Urinary incontinence is more common in women than men, affecting 10-25% of women under age 65 and 15-30% of women older than 60. Less than one half of patients seek medical care, often attributing it to a normal part of aging. There are three types of incontinence, urge, stress and overflow. All have very different etiologies and therefore treatments.
Urge incontinence or "overactive bladder" (OAB) is the most common cause of incontinence. It is characterized by urinary urgency, with or without urge incontinence, usually with frequency and nocturia, that significantly affects the lives of millions of patients. Although OAB can affect anyone at any age it tends to increase in prevalence with age.
Symptoms of OAB are thought to arise from involuntary contractions of the bladder during filling. Conservative treatments include avoidance of dietary irritants (caffeine and carbonation are classics), treatment of constipation, timed voiding, and fluid schedules. Failing these, medications may be the next option.
The classic medications used for OAB are the anticholinergics. By targeting muscarinic receptors with antagonists, the result is hopefully less forceful and inappropriate bladder contractions thereby improving bladder filling and resulting in reduced urge incontinence. Because of the widespread presence of muscarinic receptors in the body (eg. brain, GI tract, salivary glands eye and heart), antimuscarinic agents can result in unwanted side effects such as dry mouth and eyes, constipation, tachycardia and cognitive impairment. Ditropan and Detrol either TID or BID dosing vs extended release or long acting (XL/LA) versions were the first options. In my experience Ditropan remains the strongest and often times most effective at treating OAB, particularly in those patients with a true neurologic cause of their detrussor instability (eg. spinal cord injury, multiple sclerosis, stroke). However, as the dose increases from 5 to 30mg (in the XL version), so do the side effects, often to an intolerable level. Detrol (2-4mg) seems to be slightly more tolerable and has proven effectiveness as well. The newer medications available claim less adverse side effects and similar efficacy - Sanctuara (10-20mg BID), Vesicare (5-10mg QD) and Enablex (7.5-15mg QD). I have been using the latter with varied success. Both seem reasonably effective and tolerable; Enablex claims it is less likely to cause cognitive effects in the elderly as well as to have less impact on the QRS complex. So far my experiences have been favorable with both of these statements. Keeping in mind cost, plain Ditropan at 5mg TID dosing is markedly less expensive than any of the once daily dosing ie $10/per month vs. $125/month, respectively. Insurance coverage varies. Often patients have been tried on several different anticholinergic medications without success (ie daily medication at therapeutic dose for six weeks). Those patients with urodynamically documented detrussor instability may be candidates for InterStim therapy. A "pacemaker" for the bladder, InterStim is a surgically implanted device with electrodes and a battery pack that sends interrupting impulses to the S3 nerve root resulting in less detrussor hyperactivity. A relatively minor two stage procedure it can have major impact in patients with either urgency, frequency and incontinence and even some with idiopathic urinary retention.
Stress incontinence occurs when the pressure inside the bladder overcomes the ability of the urethra to contain that pressure. This occurs by either urethral hyper mobility or intrinsic sphincter deficiency. This problem can be repaired by a variety of means, from conservative treatments such as Kegel muscle exercises, and other behavioral modifications to surgical options such as periurethral bulking agents (collagen or Durasphere) or a "sling procedure." The Kegel exercises may help a woman's incontinence substantially but will not likely alleviated it entirely. Periurethral bulking agents are performed cystoscopically under sedation but are short lived with maximal benefits lasting 6-12 months; repeated injections can be performed at this interval. Pubovaginal slings remain the most effective treatment with the best long term results. The sling placed at the bladder neck or at the midpoint of the urethra. Either of these two can be accomplished with a variety of materials, including the patient's own fascia, sterilized human cadaver material, porcine material or synthetic materials. The newest way to treat SUI is a synthetic "mid urethral" sling with various types available (Monarc, ObTape, Lynx). It is an outpatient procedure under a brief general or spinal anesthetic, with usually no catheter required at dismissal and minimal morbidity to patients. Within four weeks, patients are back to normal activities.
Overflow incontinence occurs when the bladder does not empty during voiding resulting in steady, small amounts of urine leakage. It is less common than the two other types of incontinence and tends to be found in patients with neurologic disorders such as MS, diabetes, chronic constipation and can be related to some commonly used medications such as antidepressants. Treatments include aggressive management of constipation with fiber laxatives, removing an offending medication, or some form of bladder drainage such as clean intermittent catheterization or prolonged urethral catheterization such or a suprapubic tube.
Many treatment options exist for all types of incontinence; identifying those in need remains the challenge as many women do not seek medical care and/or admit the problem to their physicians. Women should no longer feel that they have to change their lifestyles, memorize bathroom locations, and avoid activities they love because of leakage.