Urinary Incontinence

Catherine E. DuBeau, MD

My prescription for urinary incontinence helped but I’m still having problems. What other options do I have? Lifestyle changes? Exercises? Surgery?

Medications are helpful for urge incontinence and overactive bladder, but they should not be the first or only step in treatment. Instead, treatment should begin by adjusting lifestyle factors that may be causing or worsening incontinence. These include avoiding or cutting back beverages that contain caffeine, such as coffee, tea (including green tea), caffeinated sodas and cocoa.

The same warning goes for alcoholic beverages. Many women believe that drinking eight to ten 8-oz glasses of water daily is necessary for good health - this is a myth! The actual recommendation is to have a total water intake equivalent to about 8 glasses, including water from food and other drinks. Some women find that some artificial sweeteners make leakage worse. While there is little scientific data on this, if you drink a lot of beverages with these sweeteners, you may want to cut back and see if incontinence improves. Weight loss and stopping smoking may help obese women and smokers.

If this has not already been done, check with your health care provider if your other medical conditions or medications may be contributing to incontinence, and need to be adjusted, further evaluated, or better treated.

Behavioral therapy methods are the next step and they can help improve urge, stress, and mixed incontinence. These methods include bladder retraining (voiding frequently during the day and learning to suppress or delay leakage from urgency) and pelvic muscle exercises (Kegels). Several scientific studies suggest that combining medications with behavioral methods is more effective than either medications or behavioral treatment alone. Women experiencing incomplete relief from their medication may find that simply adding behavioral methods will get them the outcome they want. Also, women differ in which medications they respond to best so changing medications is another option.

There are now an increasing number of surgical options for women whose incontinence does not respond to medication and behavioral therapy (referred to as refractory incontinence). Operations for stress incontinence now include less invasive options such as TVT (tension-free vaginal tape) and slings, which are done through the vagina, as well as other operations that require an incision in the abdomen (e.g., the Burch procedure). For some women with a particular type of stress incontinence, injections of bulking agents into the wall of the urethra can help keep the urethra sealed during coughing, laughing and other triggers. These agents include collagen and synthetic materials.

Some practitioners use electrical stimulation as a treatment for refractory stress incontinence. The stimulation is provided by a device the size of a large tampon that is placed in the vagina. It supplies a tiny electrical shock that stimulates the pelvic floor muscles to contract. However, several studies have found that these devices are no more effective than pelvic muscle exercises alone.

For refractory urge incontinence, there is mounting evidence that injection of Botox into the bladder wall may be effective. However, Botox has not yet been approved by the FDA for treatment of incontinence. Also, the best dose for a particular patient is not yet clear, nor is it easy to predict her risk of the potential complication of urinary retention (inability to pass urine). Another option is sacral nerve stimulation, in which an electrode is placed in the back to stimulate the lower spinal nerve (S3) that carries impulses to the bladder. If an initial trial of stimulation is effective, then a permanent electrode is placed and connected to a pacemaker-like device that is inserted under the skin.

Catherine E. DuBeau, MD
Director, Geriatric Continence Clinic
University of Chicago
National Association for Continence
American Geriatric Association