Clinical Guidelines for the Treatment of

Urinary Incontinence in Non-Pregnant Women

:Definition

Urinary incontinence (UI) is defined as the complaint of involuntary leakage of urine. It is often associated with other bothersome lower urinary tract symptoms such as urgency, increased daytime frequency, and nocturia.

Types: 1) Stress Urinary Incontinence (Urethral Underactivity) [SUI]. 2) Urge Urinary Incontinence (Bladder Overactivity). 3) Overflow Urinary Incontinence (Urethral Overactivity and/or Bladder Underactivity). 4) Mixed UI.

Prior to initiating therapy:

Identify indications for referral : Indications for further evaluation or referral prior to

initiating treatment for urinary incontinence include the presence of

Associated abdominal/pelvic pain or hematuria in the absence of urinary tract

infection, new neurologic symptoms, suspected vesicovaginal fistula or urethral

diverticulum, advanced pelvic organ prolapse, uncertainly in diagnosis, history of

pelvic reconstructive surgery or pelvic irradiation, or persistently elevated postvoid

residual (after treatment of possible causes).

Assess incontinence type and severity: Determining the classification of urinary

incontinence type (stress, urgency, mixed) can help direct treatment.

The Patient Global Impression of Improvement (PGII) and Patient Global Impression of

Severity (PGIS) (Table 1) are acceptable measures to assess improvement and satisfaction,

respectively.

Modifying contributory factors: Before starting any treatment for urinary incontinence,

contributory factors such as medical conditions and medications should be addressed,

particularly in older patients (Table 4)

INITIAL TREATMENT :

A:All Patients (conservative therapies )

Lifestyle modifications

Pelvic floor muscle exercise

●Weight loss

●Smoking cessation

●Avoid and manage Constipation

-is most effective for women with urgency incontinence Bladder training starts with timed voiding. Patients should keep a voiding diary to identify their shortest voiding interval. They are then instructed to void by the clock at regular intervals using the shortest interval between voids . -Urgency between voiding is controlled with either distraction or relaxation techniques .When the patient can go two days without leakage, the time between scheduled voids is increased until the patient is voiding every three to four hours without urinary incontinence or frequent urgency. (Table 5)

Bladder training

We suggest a trial of vaginal estrogen therapy for peri- or postmenopausal women with either stress or urgency incontinence and vaginal atrophy. Vaginal atrophy can lead to symptoms of urinary frequency and dysuria and can contribute to incontinence. Available preparations include creams, rings, and tablets as shown in the table (Table 2). We use Premarin or Estrace cream 0.5 mg twice weekly, Vagifem 10 mcg twice weekly, or the Estring.

It may take up to three months for patients to notice benefits from treatment.

Topical vaginal

estrogen

Dietary changes:

1 -Reduce consumption of alcoholic, caffeinated, and carbonated

beverages

2-Women who are drinking excess amounts of liquids (>64 ounces of

liquids) should normalize their fluid intake

3-Decrease the amount of liquid consumed before bedtime

-Initial instruction — Pelvic muscle (Kegel) exercises strengthen the pelvic floor musculature to

provide a backboard for the urethra to compress on and to reflexively inhibit detrusor

contractions

- The basic regimen consists of three sets of 8 to 12 contractions sustained for 8 to 10 seconds

each, performed three times a day. Patients should try to do this every day and continue for at

least 15 to 20 weeks

Comment [S1 :]Other patients may

have difficulty because of poor muscle isolation, low motivation, or inability to properly contract the pelvic floor. For these patients, we use supplemental

therapies such as: 1- Supervised pelvic floor therapy,

2- Vaginal weighted cones, or 3- Biofeedback (based on patient

preference, access, and availability).

• STRESS INCONTINENCE

• URGENCY INCONTINENCE/OVERACTIVE BLADDER

• MIXED INCONTINENCE

• Overflow Urinary Incontinence

B: Specific type treatment

-If step A not effective

Non-Pharmacologic

1-Pessaries:Continence pessaries may be used for women with stress incontinence as an adjunct or

substitute for pelvic muscle exercises. We find them most useful for patients who have stress incontinence

associated with specific activities or situations (eg, exercise or transient cough in the setting of upper

respiratory infection).

2-Mechanical devices :They are placed within the urethra or vagina to prevent urinary leakage (limited !! UTI,efficacy)

3- Surgery :Women without sufficient improvement with initial treatment and/or pessaries should be evaluated for surgical therapy, high cure rate with SUI.

4- Other treatments:Transurethral radiofrequency collagen denaturation (Efficacy!!),intravesical balloon device ,Urethral

bulking agent (UBA) therapy

Pharmacologic therapy!!?

1-Duloxetine : We do not routinely use duloxetine as treatment for stress

incontinence (If the patient is already treated

for Depression).

2-Alpha-adrenergic agonists (eg, phenylpropanolamine)

which stimulate urethral smooth muscle

contraction,They are no longer recommended because they

are only mildly efficacious compared with placebo and have a high rate of adverse

effects

1- STRESS INCONTINENCE

-

Pharmacologic

Therapy

1-Antimuscarinics — For women with urgency symptoms who have not had sufficient

improvement in their symptoms with initial treatment, we suggest a trial of antimuscarinics. They are thought to act primarily by increasing

bladder capacity and decreasing urgency by blocking basal release of acetylcholine during

bladder filling.

There are six antimuscarinic agents available in different doses and formulations:

darifenacin, fesoterodine, oxybutynin,

solifenacin, tolterodine, and trospium (Table 3).

A seventh, propiverine, is used primarily in Asia.

2-Beta 3 agonist: Mirabegron is a beta 3-adrenoceptor agonist, it is an option for patients who do not tolerate antimuscarinic medications or have contraindications to antimuscarinic medications (eg, narrow angle-closure glaucoma or taking cholinesterase inhibitors).

3-Combination therapy — Antimuscarinic and beta 3 agonist medications can be used together for patients with persistent symptoms who are unable to increase the antimuscarinic dose secondary to side effects or

dose limits.

**The combination of medication with behavioral therapy is more effective than either alone, but must be balanced against costs and side effects. We counsel our patients to continue pelvic floor exercise and other conservative therapies while initiating medical treatment.

Patients with persistent urgency incontinence symptoms despite an

adequate trial of initial treatments and

pharmacotherapies, or an inability to tolerate

pharmacologic therapy, can be referred to a specialist to discuss further options for

treatment. In general, we try at least one or two

pharmacotherapies prior to third-line therapies.

-acupuncture

- botulinum toxin injection

- percutaneous tibial nerve stimulation

- sacral neuromodulation (SNM)

Patients who fail other therapies

should be evaluated by a urologic

specialist to discuss surgical options.

These may include augmentation

cystoplasty, urinary diversion, or

placement of a suprapubic catheter.

2- URGENCY INCONTINENCE/OVERACTIVE BLADDER

Third-line

therapies Surgery

•The efficacy of all the antimuscarinic agents is thought to be similar. The quick onset of action of the immediate-release preparations makes them useful when continence is desired at specific times.

•We start with the lowest dose and titrate up as needed after two weeks if the patient has insufficient response and minimal side effects. We have patients follow up after four to six weeks to assess response and determine if a change in medication is necessary. Improvement in symptoms may take up to 4 weeks and it may take up to 12 weeks for medications to have full efficacy. Clinicians should avoid prematurely declaring treatment failure.

•Efficacy across the various formulations is similar and thus selection of the appropriate drug for an individual patient is primarily dictated by side effect profile, tolerability, medical comorbidities, or more commonly by insurance coverage. For most women, we are required to begin with generic therapies such as oxybutynin immediate-release.

•Patients may respond to one antimuscarinic and not another and side effect profiles differ between antimuscarinics. The oxybutynin patch tends to have the fewest side effects of dry mouth and constipation.

Anti-

muscarinics

•A postvoid residual should be checked in women at higher risk for urinary retention who are taking an antimuscarinic. These include women who develop difficulty urinating or worsening urinary incontinence symptoms while taking an antimuscarinic, who have advanced pelvic organ prolapse, or who are taking other medications with anticholinergic effects.

•Adverse drug effects :

•dry mouth, constipation, blurred vision for near objects, tachycardia, drowsiness, and decreased cognitive function.

•Extended-release formulations may have fewer side effects and have lower rates of discontinuation compared with immediate-release formulations

•Antimuscarinics are contraindicated in patients with gastric retention and angle-closure glaucoma.

Beta 3 agonist

•Mirabegron is started at 25 mg daily with increases to 50 mg daily after two to four weeks if patients are tolerating the drug but have inadequate symptom control. In patients who are taking mirabegron with an antimuscarinic, we monitor for urinary retention by measuring postvoid residual at their follow-up visit in four to six weeks or if new symptoms suggesting incomplete bladder emptying arise (urinary hesitancy, incomplete emptying, worsening urinary incontinence, or frequency).

•Adverse drug effects — Patients with severe or uncontrolled hypertension should not be prescribed mirabegron. While clinical trials have not demonstrated significant increases in blood pressure compared with placebo, patients can develop hypertension, and blood pressure should be monitored

Third line -therapies

The decision of which third-line therapy to pursue should be based on a detailed

discussion with the patient regarding safety, efficacy, time commitment, and insurance

coverage for the various approaches.

PTNS

• Acupuncture is used as an alternative therapy for patients who prefer a complementary medicine approach to treatment of urinary incontinence, but there is insufficient evidence to support general use of this therapy . Acupucture

•Botulinum toxin – For women with urgency or urgency-predominant mixed incontinence who do not respond to or cannot tolerate pharmacotherapy, injection of botulinum toxin into the detrusor muscle is an option. Botulinum

toxin

•Percutaneous tibial nerve stimulation – Percutaneous stimulation of the tibial nerve (PTNS), one type of electrical stimulation therapy, may have some benefit for women with detrusor overactivity . Methods include placement of an acupuncture needle medially behind the ankle with electrical stimulation administered for 30 minutes. These sessions occur once a week for 12 weeks followed by maintenance therapy of approximately once a month if the patient desires.

SNM

•Sacral neuromodulation – SNM is a minimally invasive electrical stimulation option for treatment for OAB symptoms, following failure of initial interventions and pharmacotherapy. SNM involves placement of a wire lead into the S3 foramen that is connected to a stimulation device.

•The procedure includes a test phase and a second implantation phase. The test phase can be done with a percutaneous trial where a temporary lead is placed usually bilaterally. However, due to high rates of migration of the percutaneous wires and failed test phases with this technique, we prefer a staged approach in which a permanent lead wire is placed into one (or, rarely, both) S3 foramina and tunneled under the skin to connect to a temporary stimulation device. For the test phase, patients are asked to maintain voiding diaries to document their urinary urgency, frequency, and leakage severity at baseline for three days and then daily during the trial. If a greater than a 50 percent improvement in any of these parameters is confirmed over a two-week trial, the patient can elect to undergo a permanent implantation with a pacemaker-like stimulator placed under the skin of the upper buttock. If the test phase is unsuccessful, then the lead is removed.

3- MIXED INCONTINENCE:

4- OVERFLOW INCONTINENCE

- Overflow incontinence can present with a variety of symptoms including involuntary,

intermittent, or continuous urinary leakage with no warning or sensation dribbling, and

incomplete bladder emptying.

- Treatment of urinary incontinence associated with impaired bladder emptying depends upon

the etiology.

1st

• Lifestyle modifications

• Pelvic floor muscle exercises

• Bladder training

2nd

• If not effective, Treated based on their predominant symptoms (stress or urgency).

Urgency VS SIUI

• urgency-predominant ? treat as pure urgency

• SUI-predominant symptoms ? we offer surgical treatment, typically with a mid-urethral sling (efficacy of surgery less!!)

- Patients who fail other therapies should be evaluated by a urologic specialist to discuss

surgical options. These may include augmentation cystoplasty, urinary diversion, or placement

of a suprapubic catheter.

Bladder outlet obstruction

•Women with bladder outlet obstruction from previous vaginal or urethral surgery are referred to a surgical specialist for further evaluation.

•Obstruction from a large cystocele or uterine prolapse can be treated with a pessary or surgically.

Detrusor underactivity

•NO Specific treatment for patients with detrusor underactivity.

• Potentially-reversible causes of impaired emptying should be addressed, such as stopping medications that impair detrusor contractility or increasing urethral tone and treating constipation.

•Sacral nerve stimulation may be beneficial for patients with idiopathic or neurogenic underactivity.

•In the United States, it is approved for the treatment of nonobstructive urinary retention. Success rates in general are not as promising as for urgency urinary incontinence and overactive bladder (OAB), but it is reasonable to try prior to more invasive and permanent solutions

•Clean intermittent catheterization may be used to manage overflow incontinence due to detrusor underactivity.

Chronic urinary retention

•When there is chronic partial urinary retention (eg, from prior spinal cord injury), clean intermittent catheterization may be used alone or in conjunction with the approaches already mantioned.

Appendix:

Table 1:

Table 2:

:Table 3

:Table 4

Table 5:

-REFERENCES: Lukacz E.S .( 2017) .Treatment of urinary incontinence in women. L. Brubaker& K. E Schmader

(Eds.), UpToDate .Available from: https://www.uptodate.com/contents/treatment-of-urinary-

incontinence-in-

women?source=search_result&search=urinary%20incontinence%20in%20women&selectedTitle=2~150

tudents:S Dharm P Prepared by

Allak-Tamara Al

Haya Balasmeh

Supervised By:

eny.eAbw-AlEshraq : Pharm D