Treatment Options
Adapted and reproduced with permission from The Foundation for Medical Practice Education, www.fmpe.org
General considerations
Although referall to specialists is required for UI patients with complex histories, family doctors can often develop an effective managment strategy based on history, physical examination, basic laboratory investigations, and possibly a PVR test.
A multifactorial, stepped approach designed to relieve the most bothersome aspects of UI is the cornerstone of successful therapy. It is appropriate to initiate lifestyle strategies and physical therapy even before definitive determination of the type of UI.
Patients with large (second or third degree) cystoceles or rectoceles will likely require either surgical repair or a pesssary, although pelvic floor exercises and pharmacotherapy have successfully helped some of these patients.
Lifestyle changes
Intake of adequate fluid (1.5 to 2 liters a day) may improve symptoms of UI [Level III Evidence], while reduction or elimination of caffeine intake may improve lower urinary tract symptoms [Level I Evidence].
Moderate physical activity may prevent or reduce lower urinary symptoms [Level III Evidence], and obese women can significantly improve urine retention by losing just 5% of their body weight.
Coughing associated with cigarette smoking can trigger or exacerbate the urge to urinate; for this and other health reasons, smokers with UI should be encouraged to quit.
Patients taking drugs known to affect bladder function may benefit from reducing their dose or switching to another drug.
Pelvic muscle exercises
Pelvic muscle exercises (PME) also called Kegel or pelvic floor muscle training exercises, offer a suitable conservative first-line treatment for patients with stress or mixed UI [Level I Evidence].
A 2006 Cochrane Database Systematic Review suggests that PMEs are most effective in patients who participate in a supervised PME program for at least 3 months.
PME involves strengthening pelvic floor muscles.
- Digital assessment of pelvic floor muscle function is advised prior to initiation of PME, to ensure that the patient is contracting the correct muscle. It can be done visually during the examination by asking the woman to contract the muscles in her vagina and observing the response.
- Some studies suggest that patients can perform these exercises adequately with verbal instructions, while other experts (including Kegel himself) argue that correct PME requires digital confirmation.
PME has a poor long-term adherence rate, so instructions should be kept simple and daily requirements realistic.
Biofeedback can help women perform these exercises properly [Level II-3 evidence]. Women experiencing difficulty should be referred to a physiotherapist.
See Kegel Exercises booklet.
Bladder retraining
Bladder retraining is recommended for management of urge and mixed UI [Level I Evidence]. This strategy, which involves gradually increasing the interval between voids until the patient is able to void every 3-4 hours while awake, usually takes several weeks to yield results.
Pharmacotherapy
A number of drugs are used to treat UI, though not all have consistent evidence to support their use (see table below). It may be appropriate to initiate drug therapy if lifestyle measures and physical therapy have not yielded satisfactory results.
Anticholinergics agents are the first-line drugs for patients with urge UI; oral oxybutynin is usually considered first line therapy [Level I Evidence]. Tolterodine, Solifecanin and Trospium Chloride are alternative agents if dry mouth limits the use of oxybutynin.
Evidence for the use of estrogen to treat stress UI in postmenopausal women is conflicting and increasingly weak, with recent data suggesting a lack of objective benefit.
Surgery
Surgery, which involves improving the urethral/bladder support mechanisms or changing the angle at which the urethra and bladder meet, is a treatment option for stress UI and can be considered as a first-line treatment in select situations when compliance with nonsurgical treatments is poor. Types of surgery include open retropubic (bladder neck) colposuspension, laparoscopic colposuspension, and suburethral sling procedures (TVTs). While short-term success rates of surgery can approach 90%, data on long-term effectiveness (>5-10 years) are limited. Surgery may also be needed to remove obstructions that cause or exacerbate UI.
Assistive devices
Pessaries are recommended for women who have symptomatic organ prolapse [Level III Evidence]. For women with atrophic changes, local estrogen therapy prior to pessary insertion may help prevent vaginal infection and ulceration.
For selected patients who are not helped by other measures, specialists may recommend occlusive devices that block the leakage of urine mechanically – intravaginal prongs, urethral barriers (foam patches or suction barriers).
Continence products such as absorbent pads may be useful as an adjunct to other therapy or for long-term care of patients with chronic, intractable UI [Level III Evidence]
See Levels of Evidence.
The bottom line
- Because of the stigma associated with UI, physicians need to take a proactive approach in discussing and identifying the problem.
- A multifaceted approach involving lifestyle modifications, pelvic muscle exercises, bladder retraining, and (in some cases) medication or surgery the cornerstone of successful UI treatment.
