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Treating Urinary Incontinence by the PCP and Urogynecologist

Maria Canter, MD , Ms , FACOG, is Co-Director of the Center for Pelvic Floor Health at Virginia Hospital Center. She graduated from Georgetown University Medical School. She completed her residency in Obstetrics and Gynecology at Georgetown University Medical Center and graduated from University of Louisville’s Urogynecology Fellowship Program. She is extensively trained in minimally invasive surgery, including specialized laparoscopic procedures to correct prolapse.

As many as 50% of women who are significantly bothered by urinary incontinence (UI) do not discuss their symptoms with a clinician, according to Maria Canter, MD, M , FACOG, Urogynecology & Pelvic Surgery Center, yet treatment can offer relief to most of them.

Prevalence

UI covers a spectrum that occurs at any age, although more commonly in women over age 40. A patient may experience:

  • Urinary stress incontinence: Urethral hypermobility or intrinsic sphincter deficiency, resulting in leakage while coughing, lifting, or other activities.
  • Detrusor overactivity incontinence (urge urinary incontinence): Strong sudden urge to void, with more than eight voids during the day or nocturia signaling the condition.
  • Overflow incontinence (urinary retention): Inability to void completely, resulting in frequent involuntary urine loss.
  • Mixed urinary incontinence: A combination of the first two conditions.

Some neurological and chronic conditions may include UI; imaging may also reveal a spinal abnormality that contributes. “However, most urge urinary incontinence is idiopathic,” Dr. Canter noted, but said not to minimize the range of morbidities, including anxiety and other psychological effects.

First-Line Treatment

If a woman experiences incontinence and is emptying completely (ultrasound or a catheter can determine if unsure), PCPs have several options. They include diet modification, training the bladder to increase the length of time before voiding, and other behavioral interventions. Pelvic floor physical therapists also can be consulted.

The next step may be medication. Anticholinergics relax the smooth muscle of the bladder. The new beta-agonist mirabegron (Myrbetriq®) received FDA approval in 2012.

Referral to a Urogynecologist

If these medications do not work or have side effects, if the woman cannot fully void, or if more complex medical conditions or pelvic floor surgery are involved, a referral to a urogynologist may be indicated. Treatments include InterStim®, Botox, and sling surgery.

The sacral neuromodulation device InterStim intercepts miscommunication between the brain and bladder and is effective in about 70% of cases. The patient “testdrives” an external device for five days; if improvement is at least 50%, it is implanted in an outpatient procedure.

Patients with UI not associated with retention may benefit from Botox injected in the bladder every 6 to 9 months; however, Dr. Canter noted a higher risk of urinary retention.

Vaginal slings can treat urinary stress incontinence and are 60–90% effective. She distinguished between these slings and the transvaginal mesh used for pelvic organ relapse that were the target of an FDA warning in 2011.

—Maria Canter, MD , Ms , FACOG

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Keep in Mind
  • About 50% of women with UI do not raise the issue with a clinician.
  • Certain neurological and chronic conditions, including MS, Parkinson’s, and uncontrolled diabetes, are flags to investigate for UI.
  • Diet, bladder training, and medication are first-line treatments.
  • Sacroneuromodulation, Botox, and vaginal sling surgery are available to the urogynecologist if medication does not work or has side effects.
Contributing to UI
Although usually idiopathic, in some cases, a trigger can be identified. For example, when Dr. Canter worked with several women in their 20s, it came out that all added the same popular powdered drink mix to their water; stopping consumption solved the problem.

Other triggers to watch for: alcohol, A-adrenergic blockers, ACE inhibitors, anticholinergics, antipsychotics, calcium channel blockers, estrogen, GABAnergic agents, loop diuretics, narcotics, NSAIDs, OCPs, sedatives, thiazolidinediones, and TZA.

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