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Urinary Incontinence

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of urinary incontinence.

Alternative Names

Incontinence

Medications

A number of medications are available that increase sphincter or pelvic muscle strength or relax the bladder, thus increasing its capacity to hold urine. Medications can be prescribed for all kinds of incontinence, but they are generally most helpful for urge incontinence.

Medications Specifically for Urge Incontinence

Anticholinergics. Anticholinergics work in the following ways:

  • They inhibit the involuntary contractions of the bladder.
  • They increase capacity of the bladder.
  • They delay the initial urge to void.

A major 2003 analysis reported that these agents produce small but significant improvements. However, the medications have not been rigorously compared with behavioral methods, such as bladder training and Kegel exercises, which are very effective for most cases of urge incontinence. Anticholinergics can have distressing side effects, notably dry mouth.

Propantheline (ProBanthine) was the most commonly prescribed anticholinergic, but has been largely replaced by newer anticholinergics with fewer side effects. They include oxybutynin (Ditropan, Oxytrol), tolterodine (Detrol), and hyoscyamine (Levbid, Cytospaz).

Extended-release versions of oxybutynin (Ditropan XL) and tolterodine (Detrol LA) are proving to be especially effective. They improve continence and have fewer adverse effects than short-acting forms. According to a 2002 study of Detrol LA, they also improve the quality of life. In a major 2003 comparison study of the extended release agents, oxybutynin was slightly more effective than tolterodine, but dry mouth was reported more often. A skin patch form of oxybutynin (Oxytrol) is now available that appears to be effective and have fewer side effects, such as dry mouth and constipation, than the oral form.

Overactive Bladder Treatments for Children

  • Ditropan XL is now approved for pediatric use in children ages 6 and older. The recommended dose is 5mg once a day.
  • A 2004 retrospective analysis found that tolterodine is also effective and well tolerated in children with urinary symptoms due to overactive bladder.

Side effects of anticholinergic agents include the following:

  • Dry eyes. Dryness in the eyes is a particular problem for people who wear contact lenses. Patients who wear contacts may wish to start with low doses of medication and gradually build up.
  • Dry mouth.
  • Headache.
  • Constipation.
  • Rapid heart rate.
  • Confusion, forgetfulness, and possible worsening of mental function, particularly in older people with dementia, such as those with Alzheimer's disease.
  • In rare cases, anticholinergics may precipitate glaucoma.

Antispasmodics. Antispasmodic drugs help relax the bladder muscle and are used for urge incontinence. Before bladder relaxants are prescribed, a thorough evaluation for obstructions in the ureter must be performed to avoid excessive urine retention. The two antispasmodics most commonly prescribed include flavoxate (Urispas) and dicyclomine (Bentyl). They also have anticholinergic properties. They have been used for years, although studies suggest that Urispas has very little benefits for most patients with urge incontinence. In May 2004, the FDA approved a new antispasmodic, Sanctura, for the treatment of overactive bladder with symptoms or urge incontinence.

Possible side effects reported with use of antispasmodic drugs include:

  • Weakness.
  • Dizziness.
  • Drowsiness.
  • Hallucinations.
  • Insomnia.
  • Dry mouth.
  • Impotence.
  • Restlessness.

M3 selective receptor antagonists: Two separate Phase III clinical trials suggest that Enablex (darifenacin hydrobromide) significantly reduces overactive bladder symptoms, including night-time awakenings and urge incontinence. FDA approval for Enablex is expected by the end of 2004.

Capsaicin and Analogs. Studies have reported beneficial effects from instillation of capsaicin, a component of hot red chili peppers, into the bladder of people with hyperactive and hypersensitive bladders. Temporary adverse effects, however, can be distressing. A capsaicin analog called resiniferatoxin may be more effective than capsaicin and have fewer side effects.

Alpha-Blockers. Alpha-blockers are drugs that relax smooth muscles and improve urine flow. They are useful for men with benign prostatic hyperplasia who have urge incontinence. They include terazosin (Hytrin), doxazosin (Cardura), tamsulosin (Flomax) and alfuzosin (Xatral). Tamsulosin may be particularly beneficial.

Medications Specifically for Stress Incontinence

Alpha-Adrenergic Agonists. Alpha-adrenergic agonists are used to strengthen the smooth muscle that opens and closes the internal sphincter. They include ephedrine and pseudoephedrine, which are common ingredients in numerous over-the-counter decongestants and appetite suppressants.

Such agents may be helpful for patients with mild stress incontinence not caused by nerve damage, although evidence on their benefits is weak. They also can have significant side effects, particularly ephedrine. In fact, products containing a similar agent, phenylpropanolamine (PPA), have been taken off the market because of reports of a higher risk for stroke in some women who took it.

Side effects include the following:

  • Agitation.
  • Insomnia.
  • Anxiety.

The may have adverse effects on the heart in people with existing heart problems. People with glaucoma, diabetes, hyperthyroidism, heart disease, or high blood pressure should avoid alpha-adrenergic agonists.

Nitrovasolidators. Deficiencies in nitric oxide, a gas that keeps blood vessels open, has been associated with many disorders, including incontinence. Agents that release nitric oxide, such as nitroflurbiprofen, are being investigated for urinary incontinence.

Tricyclic and Similar Antidepressants

Evidence indicates that both urge and stress incontinence are affected, in part, by central nervous system processes, particularly signal transmission. Investigators are particularly interested in serotonin and noradrenaline, which are chemical messengers (called neurotransmitters) that affect pathways involved with urination. (These neurotransmitters are also important for many other emotional and physical functions.) Antidepressants targeting one or both of these neurotransmitters are sometimes used for urge incontinence and may also be helpful for some people with stress incontinence.

  • Tricyclic Antidepressants. Tricyclic antidepressants include imipramine (Janimine, Tofranil), doxepin (Sinequan), desipramine (Norpramin), and nortriptyline (Pamelor). They provide multiple benefits for both urge and stress incontinence. They act as anticholinergic agents and relax the bladder. They also strengthen the internal sphincter. These drugs should be used carefully. They pose some risk for adverse effects on the heart and possibly the lungs, and they have other severe side effects in older adults. These antidepressants produce side effects similar to anticholinergic drugs, and may cause drowsiness. They may also back-fire and actually cause overflow incontinence in some people.
  • Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs). SNRIs are specially designed antidepressants that are similar to tricyclics but do not have the same side effects. The neurotransmitters serotonin and norepinephrine are thought to play key roles in the normal action of muscle at the base of the bladder. Increased neurotransmitter activity stimulates activity of the nerve that controls the urethral sphincter. It's theorized this stimulation helps tighten the urethral sphincter at the exit of the bladder, thereby helping prevent urine leaks due to physical activity. One such agent, duloxetine (Cymbalta), is being investigated for the treatment of depression and moderate-to-severe stress incontinence. Results of a large, multicenter, double-blind, placebo-controlled trial suggest that the experimental drug can effectively treat stress urinary incontinence in women. The study of more than 1,900 women demonstrated a statistically significant improvement after 12 weeks, compared to placebo. Eighty-two percent of women in the study who remained on duloxetine for one year considered themselves better. FDA approval of duloxetine is pending. The drug manufacturer anticipates final approval of duloxetine for stress incontinence in late 2004 or early 2005. Venlafaxine (Effexor) is a similar antidepressant, which is currently available, that may also prove to be helpful for patients with stress incontinence.

Other Drugs Used or Investigated for Incontinence

Desmopressin. Studies have reported that desmopressin (DDAVP), a drug used for bedwetting in children, may be helpful in the treatment of urinary incontinence in adults that occurs during sleep. The drug affects sodium levels and there is a slight risk for water intoxication with this agent.

Botulinum (Botox). Botulinum, the deadly toxin that sometimes contaminates improperly cooked foods, is also a powerful muscle-relaxant. Tiny injected amounts of a purified form (Botox) can relax the muscles and may help control over-active bladders that cause urge incontinence. It may also help relieve urinary retention that might occur after incontinence surgeries.

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