Urinary incontinence: Difference between revisions

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===Medications===
===Medications===
====Urge incontinence====
====Urge incontinence====
For urge incontinence (detrusor instability) [[Acetylcholine|anticholinergic drugs]] such as [http://dailymed.nlm.nih.gov/dailymed/search.cfm?startswith=oxybutynin oxybutynin] and [http://dailymed.nlm.nih.gov/dailymed/search.cfm?startswith=tolterodine tolterodine] are effective according to a [[systematic review]].<ref name="pmid18268288">{{cite journal |author=Shamliyan TA, Kane RL, Wyman J, Wilt TJ |title=Systematic review: randomized, controlled trials of nonsurgical treatments for urinary incontinence in women |journal=Ann. Intern. Med. |volume=148 |issue=6 |pages=459–73 |year=2008 |month=March |pmid=18268288 |doi= |url=http://www.annals.org/cgi/pmidlookup?view=long&pmid=18268288 |issn=}}</ref>
For urge incontinence (detrusor instability) [[Acetylcholine|anticholinergic drugs]] such as [http://dailymed.nlm.nih.gov/dailymed/search.cfm?startswith=oxybutynin oxybutynin] and [http://dailymed.nlm.nih.gov/dailymed/search.cfm?startswith=tolterodine tolterodine] are effective according to recent [[systematic review]]s. Tolterodine has low [[drug toxicity]].<ref>{{Cite journal
| doi = 10.1059/0003-4819-156-12-201206190-00436
| issn = 0003-4819, 1539-3704
| last = Shamliyan
| first = Tatyana
| coauthors = Jean F Wyman, Rema Ramakrishnan, François Sainfort, Robert L Kane
| title = Systematic Review: Benefits and Harms of Pharmacologic Treatment for Urinary Incontinence in Women
| journal = Annals of Internal Medicine
| accessdate = 2012-04-10
| date = 2012-04-09
| url = http://www.annals.org/content/early/2012/04/09/0003-4819-156-12-201206190-00436
}}</ref><ref name="pmid18268288">{{cite journal |author=Shamliyan TA, Kane RL, Wyman J, Wilt TJ |title=Systematic review: randomized, controlled trials of nonsurgical treatments for urinary incontinence in women |journal=Ann. Intern. Med. |volume=148 |issue=6 |pages=459–73 |year=2008 |month=March |pmid=18268288 |doi= |url=http://www.annals.org/cgi/pmidlookup?view=long&pmid=18268288 |issn=}}</ref>


A [[randomized controlled trial]] of both men and women found that the [[anticholinergic]] medication [[trospium]] is effective.<ref name="pmid17632131">{{cite journal |author=Staskin D, Sand P, Zinner N, Dmochowski R |title=Once daily trospium chloride is effective and well tolerated for the treatment of overactive bladder: results from a multicenter phase III trial |journal=J. Urol. |volume=178 |issue=3 Pt 1 |pages=978–83; discussion 983–4 |year=2007 |pmid=17632131 |doi=10.1016/j.juro.2007.05.058}}</ref>
A [[randomized controlled trial]] of both men and women found that the [[anticholinergic]] medication [[trospium]] is effective.<ref name="pmid17632131">{{cite journal |author=Staskin D, Sand P, Zinner N, Dmochowski R |title=Once daily trospium chloride is effective and well tolerated for the treatment of overactive bladder: results from a multicenter phase III trial |journal=J. Urol. |volume=178 |issue=3 Pt 1 |pages=978–83; discussion 983–4 |year=2007 |pmid=17632131 |doi=10.1016/j.juro.2007.05.058}}</ref>


A [[randomized controlled trial]] in men of behavioral therapy versus the [[anticholinergic]] medication [[oxybutynin]] (no control group) are effective.<ref name="pmid22092152">{{cite journal| author=Burgio KL, Goode PS, Johnson TM, Hammontree L, Ouslander JG, Markland AD et al.| title=Behavioral Versus Drug Treatment for Overactive Bladder in Men: The Male Overactive Bladder Treatment in Veterans (MOTIVE) Trial. | journal=J Am Geriatr Soc | year= 2011 | volume= 59 | issue= 12 | pages= 2209-16 | pmid=22092152 | doi=10.1111/j.1532-5415.2011.03724.x | pmc= | url= }} </ref> The behavioral treatment included:
A [[randomized controlled trial]] in men of behavioral therapy versus the [[anticholinergic]] medication [[oxybutynin]] (no control group) found similar effectiveness.<ref name="pmid22092152">{{cite journal| author=Burgio KL, Goode PS, Johnson TM, Hammontree L, Ouslander JG, Markland AD et al.| title=Behavioral Versus Drug Treatment for Overactive Bladder in Men: The Male Overactive Bladder Treatment in Veterans (MOTIVE) Trial. | journal=J Am Geriatr Soc | year= 2011 | volume= 59 | issue= 12 | pages= 2209-16 | pmid=22092152 | doi=10.1111/j.1532-5415.2011.03724.x | pmc= | url= }} </ref> The behavioral treatment included:
* Pelvic floor muscle training. Patients were taught "how to contract and relax pelvic floor muscles while keeping abdominal muscles relaxed"... "Participants were taught to contract their muscles for 2- to 10-second periods separated by 2 to 10 seconds of relaxation. Initial contraction duration was based on the ability demonstrated by each participant in the training session. Recommendations for daily  practice included 45 exercises, divided into manageable sessions,  usually three sessions of 15 exercises each. Across sessions, duration  was increased gradually to a maximum of 10 seconds."
* Pelvic floor muscle training
* Urge suppression techniques. "Specifically, when participants awakened at night with the urge to void, they were to remain still in bed and attempt to diminish the urgency with repeated pelvic floor muscle contractions. If successful, they could go back to sleep; if not, they could void and return to bed."
** "contract and relax pelvic floor muscles while keeping abdominal muscles relaxed"
** "contract their muscles for 2- to 10-second periods separated by 2 to 10 seconds of relaxation.
*** "Initial contraction duration was based on the ability demonstrated by each participant in the training session.”
** "Daily practice included 45 exercises”
***    "divided into manageable sessions”
***    "usually three sessions of 15 exercises each”
** "Duration was increased gradually to a maximum of 10 seconds"  
* Urge suppression techniques when awakened at night with the urge to void
** "Remain still in bed and attempt to diminish the urgency with repeated pelvic floor muscle contractions.
** "If successful, they could go back to sleep; if not, they could void and return to bed."  
* Fluid restriction (after 6:00 p.m.)
* Fluid restriction (after 6:00 p.m.)


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Urinary incontinence is defined as "Involuntary loss of urine, such as leaking of urine. It is a symptom of various underlying pathological processes."[1]

Classification

Urge incontinence

Stress incontinence

Etiology/Cause

Incontinence is more common after a hysterectomy.[2]

Diagnosis

A systematic review by the Rational Clinical Examination has reviewed hot to diagnose the types of incontinence and concluded that the "most helpful component for diagnosing urge urinary incontinence is a history of urine loss associated with urgency. A bladder stress test may be helpful for diagnosing stress urinary incontinence."[3] The bladder stress test is "performed while the woman is supine or standing, involves observation for urine loss immediately on coughing or with a Valsalva maneuver".[3]

Treatment

Clinical practice guidelines address the treatment of males. [4]

The treatment of women has been reviewed.[5][6]

Prompted voiding

Prompted voiding helps according to a systematic review.[7]

Exercises

Kegel exercises to strengthen or retrain pelvic floor muscles and sphincter muscles can reduce stress leakage.[8] Patients younger than 60 years old benefit the most.[8] The patient should do at least 24 daily contractions for at least 6 weeks.[8] A systematic review concluded "pelvic floor muscle training would resolve 490 cases of stress urinary incontinence."[9]

Weight loss

Weight loss was helpful in a randomized controlled trial.[10]

Medications

Urge incontinence

For urge incontinence (detrusor instability) anticholinergic drugs such as oxybutynin and tolterodine are effective according to recent systematic reviews. Tolterodine has low drug toxicity.[11][12]

A randomized controlled trial of both men and women found that the anticholinergic medication trospium is effective.[13]

A randomized controlled trial in men of behavioral therapy versus the anticholinergic medication oxybutynin (no control group) found similar effectiveness.[14] The behavioral treatment included:

  • Pelvic floor muscle training
    • "contract and relax pelvic floor muscles while keeping abdominal muscles relaxed"
    • "contract their muscles for 2- to 10-second periods separated by 2 to 10 seconds of relaxation.
      • "Initial contraction duration was based on the ability demonstrated by each participant in the training session.”
    • "Daily practice included 45 exercises”
      • "divided into manageable sessions”
      • "usually three sessions of 15 exercises each”
    • "Duration was increased gradually to a maximum of 10 seconds"
  • Urge suppression techniques when awakened at night with the urge to void
    • "Remain still in bed and attempt to diminish the urgency with repeated pelvic floor muscle contractions.
    • "If successful, they could go back to sleep; if not, they could void and return to bed."
  • Fluid restriction (after 6:00 p.m.)

Stress incontinence

For stress incontinence, phenylpropanolamine 50 mg twice daily by mouth can help.[15][16][17]

Topical estrogen can help[18] and can be combined with phenylpropanolamine[17].

Surgery

Among surgical options, a randomized controlled trial found greater benefit, but more complications from Fascial sling surgery as compared to Burch colposuspension.[19]

References

  1. ↑ Error on call to Template:cite web: Parameters url and title must be specified. Retrieved on 2007-10-26.
  2. ↑ Altman D, Granath F, Cnattingius S, Falconer C (2007). "Hysterectomy and risk of stress-urinary-incontinence surgery: nationwide cohort study". Lancet 370 (9597): 1494–9. DOI:10.1016/S0140-6736(07)61635-3. PMID 17964350. Research Blogging.
  3. ↑ 3.0 3.1 Holroyd-Leduc JM, Tannenbaum C, Thorpe KE, Straus SE (2008). "What type of urinary incontinence does this woman have?". JAMA 299 (12): 1446-56. DOI:10.1001/jama.299.12.1446. PMID 18364487. Research Blogging.
  4. ↑ Jones C, Hill J, Chapple C, Guideline Development Group (2010). "Management of lower urinary tract symptoms in men: summary of NICE guidance.". BMJ 340: c2354. DOI:10.1136/bmj.c2354. PMID 20484350. Research Blogging.
  5. ↑ Goode, Patricia S.; Kathryn L. Burgio, Holly E. Richter, Alayne D. Markland (2010-06-02). "Incontinence in Older Women". JAMA 303 (21): 2172-2181. DOI:10.1001/jama.2010.749. Retrieved on 2010-06-02. Research Blogging.
  6. ↑ Rogers RG (2008). "Clinical practice. Urinary stress incontinence in women.". N Engl J Med 358 (10): 1029-36. DOI:10.1056/NEJMcp0707023. PMID 18322284. Research Blogging.
  7. ↑ Fink HA, Taylor BC, Tacklind JW, Rutks IR, Wilt TJ (December 2008). "Treatment interventions in nursing home residents with urinary incontinence: a systematic review of randomized trials". Mayo Clin. Proc. 83 (12): 1332–43. PMID 19046552. [e]
  8. ↑ 8.0 8.1 8.2 Choi H, Palmer MH, Park J (2007). "Meta-analysis of pelvic floor muscle training: randomized controlled trials in incontinent women". Nursing research 56 (4): 226-34. DOI:10.1097/01.NNR.0000280610.93373.e1. PMID 17625461. Research Blogging.
  9. ↑ Tatyana A. Shamliyan et al., “Systematic Review: Randomized, Controlled Trials of Nonsurgical Treatments for Urinary Incontinence in Women,” Ann Intern Med (February 11, 2008): http://www.annals.org/cgi/content/full/0000605-200803180-00211v1
  10. ↑ Subak LL, Wing R, West DS, Franklin F, Vittinghoff E, Creasman JM et al. (2009). "Weight loss to treat urinary incontinence in overweight and obese women.". N Engl J Med 360 (5): 481-90. DOI:10.1056/NEJMoa0806375. PMID 19179316. Research Blogging. Review in: Evid Based Med. 2009 Aug;14(4):118 Review in: Evid Based Nurs. 2009 Oct;12(4):110
  11. ↑ Shamliyan, Tatyana; Jean F Wyman, Rema Ramakrishnan, François Sainfort, Robert L Kane (2012-04-09). "Systematic Review: Benefits and Harms of Pharmacologic Treatment for Urinary Incontinence in Women". Annals of Internal Medicine. DOI:10.1059/0003-4819-156-12-201206190-00436. ISSN 1539-3704 0003-4819, 1539-3704. Retrieved on 2012-04-10. Research Blogging.
  12. ↑ Shamliyan TA, Kane RL, Wyman J, Wilt TJ (March 2008). "Systematic review: randomized, controlled trials of nonsurgical treatments for urinary incontinence in women". Ann. Intern. Med. 148 (6): 459–73. PMID 18268288. [e]
  13. ↑ Staskin D, Sand P, Zinner N, Dmochowski R (2007). "Once daily trospium chloride is effective and well tolerated for the treatment of overactive bladder: results from a multicenter phase III trial". J. Urol. 178 (3 Pt 1): 978–83; discussion 983–4. DOI:10.1016/j.juro.2007.05.058. PMID 17632131. Research Blogging.
  14. ↑ Burgio KL, Goode PS, Johnson TM, Hammontree L, Ouslander JG, Markland AD et al. (2011). "Behavioral Versus Drug Treatment for Overactive Bladder in Men: The Male Overactive Bladder Treatment in Veterans (MOTIVE) Trial.". J Am Geriatr Soc 59 (12): 2209-16. DOI:10.1111/j.1532-5415.2011.03724.x. PMID 22092152. Research Blogging.
  15. ↑ Lehtonen T, Rannikko S, Lindell O, Talja M, Wuokko E, Lindskog M (1986). "The effect of phenylpropanolamine on female stress urinary incontinence". Ann Chir Gynaecol 75 (4): 236–41. PMID 3535621. [e]
  16. ↑ Collste L, Lindskog M (October 1987). "Phenylpropanolamine in treatment of female stress urinary incontinence. Double-blind placebo controlled study in 24 patients". Urology 30 (4): 398–403. PMID 3310369. [e]
  17. ↑ 17.0 17.1 Beisland HO, Fossberg E, Moer A, Sander S (1984). "Urethral sphincteric insufficiency in postmenopausal females: treatment with phenylpropanolamine and estriol separately and in combination. A urodynamic and clinical evaluation". Urol. Int. 39 (4): 211–6. PMID 6541387. [e]
  18. ↑ Holtedahl K, Verelst M, Schiefloe A (July 1998). "A population based, randomized, controlled trial of conservative treatment for urinary incontinence in women". Acta Obstet Gynecol Scand 77 (6): 671–7. PMID 9688247. [e]
  19. ↑ Albo ME, Richter HE, Brubaker L, et al (2007). "Burch colposuspension versus fascial sling to reduce urinary stress incontinence". N. Engl. J. Med. 356 (21): 2143–55. DOI:10.1056/NEJMoa070416. PMID 17517855. Research Blogging.
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