Volume 5, Number 2, Fall 2001
A number of pharmacologic therapies are avail- able for treating urge UI.(Table 3) However, caution should be exercised when treating a patient with pre- treatment PVR>100 cc due to the risk of urinary retention with these agents. Oxybutynin reduces incontinence by 9%-56% with up to 44% cure rate.4 Tolterodine reduces incontinence by 50% and decreases the number of micturitions in a 24-hour period by 21%.12 Dry mouth is a common side effect for both oxybutynin and tolterodine, however, only 40% of patients on immediate release tolterodine report dry mouth compared to 78% of patients on immediate release oxybutynin.1,12,13 The extended release preparations of both these agents have less dry mouth side effects and appear to be better toler- ated.12,13 Propantheline reduces incontinence by up to 53% but is not well tolerated in older patients.4 Hyoscyamine is rapid, short acting and can be taken sublingually. Dicyclomine improves incontinence by 62% but there are few studies on its effectiveness.4 It is not well tolerated in older patients, and treatment of UI is an unlabeled use. Flavoxate has no benefits.4 Imipramine is useful for nocturnal incontinence and mixed incontinence.4
For stress UI, phenylpropanolamine (no longer available in the U.S.) or pseudo-ephedrine has been shown to improve incontinence by 20%-60%.4 Estrogen improves incontinence by 66% within 6-12 weeks of use.4,14 In postmenopausal women without contraindications to estrogen replacement therapy, estrogen may be tried as the initial agent. Estrogen may be given orally, transdermally, or transvaginally with topical estrogen or with an impregnated ring. A progestin agent should be given to women with a uterus.
For stress UI due to urethral hypermobility, surgical techniques include the retropubic suspension (Marshall-Marchetti-Krantz procedure or Burch colo- suspension) with up to a 79% cure rate and the needle neck suspension with up to an 84% cure rate.4 For intrinsic sphincter deficiency, the Sling procedure has up to an 84% cure rate.4 Surgery can cure inconti- nence in 4 out of 5 cases but long-term success rate drops to 50% after 10 years.8
Pessaries are indicated as a temporary measure for women awaiting surgery for pelvic prolapse or as a treatment for women who are unable, for medical reasons, or unwilling to undergo correction of their prolapse.15 Complications can include erosion or ulceration of vaginal epithelium and/or a rectovaginal
and vesicovaginal fistula. Occlusive devices work by either occluding the urethral meatus or mechanically blocking leakage by supporting the urethrovesical junction. Products such as the FemAssist occlude the urethral meatus by creating suction over the urethra and can be reused for up to one week at a time.2 The Reliance Urinary Control Insert is an intra-urethral occlusive device with a 3 cc balloon that plugs the urethra. It has an 80% cure rate with stress UI.2 Introl supports the urethrovesical junction with a ring-shaped intravaginal device with two fingerlike prongs on one side. It must be individually fit and requires daily removal by the patient. It has up to an 84% cure rate in selected groups.2
Periurethral bulking agents involve the injection of polytetra-fluroethylene, collagen or autologous fat under cystoscopic guidance into an incompetent peri- urethral area. With this procedure, 49% of patients were cured and 67% showed improvement.4 Urinary tract infections and transient urethral irritation are the most common side effects. Other complications include urgency, UI, and urinary retention.4 Absorbent products (diapers, pads) are adjunctive therapy for many patients. An indwelling foley is indicated for significant, irreversible urinary retention, skin disor- ders or patient comfort/preference.4
Incontinence associated with recurrent sympto- matic urinary tract infections, history of previous anti- incontinence surgery or radical pelvic surgery, sympto- matic pelvic prolapse, abnormal PVR (>200 cc), hema- turia in the absence of infection, and failure to respond to an adequate therapeutic trial warrant further evalua- tion by an urologist or urogynecologist.4
Appell RA, Sand P, Dmochowski R, et al. Prospective randomized controlled trial of extended-release oxybutynin chloride and tolterodine tartrate in the treatment of overactive bladder: results of the OBJECT Study. Mayo Clin Proc. 2001 Apr;76(4):358-363.
Culligan P, Sand P. Involuntary urine loss in women: help for a hidden problem. Patient Care. 1998;12:141-162.
Chutka DS, Fleming KC, Evans MP, Evans JM, Andrews KL. Urinary incontinence in the elderly population. Mayo Clin Proc. 1996 Jan;71(1):93-101.
Fantl JA, Newman DK, Coiling J, et al. Urinary incontinence in adults: acute and chronic management. Clinical Practice Guidelines, No. 2, 1996 Update. Rockville (MD): U.S. Department of Health and Human Services. Public Health Service, Agency for Health Care Policy and Research. AHCPR Publication No. 92?0682, 1996. p. 3?90.
Brown JS, Seeley DG, Fong J, Black DM, Ensrud KE, Grady D. Urinary incontinence in older women: who is at risk? Study of Osteoporotic Fractures Research Group. Obstet Gynecol. 1996 May;87(5 Pt 1):715-721.
Batra SC, Iosif CS. Female urethra: a target for estrogen action. J Urol. 1983 Feb;129(2):418-420.