Treatment Options

Behavioral Treatments
One of the easiest places to start with treatment for incontinence is to change some of the ways you live your life. This includes:
• Minimizing liquids or foods that cause frequent urination. These are sometimes called “bladder irritants.” They include alcoholic beverages; caffeine such as in coffee, tea, or soda; and citrus foods or drinks. Limiting your water intake to daytime use also helps decrease nocturia.
• Eliminating behaviors that cause excessive coughing (like smoking) because the more you cough, the more your abdominal pressure increases making the pelvic floor muscles work overtime. If these muscles are weak, they cannot overcome the increase in abdominal pressure and the urine will leak out.
• Training your bladder to do more. For example when the urge to urinate comes along, waiting even a few minutes will retrain the bladder to calm down. This is called bladder training.

Medications
There are many medications that can actually cause the bladder or muscles to react differently leading to incontinence. Some of these medicines may be ones that your doctor can eliminate, decrease, or change. Here are some medications that may be contributing to the problem that are worth talking to your doctor about:
• Diuretics
• Muscle relaxants
• Opioids for pain
• Anti-histamines
• Anti-hypertensives
• Over-the-counter cold medications

There are also lots of medications used to treat incontinence. You see them advertised in newspapers and on TV commercials. They are used for urge incontinence (urgency and frequency symptoms) primarily and do not treat all kinds of incontinence. The main ones used work by acting against acetycholine receptors in the bladder lining that cause contraction of the detrusor muscle. By blocking these receptors, the bladder will not contract or spasm as much. Referred to as anti-cholinergics, they have side effects that sometimes, especially in older individuals, may be worse than the incontinence itself. Side effects like dry mouth, constipation, drowsiness, and blurred vision are common. However some of the newer long acting anti-cholinergic medications are better tolerated. The opposite extreme, urinary retention can also sometimes occur with these drugs, and can lead to infection. Some of these medicines include darifenacin (Enablex), flavoxate (Urispas), oxybutinin (Ditropan XL, Oxytrol), solifenacin (VESIcare), tolterodine tartrate (Detrol LA), trospium (Sanctura). These medications are contradindicated in those patients with narrow-angle glaucoma, myasthenia gravis, and severe ulcerative colitis.

The other type of medication used in women for stress incontinence is known as alpha–adrenergic agonists. They include pseudoephedrine (Sudafed and Trinalin) and are thought to stimulate urethral muscle contraction. Unfortunately, they do not work very well and have side effects like rapid heart rate and drowsiness. Some antidepressants with anticholinergic and alpha-adrenergic agonist properties can be used for both urge and stress incontinence including imipramine and amitriptyline. Another antidepressant called duloxetine (Cymbalta) is being used for its effects on neurotransmitters to tighten the urethral sphincter.  Anti-diuretic hormone (vasopressin) can be used at night to help with nocturia and occasionally cholinergics such as bethanecol can be used to enhance bladder contraction in the setting of overflow incontinence.

Estrogen treatments including vaginal creams and suppositories can be used for incontinence for women in estrogen deficient stares. It is believed they may help tighten the urethral sphincter muscle and enhance pelvic floor capability but there is still not definitive data to support this. With a history of breast cancer, the benefit of hormonal treatments must be weighed against the risks

Treatment of the Primary Problem
If incontinence occurs suddenly or when another diagnosis such as a nervous system problem is made, then focusing the treatment on the main diagnosis may treat the incontinence all together. For example, a urinary tract infection must always be ruled out because it can cause urinary frequency and urgency too. This is done by having your doctor send off a sample of your urine to check for infection. Another example is when the nerves to the bladder are disrupted by an injury to the spinal cord. In this case the bladder over-contracts because the link to the brain has been disrupted. In patients with a spinal cord injury, medications to relax the bladder can be quite effective.

Rehabilitation
Rehabilitation for incontinence means using exercise to regain urinary control. Many people have heard of Kegel exercises. In the 1940s, Dr. Arnold Kegel was one of the first physicians to identify that the muscles of the pelvic floor are key players in controlling urine flow and described how exercising these muscles can aid in incontinence. Physical therapy can be a first line treatment for urinary incontinence. Exercise done properly and consistently can cure the problem. There is no real downside to trying the exercises. They have no bad side effect or risk, unlike medications or surgical procedures. But it is true that if you don’t use it you lose it; therefore the exercises are done for life. The good thing is you do not need a gym or a lot of time to do it. Research has shown that doing these exercises even while doing other things works. For example, “red light Kegels” or doing pelvic floor exercises while in the driver’s seat when stopped at a red light can be effective. In fact, these exercises can be done any time: sitting, standing, during sex, or even while exercising other parts of your body. This works very well for most women who are experts in multitasking!

The trouble is that many women who are told “do your Kegels” have no idea how to do it. They are often doing it incorrectly. These are muscles that we normally do not think to “work out” because we cannot see them and we naturally rely on them to contract without thinking about it. Just as they can be assessed vaginally by a trained physician, they can be treated vaginally by a competent specially-trained physical therapist. You can find someone in your area like this by visiting the American Physical Therapy Association, Section on Women’s Health website.

It is also important to find out how well your physician knows this individual, how many patients they have treated with incontinence, and what types of courses and training they have received in pelvic floor physical therapy. A good physical therapist will also evaluate the patient for external musculoskeletal problems in addition to pelvic floor dysfunction. They use a variety of methods to teach the patient how to strengthen and coordinate the pelvic floor muscles. Education on posture and proper body mechanics and other core muscle exercises will be taught.

How does physical therapy (PT) work?
In physical therapy, patients learn about the bladder, the pelvic floor muscles, and normal emptying techniques. They are taught bladder retraining and timed schedules for urinating. Through internal or vaginal PT, exercises are taught to strengthen the pelvic floor. Techniques such as biofeedback or electrical stimulation are utilized to maximize a patient’s function. With biofeedback the physical therapist places an electrode over the pelvic floor muscles and reads the activity in the muscle group. This can be accomplished with external sensors or with a vaginal probe inserted like a tampon. A wire connects the recording to a monitor where a patient can then visualize herself contracting and relaxing the muscles appropriately. Real-time ultrasound is also being used similarly. Ultrasound is effective because the patient can see the pelvic floor muscles and the bladder itself on the screen.

Electrical stimulation is another modality used to aid the muscles in contraction and may also help the bladder to be less irritable. It is not a painful stimulation but a gentle one that provides greater body awareness for the patient. In stress urinary incontinence, electrical stimulation will provide an impulse to the Kegel muscles facilitating a contraction. In urge incontinence, the electrical stimulation is thought to reset the nerves of the bladder. Home units for both biofeedback and electrical stimulation can be prescribed for patients and Medicare now covers it when exercises alone are not helpful.

Why is PT effective?
It is effective because the focus is hands on treatment of a condition most commonly caused by muscle weakness and it addresses the pelvic floor muscles which are prone to be forgotten in exercise training in general.

How often should women do exercises? For how long? (A few months? Indefinitely?)
Women should think of these exercises as a lifelong endeavor but not something that is overwhelming. They can be performed in multiple positions, lying down, sitting, or standing. They can even be done with others around without them realizing that one is “exercising.” It is recommended that patients contract for at least 3 seconds and relax the muscles for the same period of time in sets of 10-15 several times per day, ideally at least 3 times in different body positions reflecting how these muscles need to function in the real world. Patients are instructed to think of these exercises as a daily activity similar to brushing their teeth.

Which incontinence patients are the best candidates for physical therapy?
Physical therapy has been found to be effective in all types of incontinence, stress, urge, mixed, and in fecal incontinence as well.

Which patients are not good candidates?
Patients who have had complete nerve injury to the muscles such as in the case of spinal cord injury may not be good candidates, however, physical therapy can sometimes even help those with incomplete neural injury.

Any other information you wish people knew about incontinence and its various treatments?
Often patients experience both pelvic pain as well as incontinence. Sometimes it may just be pain with intercourse. It is important to understand that physical therapy can also be effective in the treatment of pelvic pain. Most often these patients have problems primarily with relaxation of the pelvic floor muscles. Because these muscles are “tight” they may also be weak. Relaxation exercise treatments are utilized first in these patients prior to strengthening. So telling pain patients to do Kegels first is not appropriate.

Also, research now is revealing that the pelvic floor is the floor of the core. This is because these muscle work hand in hand with the deep abdominal muscles that have been found extremely important in the stability of the low back and the pelvis. S if you have low back pain and urinary incontinence, pelvic floor retraining can help both.

A prescription for physical therapy must be written for you by your doctor. The length and frequency of physical therapy varies depending on the patient and the provider. Typically a 12 session course of physical therapy on average will be sufficient, often 1-2 treatments per week for 6-12 weeks. This treatment is covered by most insurance companies. Almost all specially-trained physical therapists in female urinary incontinence are women.

Pessary
A pessary is a device shaped like a small sponge or doughnut that can be placed by your doctor vaginally to hold in your prolapsed or sagging tissues. It works like a tampon and you cannot feel it but it is more convenient because it does not need to be taken out as frequently. This along with pelvic floor exercises can be very successful in treating incontinence. Sometimes the pessary can be used after childbirth in the setting of stress incontinence associated with activities such as running.

Surgical Options
A surgical referral to a gynecologist, urologist, or urogynecologist may be made if prolapse is found or non-surgical treatments have already been tried and failed. A good health care provider will present both non-surgical and surgical options and explain all the risks and potential benefits.

For stress incontinence: these surgeries focus mainly on suspending or attaching the sagging tissues to other more solid anatomic structures in the pelvis returning the tissue to a more normal anatomic state. One complication that can occur post operatively is urgency or urinary retention.
• Injection of collagen bulking agents to the urethral sphincter
• Sling and tape procedures
• Retropubic culposuspension (Burch, Marshall-Marchetti-Krantz (MMK), needle suspension)
• Repair of prolapsed uterus or vagina

For urge incontinence:
• Sacral neuro-modulation: placement of an internal electrical stimulation unit device at the level of the third sacral nerve to aid in the reflex inhibition of bladder contraction
• Injection of Botulinum toxin to relax the bladder muscle