25th July 2023

Management

If stress incontinence is predominant:

• Pelvic floor muscle training: minimum 8 contractions performed 3 times/day for a minimum of 3 months. Continue if successful. Electrical stimulation and/or biofeedback in women who cannot actively contract pelvic floor muscles.
• Surgical treatment if conservative measures fail, i.e., open colposuspension or autologous rectus fascial sling.
• Duloxetine is used second line in women who do not want or are not surgical candidates. It increases the synaptic concentration of noradrenaline and serotonin within the pudendal nerve. This increases the stimulation of urethral sphincter striated muscles and enhances contraction.

If urge incontinence is predominant:

• Bladder retraining: minimum of 6 weeks involving pelvic muscle training, scheduled voiding intervals with stepped increases and suppression of urge with distraction or relaxation techniques.
• If bladder training alone is ineffective, antimuscarinics/anticholinergics can be offered as an adjunct, e.g., oxybutynin, tolterodine, solifenacin, and fesoterodine. They act by having a direct relaxant effect on urinary smooth muscle. Hence involuntary detrusor contractions are reduced, and bladder capacity is increased. Immediate-release formulations are more cost effective. However, extended-release formulations are associated with fewer side effects, such as dry mouth. Avoid these drugs in frail elderly women. An alternative is mirabegron – a beta-3 agonist of detrusor smooth muscle which promotes detrusor relaxation. It is avoided in patients with uncontrolled hypertension.
• Other treatment options include botulinum toxin injections.

In mixed incontinence, management is directed at the more predominant symptom; however, a combination of strategies can be used.

• Pelvic floor muscle training and bladder retraining are first line treatment.
• Drug treatment such as oxybutynin is the first line, but all antimuscarinics are equally effective. Oxybutynin should be avoided in the elderly as it impairs cognition. Newer antimuscarinics such as darifenacin, solifenacin, tolterodine and trospium are alternatives. Extended release or transdermal oxybutynin are other possibilities. Side effects include constipation, urinary retention, and confusion. Review annually, six months if over 75 years old.

Overflow incontinence:

• If secondary to bladder outlet obstruction, treat the cause, i.e., prostate hypertrophy, either benign or malignant.
• Intermittent self catheterisation, indwelling urethral or suprapubic catheterisation can be used.

Preventative measures include weight control, mainly for stress incontinence.