INTRODUCTION — The treatment of urinary incontinence will depend, in part, upon the type and cause of the incontinence. In most cases, treatment begins with conservative therapies, such as changes in lifestyle and treatment of potentially reversible factors, or behavioral treatments. If these therapies are inadequate, medication or surgery may be considered. Before embarking on a treatment plan, the patient should discuss the goals of treatment in detail with their healthcare provider.

This topic review discusses treatments for urge and stress incontinence. The causes, symptoms, and diagnosis of urinary incontinence are discussed separately. (See "Patient information: Urinary incontinence").

TREATMENTS FOR STRESS AND URGE INCONTINENCE — The following treatments may be helpful for people with both stress and urge incontinence; this is called mixed incontinence.

Fluid management — People who drink large amounts of fluids (especially those containing caffeine) often find that decreasing fluid intake can reduce the frequency of leakage. The body requires a certain amount of fluids to function; for most people, thirst is a good indicator of when fluids are needed. Older people may need to make a special effort to drink enough as they may not become thirsty in the initial stages of dehydration.

Drinking excessive amounts of fluid is of little benefit despite the popular misconception that drinking water can "flush out toxins," improve skin health, or assist with weight loss. Between 32 and 64 ounces of fluid per day (from food and fluids) is sufficient for most people; more fluids may be needed for people who are active and perspiring or when outdoor temperatures are high. Decreasing evening fluid intake (eg, no fluids after 6 to 7 PM) is advised for people with frequent nighttime voids or overnight leakage.

Potentially reversible factors — People who take certain medications (such as diuretics or "water pills"), have swollen ankles or feet (edema), are diabetic and have elevated blood glucose levels, and those who have difficulty walking are at increased risk for urinary incontinence. A variety of techniques can be used to reduce symptoms.

• People who take diuretics should take them at a time when there is easy access to a bathroom.

• People with edema should elevate their feet for several hours in the afternoon or evening, may consider wearing graduated pressure stockings, or in some cases, can take a diuretic in the afternoon. Some prescription drugs and over-the-counter medications (eg, ibuprofen and other nonsteroidal anti-inflammatory agents) can worsen edema; check with your healthcare provider. These measures may help to reduce overnight frequency, urgency, and leakage.

• People with diabetes who have elevated blood glucose levels should work with their healthcare provider to reduce blood glucose levels. Elevated blood glucose levels cause the kidneys to produce more urine, which can increase frequency, urgency, and leakage.

• People who have difficulty walking should be evaluated to determine if physical therapy could improve mobility. These people may benefit from a portable toilet that can be placed close to their bed or living area. Potential obstacles such as electrical cords, throw rugs, or furniture should be moved out of hallways and walkways.

Pelvic muscle exercises — Pelvic muscle exercises, also known as Kegel exercises, strengthen the muscles involved in closing the urethral sphincter. These are used to reduce leakage caused by stress incontinence and may help to control sudden urges in people with urge incontinence (show figure 1). (See "Patient information: Pelvic muscle exercises").

Studies have shown that, when done correctly, pelvic muscle exercises can reduce symptoms of mild stress incontinence. Patients may benefit from a visit to a physical therapist, or a urology, gynecology, or geriatric nurse specialist for detailed instructions.

TREATMENTS FOR URGE INCONTINENCE

Bladder irritants — Some foods and beverages are thought to worsen frequency and urgency. This includes caffeinated beverages and alcohol, spicy foods, and acidic foods or beverages. While this has not been proven, it is reasonable to see if eliminating one or more of these items reduces symptoms of urgency and frequency.

Bladder retraining — Bladder retraining can reduce symptoms of urge incontinence by slowly increasing the amount of urine the bladder holds, and therefore the time interval between voids (show figure 2). This regimen retrains the nerves and pelvic muscles, which can improve control of bladder contractions.

It is normal to urinate approximately every three to four hours during the day and awaken from sleeping zero to one times. With bladder retraining, the person urinates at specific intervals through the day, starting with a small time interval. For example, a person who must currently void every 30 to 45 minutes would start by voiding every 45 minutes, whether there is an urge or not.

If the patient feels the need to urge sooner, they should not to run to the bathroom, but should stand still or sit down and concentrate on decreasing the urge while doing several pelvic muscle contractions (see "Pelvic muscle exercises" above). Once the urge has decreased or passed, the person can walk slowly to the bathroom to urinate. After one to two weeks, the time interval can be increased by 30 to 60 minute increments. The goal is to increase the voiding interval to a more normal pattern, approximately every three to five hours.

For people with dementia or memory impairment, treatment focuses on encouraging the patient to use the toilet at regular intervals (usually every two to three hours) and providing positive feedback for successful toileting.

Constipation — Constipation can lead to fecal impaction (when stool collects in the rectum and is difficult to pass), which can increase symptoms of frequency and urgency. Increasing the amount of fiber in their diet to between 20 and 30 grams per day can prevent constipation. Treatment of constipation is discussed in a separate topic review. (See "Patient information: Constipation in adults").

Medications — When bladder retraining and fluid management alone are not successful in treating urge incontinence, medications can be added. Medicines that are available are called bladder relaxants or antimuscarinic agents. Medications work best when combined with behavioral therapy. In general, these drugs have similar effectiveness, but may differ somewhat in the type and severity of side effects, such as dry mouth, constipation, and heartburn.

The medication should be taken for at least four weeks to determine the response. A person who does not respond to one drug may respond to another. People who take these medications for long periods of time need to practice good dental care because dry mouth can increase the risk of cavities. There is a small risk of urinary retention (causing the bladder to incompletely empty) with these medications, especially in older people.

• Oxybutynin comes in three forms: immediate release (generic oxybutynin, taken two to three times daily), extended release (Ditropan XL®, taken once daily), and a patch (Oxytrol®, which is worn on the skin and changed twice weekly). The immediate release form is particularly useful for people who require protection at specific times (eg, when going out to dinner) since it begins to work quickly and wears off after about six hours. Side effects occur less frequently with Ditropan XL® and Oxytrol®.

• Tolterodine is available in an immediate release form (Detrol® 1 or 2 mg, taken twice daily) and extended release (Detrol LA®, 2 or 4 mg taken once daily). Side effects occur less frequently with Detrol LA® than with immediate release Detrol®.

• Trospium (Sanctura®) is taken one or two times daily on an empty stomach and is available in a 20 mg dose.

• Solifenacin (Vesicare®) is taken once a day, and is available in 5 mg or 10 mg doses.

• Darifenacin (Enablex®) is taken once a day, and is available in 7.5 mg and 15 mg doses.

Botox® — Botulinum toxin A, also known as Botox®, is a toxin produced by a bacteria that can temporarily paralyze muscles. It is available in the United States for cosmetic treatment of wrinkles. Studies have examined the use of Botox® in people with severe urge incontinence, with most studies reporting a decrease in episodes of leakage [1].

There is concern about use of Botox® because of the risk of "overtreatment", which could prevent the bladder from emptying normally and require the person to insert a catheter every time the bladder needs to be emptied. In addition, the effects of Botox® are temporary, on average lasting only three to six months.

Further study is needed before Botox® is recommended. However, the treatment holds promise for people with severe symptoms who have not responded to other treatments.

Electric stimulation — A sacral nerve stimulator (SNS) is a surgically implanted unit that stimulates a nerve in the lower back to decrease urge incontinence. It is a promising treatment for people with severe symptoms of urge incontinence, urgency and frequency, or urinary retention who have not improved with more conservative treatments. It is not clear how the treatment works, although studies show good results in most patients:

• Among 96 patients with urge urinary incontinence that had not improved with other treatments, SNS decreased leakage episodes from 11 to four per day over approximately 30 months; 26 percent of patients were completely dry [2].

• A study of 51 patients with urgency-frequency that had not improved with other treatments who did not leak urine found that at six months after the unit was implanted, the number of daily voids decreased from 17 to 10 [3].

Potential risks of the surgery include pain at the site where the unit is implanted (in the buttocks), movement of the unit over time, infection, movement of the wires, and others. More detailed information about sacral nerve stimulation is available in a separate topic review. (See "Patient information: Treatment of painful bladder syndrome and interstitial cystitis" in the section on "Electrical stimulation").

TREATMENTS FOR STRESS INCONTINENCE

Weight loss — Obesity can contribute to symptoms of stress or mixed incontinence. In people who are obese, weight loss can significantly reduce episodes of leakage due to stress incontinence.

Medication — There is currently no medication available in the United States to treat stress incontinence. Oral estrogen was previously thought to improve stress incontinence, although this has been disproven in studies. A trial of vaginal estrogen is reasonable and may improve stress incontinence somewhat.

Vaginal pessaries — A vaginal pessary is a flexible device made of silicone that can be worn in the vagina (show picture 1). It is traditionally used for women with pelvic organ prolapse (when the bladder, vagina, uterus, or rectum bulge from the vagina), but specially designed stress incontinence pessaries are also available. These help to support the urethra during a cough or sneeze, and may reduce or eliminate stress incontinence (show figure 3). A pessary is a reasonable treatment for women who want to delay surgery and for those who prefer a non-surgical treatment. When fit properly, the woman will not feel the pessary.

The pessary must be removed and cleaned with soap and water periodically. In addition, there is a small risk that the pessary can cause irritation of the vaginal tissues. Most women who use a pessary see their healthcare provider every three to six months for an examination. Some women, especially those who are sexually active, are able to learn how to insert and remove the pessary on their own.

Surgical treatments for women — Surgery offers the highest cure rate of any treatment for stress urinary incontinence, even in elderly women. Cure rates vary by procedure, although most procedures result in 85 to 95 percent of women being cured at six weeks after surgery; cure rates tend to decrease over time. Ideally, surgery should be reserved for women who have completed childbearing because pregnancy and childbirth can cause damage to the urethral supports, potentially causing incontinence to recur.

There are several surgical procedures for the treatment of SUI in women. The best procedure depends upon several factors. Each procedure has its own risks, benefits, complications, and chance of failure. Long-term outcomes are not always known because some procedures have not been used long enough to measure the incidence of incontinence 10 to 20 years after surgery. All of these issues should be discussed in detail with a surgeon who is experienced in performing procedures to treat incontinence.

TREATMENTS FOR INTRINSIC SPHINCTER DEFICIENCY — In selected women, urinary incontinence is caused by complete failure of the urethral sphincter muscles; this is called intrinsic sphincter deficiency (ISD). This may occur in women who have had previous pelvic surgery or radiation treatment who later developed scarring. ISD can also occur in postmenopausal women who have severely thinned (atrophic) vaginal tissues. ISD leakage is typically continuous and can occur while sitting or standing still.

The most effective treatment for ISD is a surgical procedure called a sling. This can be done as a day surgery, and is effective in eliminating leakage in 80 to 90 percent of women.

Another option for short-term relief of symptoms includes injections of material into the wall of the urethra to help keep the urethra closed. These are called periurethral bulking injections; the procedure can be done in the office with local anesthesia. Materials injected include collagen, Teflon®, silicone, and carbon-coated beads. In the short term, between 70 and 80 percent of women have less or no urinary leakage; this declines to about 20 percent by five years after the injections.

OTHER MEASURES

Pads — While pads are not a recommended treatment for incontinence, they are necessary for some people who are unable or unwilling to use behavioral treatments, medications, or more invasive treatments, or who have incomplete relief of leakage despite treatment.

Pads and protective undergarments are available for both men and women in a variety of sizes and absorbencies. The optimal garment depends upon the type, frequency, and amount of urine leakage. Pads designed for menstrual bleeding may be insufficient for people with sudden, large volume leakage. In addition, menstrual pads do not manage urine odor as well as incontinence products. Men may prefer a penile sheath rather than a pad; the sheath covers the penis like a condom, and is connected to a tube and bag that collects the urine.

These items are expensive and are not usually covered by insurance; in the United States, some state Medicaid plans cover the cost of pads for people with very limited incomes. In other countries, pads may be obtained for no or little cost through continence advisor nurses. Information on pad varieties and other urinary incontinence supplies is available from medical supply companies and urinary incontinence advocacy groups (see "Where to get more information" below). The U.S. National Association for Continence has an online tool that can help to choose a protective garment based upon individual characteristics (http://nafc.org).

For all protective products, it is important that the skin is kept dry and that odor is managed. Skin that is exposed to urine for long periods can become irritated, and can potentially develop skin burns or infection. Protective products for the bed or other furniture may also be needed.

Catheters — A catheter may be necessary in some people who cannot empty their bladder completely or at all. Because catheters can cause urinary tract infections and other serious complications, especially when left in place for long periods, they are usually a treatment of last resort.

A catheter may be inserted and left in the bladder, or may be inserted intermittently to drain the bladder, and then removed. A healthcare provider can teach the patient or a family member how to perform intermittent catheterization at home.

WHEN TO SEEK HELP — Patients should seek help from their healthcare provider if they are bothered by urinary frequency, urgency, or leakage, if they are awakened more than twice during the night to urinate, if there is pain with urination, or if they notice blood in the urine.

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.