Urinary incontinence can provide health care professionals with a challenge that may seem like it requires surgery when there are in fact a range of nonsurgical and even non-pharmacological options that can be employed first. To experienced urologists, this will be apparent, however other healthcare professionals who do not have a full working knowledge of urodynamic testing along with urinary incontinence treatment options may choose surgery or medication when there are many steps that can be taken and explored before resorting to more invasive options.
An Overview of Urinary Incontinence
Urinary continence is essentially the involuntary loss of urine when an individual cannot effectively retain the urine in their bladder. Although both men and women can experience urinary incontinence, it occurs at a higher rate in women, especially after menopause or as a result of obesity or a hysterectomy. There are currently 4 different types of urinary incontinence, those being stress incontinence, urge incontinence or overactive bladder (OAB), overflow incontinence, and mixed incontinence.
Stress incontinence is where urine is involuntarily expelled when stress is experienced by the bladder, such as when an individual coughs, sneezes, laughs, or changes position, all of which exert additional force on the abdomen and put stress on the bladder. This can be caused by damage to or weakness of the urinary sphincter muscle, as well as a lack of support normally provided by the ligaments holding the bladder.
Urge incontinence and overactive bladder syndrome (OAB) is the rapid and sudden onset of the urge to urinate with little warning, and because it is so difficult to control, often results in involuntary urination.
Overflow incontinence occurs when an individual does not experience the sensation of their bladder being full, even when their bladder is past its maximum capacity. Without the sensation of the bladder being full, once it has reached maximum capacity, urine is then expelled involuntarily.
Mixed incontinence is a combination of both stress and urge incontinence with characteristics of both of these types. Individuals suffering from mixed incontinence will experience a loss of urine when coughing, laughing, or putting stress on their bladder in other ways while also experiencing sudden urges to urinate.
While there do exist other causes for urinary incontinence and related health issues that are not mentioned here, the above-mentioned types of urinary incontinence are by far the most commonly seen types among patients and will be the most likely to be encountered by healthcare providers.
The Different Types of Treatment
With the different types of urinary incontinence outlined, we can now take a look at the different types of treatment available to healthcare providers that do not involve administering medications or performing surgery on patients. It is important to note that in cases when nonsurgical and nonpharmacological do not solve the root issue of urinary incontinence in patients, surgery and/or medications may then be effective, however nonsurgical and nonpharmacological options should serve as a first step before other, more invasive options are considered.
- Pelvic floor physical therapy and muscle training
Pelvic floor physical therapy (PFPT) is essentially a program of muscle training and strengthening of the pelvic floor muscles to improve pelvic floor strength, endurance, power, as well as relaxation. This is useful due to the fact that the pelvic floor muscles surround the bladder and urethra, playing a crucial role in urination and controlling the flow of urine.
The use of PFPT alone without complimentary treatments has been shown to relieve symptoms and even cure some types of urinary incontinence, and it is also often a necessary part of recovery after a patient has undergone surgery for urinary incontinence and other procedures that affect the pelvic floor muscles.
This form of treatment may be most useful for patients suffering from stress, urge, and mixed incontinence, and a collection of 31 trials involving 1817 women found that women suffering from stress incontinence who underwent PFPT were 8 times more likely to be cured of their urinary incontinence than the control groups who did not receive PFPT. All of the other types of urinary incontinence saw a five times higher rate of being cured when compared with the control groups.
Additionally, the rates of patients reporting that their urinary incontinence symptoms had improved, although weren’t completely cured, was six times higher than that of the control groups for stress urinary incontinence. All other incontinence types were twice as likely to report improvements.
- Biofeedback training
Following on from PFPT is biofeedback training, a form of pelvic floor muscle rehabilitation that utilizes a collection of electronic instruments that monitor the muscle strength and muscle performance for a more individualized PFPT regime. What makes biofeedback training useful however is that it allows patients to see when they are performing exercises correctly, which muscles they are activating and which ones need to be activated more, and gives them a better awareness of where these muscles are and how to use them. Because we cannot see the pelvic floor muscles, providing patients with visuals or computer graphs that help them understand what part of the body they need to be targeting has been shown to greatly improve the chances of recovery from urinary incontinence.
- Percutaneous tibial nerve stimulation (PTNS) treatment
PTNS has been proposed as being an effective treatment for overactive bladder syndrome (OAB) and other problems relating to the urological system such as non-obstructive urinary retention (NOUR).
Percutaneous tibial nerve stimulation treatment is a neuromodulation technique performed on the lower urinary tract through electrical stimulation of the posterior tibial nerve. The electrical stimulation itself takes place near the medial malleolus, the commonly known access point for the tibial nerve. Stimulation of this nerve has been shown to encourage effective regulation of both the bladder and the pelvic floor, effectively suppressing neurogenic detrusor overactivity.
- Pessary prosthetics
Although the pessary is one of the older gynecological tools available for modern medicine, they are still highly effective for helping female patients manage the symptoms of stress incontinence and much more outside of the field of urology. When things such as multiple vaginal childbirths, hysterectomies, and many other types of pelvic surgery weaken the pelvic floor and urinary sphincters, leading to stress incontinence, a pessary may be a great option instead of surgery.
Pessaries in themselves do not cure stress urinary incontinence. Instead, they offer additional support to the internal structures to prevent urine leakage and are appropriate for any individual who cannot undergo surgery, whether this is due to old age or current pregnancy, or for individuals who only experience stress urinary incontinence occasionally when doing heavy lifting and may not need surgery in order to continue living a normal life.
- Urethral bulking
Urethral bulking is another great option for patients who are struggling with stress urinary incontinence. Urethral bulking refers to the injection of a bulking agent around the patient’s urethra and is appropriate for patients who are not able to undergo surgery or do not wish to. The bulking agent that is injected around the urethra acts to reduce the diameter of the urethra, making it harder for urine to escape involuntarily when the patient coughs, sneezes, or puts any other pressure on the bladder.
Urethral bulking procedures have a 60% to 70% success rate which reduces the amount of leakage experienced by patients, although it is not a permanent solution to urinary incontinence with patients often requiring an additional bulking injection after 6 to 24 months. There exists a range of different bulking materials suitable for different patient needs, all of which consist of soft beads that are hypoallergenic suspended in a dissolvable gel. It is these beads that are injected into the appropriate location along the urethra to partially close the urethral opening to help prevent stress incontinence.
These procedures do not require general anesthesia or overnight hospital stays, and patients are able to eat and drink as normal before the procedure.
- Lifestyle changes
Lifestyle changes for patients will already be known by most healthcare professionals, however because of how important they are in managing and preventing most types of urinary incontinence, they deserve a mention here. A patient’s lifestyle, from the foods and drinks they consume to their weight and more all have an effect on their experience with urinary incontinence and the severity of their symptoms, and because they can control their lifestyle themselves, keeping patients informed about lifestyle impacts on incontinence allows them to play a key role in managing their recovery and reducing instances of leakage.
First of all, patients should be advised to avoid bladder irritants such as coffee, tea, alcohol, and carbonated drinks. Some acidic foods like oranges, grapefruits, lemons, and other citrus fruits along with their respective juices can also cause bladder irritation, leading to the strong need to urinate. Additionally, spicy foods along with foods rich in tomato-based products can have the same irritating effect on the bladder.
Patients should also know that it may be necessary to schedule their fluid intake. Because it can take between two and three hours for liquids to reach the bladder, patients can then use this information to plan when they should drink fluids depending on when they know a bathroom will be easily available, as well as when to stop drinking fluids before going to bed at night.
Some medications can also increase the frequency and need to urinate, so a review of the current medications a patient is taking may be necessary to see if there are any effective alternatives available to them.
And finally, if a patient is suffering from stress incontinence and are also overweight, then it may be beneficial for them to take their weight into consideration and begin engaging in regular exercise to lower their weight. Since stress incontinence is bladder leakage caused by stress on the bladder, excessive amounts of body fat can increase the amount of stress on the bladder, leading to more frequent leakages.