Incontinence
Page updated Winter 2021.
Disclaimer: Medicine is an ever-changing science. We have been witnessing changes in diagnostic and therapeutic modalities and guidelines during last several years. We have used sources believe to be reliable for purpose of this website including AUA guidelines, EAU guidelines, NCCN guidelines, Campbell-Walsh-Wein Urology, UpToDate, Merck Manual, Lexi-Comp, FDA website, and other reputable sources. However, due to possibility of human error or changes in medicine, readers are required to confirm the information provided in this website with other sources. Readers are specially required to read all parts of the product information sheet included in the package of each drug they plan to administer and follow those instructions. Readers are also needed to follow instructions of FDA and other regulatory bodies and their own department in this regard. Authors can cite information provided in our textbooks or they need to cite the original sources. This website serves as a general framework. We and other users would adjust the approach per departments policies and patients situation. Forms can be used by other health care professionals.
Overactive Bladder
Behavioral Therapies
Clinicians should offer behavioral therapies including bladder training, bladder control strategies, pelvic floor muscle training, and fluid management as first line therapy to all patients with overactive bladder.
Pharmacologic Management
Oral anti-muscarinics
Extended release (ER) formulation are preferred.
Oral β3-adrenoceptor agonists
Transdermal oxybutynin (patch or gel)
Anti-muscarinic plus β3-adrenoceptor agonist
Anti-muscarinics contraindications:
Narrow-angle glaucoma
Antimuscarinics cautions:
Impaired gastric emptying
History of urinary retention
Using other medications with anti-cholinergic properties
Frail patient
β3-adrenoceptor cautions:
Frail patient
Third-Line Treatments
Intradetrusor onabotulinumtoxinA
100U
Patient should be able and willing to perform self-catheterization if necessary.
Peripheral tibial nerve stimulation (PTNS)
Sacral neuromodulation (SNS)
Fourth-Line Treatment
Augmentation cystoplasty
Urinary diversion
Stress Urinary Incontinence
Female patients:
Non-surgical Management
Pelvic floor muscle training (± biofeedback)
Continence pessary
Vaginal inserts
Duloxetine: when surgery is not indicated. Use dose titration.
Surgical Management
Midurethral sling
Synthetic polypropylene mesh sling placement is the most common surgery currently performed for female stress urinary incontinence.
Retropubic or trans-obturator
Autologous fascia pubovaginal sling
Burch colposuspension
Bulking agents
Surgical options for Intrinsic Sphincter Deficiency:
Pubovaginal slings
Retropubic midurethral slings
Bulking agents
Cautions:
We do not suggest synthetic midurethral sling if there is:
Simultaneous urethral diverticulectomy
Simultaneous repair of urethrovaginal fistula
Simultaneous urethral mesh excision
History of radiation therapy
Significant scarring
Poor tissue quality
Recurrent Stress Urinary Incontinence
Options: synthetic sling, colposuspension or autologous sling
Overflow Incontinence
Chronic urinary retention is defined as post void residue of >300 mL that has persisted for at least six months. It can cause overflow incontinence.
If there is a treatable cause, cause should be treated.
Patient might need clean intermittent catheterization.
Bethanechol, a cholinergic agonist, is not recommended.
Incontinence after Prostate Surgery
Pelvic floor muscle exercises
It is the first line management.
Pharmacologic Management
Urgency urinary incontinence
Should be treated as mentioned in overactive bladder section.
Stress urinary incontinence
May use duloxetine only to hasten recovery of urinary continence.
Bulking Agents
Maybe used only for patients with mild incontinence.
Male Slings
May be considered as a treatment option for mild to moderate stress urinary incontinence.
Male slings will not be considered in patients with severe stress incontinence.
Men with previous radiotherapy or urethral stricture surgery may have less benefit from male slings.
Artificial Urinary Sphincter
Will be considered for patients with bothersome stress urinary incontinence.
A single cuff perineal approach is preferred.
Mechanical failure is common with the AUS.
Rate of explantation because of infection or erosion is high.