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Urinary incontinence (incontinence) — the inability to control the passage of urine — is a widespread problem that affects an estimated 25 million American adults.[1] It is more common in women than in men and occurs more often in the elderly, especially those who are homebound or living in nursing homes.
Incontinence can be due to transient factors, such as use of certain medications,[2] urinary tract infection, bladder obstruction, constipation and pregnancy.[3] It also may be caused by...
Urinary incontinence (incontinence) — the inability to control the passage of urine — is a widespread problem that affects an estimated 25 million American adults.[1] It is more common in women than in men and occurs more often in the elderly, especially those who are homebound or living in nursing homes.
Incontinence can be due to transient factors, such as use of certain medications,[2] urinary tract infection, bladder obstruction, constipation and pregnancy.[3] It also may be caused by other factors, such as multiple vaginal deliveries in women and prostate enlargement in men, or by more serious conditions, including cancer, diabetes, obesity and stroke.
Incontinence has considerable quality-of-life implications.[4] Many people with incontinence suffer in silence and do not seek medical help due to the societal stigma attached to this problem. Fortunately, inconsistence can be cured or significantly improved with the appropriate treatment.
Types of incontinence
There are three main types of incontinence for which surgery is not the first or only treatment option.[5] The most common of these is urge incontinence, which occurs when a person has a sudden, uncontrollable urge to void and has difficulty making it to the bathroom before having an accident. (Overactive bladder is a type of urge incontinence.)
The second type is stress incontinence, in which leakage of a small amount of urine occurs when coughing, sneezing or lifting something heavy. The third type is mixed incontinence, which involves urge and stress incontinence occurring together.
Treatment overview
Incontinence treatment starts with addressing any easily reversible causes or contributing factors of the condition. For example, if a medication is suspected to be responsible for the incontinence symptoms, use of the medication should be stopped or modified whenever possible. Likewise, if the symptoms are due to a urinary tract infection, an antibiotic should be taken.
Subsequent treatment is guided by the type of incontinence. Generally, treatment should begin with lifestyle changes and behavioral therapies, followed by medications. Finally, surgery can be tried if necessary.[6]
Lifestyle changes
Lifestyle changes to treat incontinence include avoiding caffeinated and carbonated drinks, cigarettes, and alcohol because these substances may irritate the bladder, cause overactive bladder or increase urine volume, all of which can contribute to incontinence.[7] Other changes include not consuming excessive amounts of fluid, avoiding constipation, exercising and, in the case of obese individuals, losing weight. Although not enough research is available about the effectiveness of these common-sense modifications, they generally are safe, are relatively low in cost and have no or few side effects.
Behavioral therapies
Behavioral treatment entails learning how to gain better control over the muscles involved in urination. Training to strengthen the pelvic floor muscles, known as Kegel exercises (see text box, page 5), is the first line of treatment for stress incontinence.[8] Patients should try to do these exercises every day for at least 15 to 20 weeks.[9] Evidence shows that Kegel exercises are more than five times as effective as no treatment in improving incontinence.[10]
Bladder training, which involves learning to extend the time between voids by training the bladder muscles to stretch more so the bladder will hold more urine (see text box, page 5), is effective in the treatment of urge incontinence.[11] Successful bladder training can take up to six weeks.[12]
Kegel exercises combined with bladder training are effective for treating mixed incontinence.[13]
How to Do Kegel Exercises[14]
How to Do Bladder Training[15],[16]
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Drug treatment
After lifestyle changes and behavioral therapy, medications are the second-choice treatment for incontinence. They are effective for urge incontinence but not effective for stress incontinence.[17] One study suggested that combining medications with behavioral therapies was more effective than either treatment option alone.[18] Therefore, patients should continue lifestyle changes and behavioral therapies even if they start taking medications for incontinence.
Anticholinergics — such as darifenacin (ENABLEX), fesoterodine (TOVIAZ), oxybutynin (DITROPAN XL, GELNIQUE, OXYTROL, OXYTROL FOR WOMEN) and tolterodine (DETROL)[19] — are the mainstay medications for urge incontinence.[20],[21] They relax the bladder so it can hold more urine, which decreases the number of daily voids. However, Public Citizen’s Health Research Group classifies these drugs as “Limited Use” because they have serious side effects including increased heart rate, high blood pressure and cognitive impairments (such as confusion, memory problems, dizziness and hallucinations), which are especially problematic in people with dementia and in the elderly. Anticholinergics also cause frequent bothersome side effects such as dry mouth, blurred vision, decreased sweating and constipation. They should be avoided in patients with urinary obstruction and in those with narrow-angle glaucoma.[22] We recommend against using the over-the-counter transdermal patch OXYTROL FOR WOMEN for overactive bladder without medical supervision to make sure this medication is not taken unnecessarily.[23]
In 2012, the Food and Drug Administration (FDA) approved mirabegron (MYRBETRIQ), a beta-3 adrenergic agonist, for treating overactive bladder with urge incontinence; we opposed this decision because the drug has only a marginal benefit and is associated with serious side effects, including increased blood pressure, allergic reactions, urinary infections and liver toxicity.[24]
We also recommend against using vaginal estrogen products, such as conjugated estrogens cream (PREMARIN VAGINAL), duloxetine (CYMBALTA) and antidepressants to treat incontinence because these are off-label uses (have not been approved as safe and effective by the FDA).
OnabotulinumtoxinA (BOTOX)
The FDA approved onabotulinumtoxinA in 2013 to treat overactive bladder with urge incontinence in adults who cannot use or do not respond adequately to anticholinergics.[25] We recommend against such use because the drug’s modest short-term benefit is outweighed by the risk of possible spread of toxins from the site of injection (bladder muscles) to other parts of the body, which can cause foods and drinks to be aspirated into the respiratory tract and lungs, leading to life-threatening complications such as pneumonia.[26] A frequent side effect of onabotulinumtoxinA is retention of large amounts of urine in the bladder that remain after voiding to an extent that requires repeated insertion of a catheter to empty the bladder.[27] Additionally, clinical trials show that onabotulinumtoxinA treatment markedly increased the risk of urinary tract infections.
What You Can Do
If you suffer from incontinence do not be embarrassed to seek treatment. Start with lifestyle changes and behavioral therapies. If your symptoms do not improve, talk to your primary care provider about adding an anticholinergic drug to your treatment. Do not use mirabegron, onabotulinumtoxinA, or any products that have not been approved to treat incontinence. You should avoid surgery until after you have tried the treatments described in this article.
References
[1]National Association for Continence. NAFC Home. http://staging.nafc.org/media/media-kit/facts-statistics. Accessed March 13, 2017.
[2]Drugs that cause loss of bladder control. Worst Pills, Best Pills News. February 2016. /newsletters/view/1015. Accessed March 13, 2017.
[3]JAMA patient page: Incontinence. JAMA. 1998;280(23):2054.
[4]Bardsley A. An overview of urinary incontinence. Br J Nurs. 2016;25(18):S14-S21.
[5]Ibid.
[6]Qaseem A, Dallas P, Forciea MA, et al. Nonsurgical management of urinary incontinence in women: A clinical practice guideline from the American College of Physicians. Ann Intern Med. 2014;161(6):429-440.
[7]Imamura M, Williams K, Wells M, Mcgrother C. Lifestyle interventions for the treatment of urinary incontinence in adults. Cochrane Database Syst Rev. 2015;12:CD003505.
[8]Qaseem A, Dallas P, Forciea MA, et al. Nonsurgical management of urinary incontinence in women: A clinical practice guideline from the American College of Physicians. Ann Intern Med. 2014;161(6):429-440.
[9]Lukacz ES. Treatment of urinary incontinence in women. UpToDate. January 6, 2017.
[10]Qaseem A, Dallas P, Forciea MA, et al. Nonsurgical management of urinary incontinence in women: A clinical practice guideline from the American College of Physicians. Ann Intern Med. 2014;161(6):429-440.
[11]Ibid.
[12]Lukacz ES. Treatment of urinary incontinence in women. UpToDate. January 6, 2017.
[13]Qaseem A, Dallas P, Forciea MA, et al. Nonsurgical management of urinary incontinence in women: A clinical practice guideline from the American College of Physicians. Ann Intern Med. 2014;161(6):429-440.
[14]National Institute of Diabetes and Digestive and Kidney Diseases. Kegel exercises. April 2014. https://www.niddk.nih.gov/health-information/urologic-diseases/bladder-control-problems-women/kegel-exercises. Accessed March 13, 2017.
[15]PubMed Health. Bladder training. December 30, 2016. https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0072614. Accessed March 13, 2017.
[16]National Institute of Diabetes and Digestive and Kidney Diseases. Treatment for interstitial cystitis. January 2017. https://www.niddk.nih.gov/health-information/urologic-diseases/interstitial-cystitis-painful-bladder-syndrome/treatment. Accessed March 13, 2017.
[17]Qaseem A, Dallas P, Forciea MA, et al. Nonsurgical management of urinary incontinence in women: A clinical practice guideline from the American College of Physicians. Ann Intern Med. 2014;161(6):429-440.
[18]Burgio K, Locher J, Goode P. Combined behavioral and drug therapy for urge incontinence in older women. J Am Geriatr Soc. 2000;48(4):370-374.
[19]Qaseem A, Dallas P, Forciea MA, et al. Nonsurgical management of urinary incontinence in women: A clinical practice guideline from the American College of Physicians. Ann Intern Med. 2014;161(6):429-440.
[20]Clemens JQ. Urinary incontinence in men. UpToDate. May 19,2016.
[21]Lukacz ES. Treatment of urinary incontinence in women. UpToDate. January 6, 2017.
[22]A Review of drugs for overactive bladder. Worst Pills, Best Pills News. February 2010. /newsletters/view/679. Accessed March 13, 2017.
[23]Do not use over-the-counter oxybutynin without first checking with your doctor. Worst Pills, Best Pills News. August 2013. /newsletters/view/863. Accessed March 13, 2017.
[24]Troubling new drug approvals of 2012. Worst Pills, Best Pills News. March 2013. /newsletters/view/839. Accessed March 13, 2017.
[25]Food and Drug Administration. FDA news release: FDA approves botox to treat overactive bladder. https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm336101.htm. Accessed March 13, 2017.
[26]Public Citizen’s Health Research Group. Petition requesting regulatory action concerning the spread of botulinum toxin (BOTOX, MYOBLOC) to other parts of the body. January 23, 2008. http://citizen.org/Page.aspx?pid=527. Accessed March 13, 2017.
[27]Allergan, Inc. Label: onabotulinumtoxin A (BOTOX). January 2016. https://dailymed.nlm.nih.gov/dailymed/getFile.cfm?setid=33d066a9-34ff-4a1a-b38b-d10983df3300&type=pdf&name=33d066a9-34ff-4a1a-b38b-d10983df3300. Accessed March 13, 2017.
