Written by Professor Barry O’Reilly and Dr Yair Daykan
In Ireland, up to one-third of the population suffers from urinary incontinence. This article explains everything community pharmacists need to understand about this condition.
What is Urinary incontinence?
Urinary incontinence is a condition of unintentional passing of urine. It’s a common problem thought to affect millions of people around the world and is commonly undertreated. It is estimated that nearly 50 percent of adult women experience urinary incontinence, and only 40% percent of symptomatic community-dwelling women seek care.
The main risk factors for urinary incontinence are:
- Age- Prevalence and severity of urinary incontinence increase with age
- Obesity- Prevalence and severity of urinary incontinence increase with BMI
- Parity-Pregnancy itself increase the risk for urinary incontinence
- Mode of delivery- women with vaginal delivery are at higher risk for stress urinary incontinence compared to Caesarean section
- Family history
- Ethnicity/race -Higher prevalence in non-Hispanic White women compared with African American women
There are several types of urinary incontinence, but the main three types including:
• Stress urinary incontinence (SUI) – urine leaks out at times when your bladder is under pressure; for example, when you laugh, cough, or perform physical exercise.
• Urge urinary incontinence – when you feel a sudden, intense urge to void, accompanied by involuntary leakage of urine
• Mix urinary incontinence- a mixture of both stress and urge urinary incontinence.
What are the possible causes urge urinary incontinence?
Neurological disorders, diabetes mellitus, some medications, acute urinary tract infections, abnormalities of the bladder or outflow of the urinary system, cognitive deficiencies caused by aging.
What are the possible causes for stress urinary incontinence?
The leading cause of this condition is the weakening of the pelvic flower muscles, which support the bladder, among other pelvic structures. When these muscles become weak, anything capable of increasing the pressure outside the bladder can lead to urine leakage. A secondary reason for this type of incontinence is the weakening of the urinary
sphincter, the muscle in charge of controlling the release of urine.
So, how would we treat urinary incontinence?
It depends on what the cause is, and it is very important to make a correct diagnosis often with urodynamic testing in order to treat appropriately.
Non-surgical treatments: The current initial treatment for all types of urinary incontinence includes lifestyle interventions, losing weight and cutting down on caffeine and alcohol, physical therapies, scheduled voiding regimes, and behavioural therapies. In particular, pelvic floor muscle training (Kegel exercises) is recommended as first-line therapy for stress urinary incontinence.
Before starting any medical treatment, it is essential to rule out other conditions that may be attributed to this condition. Some medications (Antihistamines, Analgetic and
sedative, Diuretics, Antidepressants, and antiparkinsonian medications) can contribute to urinary incontinence, so knowing our patient’s medical history is a preliminary step
in treating this condition. We routinely elicit alcohol and caffeine intake habits as they have been associated with exacerbating urinary incontinence due to its stimulant and diuretic effects. We must always rule out urinary tract infection as a cause for urgency and urinary frequency.
A new non-surgical option for stress urinary incontinence is laser therapy. IncontiLase® is a non-invasive Er:YAG laser therapy for the treatment of mild and moderate stress
urinary incontinence, based on non-ablative photothermal stimulation of collagen neogenesis, shrinking and tightening of vaginal mucosa tissue and collagen-rich endopelvic
fascia, and subsequently causing greater support to the bladder.
Drug treatments:
Urge incontinence – The option of drug treatment is considered mainly for overactive bladder. These medications help relax the bladder’s muscle tissue and are also helpful for diminishing existing symptoms and urge incontinence episodes. However, these can produce a series of annoying side effects that can aggravate bladder symptoms.
Antimuscarinic agents and Beta-3 adrenergic agonist drugs are the two main options for the treatment of urge symptoms. Both classes can be used for single-agent treatment or used together for combination treatment.
• Antimuscarinic drugs – These agents block muscarinic receptor stimulation by acetylcholine and reduce smooth muscle contraction of the bladder. Such blockade during bladder storage results in increased bladder capacity and decreased urgency. Examples of drugs in that big group family are- Fesoterodine (Toviaz), Solifenacin (Vesitrim), Darifenacin (Emselex). There are also patch and gel options. Common adverse effects include dry mouth, dry eye, and constipation.
- Beta-3 adrenergic agonist drugs – Mirabegron (Betmiga) is working by stimulating the receptors in the bladder responsible for smooth muscle relaxation. The main advantage of this drug is the reduced side effect which increases the tolerance for this treatment.
Surgical treatments:
Surgical procedures for stress urinary incontinence (SUI) include retropubic suspension (eg Burch), pubovaginal sling, transurethral bulking therapy and mid-urethral slings. The commonest procedures for SUI until recently were the mid urethral slings which are currently “on pause” in this country but widely available globally at this stage. The mid-urethral slings include the TVT (tensionfree vaginal tape) consists of placing a synthetic mesh around the urethra of the patient, increasing the positive pressure around the structures that allow urine to flow.
The other procedure, the TOT (trans-obturator tape), consists of placing a permanent tape under the urethra. The purpose is basically the same as the TVT. The success rates of the surgical procedures are between 82% and 96%. While these treatments help to reduce the symptoms of urinary incontinence, these rarely completely cure them. However, after surgery, the patient will be able to have an almost normal life, at least more than before. The other option is an injectable urethral bulking agent, which is often reserved for women who cannot tolerate or wish to defer surgery.
In case of urge urinary incontinence, Botox injections to the bladder can be helpful. Other surgical methods include placing a thin wire close to the sacral nerves responsible for
stimulating the bladder, sending electrical impulses, and improving the symptoms. This wire can be placed temporarily or indefinitely until the condition is resolved. Other surgeries are based on the increase of the bladder capacity or the removal and replacement of the bladder with a prosthesis.
Quality of life is not a matter of privilege – you can change your life, and you can start it today!
Life change modifications are highly recommended and helpful in these cases due to their lack of side effects, accessible applications, and positive results.
