Clinical Guidelines for the Treatment of

Urinary Incontinence in Non-Pregnant Women

Definition:
 Urinary incontinence (UI) is defined as the complaint of involuntary leakage of urine.
It is often associated with other bothersome lower urinary tract symptoms such as urgency,
increased daytime frequency, and nocturia.

Types:

1) Stress Urinary Incontinence (Urethral Underactivity) [SUI].

2) Urge Urinary Incontinence (Bladder Overactivity).
3) Overflow Urinary Incontinence (Urethral Overactivity and/or Bladder Underactivity).
4) Mixed UI.

Prior to initiating therapy:

 Identify indications for referral : Indications for further evaluation or referral prior to
initiating treatment for urinary incontinence include the presence of
 Associated abdominal/pelvic pain or hematuria in the absence of urinary tract
infection, new neurologic symptoms, suspected vesicovaginal fistula or urethral
diverticulum, advanced pelvic organ prolapse, uncertainly in diagnosis, history of
pelvic reconstructive surgery or pelvic irradiation, or persistently elevated postvoid
residual (after treatment of possible causes).

 Assess incontinence type and severity: Determining the classification of urinary

incontinence type (stress, urgency, mixed) can help direct treatment.
The Patient Global Impression of Improvement (PGII) and Patient Global Impression of
Severity (PGIS) (Table 1) are acceptable measures to assess improvement and satisfaction,
respectively.

 Modifying contributory factors: Before starting any treatment for urinary incontinence,
contributory factors such as medical conditions and medications should be addressed,
particularly in older patients (Table 4)
INITIAL TREATMENT :
 A:All Patients (conservative therapies )
●Avoid and manage
Constipation
Dietary changes:
Lifestyle 1 -Reduce consumption of alcoholic, caffeinated, and carbonated
●Weight loss
beverages
modifications 2-Women who are drinking excess amounts of liquids (>64 ounces of
liquids) should normalize their fluid intake ●Smoking cessation
3-Decrease the amount of liquid consumed before bedtime

-Initial instruction — Pelvic muscle (Kegel) exercises strengthen the pelvic floor musculature to
Pelvic floor provide a backboard for the urethra to compress on and to reflexively inhibit detrusor
muscle contractions
exercise - The basic regimen consists of three sets of 8 to 12 contractions sustained for 8 to 10 seconds
each, performed three times a day. Patients should try to do this every day and continue for at
least 15 to 20 weeks

Other patients may :]1Comment [S

have difficulty because of poor muscle
isolation, low motivation, or inability to
properly contract the pelvic floor. For
these patients, we use supplemental Bladder
-is most effective for
therapies such as: training
women with urgency
1- Supervised pelvic floor therapy,
2- Vaginal weighted cones, or incontinence Bladder
training starts with timed
3- Biofeedback (based on patient
preference, access, and availability). voiding. Patients should
keep a voiding diary to
identify their shortest
voiding interval. They are
then instructed to void
by the clock at regular
intervals using the
shortest interval
between voids .
-Urgency between
voiding is controlled with
either distraction or
relaxation techniques
.When the patient can go
two days without
leakage, the time
between scheduled voids
is increased until the
patient is voiding every
three to four hours
without urinary
incontinence or frequent
urgency. (Table 5)
Topical
We suggest a trial of
vaginal
vaginal estrogen
estrogen
therapy for peri- or
postmenopausal
women with either
stress or urgency
incontinence and
vaginal atrophy.
Vaginal atrophy can
lead to symptoms of
urinary frequency and
dysuria and can
contribute to
incontinence.
Available preparations
include creams, rings,
and tablets as shown in
the table (Table 2). We
use Premarin or Estrace
cream 0.5 mg twice
weekly, Vagifem 10 mcg
twice weekly, or the
Estring.
It may take up to three
months for patients to
notice benefits from
treatment.
 • STRESS INCONTINENCE
B: Specific type • URGENCY INCONTINENCE/OVERACTIVE BLADDER
treatment • MIXED INCONTINENCE
-If step A not effective • Overflow Urinary Incontinence

1- STRESS INCONTINENCE

Non- Pharmacologic
Pharmacologic therapy!!?

1-Duloxetine : We do not
routinely use duloxetine
1-Pessaries:Continence pessaries may be used for as treatment for stress
women with stress incontinence as an adjunct or incontinence (If the
substitute for pelvic muscle exercises. We find them patient is already treated
most useful for patients who have stress incontinence for Depression).
associated with specific activities or situations (eg,
exercise or transient cough in the setting of upper
respiratory infection).
2-Alpha-adrenergic agonists
(eg, phenylpropanolamine)
which stimulate urethral
smooth muscle
2-Mechanical devices :They are placed within contraction,They are no longer
the urethra or vagina to prevent urinary recommended because they
leakage (limited !! UTI,efficacy) are only mildly efficacious
compared with placebo and
have a high rate of adverse
effects

3- Surgery :Women without sufficient improvement with

initial treatment and/or pessaries should be evaluated for
surgical therapy, high cure rate with SUI.

4- Other treatments:Transurethral radiofrequency collagen

denaturation (Efficacy!!),intravesical balloon device ,Urethral
bulking agent (UBA) therapy

-
 2- URGENCY INCONTINENCE/OVERACTIVE BLADDER

Pharmacologic Third-line Surgery

Therapy therapies

1-Antimuscarinics — For women with urgency

symptoms who have not had sufficient
improvement in their symptoms with initial Patients who fail
treatment, we suggest a trial of antimuscarinics. other therapies
They are thought to act primarily by increasing should be evaluated
bladder capacity and decreasing urgency by by a urologic
blocking basal release of acetylcholine during Patients with persistent specialist to discuss
bladder filling. urgency incontinence surgical options.
symptoms despite an These may include
There are six antimuscarinic agents available in augmentation
different doses and formulations: adequate trial of initial
treatments and cystoplasty, urinary
darifenacin, fesoterodine, oxybutynin, pharmacotherapies, or an diversion, or
solifenacin, tolterodine, and trospium (Table 3). inability to tolerate placement of a
pharmacologic therapy, suprapubic catheter.
A seventh, propiverine, is used primarily in Asia. can be referred to a
specialist to discuss
further options for
2-Beta 3 agonist: Mirabegron is a beta 3- treatment. In general, we
adrenoceptor agonist, it is an option for try at least one or two
patients who do not tolerate pharmacotherapies prior
antimuscarinic medications or have to third-line therapies.
contraindications to antimuscarinic -acupuncture
medications (eg, narrow angle-closure
glaucoma or taking cholinesterase - botulinum toxin
inhibitors). injection
- percutaneous tibial
nerve stimulation
3-Combination therapy — Antimuscarinic and beta 3 - sacral neuromodulation
agonist medications can be used together for patients (SNM)
with persistent symptoms who are unable to increase
the antimuscarinic dose secondary to side effects or
dose limits.

**The combination of medication with behavioral therapy

is more effective than either alone, but must be balanced
against costs and side effects. We counsel our patients to
continue pelvic floor exercise and other conservative
therapies while initiating medical treatment.
 •The efficacy of all the antimuscarinic agents is thought to be similar. The quick onset of action
of the immediate-release preparations makes them useful when continence is desired at
specific times.
•We start with the lowest dose and titrate up as needed after two weeks if the patient has
insufficient response and minimal side effects. We have patients follow up after four to six
weeks to assess response and determine if a change in medication is necessary. Improvement
in symptoms may take up to 4 weeks and it may take up to 12 weeks for medications to have
Anti- full efficacy. Clinicians should avoid prematurely declaring treatment failure.
•Efficacy across the various formulations is similar and thus selection of the appropriate drug for
muscarinics an individual patient is primarily dictated by side effect profile, tolerability, medical
comorbidities, or more commonly by insurance coverage. For most women, we are required to
begin with generic therapies such as oxybutynin immediate-release.
•Patients may respond to one antimuscarinic and not another and side effect profiles differ
between antimuscarinics. The oxybutynin patch tends to have the fewest side effects of dry
mouth and constipation.

•A postvoid residual should be checked in women at higher risk for urinary retention who are
taking an antimuscarinic. These include women who develop difficulty urinating or worsening
urinary incontinence symptoms while taking an antimuscarinic, who have advanced pelvic organ
prolapse, or who are taking other medications with anticholinergic effects.

•Adverse drug effects :

•dry mouth, constipation, blurred vision for near objects, tachycardia, drowsiness, and
decreased cognitive function.
•Extended-release formulations may have fewer side effects and have lower rates of
discontinuation compared with immediate-release formulations
•Antimuscarinics are contraindicated in patients with gastric retention and angle-closure
glaucoma.

•Mirabegron is started at 25 mg daily with increases to 50 mg daily after two to four weeks if
patients are tolerating the drug but have inadequate symptom control. In patients who are
taking mirabegron with an antimuscarinic, we monitor for urinary retention by measuring
Beta 3 postvoid residual at their follow-up visit in four to six weeks or if new symptoms suggesting
agonist incomplete bladder emptying arise (urinary hesitancy, incomplete emptying, worsening urinary
incontinence, or frequency).
•Adverse drug effects — Patients with severe or uncontrolled hypertension should not be
prescribed mirabegron. While clinical trials have not demonstrated significant increases in blood
pressure compared with placebo, patients can develop hypertension, and blood pressure should
be monitored
 Third line -therapies
The decision of which third-line therapy to pursue should be based on a detailed
discussion with the patient regarding safety, efficacy, time commitment, and insurance
coverage for the various approaches.

• Acupuncture is used as an alternative therapy for patients who prefer a complementary medicine approach
to treatment of urinary incontinence, but there is insufficient evidence to support general use of this
Acupucture therapy .

•Botulinum toxin – For women with urgency or urgency-predominant mixed incontinence who do not
respond to or cannot tolerate pharmacotherapy, injection of botulinum toxin into the detrusor muscle is an
Botulinum option.
toxin

•Percutaneous tibial nerve stimulation – Percutaneous stimulation of the tibial nerve (PTNS), one type of
electrical stimulation therapy, may have some benefit for women with detrusor overactivity . Methods
PTNS include placement of an acupuncture needle medially behind the ankle with electrical stimulation
administered for 30 minutes. These sessions occur once a week for 12 weeks followed by maintenance
therapy of approximately once a month if the patient desires.

•Sacral neuromodulation – SNM is a minimally invasive electrical stimulation option for treatment for OAB
symptoms, following failure of initial interventions and pharmacotherapy. SNM involves placement of a
wire lead into the S3 foramen that is connected to a stimulation device.
•The procedure includes a test phase and a second implantation phase. The test phase can be done with a
percutaneous trial where a temporary lead is placed usually bilaterally. However, due to high rates of
SNM migration of the percutaneous wires and failed test phases with this technique, we prefer a staged
approach in which a permanent lead wire is placed into one (or, rarely, both) S3 foramina and tunneled
under the skin to connect to a temporary stimulation device. For the test phase, patients are asked to
maintain voiding diaries to document their urinary urgency, frequency, and leakage severity at baseline
for three days and then daily during the trial. If a greater than a 50 percent improvement in any of these
parameters is confirmed over a two-week trial, the patient can elect to undergo a permanent
implantation with a pacemaker-like stimulator placed under the skin of the upper buttock. If the test
phase is unsuccessful, then the lead is removed.
3- MIXED INCONTINENCE:

• Lifestyle modifications
• Pelvic floor muscle exercises
1st • Bladder training

• If not effective, Treated based on their predominant

symptoms (stress or urgency).
2nd

• urgency-predominant ? treat as pure urgency

• SUI-predominant symptoms ? we offer surgical treatment,
Urgency
typically with a mid-urethral sling (efficacy of surgery less!!)
VS SIUI

4- OVERFLOW INCONTINENCE
- Overflow incontinence can present with a variety of symptoms including involuntary,
intermittent, or continuous urinary leakage with no warning or sensation dribbling, and
incomplete bladder emptying.
- Treatment of urinary incontinence associated with impaired bladder emptying depends upon
the etiology.
 Bladder outlet
Detrusor underactivity Chronic urinary retention
obstruction
•Women with bladder •NO Specific treatment for •When there is chronic
outlet obstruction from patients with detrusor partial urinary retention
previous vaginal or underactivity. (eg, from prior spinal cord
urethral surgery are • Potentially-reversible causes injury), clean intermittent
referred to a surgical of impaired emptying should catheterization may be
specialist for further be addressed, such as used alone or in
stopping medications that
evaluation. impair detrusor contractility conjunction with the
•Obstruction from a large or increasing urethral tone approaches already
cystocele or uterine and treating constipation. mantioned.
prolapse can be treated •Sacral nerve stimulation may
with a pessary or be beneficial for patients
surgically. with idiopathic or neurogenic
underactivity.
•In the United States, it is
approved for the treatment
of nonobstructive urinary
retention. Success rates in
general are not as promising
as for urgency urinary
incontinence and overactive
bladder (OAB), but it is
reasonable to try prior to
more invasive and
permanent solutions
•Clean intermittent
catheterization may be used
to manage overflow
incontinence due to detrusor
underactivity.

- Patients who fail other therapies should be evaluated by a urologic specialist to discuss
surgical options. These may include augmentation cystoplasty, urinary diversion, or placement
of a suprapubic catheter.
Appendix:

Table 1:
Table 2:
Table 3:
Table 4:
Table 5:
-REFERENCES:

Lukacz E.S .( 2017) .Treatment of urinary incontinence in women. L. Brubaker& K. E Schmader

(Eds.), UpToDate .Available from: https://www.uptodate.com/contents/treatment-of-urinary-
incontinence-in-
women?source=search_result&search=urinary%20incontinence%20in%20women&selectedTitle=2~150

Prepared by Pharm D Students:

Tamara Al-Allak
Haya Balasmeh

Supervised By:

Pharm D: Eshraq Al-Abweeny.