Treatment of urinary incontinence: what drugs will help? + other options

Recognition of the problem, diagnosis and subsequent treatment of urinary incontinence is of great and complex importance in affected patients.

In some cases, treatment of incontinence brings about the complete elimination of the urine leakage problem. In other, mostly chronic cases, treatment acts as a mitigation of the severity of urine leakage.

Appropriate and targeted treatment reduces or eliminates the problem of leaking urine. In addition, it also helps patients mentally and socially, i.e. improves their quality of life.

There are several treatment options for incontinence, namely:

• Regimen treatment (conservative)
• Pharmacological treatment - treatment with drugs
• Surgical treatment

The choice of the appropriate method or combination of these methods always depends on the specific type and degree of incontinence that the patient has been diagnosed with, as well as their age and general health.

The treatment of first choice is usually the one that is the least invasive and has the least potential side effects.

Regimen treatment (conservative)

Regimen treatment is intended to represent a change in the patient's current approach and experienced functioning. It includes lifestyle modification, exercise and pelvic floor strengthening.

Regimen treatment is most important and produces the best results in stress incontinence.

Lifestyle modification includes weight reduction, smoking cessation, optimizing daily fluid intake, scheduled voiding or toilet training. These are the main steps to reduce the incidence and worsening of incontinence symptoms.

Bladder training is also one of the treatments for incontinence. This involves deliberately withholding urine in patients who are used to urinating frequently. This increases the capacity of the bladder and reduces the contractility of its muscles.

A series of exercises to strengthen the pelvic floor muscles, known as Kegel exercises, are also very effective. Patients learn to consciously contract the pelvic floor muscles before and during any increase in abdominal pressure, for example, when coughing.

The aim is to improve support and urethral function, especially in women who can contract the pelvic muscles of their own accord, thereby clamping the urethra.

In order to achieve results, the intensity and regularity of the exercises are particularly important.

Table: Examples of time-saving and physically demanding pelvic floor strengthening exercises

For women who want to avoid surgery and are unable to follow regimen measures such as regular exercise and lifestyle modifications, there is the option of using vaginal continence pessaries.

They are used especially in women with stress incontinence.

Pharmacological treatment

Several groups of medicines are used in the treatment of urinary incontinence. The choice of the appropriate medicine takes into account the specific type of incontinence, the patient's general health, the risk of side effects and whether the patient is taking other medicines.

Pharmacological treatment should always be preceded by a regimen. Only in the event of its failure is the use of medication considered.

For some drugs, the final effect of treatment may take several weeks to be seen. Patients should be warned not to stop treatment arbitrarily and without consulting their doctor.

Pharmacological treatment primarily helps to relieve the symptoms of incontinence.

Table of drugs used to treat stress and urge urinary incontinence

The first group of drugs are anticholinergics, also called antimuscarinics. They are used for urge incontinence and are the drugs of first choice.

Anticholinergics act directly on the muscles of the bladder (detrusor) and increase the bladder capacity. This leads to a reduction in the urge to urinate, the frequency of voiding and, to a small extent, the frequency of urination during the night.

The most common side effects of anticholinergics include dry mouth, headache, blurred vision, slowed digestion to constipation, drowsiness and confusion.

In the event of significant side effects with first generation anticholinergics, switch to second generation anticholinergics.

β3 adrenergic receptor agonists are used in the treatment of urge incontinence. They act directly on the bladder musculature (detrusor).

They are usually used in cases where anticholinergic treatment is not tolerated or possible for the patient.

Side effects include, in particular, an increase in blood pressure. Therefore, they should not be used in patients with high blood pressure.

Serotonin and noradrenaline reuptake inhibitors are used in the treatment of stress incontinence. Their effect is to strengthen the urethral sphincter, thereby increasing its resistance and relieving symptoms of urinary leakage.

Hormonal drugs from the estrogen group are used in low doses in women with flaccid vaginal mucosa.

Surgical treatment

The third line of treatment is surgical treatment.

This includes the administration of onabotulinumtoxin A, known as Botox. It is injected into the bladder wall, where it acts on the neuromuscular junction and inhibits bladder irritability.

This method is used in cases of urge incontinence when pharmacological treatment has failed. Its effectiveness is comparable to pharmacological treatment, but without the need for daily administration.

The injections are administered under general anaesthesia. Therefore, we speak of third-line treatment.

The effect persists for approximately 9-12 months and must be repeated thereafter. The risks of this procedure include, in particular, a temporary problem with urinary retention, the occurrence of urinary tract infections or the formation of residual urine.

Another surgical treatment option is nerve stimulation of the tibial nerve. The tibial nerve is the nerve running from the inside of the ankle along the lower leg to the sacral nerves.

By stimulating this nerve, excitations are transmitted to the lower urinary tract. This modifies the sensitivity and contractility of the bladder and thus the urinary reflex itself.

Nerve stimulation is recommended for women with urge incontinence who do not respond to anticholinergic treatment.

Sacral nerve modulation is also used for urge incontinence. This is a process whereby a stimulator implanted in the pelvic area is used to dampen the excess excitations arising in the bladder via lead electrodes.

This method is invasive, but it is more effective than pharmacological treatment and provides long-term relief of incontinence symptoms.

The surgical treatment option for women with stress incontinence is suburethral tape implantation. This is a minimally invasive procedure in which a prolene tape is inserted under the urethra.

The tape is placed under the central part of the urethra in a loop shape or horizontally. Its purpose is to provide support for the urethra and ensure that it is fixed to prevent sagging and subsequent urine leakage.

The procedure is highly effective, especially in the first few years. In the long term (after about 10 years), it loses its effect and the symptoms of urinary incontinence return. This is mainly due to the fact that the woman neglects to take care of the pelvic floor and overexerts it.

All vaginal surgeries affect sexual function.

An important and integral part of urinary incontinence is the use of protective incontinence aids. Incontinence aids do not address the cause, they only have a protective function.

Their importance lies in improving the patient's quality of life. The patient feels protected and does not have to worry that an unexpected leakage of urine will cause him or her inconvenience. This also allows the patient to integrate into normal life and carry out activities like any other person.

Incontinence aids have found their place especially in chronic incontinent patients, those who do not respond to treatment regimens, are not suitable candidates for surgery or do not consent to surgery.

When selecting the appropriate aid, consideration is given to the patient's gender, age, body weight, degree of mobility and intensity of urine leakage.

Patients are offered aids with graduated absorption rates, ranging from lower absorption in the case of pads or insertable nappies to high absorption in the case of pull-ups, nappies or pads for supine patients.