Treatment options for urinary incontinence

By Ivy M. Alexander, MS, C-ANP

Adult Nurse Practitioner, Assistant Professor

Yale University School of Nursing

Adult and Family Nurse Practitioner Programs

New Haven, CT

Urinary incontinence (UI) affects 25% to 34% of women living at home. Despite recent research supporting the effectiveness of exercise regimens in treating UI,1 some women require medication, assistive devices, or surgical interventions. Take a look at the following interventions, which often are useful in conjunction with behavioral interventions to treat stress, urge, or mixed incontinence. (For a review of UI types and discussion of behavioral interventions, see Contraceptive Technology Update, March 2000, Mid-Years Women’s Health column, p. 36.)

Although absorbent products can ease embarrassment, they should not be perceived as a UI solution. Several assistive devices for stress or urge incontinence are available, with most working by obstructing the urethral opening or by supporting the urethra and bladder through the vaginal wall. Intravaginal supportive devices include pessaries (silicone or plastic rings) and tampons. External disposable devices obstruct the urethral opening to prevent urine loss and must be removed prior to urinating. The FemAssist personal urinary control device (Insight Medical Corp., Bolton, MA) and the CapSure continence shield (Bard Urological Division, Covington, GA) are held in place by suction, while the Impress softpatch (UroMed, Needham, MA) has an adhesive surface.2,3

Specially manufactured "plugs" are inserted directly into the urethra and seal in urine to prevent leakage. The FemSoft self-inserted device (Rochester Medical, Stewartville, MN) recently received federal regulatory approval for use in stress or mixed incontinence. The device is cylindrical with a bulb-shaped area near the end and a tab at the tip, which remains outside the urethral meatus. When the woman needs to urinate, she pulls on the tab to remove the insert.3,4

Examine medications

Medications for stress or urge incontinence can be an important second-line treatment for women who do not achieve adequate control using behavioral methods alone. They reduce uninhibited bladder contractions to increase storage capacity, while maintaining voluntary contraction for emptying. Success is significantly improved when medications are used in addition to behavioral interventions.

Oxybutynin (Ditropan, Ditropan XL from Alza Pharmaceuticals, Palo Alto, CA) is an anticholinergic and smooth muscle relaxant available in both short-acting and controlled-release formulations. The short-acting formula dose is 2.5 mg to 5 mg BID or TID. The controlled release dose is 5 mg to 30 mg daily. The XL formula is equally effective and has been associated with fewer side effects.

Begin with a low dose and titrate up until symptoms are well-controlled without undue side effects. Side effects reflect the anticholinergic properties and include dry mouth, tachycardia, constipation, transient blurred vision, and urinary retention. Anticholinergics are contraindicated in patients with narrow angle glaucoma, most cardiac arrythmias, intestinal obstruction, obstructive uropathy, and myasthenia gravis.5,6,7

Tolterodine (Detrol, Pharmacia & Upjohn, Bridgewater, NJ) is a muscarinic antagonist. Start patients at 2 mg BID and reduce to 1 mg when adequate control is achieved. Patients with hepatic impairment or concomitant use of CYP3A4 inhibitors should use only 1 mg BID. The contraindications and side effects are similar to those with oxybutynin.5,6,7

Women with stress or urge incontinence symptoms associated with vaginal or urethral atrophy may benefit from oral or intravaginal estrogen replacement therapy. It may be given alone or in combination with other incontinence medications.6

Desmopressin (DDAVP, Rhone-Poulenc Rorer Pharmaceuticals, Collegeville, PA) is a synthetic vasopressin. It is used primarily for nocturnal enuresis and is given orally or intranasally. Doses are titrated from 0.1-0.6 mg PO or 10 mcg to 40 mcg intranasally at bedtime.5,7 Other less-often used medications include alpha-adrenergic agents and tricyclic antidepressants.6,7

New therapies under investigation include:

• duloxetin, a centrally acting serotonin and norepinephrine reuptake inhibitor for use in stress and urge incontinence;

• capsaicin, used in a intravesical instillation to impair the fibers that cause reflex voiding, thus reducing leakage;

• resiniferatoxin, a more selective and less irritating analog of capsaicin.5

Surgery is available

Although generally used as a last resort, several surgical procedures are available. Collagen injection into the sphincter can provide symptom relief, but relapse is common; the cure rate is 30% to 40%. Procedures designed to support the bladder neck and anterior vaginal wall have success rates of 80% to 90%.

Bladder augmentation, which increases the bladder capacity by inserting a piece of intestine, also is successful but requires a five-hour procedure and a lengthy recovery. A relatively new procedure, sacral nerve stimulation, treats urge incontinence through biofeedback using a pulse generator connected to an electrode implanted in the S3 nerve.3,5

The most important message for patients is: Don’t give up! Ask your patients about incontinence and encourage them to try behavioral options first. If reducing irritants (such as artificial sweeteners, caffeine, spicy or acidic food, and alcohol), bladder retraining, urge suppression, and pelvic muscle exercises are not successful, then women need to know that other effective options do exist. Careful counseling and frequent reinforcement and assessment are necessary for regaining bladder control.

References

1. Sampselle CM, Wyman JF, Thomas KK, et al. Continence for women: A test of AWHONN’s evidence based protocol in clinical practice. JOGNN 2000; 29:18-26.

2. Elia G. Stress urinary incontinence in women: Removing the barriers to exercise. Phys Sports Med 1999; 27:39-52.

3. Tyler A. Bladder control: There’s no need to suffer in silence. Female Patient 1999; suppl:27-31.

4. New Products Listing. Contemp Nurse Prac 2000; 4:25 and Web: www.rocom.com.

5. Chancellor MB. Urinary incontinence: New treatment options. Consultant 1999; May (suppl):S15-S19.

6. Butler RN, Maby JI, Montella JM, et al. Urinary incontinence: Primary care therapies for the older woman. Geriatrics 1999; 54:31-44.

7. Murphy JL (ed). Nurse Practitioners’ Prescribing Reference. New York City: Spring 2000.