TREATMENT OPTIONS FOR URINARY INCONTINENCE AND URINE LEAKAGE
When talking about treatment for urinary incontinence, it is important that you understand all the treatment options available to you, and that you share your thoughts and any concerns with your doctor. There are several kinds of treatment: management and restoration. Treatment options vary in invasiveness and effectiveness depending on the cause and the severity of the incontinence.
HERE ARE SOME OPTIONS THAT ARE OFFERED TO WOMEN WITH URINARY INCONTINENCE:
Behavioral therapy: It includes maintaining a strict schedule of avoiding and monitoring fluid intake. Behavioral treatment is ideal for those who suffer from stress urinary incontinence. This is based on learning techniques that can teach you ways to control your bladder and sphincter muscles. Prompting or scheduling voiding (used in women who can recognize some degree of bladder fullness). A diet that is low in bladder irritants such as coffee and soda is also helpful.
Pelvic muscle exercises: These exercises are meant to retrain the bladder, as well as work out the pelvic floor. The most common exercises are called Kegel exercises and are used to strengthen the weak muscles surrounding the bladder. These exercises involve identifying the pelvic floor muscles that purposely interrupt the flow of urine in midstream, and then tightening these muscles for three seconds and relaxing them for three seconds. Kegel exercises are commonly repeated 10 to 15 times per session, at least three times per day.
There are other very interesting biofeedback devices on the market now that help women exercise their pelvic muscles before it is too late. Vaginal weights are gaining popularity, as they are a simple and private way in which a woman can work out the muscles of the pelvic floor before surgical options are considered. There are also biofeedback techniques and treatment plans that are truly beneficial for a woman who has pelvic floor weakness and urinary incontinence. Speak with your doctor about possible noninvasive ways to address the problem. Keep in mind that prevention is the key and it is best not to wait until the problem is severe.
Protective Undergarments: Products such as pads, undergarment liners and absorbent underwear are worn to absorb urine that has leaked from the bladder.
External Devices: Pessary device – Some women with urinary incontinence use a pessary device, a stiff ring that is inserted into the vagina where it presses against the wall of the vagina and the urethra. The pressure helps reposition the urethra, preventing leakage. Other external devices include an indwelling catheter. Some women may require the indwelling catheter. It is left in place 24 hours a day to continually collect urine in an external drainage bag.
Bulking Injections: The main goal of the bulking injection is to thicken up the urethral lining so the urethra can close more tightly. An example of a bulk-producing agent is collagen.
Medications: A number of medications can help bladder control problems due to urge incontinence. However, there are presently no medicines currently available to treat stress incontinence. If your doctor determines you have mixed (stress and urge) incontinence, you may find drug therapy helpful in addressing the urge component of your incontinence. There are fewer options for stress incontinence, which is usually when urine leakage happens with sudden physical movement or activity, such as coughing, sneezing or heavy lifting.
When a woman has overactive bladder and urge incontinence there are effective medications available for treatment. Stress and urge incontinence is a bladder control problem characterized by a sudden, intense urinary urge almost always followed by some form of leakage of urine. These medications can be divided into two classes: anticholinergic prescription medication and estrogen.
Anticholinergic Prescription Medications: When the bladder is overactive, it is characterized by abnormal bladder contractions, which make a woman want to urinate even when her bladder isn't full. This is one of the causes of urge incontinence. Anticholinergic drugs block the action of a chemical messenger or hormone called acetylcholine. Acetylcholine sends signals to the bladder that trigger these urge contractions.
The most common anticholinergic medications used for urinary stress and urge incontinence are:
Some of these medications are available in an extended-release form so that it is convenient and the medication can be taken once a day. The extended-release forms may have fewer side effects, yet in some instances, the immediate-release form may be helpful if a woman has the problem only at certain times, such as at night or when traveling. Oxybutynin is also available as a cream or skin patch that delivers a continuous amount of medication and that can also be an option for women.
The most common side effect of these medications that block acetylcholine is that they cause a dry mouth. It can be quite uncomfortable and the decreased saliva production can cause some dental issues. Also there may be generalized dryness including vaginal dryness. Other side effects include constipation, heartburn, blurry vision, rapid heartbeat (tachycardia), flushed skin, urinary retention and cognitive side effects, such as impaired memory and confusion. When using the oxybutynin skin patch, the most common side effect is skin irritation.
Estrogen and Hormone treatments: When a woman has urinary incontinence, and has had menopause, estrogen and hormone treatments can be used as part of the treatment plan. Menopause and low-female hormone state can happen for a woman due to the natural process of aging, a total or partial hysterectomy, or following childbirth after a steep drop in hormones with the delivery of the baby and the placenta, a “hormone-making machine.”
The urogenital areas are specifically receptive to estrogen, progesterone and testosterone – in general all the sex hormones. These hormones have profound effects on a woman’s bladder and urethra and help maintain the strength and flexibility of the tissues of the pelvic and vaginal areas, as well as urethral and bladder tissues. After hormones drop due to menopause, the lack of hormones contributes to the generalized weakness, atrophy and generalized deterioration of the floor of the pelvis, and the tissues that support the bladder and urethra. Because of these changes the weak tissues aggravate stress incontinence. On the other hand, for treatment purposes, estrogen is known to improve blood flow, enhance nerve function and correct tissue deterioration in the urethra and vaginal areas.
Estrogen treatments can be provided to a woman with urinary incontinence by applying a low-dose form locally in the vagina, in the form of vaginal cream, vaginal suppository, vaginal ring, or vaginal tablet. Medical research has shown that topical vaginal estrogen helps tone and rejuvenate the pelvic floor and urogenital areas, as well as relieve some of the symptoms of stress incontinence or urge incontinence.
Important to note: Both prescription hormone treatment, and anticholinergic medications should be used in combination with other therapies, such as pelvic floor muscle training. Kegel exercises, home pelvic floor muscle work with vaginal weights and pelvic floor physical therapy and neuro-feedback training. Pelvic floor exercises should be continued for at least 12 weeks in order to see an improvement, and unless continued, the symptoms can return within four weeks. Combination hormone replacement therapy (estrogen plus progestin) is much stronger than topical estrogen and is no longer used specifically to treat urinary incontinence. Yet it is usually used under circumstances which include urinary incontinence among other complaints and in a woman who has no contraindications for systemic and higher dose of estrogen and progesterone.
When estrogen treatment is not an option and anticholinergic medications have been tried, other alternatives exist to treat urinary incontinence. Other options include medications including the use of imipramine, usually prescribed as an antidepressant, and a hormone called desmopressin. In some clinical studies the use of Botox – botulinum toxin – which inhibits the contraction of muscle.
DIFFERENT AND ALTERNATIVE PRESCRIPTION OPTIONS FOR URINARY INCONTINENCE
Imipramine: Imipramine is medication under the category of tricyclic antidepressants. Another effect includes what it does to the muscles of the bladder. Imipramine causes general bladder muscle relaxation, and at the same time, it causes the contraction of the muscle at the neck of the bladder – the urinary sphincter. Therefore, it is used for urge, stress incontinence, and night incontinence.
Side effects include dry mouth, blurry vision and constipation and drowsiness – for this reason it is recommended to take at night usually at bedtime. Serious side effects from imipramine are rare, but it has been reported that it can cause heart problems, such as an irregular heartbeat. Imipramine can also cause dizziness or fainting from reduced blood pressure when you stand up quickly. Lastly, this class of medication usually interacts with many different medications, so make sure your doctor knows which medications you're taking before you begin taking imipramine.
Desmopressin: Desmopressin is a man-made, synthetic version of a natural body hormone called anti-diuretic hormone (ADH, which decreases the production of urine. The purpose of this hormone is to decrease the amount of urine produced, and it usually follows a day/night pattern (circadian rhythm), and it is higher during the night. Understandably so, when it is higher in the system, a person will not need to wake up to go to the bathroom. In some children who have nighttime bed-wetting, it has been shown that they have decreased production of ADH at night. Research suggests that desmopressin may also reduce urinary incontinence in adult women.
The side effects of desmopressin are uncommon when prescribed correctly. If the dose is too high, there is a risk of water retention. This will dilute the blood, and cause imbalances in the chemicals of the blood and cause a low sodium level (hyponatremia). In rare cases, too much desmopressin can cause seizures, brain swelling and death. Be sure your doctor knows your full medical history and is aware of all the medications you are taking before you begin using this medication.
Botulinum toxin type A (Botox): Injections of Botox block the actions of acetylcholine a chemical that usually makes the muscles contract. Therefore, blocking this agent causes muscle paralysis. When injected into the bladder, it decreases the actions of the bladder muscle, therefore it is used in people who have an overactive bladder. Studies have found that Botox significantly improves symptoms of incontinence and causes few side effects. Usually the injections need to be repeated every 6 to 9 months. It is commonly used in people who have tried all other options without resolution. The Food and Drug Administration (FDA) has not yet approved this drug for incontinence, so it may not be covered by some insurance.
Side effects are not common, yet in some studies increase in urinary tract infections have been reported.
Surgery: There are surgical options to treat urinary incontinence. These include:
Retro pubic Suspension: This surgical option treats hypermobility and is often referred to as the Burch procedure. The purpose is to elevate and restore the urethra and bladder neck to a higher anatomical position.
Slings: The sling serves as support for the urethra during increased abdominal pressure. Bone-fixated slings treat incontinence by supporting the urethra with a graft material that is secured to the pubic bone. Self-fixating slings treat incontinence by supporting the urethra. The sling is secured in place by friction and natural tissue ingrowth, rather than by sutures or screws.
In conclusion, urinary incontinence can be quite challenging for a woman. Know the facts, trust yourself and your relationship with your doctor and have a conversation about this. Things can be done – you are not alone.
In our next blog, I will discuss the PELVIC FLOOR AND PELVIC PROLAPSE: WHAT IS IS AND HOW TO PREVENT IT
Hope you enjoyed learning about this common problem and can start the discussion with your doctor about what you can do and prevent complications from this issue.
Dr. Margarita Ochoa-Maya, MD