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URINARY INCONTINENCE OVERVIEW — Up to 50 percent of women experience urinary leakage during their lifetime, and 10 to 20 percent suffer from bothersome leakage. It is important to understand that leakage is not a normal part of aging and that treatments are available to reduce or eliminate the problem. Your health care clinician can help you with treatment if you are bothered by leaking urine, having to rush to the toilet frequently, or getting up from sleeping to go to the toilet.
This article discusses treatments for the two main types of leakage in women, stress incontinence and urgency incontinence. These treatments also apply to women who have a combination of urgency and stress incontinence, called mixed incontinence. Information about the different types of urinary incontinence and the causes, symptoms, and diagnosis of urinary incontinence is available separately. (See "Patient education: Urinary incontinence in women (Beyond the Basics)".)
More detailed information about urinary incontinence is available by subscription. (See 'Professional level information' below.)
BEFORE STARTING TREATMENT — Certain health conditions can worsen urine leakage. You should talk to your health care provider about treating these conditions and any medications that might be worsening your urinary leakage.
Your primary care clinician can help you initiate treatment, but you should seek treatment from a continence specialist if you experience accidental urine leakage that starts suddenly, particularly if it happens along with other symptoms such as bowel incontinence, numbness, or weakness in your legs. Also, you should seek care from a health professional if you have an inability to urinate, blood in the urine, multiple infections (three or more in one year), fevers, pain, or vaginal prolapse (a bulge) beyond the opening of the vagina.
INITIAL TREATMENTS — The following treatments may be helpful for women with stress and/or urgency incontinence.
Lifestyle modification — Some changes in your lifestyle may help symptoms of urinary leakage.
●Weight loss – If you are overweight or obese, talk to your health care provider about strategies to lose weight. In people who are obese or overweight, losing weight often helps to reduce urine leakage in addition to improving other chronic medical conditions that are associated with incontinence (eg, diabetes and hypertension).
●Fluid management – If you drink large amounts of fluids, you may find that cutting back on fluids will reduce your leakage. A total of 64 ounces of all liquids (water, juice, milk, etc) per day is sufficient for most people; you may need more fluid when you are active and sweating or if it is hot. If you drink too little fluid, your urine may become very concentrated and darker than usual; this can irritate your bladder and increase the urgency to urinate. One recommendation is to drink small amounts of fluid at regular intervals throughout the day (rather than drinking larger amounts all at once).
We also suggest reducing the amount of alcoholic, caffeinated, and carbonated beverages you drink. This may help decrease urinary urgency and leakage.
If you get up frequently during the night to urinate, stop drinking fluids three to four hours before you go to bed. You can also wear compression stockings during the day to prevent fluid from pooling in your legs during the day, which is eliminated at night when you are sleeping. If you have leg swelling, you can elevate your legs above the level of your heart before you go to bed.
●Avoiding constipation – Constipation can make urinary leakage worse. Increasing the amount of fiber in your diet to 30 grams per day may prevent constipation. Treatment of constipation is discussed in a separate topic. (See "Patient education: Constipation in adults (Beyond the Basics)".)
●Scheduled voiding – Emptying your bladder ("voiding") at regular intervals, rather than waiting until your bladder is very full, can decrease episodes of urgency incontinence and prevent stress leakage during physical activity with a full bladder. Try urinating every three to four hours regularly throughout the day.
Pelvic muscle exercises — Pelvic muscle exercises, also known as Kegel exercises, strengthen the muscles involved in controlling urine leakage. This is explained in a table (table 1). (See "Patient education: Pelvic floor muscle exercises (Beyond the Basics)".)
Practicing these exercises on a regular basis helps to strengthen the muscles used to support the urethra and prevent leakage caused by stress incontinence (eg, coughing, laughing, sneezing). If you have sudden urges to urinate, you can also perform these exercises to help temporarily control the urge. To do this, you need to stop what you are doing and do three quick pelvic floor contractions until the urgency subsides. Using this "freeze and squeeze" technique can reduce bladder contractions and give you more time to get to the toilet. If you have difficulty doing these exercises there are a lot of options that can help, including mobile apps, vaginal cones, pelvic floor exercise devices, and supervised physical therapy. Talk to your health care provider to see what options are available to help you do the exercises better.
Bladder training — Bladder training can help you learn to go to the bathroom less frequently by "retraining" your bladder to hold more urine. Bladder training has two components: going to the bathroom on a schedule while you are awake and using strategies to control sudden urges. A table describes a method for bladder training (table 2).
●You begin by going to the bathroom at specific intervals during the day, starting with a short time interval between trips to the bathroom.
●If you have an urgent need to urinate before it is time to go the bathroom again, try to suppress the urge by standing or sitting still, performing the pelvic muscle exercise described above ("freeze and squeeze"), and thinking of the urge as a wave that is fading away.
●When your urine control improves, increase the time between bathroom trips by 15 minutes. Your goal is to slowly increase this time up to a more normal interval. It is normal to urinate approximately every three to four hours during the day and for older adults to wake from sleeping to urinate up to once per night.
Topical vaginal estrogen — Vaginal estrogen may be helpful for women who are near menopause or have gone through menopause and have urinary incontinence and vaginal atrophy (dryness). (See "Patient education: Vaginal dryness (Beyond the Basics)".)
TREATMENTS FOR STRESS INCONTINENCE — If you continue to have symptoms despite the initial treatments for stress urinary incontinence, you can discuss other options with your health care provider.
●Supervised pelvic floor physical therapy – If you are not performing Kegel exercises effectively, you may benefit from formal instruction on how to do them. There are nurses and physical therapists specifically trained to assist with these exercises for your pelvic floor muscles, like having a "personal trainer."
●Vaginal pessaries – A vaginal pessary is a flexible device made of silicone that can be worn in the vagina. A pessary can help to reduce or eliminate stress incontinence to support the urethra. A pessary is a reasonable treatment if you want to delay or avoid surgery. When fit properly, you will not feel any discomfort with the pessary.
The pessary must be removed and cleaned with soap and water periodically. Many women can learn to do this on their own and are advised to remove it overnight once every week or two. For those women who cannot remove the device, the pessary can be monitored, cleaned, and replaced by a health care provider every three to six months. There is a small risk that the pessary can cause irritation or an erosion of the skin inside the vagina. If this occurs, vaginal estrogen and/or more frequent removal can resolve the problem.
Over-the-counter support devices are also available for stress incontinence and may be an option for women who don’t have access to obtain a pessary or want to try something on their own before evaluation and treatment by a health care provider.
●Medications – In the United States, there are no medications that have been approved for stress incontinence. Multiple medications have been evaluated for stress incontinence, but none are approved by the US Food and Drug Administration (FDA). You should talk to your health care provider about whether or not there are any medication options that are appropriate for you.
●Urethral bulking injections – Urethral bulking injections are outpatient (in-office) procedures performed with local anesthesia. After numbing the urethra, the clinician injects a filler material in the urethra to increase resistance to the urine flow that occurs with activities (ie, stress urinary incontinence). No incisions or recovery time is needed; however, urethral injections are less effective compared with traditional surgery for stress urinary incontinence.
●Surgery for stress urinary incontinence – Surgery offers the highest cure rate of any treatment for stress urinary incontinence, even in older women. There are several surgical procedures for the treatment of stress incontinence. Each procedure has its own risks, benefits, complications, and chance of failure. These issues should be discussed in detail with a surgeon who is experienced in performing procedures to treat incontinence.
In general, surgery for stress urinary incontinence is not recommended until you are finished having children because pregnancy and childbirth can cause damage, potentially allowing leakage to recur.
●Laser treatments – There is currently not enough evidence to support the use of vaginal laser treatment for stress urinary incontinence; however, research studies are underway. These treatments are not covered by insurance.
TREATMENTS FOR URGENCY INCONTINENCE AND OVERACTIVE BLADDER — If you continue to have symptoms despite initial treatments for urgency incontinence, you can discuss other options, such as medication and nerve stimulation, with your health care provider.
Medications — In some people, urgency incontinence is more severe and a medicine is needed to get symptoms under control. There are two main classes of medications: anticholinergics and beta adrenergics. Examples of anticholinergic medications include darifenacin (brand name: Enablex), fesoterodine (brand name: Toviaz), oxybutynin (sample brand names: Ditropan, Oxytrol, Gelnique), solifenacin (brand name: VESIcare), tolterodine (sample brand name: Detrol), and trospium (brand name: Sanctura). There are two beta adrenergic medications called mirabegron (brand name: Myrbetriq) and vibegron (brand name: Gemtesa).
Some people take medicine temporarily, until symptoms improve, while others take medication indefinitely.
●The most common side effects of anticholinergic medications are dry mouth and constipation. Other side effects include blurred vision for near objects, fast heart rate, drowsiness, urinary retention, and decreased cognitive function. These medications should not be used in patients with certain heart arrhythmias, gastric retention, myasthenia gravis (a thyroid disease), or narrow angle-closure glaucoma. The Oxytrol patch is associated with the least amount of these side effects and is available over the counter without a prescription. In the United States, tolterodine is also available without a prescription, whereas the other medications require a prescription. New evidence has linked long-term exposure of anticholinergics at high doses to dementia. Mirabegron works differently than the other medications and does not cause dry mouth and constipation side effects but may raise blood pressure, so you should have your blood pressure monitored carefully while taking this medication. Vibegron does not have the same issues with elevating blood pressure and can be chewed or crushed for people with difficulty swallowing pills. Some studies show that taking both an anticholinergic and a beta adrenergic together may be more effective than taking either one alone.
●There are several strategies to prevent and treat dry mouth and constipation. These include sucking on sugar-free candy or chewing gum and using over-the-counter oral lubricants. Constipation can be managed typically with fiber supplementation and dietary options such as prunes and prune juice. It is important not to drink more water to combat these symptoms, as excessive fluid intake can result in more urine leakage.
●There is a small risk of urinary retention (not being able to empty the bladder completely) with these medications, especially in older people. If you develop difficulty urinating or feel like you are not completely emptying your bladder, you should follow up with your provider for evaluation.
Other therapies — If medications are not enough to improve your symptoms, there are other options for treatment that you can discuss with your health care provider.
●Acupuncture – Acupuncture might improve stress and/or urgency urinary incontinence in some women.
●Percutaneous tibial nerve stimulation – This treatment involves placing a hair-thin needle (like acupuncture) into a nerve near the ankle. This nerve is connected to nerves in the lower back that affect your bladder. The needle is connected to a small device that sends electrical pulses to the nerve. The treatment is not painful. This treatment is performed in a health care clinician's office once per week for 12 weeks and, if needed, can be continued monthly for maintenance. However, you must not use this treatment (it is "contraindicated") if you have a cardiac pacemaker or infection or severe swelling of your ankles.
●Botox – Botulinum toxin A, also known as Botox, is a toxin produced by a bacteria that temporarily paralyzes muscles. Studies have examined using injections of Botox into the bladder as a treatment for urgency incontinence, for people who have not responded to other treatments. Botulinum toxin A is as effective as oral medication in decreasing leakage and more effective in eliminating leakage altogether.
However, there is a risk that botulinum toxin A will cause urinary tract infections or prevent the bladder from emptying. If you are unable to empty your bladder, you would need to insert a catheter (a thin tube) into your bladder several times per day to empty. However, the side effects are usually temporary (a few weeks). The decrease in leakage with botulinum toxin A injection can last six months or longer and the procedure needs to be repeated to not have leakage.
●Sacral neuromodulation – A sacral nerve stimulator (SNS) is a surgically implanted device that treats urinary incontinence. The device is placed under the skin in the upper buttock and is connected by wires to a nerve (the sacral nerve) in the lower back. It sends electrical pulses to the sacral nerve, which helps people with urgency incontinence, urgency and frequency, or urinary retention who have not improved with other treatments. It is similar to Botox in treating incontinence and can be tested first before the permanent implant is placed. Newer technology allows people with a SNS device to undergo MRI procedures if needed (in the past, a person with this device could not get an MRI). There are options of a rechargeable battery that is expected to last more than 15 years versus a non-rechargeable battery that lasts between 5 and 10 years. The devices range in size from 2.8 x 2.8 cm (about 1 inch square) to 4.4 x 5.5 cm (about 2 inches square).
Potential risks of the surgery include pain at the site where the unit is implanted (in the buttocks), movement of the device over time, infection, and others. More detailed information about sacral nerve stimulation is available separately. (See "Patient education: Treatment of interstitial cystitis/bladder pain syndrome (Beyond the Basics)", section on 'Electrical stimulation for painful bladder'.)
OTHER MEASURES
Pads — While pads are not a recommended treatment for incontinence, they are necessary in some cases. Pads and protective undergarments are available in a variety of sizes and absorbencies, depending upon how much you leak. Pads designed for menstrual bleeding are usually not typically adequate.
Information on pad varieties and other urinary incontinence supplies is available from medical supply companies and urinary incontinence advocacy groups (see 'Where to get more information' below). The United States National Association for Continence has an online tool that can help you to choose a protective garment.
Whatever pad you choose, it is important to keep your skin dry and to control urine odor. If your skin is exposed to urine for long periods, it can become irritated and can potentially develop skin burns or infection. Use of zinc-based barrier products can help protect the skin (ie, zinc oxide). Protective products for the bed or other furniture may also be needed.
Pads are expensive and are not usually covered by insurance; in the United States, some state Medicaid plans cover the cost of pads for people with very limited incomes. In other countries, pads may be obtained for no or little cost through continence advisor nurses.
Suction catheters — There are commercially available devices that wick moisture from undergarments using an external catheter (flexible tube) and a portable suction machine. These can be used at home to help minimize moisture and skin damage from wet undergarments or pads.
Portable toilet — If you have difficulty walking, talk to your health care clinician. You may benefit from a portable toilet (ie, commode) that can be placed close to your bed or living area. In addition, move electrical cords, loose rugs, or furniture out of hallways and walkways so that you do not trip or fall on the way to the bathroom.
WHERE TO GET MORE INFORMATION — Your healthcare clinician is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient education: Urinary incontinence in females (The Basics)
Patient education: Pelvic muscle (Kegel) exercises (The Basics)
Patient education: Neurogenic bladder in adults (The Basics)
Patient education: Surgery to treat stress urinary incontinence in females (The Basics)
Patient education: Treatments for urgency incontinence in females (The Basics)
Patient education: Using a catheter to empty the bladder (The Basics)
Patient education: Vaginal dryness (The Basics)
Patient education: Pelvic organ prolapse (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: Urinary incontinence in women (Beyond the Basics)
Patient education: Pelvic floor muscle exercises (Beyond the Basics)
Patient education: Constipation in adults (Beyond the Basics)
Patient education: Treatment of interstitial cystitis/bladder pain syndrome (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Female urinary incontinence: Evaluation
Lower urinary tract symptoms in males
Effect of pregnancy and childbirth on urinary incontinence and pelvic organ prolapse
Pelvic organ prolapse and stress urinary incontinence in females: Surgical treatment
Stress urinary incontinence in females: Persistent/recurrent symptoms after surgical treatment
Female urinary incontinence: Treatment
Vaginal pessaries: Indications, devices, and approach to selection
Female stress urinary incontinence: Choosing a primary surgical procedure
Surgical management of stress urinary incontinence in women: Choosing a type of midurethral sling
Surgical management of stress urinary incontinence in females: Retropubic midurethral slings
Surgical management of stress urinary incontinence in females: Transobturator midurethral slings
The following organizations also provide reliable health information.
●National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
●National Institute on Aging
●The American Urogynecology Association
●Pelvic Floor Disorders Research Foundation
(http://www.voicesforpfd.org/)
●National Association for Continence
1-800-BLADDER
●Simon Foundation
●National Institute of Diabetes & Digestive & Kidney Diseases
●American Urological Association Foundation
●For continence resources in other countries, go to Continence Worldwide
●International Urogynecological Association
(https://www.yourpelvicfloor.org/leaflets/)
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ACKNOWLEDGMENT — The editorial staff at UpToDate would like to acknowledge Catherine E DuBeau, MD, who contributed to an earlier version of this topic review.
