Your doctor or continence adviser may suggest any of the following options:
Medication for Stress Incontinence
If your main problem is stress incontinence, in Europe, there is now a specialist medication, duloxetine, which is taken twice daily. Duloxetine halves the number of leakage episodes, and 1 in 10 women taking it becomes completely dry. Nausea is the most common side effect, but this often wears off within a few weeks (Drug and Therapeutics Bulletin 2007;45:29–32). Other side effects include dry mouth, fatigue and constipation. There have been concerns (but no proof) that it could lead to suicidal thoughts either during treatment or if it is suddenly stopped (Current Problems in Pharmacovigilance 2006;31:2). If your doctor prescribes duloxetine for you, it is important that you continue pelvic floor muscle exercises as well, because the combination of the medication and the exercises gives maximum benefit (Annals of Internal Medicine 2008;148:459–473).
Medication for Overactive Bladder
If you have an overactive bladder, there are some drugs you can get from your doctor that may help. The medication may take some time to work, so stay with it. Many people who take these drugs find that the urgency becomes less of a problem and they do not go to the bathroom as often. Many of these medications work in a similar way and are equally as effective as each other but differ in the likelihood of various side effects. Some make you less alert, so you have to be careful about driving or operating dangerous machinery while taking them. So if you experience side effects, discuss with your doctor whether a different medication would suit you better.
- Oxybutynin and tolterodine are the most common medications for overactive bladder. These drugs work in the same way by calming the bladder muscle. Their side effects are dry mouth, constipation and blurring of vision. Doctors now usually prescribe extended-release types of these drugs, which you need to take only once a day and which are less likely to have side effects. Extended-release tolterodine seems to have slightly fewer side effects than extended-release oxybutynin (Mayo Clinic Proceedings 2003;78:687–695). Oxybutynin is also available as a skin patch that you apply twice a week and as a skin gel that you apply every day; this form of drug delivery (through the skin) has fewer side effects than the tablet form, but some people may develop a skin rash or itching.
- Solifenacin is another medication that calms bladder muscle. It is also taken once daily. It can cause a dry mouth, but this not very likely especially when the lower dose is used (Prescriber 2010;21:13–29). It seems to be effective at reducing leakage, needing to rush to the toilet and having to pass urine at night.
- Darifenacin is another medication, taken once a day. It can cause constipation but seems to be effective in reducing leakage. Typically, someone with 16 episodes of incontinence per week would have only 7 episodes per week while taking darifenacin (Drug and Therapeutics Bulletin 2007;45:44–48). One benefit of darifenacin is that it does not cause confusion in elderly people, which can occur with some bladder-calming drugs.
- Fesoterodine is another new drug. It seems to be as effective as some of the other drugs, but less likely to cause constipation (Prescriber 2010;21:13–29).
- Trospiumchloride works in a similar way to oxybutynin. It can be taken several times a day or once daily. It seems to be as effective as oxybutynin and tolterodine, but possibly with fewer side effects (Prescriber 2010;21:13–29).
- Imipramine and amitriptyline help urge incontinence by a different action from their antidepressant effect and are particularly useful for men and women whose main problem is having to pass urine at night. However, these drugs have serious side effects and some people cannot tolerate them.
- Desmopressin is sometimes used for people whose main problem is constantly having to get up and pass urine at night.
- In 2012, Mirabegron, a so called selective β3-AR agonist, was approved in the EU and the USA to treat the symptoms of overactive bladder. Mirabegron relaxes the muscles around the bladder, thus enabling it to hold more liquid. As a result, the need to urinate is reduced.
A number of special devices to help keep the urethra (tube that carries urine from the bladder) closed are available.
Hormone Replacement Therapy (HRT)
In the past, doctors thought that HRT might help stress incontinence and overactive bladder. This has now been disproved by a study in the USA of more than 25 000 women. In fact, women taking HRT were actually more likely to develop stress incontinence or overactive bladder. If they already had a leakage problem, HRT made it worse (Journal of the American Medical Association 2004;172:1919–1924). However, oestrogen in a cream, pill or ring that is inserted into the vagina may help lessen symptoms of urgency and frequency (Cochrane Database Systematic Reviews 2009(4):CD001405).
Botulinum Toxin (Botox)
Tiny injections of botox into the wall of the bladder are being investigated as another method of calming the bladder muscle in women with an overactive bladder. Botox injections have been approved for women with multiple sclerosis who have overactive bladder symptoms. The effects wear off gradually after a few months, and then the injections would have to be repeated. So far, research studies have involved only a small number of patients, so it is difficult to know how effective this treatment really is, and whether it is safe long term, but it does seem to be a promising treatment (British Journal of Urology 2009;103:1509–1515). One disadvantage is that it can sometimes hinder proper emptying of the bladder for a while, so everyone having the treatment is shown how to insert a tube into the bladder just in case.
Special Hospital Tests
If the cause of your incontinence is not obvious to your doctor, you may be referred to hospital for urodynamic tests to obtain an accurate diagnosis. A small tube (1 mm in diameter) is inserted into the bladder to measure pressures, and sometimes a small tube is also inserted into the back passage. These may cause some discomfort.
Surgery for Stress Incontinence
A surgical operation is an option, and you would need to have urodynamic tests first, to be absolutely sure what type of incontinence you have. This is because surgery is usually only for stress incontinence; it cannot really help overactive bladder. If the pelvic floor muscles have become weak, the bladder neck (bottom part of the bladder) and top of the urethra will not be in their correct position, and so will not function effectively (with the help of the pelvic floor muscles) to stop leakage of urine. Surgery aims to lift the neck of the bladder and the urethra and keep them in their anatomically correct position. There are many different operations for stress incontinence, but the commonest are as follows.
- The tension-free vaginal tape (TVP) ‘retropubic sling’ operation is now very popular. It is possible to do it under a local anaesthetic or spinal block (that is, without a general anaesthetic). Working through the vagina and two small incisions in the stomach, the surgeon places special polypropylene (prolene) tape beneath the urethra and adjusts the tension on the tape until it is just right. After the operation, about 62% of women no longer have leakage of urine (New England Journal of Medicine 2010;362:2124–2125).
- Another sling operation, the ‘transobturator sling’ attaches the tape in a slightly different place. Theoretically, there is less risk of injury to the bladder with this operation. Afterwards, about 56% of women no longer have leakage of urine (New England Journal of Medicine 2010;362:2124–2125).
- In the Burch colposuspension operation, the surgeon attaches the top of the vagina to ligaments that lie close to the pubic bones, thereby supporting the bladder neck. This is a more major operation than the sling operations. The cure rate is approximately 50%, but problems (such as an urgent need to pass urine called urgency) can occur later (New England Journal of Medicine 2007;356:2143–2155).
Bulking injections (for stress incontinence) of synthetic or autologous fibres are injected into the walls of the urethra to support and close them to prevent urine leakage. The material is injected by inserting a needle alongside the urethra, or into the urethra and through its wall. A local anaesthetic is given to prevent pain. Most women need two or three injections, given at weekly intervals. They have to be given by an expert, and you will need urodynamic tests first to measure how your bladder is working.
About 40% of women find their symptoms are cured or improved by the treatment. However, the effect may not last. After 3 years only 50% remain cured, and after 5 years only 26%. For this reason, bulking injections are not often used in Europe, but they may be suitable for people who are not fit enough for a surgical operation.
An electrode in the vagina or rectum, attached to a battery, makes the pelvic floor muscles contract. The electrical current is tiny, so there is no need to worry. The apparatus is used for 30 minutes a day. This normally has to be arranged through a hospital clinic, because it is suitable only for women with severe incontinence who cannot be treated by other methods.
First published on: embarrassingproblems.com
Reviewed and edited by: Dr Diane Newman
Last updated: October 2020