Treatment of urinary incontinence

A. Rehabilitation of the pelvic floor muscles is the common goal of treatments through the use of pelvic muscle exercises (Kegel's exercises), weighted vaginal cones and pelvic floor electrical stimulation.

B. A set of specially designed vaginal weights can be used as mechanical biofeedback to augment pelvic muscle exercises. The weights are held inside the vagina by contracting the pelvic muscles for 15 minutes at a time.

C. Pelvic floor electrical stimulation with a vaginal or anal probe produces a contraction of the levator ani muscle. Cure or improvement in 48 percent of treated patients, compared with 13 percent of control subjects.

D. Occlusive devices, such as pessaries, can mimic the effects of a retropubic urethropexy. A properly fitted pessary prevents urine loss during vigorous coughing in the standing position with a full bladder.

E. Medications such as estrogens and al-pha-adrenergic drugs may also be effective in treating women with stress incontinence. Stress incontinence may be treated with localized estrogen replacement therapy (ERT). Localized ERT can be given in the form of estrogen cream or an estradiol-impregnated vaginal ring (Estring).

Medications Used to Treat Urinary Incontinence

Drug

Dosage

Stress Incontinence

Pseudoephedrine (Sudafed)

15 to 30 mg, three times daily

Vaginal estrogen ring (Estring)

Insert into vagina every three months.

Vaginal estrogen cream

0.5 g, apply in vagina every night

Overactive bladder

Oxybutynin transdermal (Oxytrol)

39 cm2 patch 2 times/week

Oxybutynin ER (Ditropan XL)

5 to 15 mg, every morning

Tolterodine LA (Detrol LA)

2-4 mg qd

Generic oxybutynin

2.5 to 10 mg, two to four times daily

Tolterodine (Detrol)

1 to 2 mg, two times daily

Imipramine (Tofranil)

10 to 75 mg, every night

Dicyclomine (Bentyl)

10 to 20 mg, four times daily

Hyoscyamine (Cystospaz)

0.375 mg, two times daily

F. Alpha-adrenergic drugs such as pseudoephedrine improve stress incontinence by increase resting urethral tone. These drugs cause subjective improvement in 20 to 60 percent of patients.

G. Surgery to correct genuine stress incontinence is a viable option for most patients. Retropubic urethropexies (ie, Burch laparoscopic and Mar-shall-Marchetti-Krantz [MMK] procedures) and suburethral slings have long-term success rates consistently reported in the 80 to 96 percent range.

H. Another minimally invasive procedure for the treatment of stress incontinence caused by intrinsic sphincter deficiency is periurethral injection.

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