There are a variety of ways to treat or even completely control urinary incontinence, but it depends on the cause. While there are sometimes multiple factors in play that cause this condition, treatment options are limited by patient motivation, cognitive level, physical impairment, or anatomic abnormalities of the urinary tract. For most, conservative management is the first line strategy and often is quite successful in decreasing the severity of leakage.
Behavior modification and bladder retraining are among the first strategies employed. Timed voiding and double voiding are habits that are easy to adopt and can help empty residual or retained urine from the bladder. Taking inventory of how much and what kinds of fluids are consumed over the course of the day is important. Caffeine intake in the form of coffee, tea, soda, or bladder irritants such as vinegar in salad dressing, citrus or other foods, if eaten in large quantity can be an easy culprit for bladder misbehavior. Simply reducing water consumption will less the sense of urinary urgency, frequency and incontinence, either urge or stress provoked. Timing of fluid consumption is also simple to adjust, that is, minimize caffeine or water at least 3 hours prior to bedtime to less nighttime bathroom trips.
Timing of medication during the day, such as when to take a diuretic/ water pill for high blood pressure, can impact frequency of bathroom trips. Diuretics force more urine production by the kidneys to lower blood pressure, but the bladder must still store and expel it. Forcing more urine production in the afternoon may leave someone relatively “drier” prior to bedtime, and may also less nighttime bathroom trips.
Pelvic floor retraining in the form of Kegel muscle exercises can help to strengthen the urinary sphincter and pelvic floor muscles to curb leakage of urine when a sneeze comes on or the urge becomes great. Squeezing down on the sphincter before sneezing gets the body ready for the rise in pressure that may force urine past the sphincter. Repetitively practicing Kegel muscle exercises can curb incontinence a great deal, but these exercises must be performed daily.
There are some “reversible” causes of incontinence which are not the bladder’s fault, but when addressed can lessen urinary leakage. Urinary tract infection can cause pain and urinary loss and simply antibiotic prescription can easily remedy this. Untreated diabetes can promote urine production and overwhelm the bladder leading to incontinence. In the elderly or frail population, delirium or dementia often lead to incontinence because of lack of perception of the need “to go”. Poor mobility due to weak or injured legs or back will hinder someone simply from getting to the bathroom in time and lead to an incontinence episode. Severe constipation, urethral tissue thinning from lack of estrogen, and even simply depression, are all treatable and reversible causes of incontinence. Those caring for others with cognitive impairments can prompt them to void on a schedule and maintain easy access to toilets to minimize urinary incontinence.
Medications for overactive bladder are frequently used in conjunction with bladder retraining since together the combination will have an additive effect. All overactive bladder medications essentially will confer the same benefit in a majority of those who are prescribed them. They can lower the sense of urgency, frequency, and urge incontinence by about 2/3. All can lead to common side effects such as dry mouth, dry eyes, and constipation. Avoiding overuse of other medications, such as diuretics, certain antidepressants, antihistamines, and cough or cold preparations may also have a significant impact on lower urinary incontinence. There are no medications that are approved to treat stress incontinence.
If medications for overactive bladder lead to undesirable side effects or do not work, a bladder neurostimulator may be placed to help control symptoms. Similar to a pacemaker, the neurostimulator dampens the urge signals from the bladder allowing for a normal voiding pattern. It is placed in the buttock and approximately ¾ of individuals who are symptomatic with urgency, frequency and urge incontinence can be treated permanently this way. It is considered minimally invasive and placed as an outpatient.
For stress incontinence that occurs with coughing, sneezing, laughing and exercise, minimally invasive outpatient procedures such as slings or urethral injections are highly successful and can achieve dryness in the majority of those who have it. A “sling” is narrow strip of mesh that can be placed under the urethra and serves as a backboard of support under the urethra during activity or coughing. Patients can return to work in a relatively short period of time after a brief recovery period. A urethral injection adds bulk or “beefs up” the urethra by injecting a substance via a scope into the urethra itself. It is an acceptable alternative for those who are not sling candidates. Pre-operative bladder testing with urodynamics and a full history and physical are required to assess who is an appropriate surgical candidate.
Matthew E. Karlovsky, M.D.
Center for Urological Services, P.C.
4545 E. Chandler Blvd, Suite 300
Phoenix (Ahwatukee), AZ 85048