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A 72-year-old woman has a 6-month history of almost daily urinary incontinence that frequently occurs without warning. She was diagnosed with urge incontinence 6 weeks ago, and oxybutynin was started. Although the frequency of episodes has decreased, incontinence still occurs two to three times each week, especially when she is away from home and not near a bathroom. There is no dysuria or nocturia.
Results of the physical examination are unremarkable.
Relevant laboratory results, including urinalysis and urine culture, are normal.
Which of the following is the best treatment for this patientís persisting urge incontinence?
A. Bladder training
B. Pubovaginal sling surgery
C. Transanal electrostimulation
D. Vaginal estrogen cream
E. Vaginal pessary
Answer: A, Bladder training.
Educational Objective: Treat urge urinary incontinence that has only partially responded to anticholinergic medication.
Critique: This patientís signs and symptoms are most consistent with urge urinary incontinence, the most common type of incontinence in elderly women. It is typically due to detrusor sphincter instability that increases with aging. Episodes are usually preceded by a normal sensation of needing to void. Factors that impair mobility (for example, Parkinson disease and osteoarthritis) may increase the risk of incontinent episodes by impeding the patientís ability to get to the bathroom promptly. Anticholinergic agents such as oxybutynin are effective in many patients with urge incontinence but may need to be combined with behavioral therapy or other treatment if a complete response is not achieved. Because oxybutynin has been only partially effective in this patient, she may benefit from bladder training, which is a formalized toileting technique to increase functional bladder capacity by gradually increasing the time between voiding.
Surgical procedures, such as pubovaginal sling procedures and retropubic suspension, are indicated for patients with moderate to severe stress urinary incontinence that is unresponsive to pelvic floor muscle training. However, surgery is not indicated for urge incontinence. Transanal electrostimulation of the bladder is accomplished by applying a small device in the vagina or anus. Some experts believe that this treatment has some efficacy for urge incontinence, but objective findings are inconclusive, and this therapy cannot be recommended at this time.
Results of randomized clinical trials have shown possible, but inconsistent, improvement in urinary incontinence with estrogen delivered by transdermal patch or vaginal cream or gel. However, these studies have typically been in women with stress, rather than urge, incontinence.
Medical devices such as vaginal pessaries or cones are not indicated for urge incontinence. Although these devices are commonly prescribed for stress incontinence, they have not been shown to be effective for this indication.
Key Point: Surgery is not indicated for patients with urge urinary incontinence.
Ostaszkiewicz J, Roe B, Johnston L. Effects of timed voiding for the management of urinary incontinence in adults: systematic review. J Adv Nurs. 2005;52(4):420-431. [PMID: 16268846]Table of Contents
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