Incontinence

Page updated Winter 2021.
DisclaimerMedicine is an ever-changing science.  We have been witnessing changes in diagnostic and therapeutic modalities and guidelines during last several years. We have used sources believe to be reliable for purpose of this website including AUA guidelines, EAU guidelines, NCCN guidelines, Campbell-Walsh-Wein Urology, UpToDate, Merck Manual, Lexi-Comp, FDA website, and other reputable resources. However, due to possibility of human error or changes in medicine, readers are required to confirm the information provided in this website with other sources. Readers are specially required to read all parts of the product information sheet included in the package of each drug they plan to administer and follow those instructions. Readers are also needed to follow instructions of FDA and other regulatory bodies and their own department in this regard. Authors can cite information provided in our textbooks or they need to cite the original resources. This website serves as a general framework. We and other users would adjust the approach per departments policies and patients situation. Forms can be used by other health care professionals.
 
Overactive Bladder
                                                      
Behavioral Therapies 

Clinicians should offer behavioral therapies including bladder training, bladder control strategies, pelvic floor muscle training, and fluid management as first line therapy to all patients with overactive bladder.

Pharmacologic Management

Oral anti-muscarinics 

Extended release (ER) formulation are preferred.

Oral β3-adrenoceptor agonists

Transdermal oxybutynin (patch or gel) 

Anti-muscarinic plus β3-adrenoceptor agonist

Anti-muscarinics contraindications:

Narrow-angle glaucoma

Antimuscarinics cautions:

Impaired gastric emptying

History of urinary retention

Using other medications with anti-cholinergic properties

Frail patient

β3-adrenoceptor cautions:

Frail patient

Third-Line Treatments

Intradetrusor onabotulinumtoxinA

100U

Patient should be able and willing to perform self-catheterization if necessary.

Peripheral tibial nerve stimulation (PTNS)

Sacral neuromodulation (SNS)

Fourth-Line Treatment

Augmentation cystoplasty 

Urinary diversion 

Prostate Surgery Incontinence

Pelvic floor muscle exercises

It is the first line management.

Pharmacologic Management

Urgency urinary incontinence 

Should be treated as mentioned in overactive bladder section.

Stress urinary incontinence 

May use duloxetine only to hasten recovery of urinary continence.

Bulking Agents:

Maybe used only for patients with mild incontinence. 

Male Slings 

May be considered as a treatment option for mild to moderate stress urinary incontinence.

Male slings will not be considered in patients with severe stress incontinence.

Men with previous radiotherapy or urethral stricture surgery may have less benefit from male slings.

Artificial Urinary Sphincter

Will be considered for patients with bothersome stress urinary incontinence.

A single cuff perineal approach is preferred.

Mechanical failure is common with the AUS.

Rate of explantation because of infection or erosion is high.

Chronic Urinary Retention

Is defined as post void residue of >300 mL that has persisted for at least six months.

Can cause overflow incontinence.

If there is a treatable cause, cause should be treated.

Patient might need clean intermittent catheterization.

Bethanechol, a cholinergic agonist, is not recommended.

Female Stress Urinary Incontinence 


Non-surgical Management

Pelvic floor muscle training (± biofeedback)

Continence pessary

Vaginal inserts

Duloxetine

When surgery is not indicated. Use dose titration.

Surgical Management Options

Midurethral sling 

Synthetic polypropylene mesh sling placement is the most common surgery currently performed for female stress urinary incontinence.

Retropubic or trans-obturator 

Autologous fascia pubovaginal sling

Burch colposuspension

Bulking agents

Intrinsic Sphincter Deficiency

Surgical options include:

Pubovaginal slings

Retropubic midurethral slings

Bulking agents

Cautions:

We do not suggest synthetic midurethral sling if there is:

Simultaneous urethral diverticulectomy

Simultaneous repair of urethrovaginal fistula

Simultaneous urethral mesh excision 

History of radiation therapy

Significant scarring

Poor tissue quality

Recurrent Stress Urinary Incontinence

Options: synthetic sling, colposuspension or autologous sling