Comprehensıve Revıew of Urınary Incontınence Treatment Methods

Table of Contents

Comprehensıve Revıew of Urınary Incontınence Treatment Methods

This publication presents a comprehensive review of UI (Urınary Incontınence) by summarizing the relevant anatomy and the current available UI treatment methods (Urınary Incontınence) Incontinence that span pharmacotherapy, modified behavioral methods, physiotherapy, a variety of minimally invasive surgeries, old botulinum toxin injection therapy, and traditional retropubic surgery. It is expected that this special collection can offer some help to readers, including both clinicians and patients, and encourage more research to find a refined treatment strategy, especially for difficult patients who have failed some prior attempts.

Urinary incontinence (UI) is any urinary leakage and is a symptom rather than a disease. UI is a common and distressing condition. It has been reported to impair the quality of life for 20% to 30% of women and 10% to 15% of men. Women of all ages can suffer from UI; 25% of young women with UI report a daily occurrence of UI. 

Although UI occurs more frequently among aging women, it is not an inevitable part of aging. The degree to which symptoms bother a person may interfere with the person’s health or independence, with a decrease in social activities, a loss of self-confidence and self-esteem, an increase in caregiver burden, stress, depression, and sleep problems. Therefore, UI is associated with many negative emotional, psychological, social, economic, and hygiene problems.

Defınıtıon and Types

Urinary incontinence is defined by the International Continence Society as the involuntary loss of urine that represents a hygienic or social problem to the individual. These problems may vary with each person, negatively impacting the quality of life and psychological and social well-being. There are three main types of urinary incontinence according to the International Continence Society: stress urinary incontinence (SUI), urgent urinary incontinence (UUI), and mixed urinary incontinence (MUI), which is a combination of SUI and UUI. SUI is characterized by leakage during efforts such as coughing, sneezing, lifting, jumping, etc.

UUI is characterized by an abrupt, compelling desire to urinate with an inability to delay and loss of urine. Women frequently involved pelvic floor diseases, resulting in predominantly SUI or MUI, while the main causes of UUI constitute genitourinary syndrome of menopause, overactive bladder, and associated factors.

Behavıoral and Non-Pharmacologıcal Therapıes

Pelvic exercises prepare the pelvic floor muscles, responsible for urinary, anal, and sexual functions, for possible increases in pressure. It is based on the same principles used in muscle exercise for other bodily parts. It consists of three stages: 1. identification of the pelvic muscles, 2. how to do the exercises, and 3. precautions and essential details of the exercises. It is suggested that stabilization exercises be associated with Pilates-based exercises. 

Whether the exercises are effective or not, they are sufficiently reliable according to the individual perception of the muscle. In addition to the active exercise program, additional techniques such as biofeedback, electrical stimulation, vaginal cones, weighted balls, and pressure gauges are used. Each one of the techniques is used in common points and differs in approach. They apply to all UI patients, but especially to SUI patients.

Behavioral therapy, the basis of nonpharmacological therapy, first aims for the reduction of UI episodes and then increases the time between episodes, ultimately aiming to achieve a complete cure. In other words, decreasing the frequency of UI episodes is expected to be associated with a decrease in their severity and an increase in the quality of life. Researchers have shown that instinctive habits, such as urine holding, fluid regulation, and the instinctive tension of buttocks and pelvic floor muscles, increase the risk of UI. 

The regular filling and emptying of the bladder is set as first-degree bladder retraining and is specifically recommended for individuals with high bladder capacity. Schedules that are not compatible with the individual’s lifestyle should be avoided.

Pelvıc Floor Muscle Exercıses

The increase in resting pressure due to an increase in muscle strength and endurance is especially important for women who have suffered from urethral hypermobility in the bladder neck. The pelvic floor muscles can be strengthened with Kegel exercises, complex exercises aimed at improving coordination between the muscles of the pelvis and bladder (i.e., by normalizing the operation of the pelvic floor musculature).

Such exercises could help sufferers who are unable to hold at the beginning of the treatment or with small stress incontinence. Overflow incontinence is a case of urinary incontinence, and treatment must first involve early drainage of the bladder with a catheter, which can relieve voiding difficulties usually associated with this form of incontinence.

Ordinary urinary incontinence can be due to a voluntary relaxation of the pelvic floor musculature or involuntary bladder contractions. Pelvic floor muscle exercises are first advised to these patients to teach them to strengthen the pelvic floor musculature and improve coordination of urethral sphincter function. It is also advised for some patients who have undergone a surgical procedure to increase the chance that the surgery will be a complete success. 

A more powerful pelvic floor musculature is expected to stretch the muscles at the bladder base to help sustain bladder neck closure during a rise in intra-abdominal pressure initiated during work or when sneezing.

Bladder Traınıng Techıques

Prompted voiding (prompted timed voiding) – This method consists of staff or family members reminding the patient to regularly empty their bladder when they experience mild-to-moderate incontinence or when it is expected that incontinence may occur in order to avoid wetting.

This technique also involves keeping a record of the patient’s response, which should target indicators of incontinence (such as urine volume and fluid intake) and adjusting the plan according to the patient’s voiding pattern. This method is generally applied to individuals with cognitive and communication problems, such as dementia, as its goals are mainly to create a routine, reinforce the use of correct incontinence management skills, and prevent urinary incontinence.

Bladder retraining (habit training) – This technique aims to delay the time between when patients perceive the desire to urinate and the actual void. Based on a fixed schedule for voiding, a healthcare provider instructs the patient about the time intervals for voiding (for example, every 1.5 hours) and asks the patient to void at each scheduled time, regardless of the presence or absence of sensations of bladder fullness.

This method also includes instruction about relaxation, stress management, and distracting the mind from the need to urinate. Gradually, the timing for voluntary urination increases over time, and the patient can independently increase the time intervals as long as no discomfort or distress is experienced. It is fundamental that the patient calculates the volume of each void to compare the progress achieved over time.

Pharmacotherapy

The basic pharmacologic options for treatment of urgency predominant incontinence include anticholinergic activity specifically targeting the bladder, beta-3 agonists, and intradetrusor onabotulinumtoxinA injections.

Oxybutynin has long been the standard treatment for urgency UI. Over time, safety and tolerability concerns led to the development of new medications with a focus on increased bioavailability and fewer adverse side effects (lower rates of sedation, dry mouth, blurred vision, constipation, and tachycardia). These newer agents, despite their higher cost, produce a step-down change in the relative proportion of extended-release (ER) and immediate-release (IR) medication prescribed in managed care populations. Unfortunately, these agents have been associated with complaints of cognitive dysfunction and impaired memory among the elderly living with dementia.

These concerns appear linked to P-glycoprotein (PgP) proteins playing a role in neuroprotection by preventing toxins from entering the brain micro-environment. The controversy about anticholinergic effect on the brain, and concern regarding the unintended initiation of a progressive cognitive decline and increased mortality, must be openly discussed with the elderly patient.

Before discussing pharmacotherapy, it is important to identify and correct contributing factors that may worsen incontinence prior to starting medication. These factors may include excessive urine production (such as from diabetes or congestive heart failure), constipation, and medication use (such as diuretics). In our practice, we do not initiate pharmacotherapy without evidence of improvement through conservative measures such as physical therapy, dietary changes, and bladder retraining. It is also critical to attend to the role of coexisting UI symptoms like nocturia, frequency, pelvic pain, or urgency.

The patient with urgency predominant UI should be treated in one direction, most likely with anticholinergic medication, while a patient with stress predominant UI from intrinsic sphincter deficiency may have increased sensitivity to stress incontinence symptoms by using anticholinergics due to an inability to contract the bladder.

Antıcholınergıc Medıcatıons

Anticholinergics inhibit muscarinic receptors in the detrusor muscle of the bladder. These muscles should contract during the storage phase of the bladder cycle to promote continence. Thus, inhibition of this action causes relaxation of the muscle and increased bladder capacity. The anticholinergic class of medications has been available for many years.

The list includes oxybutynin (Ditropan, Ditropan XL, and Gelnique), solifenacin (VESIcare), tolterodine (Detrol and Detrol LA), darifenacin (Enablex), trospium (Sanctura and Sanctura XR), and fesoterodine (Toviaz), the most recent anticholinergic approved by the United States Federal Drug Administration (FDA). Also, several other medications belonging to other therapeutic classes possess some anticholinergic action and are used in OAB. The list contains flavoxate (Urispas), imipramine (Tofranil), and hyoscyamine (Anaspaz, Levbid, Levsin, Nulev, and Symax) among others.

Most overactive bladder anticholinergics are known for side effects due to anticholinergic action, such as dry mouth, constipation, blurred vision, and tachycardia. The latest evidence from the EMBARK study, one of the most extensive clinical trials for efficacy, tolterodine and trospium, showed less severe constipation, and trospium proved to have little effect on memory. 

There are several generic forms for urination anticholinergics. All have demonstrated their efficacy in OAB, and the generics are as clinically effective as the original costing about half as much. However, effective and safe treatment for storage symptoms should be identified by symptoms, avoiding adverse effects and maximally improving the affected sexual activity of every patient.

Beta-3 Adrenergıc Agonısts

In clinical trials, Mirabegron proved to be superior to Tiotropium, Solifenacin, and Tolterodine in terms of efficacy in treating symptoms of overactive bladder syndrome, with similar safety profiles with the use of placebo, Solifenacin 10 mg, and Tolterodine extended release 4 mg. 

A significant advantage of Mirabegron over currently used antimuscarinics is that it increases bladder capacity in patients with neurogenic detrusor overactivity, which may lead to the resolution of urinary incontinence caused by overactivity of the detrusor, and may also be used to treat people who cannot tolerate antimuscarinics.

The approval of Mirabegron for use as monotherapy or combined therapy with imaging examinations (Cystoscopy) or vaginal surgery makes it unique in its class of drugs commonly used to treat symptoms of overactive bladder syndrome. However, Mirabegron is not always tolerated. Its use can be accompanied by such side effects as headache, increased blood pressure, nasopharyngitis, dizziness, and diarrhea. Currently, Mirabegron is produced and marketed globally by Astellas Pharma and Pfizer.

Beta-3 adrenergic receptors are found in the bladder detrusor muscles. They are an important target in the treatment of overactive bladder syndrome. Through their action, relaxation of the detrusor muscle occurs, leading to an increase in bladder capacity, an increase in the time interval between detrusor contractions without blocking the contractile function of the detrusor, and thereby reducing the degree of incontinence. 

Beta-3 adrenergic agonists were first developed in the mid-1980s. The development of Mirabegron is the most successful. To date, it is the only beta-3 adrenergic agonist approved for use as a treatment for incontinence. Scientific evidence has shown that Mirabegron effectively reduces the number of micturitions and episodes of urinary incontinence, increases the volume of the worm, and reduces the volume of the residual urine in patients with overactive bladder syndrome.

Surgıcal Treatment

Bladder neck slings can be paired with and replaced by an anti-incontinence tape. Laparoscopic techniques include apical, paravaginal, and retropubic arrangements of the support mesh in the anterior vaginal wall. All these methods can be performed laparoscopically or with robotic assistance.

Although they are similar to other laparoscopic procedures, they still cannot compete with the anti-incontinence tape for longer patient roderation in the seat. This is why today, there are many minimally invasive operations that we do not perform frequently and for which we are relatively less experienced and know their long-term effects. Most of our experience with some procedures comes from texts that we have written ourselves. We must add to these texts, curriculum vitae, and the out-of-hospital market as well as recommendations for the treatment regime with these procedures.

In severe conditions, the most recommended type of surgery is bladder suspension or artificial urinary sphincter (AMS). All surgeries, however, have the same objective – to create a strong, long-term urethral under the neck so that the body does not leak urine. Bladder support is achieved through the Briggs operation, which is done laparoscopically and in a minimally invasive way, or in a variety of ways (suprapubic, overtape, lathamac or paretta). 

Anti-incontinence tape has been developed into a minimally invasive method and replaced other operative experimental procedures for the treatment of stress urinary incontinence in women. It was first tested in 1990 and is the method of choice for surgical treatment for the past decade. Due to the many positive aspects of the method, it has become a routine surgical procedure. According to a recently published paper, the method is quite safe, admissible, and effective.

Mıdurethral Slıngs

The primary advantage of the midurethral sling is the large volume of data regarding its efficacy and safety. The approach is based on the tension-free idea. The primary principle is that the portion of the sling lying within the abdominal-controlled pressure of the bladder neck is an unpressurized tube. In the treatment of stress urinary incontinence, the midurethral sling replaces the anterior ligament through either a retropubic or transobturator transvaginal approach, depending on surgeon preference and the patient’s anatomy. Treatment cure is achieved with tension on the sling present when abdominal pressure exceeds sphincter pressure, thereby allowing bladder neck support against the retropubic or transobturator position of the sling when needed by the urethra.

The midurethral sling, in particular the tension-free vaginal tape, has become the primary surgical treatment for female stress urinary incontinence. It is the treatment approach with the largest volume of data on its clinical efficacy. Although some issues with the approach exist, such as the high sling revision rate, the majority of women achieve complete or substantial cure of stress incontinence symptoms and quality of life following the procedure.

Artıfıcıal Urınary Sphıncter Implantatıon

The artificial urinary sphincter (AUS) is commonly used to manage stress urinary incontinence in males. In recent years, it has been gaining acceptance for usage in women who are symptomatic despite the intermediate use of other more conservative treatments, especially in cases of extreme stress urinary incontinence. 

Since its initial invention described by Dr. Scott, the device has had over 900 modifications with the aim to achieve low complication rates, a high degree of patient satisfaction, and great continence improvement. The AUS is a hybrid device and is compliant with the 2001 Medical Device Directive. It is composed of the uninhibited device, which is an implantable fluid-filled liquid silicone double-cuff system, and an antibulking pump. The AUS actuates purposefully by the activity of the pump and a control system placed into the body.

The artificial urinary sphincter provides a solution for those patients with stress urinary incontinence who are dissatisfied with, intolerant of, or have been unsuccessful with conservative treatments. It remains the gold standard for the treatment of male stress urinary incontinence. 

It has been more than 40 years since it was first described by Furlow, and over time it has been improving, achieving good continence outcomes and patient satisfaction rates, with a low complication rate. In recent years, it has been gaining acceptance for usage in women, especially in cases of extreme stress urinary incontinence. In this chapter, we will provide an exhaustive review of the AUS and its history, anatomy, perioperative and intraoperative setting, troubleshooting, and the section will conclude with a discussion of the future.

Emergıng Therapıes and Future Dırectıons

We are an increasingly individual and necessarily active society. It is increasingly common to require exertion periods equivalent to or greater than the youthful phase of life. With aging generations and a longer average life of the population,

it is predictable that urinary loss and sexual consequences linked to muscle incompetence will increase. And that repercussions range from sexual problems to economic questions, from spending on pads and guardians to the consequences of their inadequate use for skin, medical consultations, and even complications such as urinary tract infections. Providing appropriate care is becoming increasingly critical. 

Progress in modern medicine and the search for wellbeing results are primarily in treating the symptoms of deficient muscle performance. A multitude of interventions has already been proposed, of varying degrees of invasiveness, and new forms of proposing results for the treatment of SUI in men and women are constantly being investigated.

Nowadays, modern medicine has its research and development focusing mainly on the details of the human body, leading to the development of, for example, smart clothing used in some studies to monitor people’s health. That being said, the treatment of urinary incontinence is still being addressed with a strong hospital character, with few or no non-hospital therapeutic proposals. 

This chapter aims to discuss the current state and future directions of therapeutic perspectives for the treatment of this condition. After a comprehensive review of the most common urinary incontinence treatment methods, we present some emerging therapies, including drugs, neuromodulation, injections and stem cells, as well as the use of light and its photochemical effects in new treatments, in particular by the injection of phenylephrine, the use of Er:YAG and pulsed dye lasers and the use of light with platelet-rich plasma gel. Concluding this chapter are the comments and perspectives for the future on the subject.

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