Incontinence

Updated 10 June 2016

Treating incontinence

There are a number of different treatment options for incontinence including both surgical and non-surgical solutions.

1

The treatment of incontinence will vary according to the cause, type and severity of the problem.

Many people are hesitant to see a doctor for incontinence as they feel embarrassed or believe it can't be treated or that the problem will eventually go away by itself. This may be true in a few cases, but many cases can be successfully treated or managed. The treatment of incontinence will vary according to whether it is faecal or urinary incontinence and will depend on the cause, type and severity of the problem.

Treating Urinary Incontinence

1. Stress incontinence 

Non-medical treatment

• Weight loss 
• Cessation of smoking 
• Pelvic floor exercises 
• Vaginal weights 
• Biofeedback 
• Electrical stimulation 

Non-medical treatment can be very effective in motivated patients with minor degrees of stress incontinence. The short-term results are often very good, but this isn't always maintained in the long term. Published studies quote cure/improvement rates of 50-80% for pelvic-floor exercises. 

Medical treatment 

• Oestrogens 
• Alpha-agonists 
• Combination of the above 

Medical treatment doesn't have a great role in stress incontinence. Postmenopausal atrophy affects the closure of the urethra. Oestrogens, which can be taken orally or applied locally, restores the bulk of urethral tissue leading to more effective closure. Alpha-agonists increase the tone in the bladder neck, thereby increasing outflow resistance. Some studies indicate a beneficial effect using a combination of oestrogen and an alpha-agonist in older post-menopausal women. 

Surgical treatment

• Periurethral injections of bulking agents 
• Suspension operations 
• Sling operations 
• Artificial urinary sphincters 

Periurethral injections involve the injection of bulking agents into the urethra to improve effective urethral closure. Commonly used agents include fat, collagen, Teflon paste and silicon particles. Injection therapy is suitable for women with intrinsic sphincter deficiency rather than hypermobility, as well as for men with post-prostatectomy incontinence. The major advantage of injection therapy is that it's a minor procedure. Short-term results are good, but often not maintained long-term. 

The various suspension operations restore the normal anatomy in patients with hypermobility and improve the support of the urethra and the bladder neck. Open suspension operations like the Burch coposuspension provide the best long-term results. The various needle suspensions have fallen into disuse due to high failure rates. 

Urethral slings can be used in people with intrinsic sphincter deficiency as well as those with hypermobility. It involves the placement of a strip of tissue or artificial substance that supports the urethra and bladder neck like a hammock. It increases outflow resistance and improves urethral closure by supporting the mid urethra. The vast majority of patients can be rendered dry in this way, but the operation does carry the risk of difficulty with passing urine afterwards. Other complications include infection or erosion of the synthetic sling material which then has to be removed. 

An artificial urinary sphincter (AUS) made of silicone can be used in someone with total incontinence resulting from irreparable damage to the sphincter. The AUS consists of a small cuff that is placed around the urethra (bladder tube), with a reservoir (balloon) that is placed in the lower belly next to the bladder. Both of these are connected with a small tube to a valve placed in the scrotum, which the person then uses to inflate or deflate the cuff. An AUS is very effective, but it is quite expensive, and there is a risk of infection or erosion of the synthetic material. 

2. Urge incontinence

Non-medical treatment

• Bladder training 
• Biofeedback 
• Pelvic floor exercises 

Voiding by the clock and progressively increasing the time between voids can improve the symptoms of patients with urge incontinence and otherwise normal bladders. This can be combined with biofeedback and pelvic floor exercises. 

Medical treatment

• Oxybutynin 
• Tolterodine 
• Imipramine 

Drug therapy forms the mainstay of treatment for patients with urge incontinence due to bladder instability. These anticholinergic agents relax the bladder muscle and increase bladder capacity. Side effects include a dry mouth, constipation and blurred vision. 

Surgical treatment 

Injection of botulinum A toxin (Botox) into the bladder muscle (detrusor) can be used if the urge incontinence is due to a neurological disease causing overactive bladder contractions. 

Tiny bladders due to radiation or tuberculosis can be enlarged surgically. A segment of intestine is patched onto the opened bladder, thereby increasing the capacity. Patients with intractable bladder instability who have failed medical treatment can also be treated in this way. 

3. Overflow incontinence

Overflow incontinence due to bladder outflow obstruction is treated by surgically alleviating the obstruction. The most common example would be a man with prostatic enlargement treated by resection of the prostate gland. If the incontinence is due to failure of the bladder to contract then intermittent clean self-catheterisation is the most appropriate treatment. Permanent indwelling catheters should be avoided if at all possible. 

4. Total incontinence 

Total incontinence due to a vesicovaginal fistula or aureterovaginal fistula is treated by surgical repair of the defect. 

Treating faecal incontinence

Once your doctor has established the underlying cause of faecal incontinence, they will decide on the most suitable treatment, which could involve a combination of medication, exercise and other methods. 

Let’s look at some of the treatment options available for FI:

Dietary changes: If your FI is caused by diarrhoea or constipation, making changes to your diet may sometimes help to normalise and regulate bowel movements. Your doctor may ask you to keep a food diary to monitor the impact of dietary changes. For example, he or she may suggest increasing your intake of high-fibre foods and fluids, or to eliminate foods that may exacerbate the problem. 

Medications: Your doctor may recommend specific medication or bulking agents such as fibre supplements to change stool consistency, depending on whether you suffer from diarrhoea or constipation. Another option is Solesta, an injectable FDA-approved gel that's injected into the anus and effectively reduces or completely treats FI in some people. This gel narrows the anal opening by increasing the growth of rectal tissue and helping it to remain tightly closed. 

Bowel retraining: This routine encourages normal bowel movements and helps you achieve greater control by becoming more aware of the need to use the toilet. It may incorporate various aspects such as making a conscious effort to have a bowel movement at a specific time of day and using suppositories to stimulate bowel movements. 

Biofeedback: This improves the strength and coordination of the anal muscles that help control bowel movements, and heightens the sensation related to the rectum filling with stool. It usually involves a specially trained physiotherapist teaching you simple exercises to strengthen your pelvic-floor muscles, sense when stool is ready to be released and contract the muscles if it's not appropriate to have a bowel movement at a specific time. 

Kegel exercises: Also called pelvic-floor exercises, these focus on strengthening the muscles of the anus, buttocks and pelvis. When done correctly, they can be effective in improving or resolving FI. They involve a routine of repeatedly contracting muscles used when making a bowel movement. Hold these muscles as if you're trying to stop the flow of stool or passing gas for a slow count of five, and then relax. Kegel exercises should be done in a series of 30 contractions three times a day. They usually strengthen the pelvic-floor muscles within a few weeks. 

Surgery: In some cases, surgery may help people with severe FI who haven't responded to other treatments or people with an underlying condition causing incontinence that need surgery to regain control. There are various surgical options and your doctor will probably refer you to a specialist. 

Read more:

Diagnosing incontinence

Preventing incontinence

Risk factors for incontinence

Image: Foley catheter and drainage bag with sterile gloves and specimen container on blue background from Shutterstock

 

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Incontinence Expert

Prenevin Govender completed his MBChB at the University of Cape Town in 2001. He obtained his Fellowship of the College of Urologists in 2009 and graduated with distinction for a Masters in Medicine from the University of Cape Town in 2010. His special interests include laparoscopic, pelvic organ prolapse and urinary incontinence surgery. He consults full-time at Life Kingsbury Hospital in Claremont.

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