TREATING INCONTINENCE

A multidisciplinary team of healthcare professionals is involved in the diagnosis and treatment of incontinence. They include:

• Urologists
• Urogynecologists, who are specially trained in the care of women with pelvic floor disorders
• Primary care providers such as physicians and nurse practitioners
• Nurses, including those with specialized training and certification in incontinence care. In conjunction with other disciplines, nurses are involved in patient assessment, addressing behavioral and lifestyle changes, and interventions such as bladder training.
• Physical therapists are proficient in the evaluation and treatment of urinary and fecal incontinence and may also specialize in interventions for pelvic floor disorders, including instruction in pelvic floor exercises, manual manipulation, and other treatment modalities (such as electrostimulation, biofeedback, and/or vaginal dilators or weighted vaginal cones).
• Occupational therapists are involved in training to increase the awareness of pelvic floor muscle activity and developing lifestyle interventions (i.e., ADL, IADL, home assessment) to cope with urinary incontinence.
  (APTA, 2018; AUGS, 2017; Wallace et al., 2019; WOCN, 2016)

During the assessment process and before interventions are put in place, it is important for each clinician to establish the patient’s perception of the severity of the problem and its impact on their life. Treatment should be guided by the limitations incontinence places on the patient and the degree of intervention preferable to them (Stoppler, 2017).

Treatment generally begins with noninvasive interventions that reduce incontinence and enhance coping skills.

Lifestyle Interventions

Lifestyle and behavioral interventions are the first line of treatment for urinary incontinence and may include smoking cessation and weight loss. Obesity increases pressure on the bladder and pelvic floor muscles and increases the risk of developing stress urinary incontinence. It has been shown that for every five-unit increase in body mass index (BMI) females increase their likelihood of developing urinary incontinence by as much as 70% (WOCN, 2016; Cunningham & Valasek, 2019; Schuiling, 2017).

Patients are also instructed to avoid dehydration. Decreased fluid intake can cause concentrated urine, which can irritate the bladder. It can also lead to the formation of kidney stones and increase the risk of urinary tract infections and constipation. Adults ages 65 and over are particularly susceptible to the effects of dehydration. Older patients are educated not to wait to feel thirsty before drinking fluids and that dark-colored urine can be a sign of dehydration.

The timing of fluid intake is discussed with the patient, with the recommendation to limit fluid intake in the later part of the day (Simon Foundation, 2019a).

Other lifestyle interventions that maybe beneficial in treating incontinence include:

• Reducing coffee intake
• Limiting intake of alcohol and carbonated beverages
• Preventing constipation

Bladder Retraining

For urge and stress incontinence, a bladder-retraining program can be initiated during the daytime hours.

To begin, the patient is asked to maintain a voiding diary to establish their voiding pattern. Then, the patient is asked to void 15 minutes prior to their usual voiding time in order to avert the urge sensation to void. For example, if the voiding diary shows that the patient voids every 90–95 minutes, the retraining program will start with voiding every 60 minutes. If the urge to void arises before the 60-minute interval, the patient is encouraged to postpone voiding if possible until the scheduled time, or at a minimum to wait for five minutes beyond the initial urge to void. At intervals that are comfortable for the patient, perhaps weekly, a goal is set to extend the voiding time by another 15–30 minutes until a 3- to 4-hour time period is achieved between each void (Schuiling, 2017).

Urinary Incontinence Products

Some patients may need to or choose to use incontinence products, including:

• Patients for whom incontinence can be completely reversed
• Patients who have to cope with incontinence for a period of time, e.g., those waiting to achieve the benefits of pelvic floor muscle training
• Patients who choose incontinence management over other interventions

For all of these people, incontinence products are an essential intervention in maintaining their personal and social activities (WOCN, 2016).

Absorbent products can include panty liners, pads, and specially designed underwear. Patients with female anatomy are advised to use incontinence pads rather than feminine hygiene pads for moderate to heavy leakage. Incontinence products are created with the surface area nearest to the urethral orifice, which is superior to the vagina. These products are highly absorbent, with a decrease in skin irritation, when compared to less absorbent products (UCF, 2019).

For patients with male anatomy, a drip shield can be used for mild episodes of incontinence, while a drip guard is useful for more excessive leakage. The shields have a waterproof backing. They are placed over the head of the penis and can be secured in place by wearing relatively snug-fitting underwear (Underwood, 2017).

When deciding on the optimal product(s) to use, the clinician, patient, and caregiver take into consideration the following factors:

• Severity of the incontinence problem
• Anatomy of the patient
• Physical build, height, and weight of the patient
• Mental capacity
• Mobility level
• Problems with dexterity
• Eyesight
• Lifestyle, including home and work environments
• Level of independence or assistance needed
• Available storage
• Personal preferences and priorities, such as need for discreetness
  (Abrams et al., 2017)

Treating Incontinence-Associated Dermatitis

The primary approach to the treatment of IAD includes:

• Reversing the cause(s) of incontinence or reducing the incidence of incontinence
• Avoiding cleansing the perineal area with soap; substituting cleansing products that prevent overdrying or irritation of the skin
• When bathing, using warm, not hot, water and refraining from vigorous rubbing or scrubbing of the skin
• After cleansing and drying, applying a barrier cream such as zinc oxide or dimethicone

If an absorptive product is used for incontinence containment, it should wick urine (and stool, if applicable) away from the skin (WOCN, 2016).

Psychological and Emotional Interventions

Psychological and emotional interventions aim to enhance the patient’s ability to cope with urinary symptoms. Many people with urinary incontinence feel alone and are unable to talk to family or friends about their problem. Being able to talk to a clinician about constant fear of uncontrolled urinary leakage and the feelings of embarrassment and depression is an important step in developing coping mechanisms (Underwood, 2017; Shah, 2019).

Incontinence Devices

Pessaries provide a low-risk treatment choice for many women and are used frequently. These devices are fitted into the vagina and provide support to pelvic organs that have moved downward. They also supply compression to the urethra to decrease the risk of urinary incontinence. Whether the patient is sexually active will influence the type of pessary used. Most women find pessaries comfortable.

Pessaries are fitted by the clinician and usually require follow-up appointments every 3–6 months to ensure the patient is appropriately self-managing pessary use. During the follow-up visit, the clinician exams the vaginal vault for any signs of mechanical erosion or other lesions. The clinician also inspects the pessary for any signs of damage (WOCN, 2016).

Pessaries are not suitable in all cases, such as for women who have scarring of the vagina, vaginal dryness, or a restricted or shortened vagina. Women with weakened pelvic muscles may have difficulty keeping a pessary in place, but strengthening of pelvic floor muscles may alleviate this problem (AUGS, 2016).

Men with urinary incontinence can use clamps as an alternative to pads and collection devices. A clamp prevents incontinence by exerting pressure on the penis. It is placed around the base of the penis and secured just to the point where it will prevent urine leakage. Clamps are recommended for men who are diagnosed with stress incontinence only.

The use of clamps requires careful assessment by the clinician. The clinician must ensure that the patient has no cognitive deficits and that they have the manual dexterity to apply and remove the clamp safely. Patients are educated to use clamps with caution since they can impede blood flow, resulting in ischemic damage to the penis. Patients are also reminded to be alert for signs of skin damage to the penile surface caused by the clamp. Clamps have been found to be most successful in situations that require short-term usage, such as when a patient has to attend a meeting or is engaged in recreational activities (WOCN, 2016).

Pelvic Floor Exercises

In 1950, Dr. Arnold Kegel developed pelvic floor exercises known as Kegel’s exercises (Haag, 2019). More generally referred to as pelvic floor muscle training (PFMT), this is the first-line treatment for women with urinary incontinence. It has been found that PFMT provides benefits regardless of the type of incontinence present. Although there is abundant evidence that PFMT is a safe and effective treatment, many candidates who could benefit from PFMT have only a scant understanding and insight into this treatment choice.

Positive results reported by women include decreased episodes of incontinence and an improved quality of life (Dumoulin et al., 2018). Research has been shown that strengthening the muscles of the pelvic floor can diminish the incidence of urinary incontinence by up to 90% (Mayo Clinic, 2017).

PFMT has not been as well studied in men as it has been in women, but it is still considered a primary recommendation for men with urinary incontinence after radical prostatectomy (WOCN, 2016). Continence may be regained sooner if PFMT instruction is introduced in the preoperative or immediate postoperative period to male patients undergoing radical prostatectomy surgery (Abrams et al., 2017).

Instruction in pelvic floor muscle training is provided by physical therapists who have obtained specialized PFMT training. Important first steps include patient education about the utility of PFMT, exploring patients’ treatment expectations, and realistic goal setting. Patients are advised that PFMT requires a time commitment and that positive results may only be noticeable after several treatment sessions (Wallace et al., 2019).

How does PFMT work? During a strong contraction, the levator ani muscles are moved upward and forward, facilitating compression of the urethra and adding to urethral closing pressure. Strengthened pelvic floor muscles give support to the bladder neck and the proximal urethra. Maintaining the urethra in its normal position during pursuits that heighten intra-abdominal pressure decreases the likelihood of urine leakage.

In conjunction with the patient, the clinician creates an individualized program of exercises. A key factor to success is the patient’s level of motivation and their willingness to adhere to the exercise maintenance program (Abrams et al., 2017).

The clinician first teaches the patient how to identify the pelvic floor muscles by instructing them to “draw in” or contract the muscles around the vagina and/or anal sphincter, as if they are trying to stop urination or defecation. The contraction of these muscles is maintained for about 10 seconds, followed by a period of relaxation for a minimum of 10 seconds. A typical training schedule is to perform 3–4 rounds of pelvic muscle exercises each day and to include 10–15 repetitions in each round. The clinician teaches the patient to perform the exercises while sitting, standing, and lying supine. The patient is counseled not to use the abdominal or buttock muscles while doing pelvic floor muscle exercises. For some patients this takes time and conscious effort to master (WOCN, 2016).

Pharmacology

Several different classes of medications are used to treat urinary incontinence. These include:

• Anticholinergics (also known as antimuscarinics) reduce bladder contractions, increase bladder capacity, and decrease the urgency to void. Medications in this category include fesoterodine (Toviaz) and solifenacin (VESIcare).
• Beta-3 agonists, such as mirabegron (Myrbetriq), have been shown to reduce the number of incontinent episodes per day (Bragg et al., 2014).
• Anti-depressants. Impramine (Tofranil) is a tricyclic antidepressant sometimes used to treat bed wetting in children 6 years of age and up. Duloxetine (Cymbalta) is a serotonin/norepinephrine reuptake inhibitor approved in Europe for the treatment of stress urinary incontinence, but it is not approved by the Federal Drug Administration (FDA) for incontinence treatment in the United States.
• Topical estrogen. Estrogen receptors are found in the vagina and also in the tissues of the bladder and urethra. It is thought that estrogen deficiency contributes to the development of urinary incontinence (Abrams et al., 2017; WOCN, 2016).

Surgical Interventions

The most commonly used surgical interventions are described below:

• Sling procedures are used for urethral support and to exert external urethral compression. The most frequently performed sling procedure involves the placement of a synthetic mesh to form a suburethral sling. The midurethral sling procedure is currently regarded as the “gold standard” for the treatment of stress urinary incontinence in women. Sling procedures are also regarded as an effective choice for male patients coping with incontinence after prostatectomy surgery, in particular those with slight to moderate leakage.
• Artificial urinary sphincter. For male patients this procedure has been found to give the best long-term success in dealing with urinary incontinence after radical prostatectomy surgery. It is regarded as the primary surgical intervention for these patients.
• Urethral bulking agents. The injection of bulking agents is used to cushion the urethral mucosa, thereby increasing urethral coaptation (closing) and reestablishing continence. Collagen and synthetic agents are used as bulking materials. The body will eventually absorb collagen, and so collagen bulking agents usually require repeat injections every 6 to 18 months. Synthetic materials require less-frequent repeat treatments.
  (WOCN, 2016; Abram et al., 2017; Shah, 2019)