanol with saline. The solution is left in the bladder for approximately 30 minutes. A small urethral catheter and balloon occlusion of the vesical neck are used to minimize spillage and leakage.
Adverse effects can include transient worsening of irritative symptoms or incontinence, perineal pain, a burning sensation, hematuria, and UTI. Administration in the office or hospital, continuous blood pressure monitoring, and the ability to treat acute hypertension are recommended in patients with spinal cord injuries due to the rare possibility of exacerbation of autonomic dysreflexia. At times, administration of capsaicin is best accomplished under general anesthesia.
Resiniferatoxin, a naturally occurring pungent substance from the Euphorbia resinifera plant, has been shown to have very potent capsaicinlike activity. This substance has been used successfully to treat detrusor overactivity and neurogenic detrusor overactivity. In one small study, some patients who failed capsaicin therapy responded to resiniferatoxin. More research is underway to clarify the role of these therapies in the treatment of urge incontinence disorders, sensory urgency, and interstitial cystitis.
Intravesical oxybutynin has been used in patients who are nonresponsive to the oral form or have severe adverse effects. The medication is self-administered following clean catheterization. This therapy has been shown to be safe and efficacious. Studies have shown that tissue and plasma concentration of the drug are higher after intravesical administration than after oral administration.
Despite higher plasma levels, adverse effects appear to be minimal. This finding suggests that a hepatic metabolite may be responsible for many of the adverse effects observed after oral administration.
Potassium channel openers relax smooth muscle by increasing potassium efflux, with resultant membrane depolarization. Supersensitivity of the detrusor muscle to depolarizing stimuli, such as potassium, in individuals with urge incontinence is the theoretical basis for the use of these agents in patients with detrusor overactivity. One problem in the development of potassium channel openers for use in bladder disorders has been the lack of organ specificity. Overall progress toward the development of a viable clinical formulation has been disappointing.
Prostaglandin may have an excitatory role in bladder contractility, and prostaglandin inhibitors, in theory, may block bladder contractility. Clinical trials (eg, with indomethacin) have shown mixed and generally not impressive results. One research group reported evidence of the role of a relative prostacyclin deficiency in the promotion of bladder contractions. Pharmacotherapy to increase the ratio of prostacyclin to other prostaglandins has not been investigated to date.
A pilot study by Kuismanen et al suggested that urethral injection of a combination of patient-derived adipose stem cells (ASCs) and collagen can improve the symptoms of stress urinary incontinence in women, possibly providing a nonsurgical alternative to sling procedures for this condition. All five women in the study, each of whom received ASCs and collagen for stress urinary incontinence, demonstrated subjective improvement. In addition, three women passed the cough stress test at 1-year follow-up, and two women considered themselves cured. [79, 80]
Treatment of Nocturnal Enuresis
Such basic measures as evening fluid restriction and daytime bladder training can be beneficial.  Nasal DDAVP at 10-40 mg decreases nighttime urine production. Imipramine (2 mg/kg/d) has been one of the most common pharmacologic therapies. Oxybutynin and other anticholinergics have been used.
Ephedrine was found to be moderately beneficial in one trial. Some believe that this agent works by increasing urethral alpha-sympathetic tone.
Although pharmacologic treatment can help, the underlying disorder often returns after discontinuation. Conditioning therapy with moisture-sensitive alarms are effective. Positive results usually persist even after the device is removed.
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, DDAVP can be used to decrease nighttime urine production and help reduce nocturia; however use caution regarding the risks of hyponatremia, especially in elderly patients.
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.
Pelvic Floor Rehabilitation
A level A guideline from the American Congress of Obstetricians and Gynecologists (ACOG) recommends pelvic floor training as an apparently effective noninvasive treatment for adult women with stress and mixed incontinence.  In women with mild stress urinary incontinence without vaginal prolapse, a success (ie, cure, improvement) rate of 75-80% may be attained by properly performed pelvic floor exercises.
Pelvic floor exercises (ie, Kegel exercises) work best in mild cases of stress incontinence associated with urethral hypermobility but not intrinsic sphincter deficiency. They also benefit men who develop urinary incontinence following prostate surgery. 
Kegel exercises have been shown to improve the strength and tone of the muscles of the pelvic floor (ie, the levator ani, and particularly the pubococcygeus). During times of increased intra-abdominal pressure, tensing of these muscles tightens the connective tissue that supports the urethra. Thus, pressure transmission to the urethra may increase, and the urethra compresses shut during times of increased stress.
The exercises consist of voluntary contractions of the muscles of the pelvic floor. Because both fast-twitch and slow-twitch muscle fibers are found in the levator ani complex, both rapid contractions and slow contractions held for maximal duration should be performed to achieve the best possible results.
Patients can perform pelvic floor muscle exercises 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. The patient can confirm that she is using the correct muscles at home by periodically performing the contractions during voiding with the goal of interrupting the urinary stream.
If instructions for Kegel exercises are provided verbally or in written form alone, a significant percentage of individuals perform repetitive Valsalva maneuvers or gluteal contractions rather than pelvic muscle contractions. Therefore, instructing the patient in the examining room by having her squeeze the examiner's intravaginal or intrarectal finger is important.
Initially, patients are instructed to 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, during such activities as driving, reading, or watching television. An alternate program requires 1 set of exercises every time the patient uses a bathroom. Soon after starting the exercises, the patient may be able to hold each contraction for at least 10 seconds, followed by an equal period of relaxation.
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.
Approximately 6-12 weeks of exercises are required before improvement is noted, and 3-6 months are needed before maximal benefit is reached. The key to success with pelvic floor exercises is a commitment on the patient’s part to performing them for a long period of time. Patients who do not tend to revert back to pretherapy levels of incontinence.
Individuals who benefit most tend to be young healthy women who can identify the levator ani muscles (specifically, the pubococcygeus portion) accurately. Older adults with weak pelvic muscle tone or women who have difficulty recognizing the correct muscles need adjunctive therapy such as biofeedback or electrical stimulation. Patients with severe neuromuscular damage to the pelvic floor may not be able to perform Kegel exercises, even with proper instruction.
Internet and mail-based treatment programs based on pelvic floor muscle training significantly improved symptoms and condition-related quality of life in a study of 250 community-dwelling women (aged 18-70 years) with stress urinary incontinence. At 1-year follow-up, 69.8% (60/86) of patients in the Internet treatment group and 60.5% (46/76) of patients in the postal treatment group reported continued satisfaction with their treatment result. At 2-year follow-up, these proportions were 64.9% (48/74) and 58.2% (46/79), respectively. 
Pelvic muscle exercises may be used alone, augmented with vaginal cones, reinforced with biofeedback therapy, or enhanced with electrical stimulation.
Vaginal cones are weighted devices designed to increase the strength of the pelvic floor muscles. The cones are available in sets of 5, with identical shape and volume but increasing weights (ie, 20 g, 32.5 g, 45 g, 60 g, 75 g). As part of a progressive resistive exercise program, a single cone is inserted into the vagina and held in place by tightening the 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 cones also may be useful for postmenopausal women with stress incontinence; however, the cones are not effective in the treatment of pelvic organ prolapse.
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, thereby providing incentive and confirmation of proper performance of the muscle contractions.
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 the exercises are 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.
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 with 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 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.
Like biofeedback, pelvic floor muscle electrical stimulation has proved effective in treating female stress incontinence. It may be effective in men and women with urge or mixed incontinence. Urge incontinence secondary to neurologic diseases may be decreased with this therapy. Unfortunately, this treatment does not appear to benefit patients who are cognitively impaired.
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.
Electrical stimulation appears to be the most effective when augmented with pelvic floor exercises. 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.
The 2 main modes of electrical stimulation therapy are long-term stimulation and short-term maximal stimulation. Long-term therapy requires the use of an intravaginal or intra-anal probe for several hours a day. Low intensity, subthreshold stimulation is used. Patient acceptance can be low due to the discomfort of wearing the probe for several hours each day.
Short-term maximal stimulation therapy was developed because it is more practical, and high intensity stimulation may produce a better inhibitory effect. Maximal inhibition of involuntary bladder contractions takes place at stimulation intensity levels that are 2-3 times sensory threshold levels. The closer the proximity of the stimulating device to the selected nerve, the lower the intensity can be and remain effective. In practical terms, maximal tolerance levels usually are approximately 1.5-2 times the sensory perception threshold.
Short-term maximal therapy uses high-intensity stimulation for 15-30 minutes once or twice a day. Treatment generally is continued over several weeks. Improvement rates of 52-77% have been documented. Carryover effects of 31-92% have been shown for as long as 1 year after therapy.
Transcutaneous electrical nerve stimulation (TENS) has been tried in patients with detrusor overactivity, using several different methods. Applying a positive electrode applied to the area of the anal sphincter and a negative electrode to the posterior tibial nerve has yielded mixed results in 2 studies. TENS of the S2-S3 dermatomes has been tried with some success.
An interesting method of alternating stimulation of the hamstring and quadriceps muscle groups has been reported. In this study, which included patients with detrusor overactivity, 20 minutes of stimulation per day was given for 14 consecutive days and clinical improvement was observed in 68% of subjects. The mechanism of detrusor inhibition by this method of TENS is unclear but may involve increases in segmental inhibitory tone due to manipulation of peripheral neural input.
Interferential therapy is a type of TENS in which external electrodes are positioned over the pelvis, and the interference produced by the competing electrical fields produces low-level nerve stimulation in the area of interference. A small study showed a 90% improvement rate in 20 patients with detrusor instability that was unresponsive to pharmacotherapy. In 18 months of observation, no complications were reported, and no recurrences were observed.
Acupuncture is a promising alternative therapy. A 77% improvement rate with 63% of patients dry was reported in a study of weekly therapy sessions for 10-12 weeks. However, note that no good randomized prospective trials have been performed on this modality.
Extracorporeal magnetic resonance therapy
Extracorporeal magnetic resonance therapy has been introduced as a therapy for stress incontinence. The NeoControl unit (Neotonus, Marietta, Ga.) was approved by the Food and Drug Administration (FDA) for this purpose in 2000. Resonating magnetic flux within a magnetic field induces electrical depolarization of targeted nerves and muscles. No probes are required. The patient simply sits on a chair containing the magnetic device.
A small study achieved an improvement rate of 77% after 8 weeks of therapy, with 56% of patients being completely dry. However, a 3-year follow-up study found that the benefits tend to be temporary: at 6 months, the recurrence rate was 53%. 
Given that obesity has been identified as a risk factor for development of urinary incontinence, it is not surprising that interventions to address obesity can result in improved continence. Researchers who followed a prospective cohort of women who were morbidly obese found that prevalence of urinary incontinence decreased after bariatric surgery. The magnitude of weight loss was associated with reduction in urinary incontinence prevalence. 
Another group demonstrated that a behavioral intervention targeting weight loss reduced urinary incontinence in women who were overweight and obese compared with a control group. 
The benefits of weight loss in patients who are overweight or obese are numerous and encompass improvements in type 2 diabetes mellitus, hypertension, dyslipidemia, and mood. The results above should encourage patients to consider weight loss as a first-line treatment for reducing urinary incontinence before embarking on more invasive medical and surgical therapies.
A study by Phelan et al found that moderate weight loss reduced the incidence of urinary incontinence among overweight/obese women with type 2 diabetes; however, it did not improve the resolution rates. 
A level A guideline from the ACOG recommends behavioral therapy, including bladder training and prompted voiding, as a noninvasive method for improving symptoms of urge and mixed incontinence in women.  Timed, frequent voiding can be used to minimize incontinence, especially if the bladder is kept empty before incontinence-producing activities.
Bladder training is most useful in young women. It may not be successful in frail older women. It is difficult to implement in cognitively impaired persons.
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; however, it also may be used for stress and mixed incontinence. Often, these 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. 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 also 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. The interval goal between each void usually is set at 2-3 hours, but may be set further apart if desired.
As the bladder becomes accustomed to this delay in voiding, the interval between mandatory voids is increased progressively, in 15- to 30-minute increments, with simultaneous distraction or relaxation techniques and dietary modification. Typically, the interval is increased by 15 minutes per week until the patient reaches a voiding interval of approximately 3-4 hours.
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.
Bladder training can be conducted with or without simultaneous pharmacotherapy. Subjective response rates of 85% and objective response rates of 50% have been achieved with short-term observation.
Symptoms of urgency and frequency can develop over time with this strategy due to decreased bladder capacity. Anticipatory pelvic floor contractions can be taught to patients to cut down on incontinence episodes. The patient is taught to perform a strong pelvic floor contraction just before anticipated episodes of increased intra-abdominal pressure, such as a cough or a sneeze.
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 urge 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.
Clearly, behavioral therapies can be successful in the highly motivated patient in the short-term. Long-term efficacy is much less certain, and relapse rates, when reported, have been high. In addition to a highly motivated patient, this type of therapy requires a dedicated team to provide support and reinforcement to the patient.
Modification of activity occasionally can be a solution to incontinence-related specific activities. For example, if a woman experiences incontinence only during high-impact aerobics, substitution of another fitness activity, such as swimming, may solve the incontinence problem.
Surgical care for stress incontinence involves procedures that increase urethral outlet resistance, which include the following  :
Bladder neck suspension
Midurethral sling surgery
In a randomized study of 460 women with moderate to severe stress urinary incontinence, 90.8% of those who underwent midurethral sling surgery reported improvement at 1-year follow-up, compared with 64.4% of those who underwent physiotherapy training. [90, 91] The rate of objective cure was 76.5% in the surgery group and 58.8% in the physiotherapy group.
The transobturator male sling may be of particular benefit to patients who experience stress incontinence after prostatectomy. 
The AMS 800 (American Medical Systems, Minnetonka, Minn) artificial urinary sphincter is a standard option for the surgical management of male stress urinary incontinence. A retrospective review by Yafi et al of 27,096 cases of AMS 800 primary implantation determined that 21.1% of cases required either revision or explantation. Younger patient age and penoscrotal surgical approach were associated with higher rates of device explantation and revision, while use of a tandem cuff was associated with higher explantation rates.
Transobturator vaginal tape (TVT-O) is widely used for stress incontinence in women. In an Italian study of 181 consecutive cases of TVT-O surgery, Serati et al found no significant difference between older women (70 years or older) and younger women in terms of cure rate, voiding dysfunction, vaginal erosion, persistent groin pain, or onset of de novo overactive bladder.  The cure rate was 88.3% for the older group and 92.5% for the younger group.
In a study specifically focusing on the use of TVT-O in women with urodynamically proven, pure stress incontinence, Serati et al found TVT-O implantation to be a highly effective treatment option in this population, with a very high cure rate and a low complication rate.  The 5-year subjective cure rate was 90.3%, and the 5-year objective cure rate was 90.8%. The incidence of de novo overactive bladder was 24.3% at 5 years; no factor predictive of this condition was identified.
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.
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.
Spicy foods may contribute to urge incontinence. Some examples of hot spices include curry, chili pepper, cayenne pepper, and dry mustard. A few medical reports have indicated that the avoidance of spicy foods may have a beneficial effect on urinary incontinence.
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.
The quantity and types of fluids consumed influences urinary voiding symptoms. 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. They may simply enjoy the taste, they may be on medication that makes their mouths dry, or they may be on a weight-loss diet that requires consuming abundant amounts of water. Drinking water to excess actually worsens irritative bladder symptoms.
In contrast, some older women do not drink enough fluid to keep themselves well hydrated. They minimize their fluid intake to unacceptable levels, thinking that 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.
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.
Many beverages contain 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. Of these 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 fruit drinks, and acidic juices may worsen irritative voiding or urge symptoms. Consumption of artificial sweeteners also has been theorized to contribute to urge incontinence.
Emergency Department Care
Practically speaking, patients in whom more serious pathology has been ruled out will be referred for outpatient treatment.  If reversible causes of urinary incontinence are evident (eg, UTI, hyperglycemia in diabetic patients) they should be treated in the emergency department. [31, 25]
All suspected cases of cauda equina syndrome, spinal cord compression, or paraspinal abscess warrant admission and neurology and neurosurgery consultation.  The following conditions warrant a urology consultation, although for ED patients, this can be obtained in the outpatient setting  :
Suspected bladder neoplasm, unexplained hematuria, and recent voiding symptoms
History of prior radical pelvic surgery or pelvic radiation
Prior pelvic incontinence surgery
Gross pelvic prolapse
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- Approach Considerations
- Absorbent Products
- Urethral Occlusion
- Suprapubic catheters
- Pharmacologic Therapy
- Treatment of Nocturnal Enuresis
- Pelvic Floor Rehabilitation
- Weight Loss
- Behavioral Approaches
- Surgical Treatment
- Dietary Modification
- Emergency Department Care
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