Once you understand the reason for your incontinence, the choice of what to do about it, and if and how to treat it, is up to you. Most professionals suggest that their patients first try a form of treatment other than the use of medication or surgery.
Depending upon the type and cause of your incontinence, lifestyle changes, or exercises, with or without equipment to help identify and strengthen the pelvic floor muscles, may help. For some, medications that affect the bladder or the sphincter can be effective. Surgery, an artificial sphincter, or an injection of a substance into the sphincter muscle may be recommended. Absorbent products or collection devices may help. Whichever you choose, be sure to discuss the latest information available with your health care professional. You may find that something new has been developed which may be appropriate for you.
Developed by Dr. Arnold Kegel, these exercises are designed to strengthen the muscles of the pelvic floor so that the bladder is kept in place and the urethra stays shut tight. Kegel exercises work best for people who have stress or mixed incontinence, but anyone can try them, even as a preventive measure to keep your pelvic floor muscles strong.
Stand, sit or lie down with your knees slightly apart. Relax.
Find your pelvic muscle. Imagine that you are trying to hold back urine or a bowel movement. Squeeze the muscles you would use to do that. DO NOT tighten your stomach or buttocks.
Women: to make sure you’ve got the right muscle, insert your finger into your vagina while you do the exercise. You should feel a tightening around your finger.
Men: when you tighten the pelvic floor muscle, your penis will twitch and contract in towards your body.
Stick to it! You should begin to see results after a few weeks. Like any other muscle in your body, your pelvic muscles will only stay strong as long as you exercise them regularly.
If you’re having a hard time doing Kegel exercises, your healthcare professional can teach you how to do them correctly. He/she may even suggest a tool or device to help make sure you’re using the right muscles (see “Behavioural training aids” in the sidebar).
Pelvic floor retraining with vaginal cones (i.e. LadySystem) is a non-surgical method to help women strengthen their pelvic floor muscles by doing their exercise once or twice daily, at home. Using a set of small cones identical in shape and size but of differing weights, the exercise consists of inserting a cone in the vagina, starting with the lightest one that can comfortably be retained and moving up to increasingly heavier cones as the pelvic floor muscles become stronger.
Your doctor may also suggest biofeedback, a training technique that’s used to monitor the contraction of the pelvic floor muscles as you do your Kegel exercises. Biofeedback uses a machine that records the contractions of your muscles and translates the movement into a visual signal that you can watch on a monitor. Some people find this helpful in learning how to do Kegel exercises correctly.
Biofeedback training is usually given in a hospital or private clinic by a physiotherapist, doctor, nurse or trained technician, but you can also buy or rent a machine to use at home.
Some people, especially those with urge incontinence, find that modifying their bathroom habits helps ease the symptoms of urinary incontinence and helps improve healthy bladder control. There are two basic strategies involved in bladder retraining:
A person who drinks five to eight cups of liquid per day should be able to wait at least two hours between bathroom visits. If you’re going to the bathroom more often, are getting up more than once or twice during the night, or can’t delay the urge to empty your bladder for at least 30 minutes, bladder retraining may be helpful. To get started, keep a voiding diary for two days (page 12) and bring it to your doctor for advice on a training program that will work for you.
Medications are often used in combination with the behavioural techniques described earlier to treat urinary incontinence. Again, your doctor will help you decide which is best for you based on the type of incontinence you have, as well as the severity of your symptoms.
Drugs used to treat OAB block the abnormal contractions of the bladder muscle and can therefore also help ease the symptoms of urge urinary incontinence in both men and women. You’ll find a list of OAB medications available in Canada on page 20. Generally speaking, these drugs fall into three categories:
Anticholinergic medications block the action of acetylcholine, a chemical messenger that tells the muscles of the bladder wall to contract. Unfortunately, acetylcholine acts in other parts of the body as well, so medications that block it can cause unwanted side effects like dry mouth, blurred vision, impaired cognition and constipation. New “extended” or “prolonged” release versions of anticholinergic medications reduce the incidence of side effects and improve compliance because they only need to be taken once a day to produce a steady absorption rate and constant blood levels of the drug.
|DRUG NAME||DRUG TYPE||DOSING|
|Oxybutynin, sold as:
(generics also available)
Ditropan XL®, Uromax®
(both controlled release)
Oxytrol® (skin patch)
|Oxybutynin chloride gel, sold as:
(rubbed into arm, thigh or stomach area)
|Tolterodine, sold as:
|Trospium chloride, sold as:
|Solifenacin, sold as:
|Darifenacin, sold as:
(selective for bladder)
|OnabotulinumtoxinA, sold as:
|Neurotoxin||Every 36 to 42 weeks|
|Fesoterodine, sold as:
|Mirabegron, sold as:
|Beta 3 receptor agonist||Once daily||SIDE EFFECTS|
|The most common adverse events found with anticholinergic medications include (but aren’t limited to): dry mouth, constipation, impaired cognition and blurred vision. Talk to your doctor about limiting these side effects and which medication may be right for you.|
The two most commonly prescribed anticholinergic drugs are oxy- butynin (Ditropan®, Ditropan XL®, Oxytrol®) and tolterodine (Detrol®), both of which are available in extended-release formulations.
Recently, medications have been developed that also limit unwanted side effects. These medications include darifenacin (Enablex®), solifenacin (Vesicare®), trospium (Trosec®), fesotoredine (Toviaz®), Myrbetriq® (mirabegron) and oxybutynin chloride gel (Gelnique®). Gelnique, is rubbed into the skin, making side effects like dry mouth milder because of constant absorption rates. Myrbetig is a new drug that works by a different mechanism to relax the bladder muscle without blocking the action of acetyl choline and therefore produces lesser side effects. The other drugs are anti-cholinergics but are more specific to the bladder muscle.
OnabotulinumtoxinA (Botox®) is a neurotoxin that makes the bladder muscles relax by blocking the transmission of nerve signals. It has been approved by Health Canada for the treatment of overactive bladder with symptoms of urinary incontinence, urgency,and frequency, in adult patients who have an inadequate response to or are intolerant of anticholinergic medication. OnabotulinumtoxinA (Botox®) is also approved for the treatment urinary Incontinence caused by neurogenic bladder associated with multiple sclerosis or subcervical spinal cord injury in adults who don’t respond to anticholinergic medications. Given by injection through an endoscope inserted into the bladder (cystoscope) under local anesthetic, Botox® takes effect within about two weeks and lasts anywhere from 36 to 42 weeks.
Re-injection can be considered when the effect diminishes but not within three months of the last injection
Since estrogen helps keep the urethra healthy and strong, the drop in estrogen that occurs in women after menopause especially with aging may contribute to incontinence. Applying estrogen in the form of a vaginal cream (e.g. Premarin®), tablet (e.g. Vagifem®) or ring (e.g Estring®) may help ease symptoms of both stress and urge incontinence.
Hormone replacement therapy (HRT) contains a combination of estrogen and progestin in pill form. Since it acts on the whole body, estrogen taken this way doesn’t seem to help with incontinence and may actually increase the risk of breast cancer.
Generally speaking, there isn’t a lot of scientific evidence to support the use of estrogen to treat incontinence, but some women have found it helpful. Doctors usually recommend estrogen in combination with behavioural treatments.
This is a man-made version of antidiuretic hormone, which stops the production of urine while you sleep. Desmopressin is available as a nasal spray and in pill form and is taken at night to prevent bedwetting and nocturnal enuresis.
Bulking agents may be an effective treatment for both men and women with stress urinary incontinence caused by a damaged urinary sphincter. Bulking agents are injected into the tissue that surrounds the urethra, building it up to reinforce the sphincter. Several different agents can be used: collagen, hyaluronic acid, Teflon, silicone and rubber particles. The procedure can be done in just a few minutes with mild anesthesia. The downside is that the effects only last a few years so you’ll have to go back for more shots, at a cost of as much as $2,000 per series of injections (which usually has to be paid by the patient, since provincial and private plans don’t typically cover these treatments). Studies show that up to 75% of women with stress urinary incontinence will benefit from the injections, at least in the short term.
Women who have a pelvic organ prolapse may use a pessary to keep the fallen organ in place. Usually made of rubber or silicone, the pessary is placed deep into the vagina so that it rests against the cervix and holds up the bladder and uterus. Pessaries come in several different shapes and sizes. In most cases, you’ll have to visit your doctor or healthcare professional to have the pessary fitted. You don’t have to remove the pessary when you go to the bathroom, but it should be taken out and cleaned regularly. You should also see your doctor for a vaginal exam on a regular basis. Some pessaries may help with female stress incontinence, even if you don’t have a prolapse by re-positioning the bladder neck.
If you’re incontinent because you’re unable to empty your bladder properly, your doctor may Recommend a catheter, a soft tube that’s inserted into the urethra to drain the bladder. The end of the catheter has holes, or “eyelets”, through which the urine passes. Catheters can either be used every time you need to go to the bathroom (this is called self-intermittent catheterization), or worn Constantly, in which case the catheter is tied to an external bag, usually attached to the leg, that holds the urine. Catheters that remain in place are called in-dwelling or Foley catheters.
In-dwelling catheters are usually only used if other treatments don’t work, because they increase the risk of bladder infections, damage to the bladder and urethra and formation of bladder stones.
These risks are much lower with intermittent catheterization. Your doctor will recommend the right size catheter and teach you how and when to use it. Most catheters are disposable, meaning you use them once then throw them away, but there are a few that can be cleaned and reused.
If more conservative treatments haven’t helped, your doctor may recommend surgery to treat stress urinary incontinence (most surgical procedures only work for this type of incontinence). The risks of surgery are higher, but it may also provide long-term relief in severe cases. Women who are still planning on having children are usually told to wait to have surgery, because the strain of pregnancy and delivery may “undo” the surgeon’s work.
The type of procedure that’s right for you will depend on the exact cause of your incontinence. Discuss the benefits and potential risks of each procedure with your doctor before making a decision. Here’s a brief description of some of the most common Procedures.
A sling is a strip of tissue, most often a synthetic mesh tape, that’s placed under the urethra for support. There are several types of sling procedures (tension-free vaginal tape, transobturator tape), the main difference being where and how the sling is attached to the body. Your surgeon will explain the pros and cons of each option to you.
Sling procedures (also called “tapes”) are the most commonly performed type of incontinence surgery in women and can be done under local or regional anesthesia, in an operating room or outpatient clinic. Recovery time is very short, usually one or two weeks.
Studies have shown that these types of operations are highly effective at reducing the symptoms of stress urinary incontinence. More recently, surgeons have developed sling procedures for men.
This procedure is designed to lift the bladder up so it doesn’t sag. It can be performed laparoscopically, which is less invasive and leaves smaller scars, but, unlike with sling procedures, you’ll need about six weeks to recover. The good news is that many people find it provides significant long-term relief from symptoms of stress incontinence. Again, there are several variations of the procedure (you may hear the terms “retropubic suspension”, “colposuspension” or the “Burch procedure”), which your surgeon will explain to you during your consultation.
Unlike the previous two procedures, which are only done in people with stress urinary incontinence, sacral nerve stimulation (SNS) is used to correct problems related to overactive bladder, urge urinary incontinence and urinary retention. A small device is surgically implanted next to the sacral nerve in the lower back, which plays a critical role in bladder emptying. By stimulating the nerve with electrical current, SNS restores the signalling pathways that are needed for the bladder to work properly. The procedure is reversible, meaning that the device can be removed at any time. Unfortunately, there are very few hospitals in Canada equipped to perform this procedure.
Surgery itself increases the risk of urinary incontinence. Other potential risks are: