Urinary Incontinenc: Diagnosis and Treatment

by Food and Drug Administration (FDA)

(Page 2 of 3)

The first step toward successful treatment is to determine the type of incontinence and the cause. A doctor's evaluation usually includes a physical examination, medical history, and urine tests. The patient may be asked to keep a bladder record and may be referred to a urologist or urogynecologist for more specialized follow-up testing.

Treatment options fall into four broad categories — behavioral, devices, medications, and surgery. Generally, those options that are least invasive, dangerous or expensive are tried first.

Behavioral options require patients to learn new behaviors to help them regain control over urination. Behavioral methods work best with motivated patients willing to invest time and effort. Success rates are high for those who persist — most improve and many become dry. Behavioral treatments are generally free of side effects, noninvasive, and don't limit further treatment options.

For people with urge incontinence, bladder or habit training can help reassert control over the bladder. The patient is instructed to urinate at intervals, say, every hour or so. After achieving dryness for a few days, the interval increases. This cycle continues until the patient attains an acceptable interval of several hours. Other steps may include eliminating dietary caffeine and reducing fluids in the evening to improve sleep. Limiting overall fluid intake is not recommended, however, to avoid dehydration.

The goal with stress incontinence is to increase resistance in the sphincter and urethra. Most women see significant improvement, and many achieve dryness, with pelvic muscle exercises (PMEs), also known as Kegel exercises. PMEs are performed by tightening the pelvic floor muscles as if to control urination or defecation. Patients are generally told to sustain a contraction for at least 10 seconds, followed by an equal period of relaxation. The exercises should be performed about 30 to 80 times a day for at least eight weeks. Older adults may require longer training. Sometimes PMEs are combined with biofeedback to help establish better awareness of muscle function.

"Patients should not give up on the exercises too quickly," stresses Rao Nimmagadda, Ph.D., in FDA's urology devices branch.

It may take awhile to determine whether PMEs help. And, as with any exercise program, the beneficial effects last only as long as the exercise continues. For some people, electrostimulation via a small rectal or vaginal probe may help in building or maintaining muscle tone. These devices passively exercise the pelvic floor muscles with painless electrical pulses.

New Devices

Two new treatment methods became available last summer, when FDA reviewed for marketing two new prescription devices for stress incontinence in women. UroMed Corp., of Needham, Mass., makes both the Reliance Urinary Control Insert, sometimes called a urethral plug, and the Miniguard Patch. The Reliance Insert is a single-use, balloon-tipped cylinder about one-fifth the size of a tampon that's placed in the urethra with an applicator. A gentle push fills the small balloon inside the bladder with air. The balloon holds the device in place and prevents leakage. When the woman wishes to urinate, she pulls a string to deflate the balloon, then removes the insert. After urinating she may insert a new device.

Since the device is inserted into the urethra, it is associated with a fairly high infection rate. According to the manufacturer, urinary tract infections were more common during the first month of the trial and diminished as women learned how to use the device.

"It's not for everybody. It has to be individualized," says Grannum Sant, M.D., chair of urology, Tufts University School of Medicine, in Boston, who helped test the device. For women in the clinical trial, inserting the device became easy, Sant says, and their quality of life improved considerably as they resumed aerobics, biking, dancing, and other physical and social activities. Many women, Sant says, will probably use the device only during activities they know cause leakage. "In real life it's not going to be used constantly around the clock like we did in the study. Therefore the complication rate and discomfort rate — which was acceptable — is going to be even less," Sant says.

The other new device, the Miniguard Patch, is expected to be on the market later this year. It is a completely external, single-use foam pad a little bigger than a postage stamp. The patch is coated with a gel-like adhesive on one side and fits between the labial folds over the opening of the urethra, where it provides opposing pressure and a barrier to leakage. The patch is removed for urination and a new one applied afterwards.

For women used to wearing cumbersome pads, "The patch is a neater way of doing it. They don't feel so bulky," says Patricia Burns, Ph.D., a registered nurse and dean of the School of Nursing at the University of South Florida, in Tampa. Burns, who also maintains an incontinence practice, helped test the device.

About the Author

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FDA is A United States government body that oversees medical devices, including contact lenses, intraocular lenses, excimer lasers and eyedrops. In the US, these products must be approved by the FDA before they can be marketed.