genitourinary disorders
Urinary Incontinence in Adults
Treatment of Urinary Incontinence in Adults
Bladder training Kegel exercises Medications Specific causes are treated, and medications that can cause or worsen incontinence are stopped or the dosing schedule is altered (eg, a diuretic dose is timed so that a bathroom is near when the medication takes effect). Other treatment is based on type of incontinence. Regardless of type and cause, some general measures are usually helpful. Patients are instructed to limit fluid intake at certain times (eg, before going out, 3 to 4 hours before bedtime), to avoid fluids that irritate the bladder (eg,caffeine-containing fluids), and to drink 48 to 64 ounces (1500 to 2000 mL) of fluid a day (because concentrated urine irritates the bladder). Some patients, especially those with restricted mobility or cognitive impairment, benefit from a portable commode. Others use absorbent pads or specialized padded undergarments. These products can greatly improve the quality of life of patients and their caregivers. However, they should not be substituted for measures that can control or eliminate incontinence, and they must be changed often to avoid skin irritation and development of Introduction to Urinary Tract Infections (UTIs) (UTIs). Patients may benefit from bladder training (to change voiding habits) and changes in fluid intake. Bladder training usually involves timed voiding (every 2 to 3 hours) while awake. Over time, this interval can be increased to every 3 to 4 hours while awake. Prompted voiding is used for cognitively impaired patients; they are asked about every 2 hours whether they need to void or whether they are wet or dry. A voiding diary helps establish how often and when voiding is indicated and whether patients can sense a full bladder. Pelvic muscle exercises (eg, Kegel exercises) are often effective, especially for stress incontinence. Patients must contract the pelvic muscles (pubococcygeus and paravaginal) rather than the thigh, abdominal, or buttock muscles. The muscles are contracted for 10 seconds, then relaxed for 10 seconds 10 to 15 times 3 times a day. Re-instruction is often necessary, and biofeedback is often useful. In women<75 years, cure rate is 10 to 25%, and improvement occurs in an additional 40 to 50%, especially if patients are motivated; do the exercises as instructed; and receive written instructions, follow-up visits for encouragement, or both. Weak or dysfunctional pelvic floor muscles can often be strengthened through specialized physical therapy programs directed by practitioners who have expertise in this area. Pelvic floor electrical stimulation is an automated version of Kegel exercises; it uses electrical current to inhibit detrusor overactivity and contract pelvic muscles. Advantages are improved compliance and contraction of the correct pelvic muscles, but benefits over behavioral changes alone are unclear. Drugs are often useful (see table). Such drugs include anticholinergics and antimuscarinics, which relax the detrusor, and alpha-agonists, which increase sphincter tone. Drugs with strong anticholinergic effects should be used judiciously in older patients. Alpha-antagonists and 5-alpha-reductase inhibitors may be used to treat outlet obstruction in men with urge or overflow incontinence. Some of these drugs are used off label. Treatment aims to reduce detrusor overactivity; it begins with bladder training, Kegel exercises, and relaxation techniques ( Treatment references ). Bladder traininghelps patients tolerate and ultimately inhibit detrusor contractions. Regular voiding intervals are gradually lengthened (eg, 30 minutes every 3 days that urinary control is maintained) to improve tolerance of detrusor contractions.Relaxation techniquescan improve emotional and physical responses to the urge to void. Relaxing, standing in place or sitting down (rather than rushing to the toilet), and tightening pelvic floor muscles can help patients suppress the urge to void. Medications(see table) should supplement, not replace, behavioral changes. The most commonly used areoxybutyninandtolterodine; both are anticholinergic and antimuscarinic and are available in extended-release forms that can be taken orally once a day.Oxybutyninis available as a skin patch that is changed twice a week as well as topical gels that are applied to the skin daily. is administered via cystoscopic injection into the detrusor muscle and is useful in treating urge incontinence refractory to other treatments in patients with neurologic causes (eg, Multiple Sclerosis (MS) , Sacral nerve stimulationis indicated for patients with severe urge incontinence refractory to other treatments. It is thought to work by centrally inhibiting bladder sensory afferents. The procedure begins with percutaneous nerve stimulation of the S3 nerve roots for at least 3 days; if patients respond, a neurostimulator is permanently implanted under the buttock skin. Posterior tibial nerve stimulation(PTNS) is a similar technique of electrical neuromodulation for the treatment of voiding dysfunction that was developed as a less invasive alternative to traditional sacral nerve stimulation. A needle is inserted above the medial malleolus near the posterior tibial nerve followed by the application of low-voltage stimulation in 30-minute sessions given weekly for 10 to 12 weeks. The durability of PTNS is uncertain. Surgeryis a last resort, usually used only for younger patients with severe urge incontinence refractory to other treatments. Augmentation cystoplasty, in which a section of intestine is sewn into the bladder to increase bladder capacity, is most common. Intermittent self-catheterization may be required if augmentation cystoplasty results in weak bladder contractions or poor coordination of abdominal pressure (Valsalva maneuver) with sphincter relaxation. Detrusor myomectomy may be done to decrease undesired bladder contractions. As a last resort, a urinary diversion can be created to divert the urine away from the bladder. Choice of procedure is based on presence of other disorders, physical limitations, and patient preference. Treatment includes bladder training and Kegel exercises. Medications, surgery ( Treatment references ), other procedures, or, in women, occlusive devices are also usually needed. Treatment is generally directed at outlet incompetence but includes treatments for urge incontinence if detrusor overactivity is present. Avoiding physical stresses that provoke incontinence can help. Losing weight may help lessen incontinence in obese patients. Drugs(see table) includepseudoephedrine, which may be useful in women with outlet incompetence;imipramine, which may be used for mixed stress and urge incontinence or for either separately; andduloxetine. If stress incontinence is due to atrophic urethritis, topicalestrogen(estradiol) is often effective. provide the best chance of cure when noninvasive treatments are ineffective. Bladder neck suspension is used to correct urethral hypermobility. Suburethral slings, injection of periurethral bulking agents, or surgical insertion of an artificial sphincter is used to treat sphincter deficiency. Choice depends on the patient’s ability to tolerate surgery and need for other surgeries (eg, hysterectomy, cystocele repair) and on local experience ( Treatment references ). may be used in older women with or without bladder or Uterine and Apical Prolapse if surgical risks are high or if prior surgery for stress incontinence was ineffective. Various mesh slings can be used. Pessaries may be effective; they elevate the bladder neck, elevate the vesicourethral junction, and increase urethral resistance by pressing the urethra against the pubic symphysis. Newer, possibly more acceptable alternatives include silicone suction caps over the urethral meatus, intraurethral occlusive devices inserted with an applicator, and intravaginal bladder neck support prostheses. Removable intraurethral plugs are under study. Exercise regimens using vaginal cones—in which progressively heavier cones are inserted into the vagina and retained for 15 minutes twice a day by contracting pelvic floor muscles—are also under study. Treatment depends on whether the cause is outlet obstruction, detrusor underactivity, or both. Outlet obstruction due to Treatment or Detrusor underactivity requires bladder decompression (reduction of residual volume) by intermittent self-catheterization or, rarely, temporary use of an Bladder Catheterization . Several weeks of decompression may be required to restore bladder function. If bladder function is not fully restored, maneuvers to augment voiding are used. Examples include Double voiding (attempting to empty the bladder a second time before leaving the restroom) Valsalva maneuver Application of suprapubic pressure (Credé method) during voiding mandelate to prevent Introduction to Urinary Tract Infections (UTIs) (UTIs) in patients who require intermittent self-catheterization is controversial but probably indicated if patients have frequent symptomatic UTIs or a valvular or orthopedic prosthesis. Such prophylaxis is not helpful with indwelling catheters. Additional treatments that may induce bladder contraction and promote emptying include electrical stimulation and the cholinergic agonistbethanechol. However,bethanecholis usually ineffective and has adverse effects (see table). Absorbent pads, special undergarments, and intermittent Bladder Catheterization may be needed. Indwelling urethral catheters are an option for patients who cannot walk to the toilet or who have For men who can comply with treatment, condom catheters may be preferable because they reduce risk of Introduction to Urinary Tract Infections (UTIs) ; however, these catheters may cause skin breakdown and reduce motivation to become dry. New external collection devices that use low-pressure suction to "wick" urine away from patients into a canister may be effective for incontinent women. If involuntary bladder contractions persist, 