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Treatments/Management Options

31 January 2013

It is imperative that patients should be carefully and thoroughly assessed and preliminary investigations undertaken, eg urinalysis, to ensure that the appropriate treatment and management options are considered.

Stress Urinary Incontinence (SUI)

The first-line conservative option for SUI is pelvic floor muscle strengthening exercises.  These should be supervised and undertaken daily. A trial period of 3 months should be offered.²⁵ NICE 2006 CG40    A vaginal examination (rectal in men) is necessary to ascertain the baseline strength of the pelvic floor muscle contraction.  This will allow the patient to aim for improvement, ultimately to achieve their maximum potential.  “The Knack” manoeuvre is another conservative option to prevent urinary leakage and so enhance continence. This involves patients being taught to consciously contract their pelvic floor muscle one second prior to physical stress such as sneezing, coughing or lifting and to maintain that contraction during the stress to prevent the urethra and the base of the bladder from descending.²⁶ Millar et al 1996

Lifestyle interventions such as weight loss, fluid and dietary advice, exercise for general fitness as well as pelvic muscle strength, cessation of smoking, and relief of constipation are other conservative measures than can be adopted to assist with SUI.

There are several surgical options to treat SUI when conservative options have failed.   Retropubic mid-urethral tape procedures are recommended.   Alternatively, and if clinically indicated, a colposuspension or sling procedure may be undertaken.²⁵ NICE 2006 CG40    

Overactive Bladder (OAB)  With or Without Urgency & Urge Urinary Incontinence
(See OAB, urgency and urge urinary incontinence in Types of Urinary Incontinence, Symptoms and Causes above to appreciate the link between all 3 symptoms)

Treatment should centre on how much the problem is affecting the individual’s quality of life and also whether the sufferer wants it.  There are, however, specific lifestyle modifications that the sufferer can make to manage urinary problems and promote a healthy bladder following appropriate instruction and support.  These include:

Lifestyle Modification

Awareness
Few people know how much urine their bladder can hold. Educating patients about the lower urinary tract as a starting point and encouraging them to keeping a bladder diary from which a baseline can be established to monitor improvement is key.²⁷ Wein AJ 2003

Diet and Fluid Advice
It is widely accepted that disruption to the natural human circadian rhythm (body clock linked to the light-dark/day-night cycle) has a negative effect human health.  Disruption to the circadian cycle can be due to many factors²⁸ WebMD (2012) including light deprivation resulting in disruptions to sleep and eating patterns, particularly in those with depression, jet lag or regular shift work.²⁹⁺³⁰ Boyce & Barriball (2010); Straus S (2006) Examples of general advice on how to reset the body clock may include adherence to a routine sleep schedule and getting enough sleep; taking regular meals avoiding eating and exercising close to bedtime;  light therapy to boost production of the hormone melatonin produced by the pineal gland in the brain which assists with controlling sleep and waking cycles; and prescribed medications such as a melatonin supplement or antidepressants.

Beverages that may aggravate the bladder include alcohol and those containing caffeine which have a diuretic effect ie tea, coffee, caffeinated soft drinks as well as those that are carbonated and which contain artificial sweeteners such as saccharine  and aspartame . Certain foods that may aggravate the bladder any time of the day include those that are spicy or acidic as well as chocolate, sugars and artificial sweeteners.   Eliminating these followed by a gradual introduction of them may inform the individual which ones should be avoided or replaced with non-caffeinated substitutes.²⁸⁺³¹ WebMD (2012); B&BF 2013

Other Lifestyle Modifications
Promoting regularity of bowel movements, smoking cessation, weight control and managing fluid intake.³² Wymen JF 2009 (1.5-2litres per day) are other helpful measures to help minimise bladder contractions and increase the individual’s bladder capacity.

Behavioural Modification

Pelvic Floor Muscle Exercises (PFME’s)
Pelvic floor muscle exercises are taught by appropriately trained healthcare professionals who also offer support and follow up evaluations.  The purpose of PFME’s, preferably with biofeedback, is to try and inhibit spontaneous bladder contractions and to increase bladder outlet resistance in order that leakage can be reduced and voiding intervals increased.

Bladder Retraining
This is a behavioural technique with the purpose of increasing bladder capacity and reducing frequency.  The first step is to make an assessment of the bladder capacity.  This can reveal whether the volume is variable (100 – 300ml) or a constant low capacity measurement (100ml).  Delaying voiding and adopting urge suppression techniques can be used to inhibit detrusor contractions, increase bladder capacity to reduce urgency, frequency, and urge incontinence.³³ Burgio KL et al 2011

Pharmacotherapy

Pharmacotherapy treatment has historically focused on treating the symptoms of frequency and urge incontinence by using appropriate drugs.²⁶ Millar et al 1996 Anticholinergic/muscurinic medication may be prescribed to relax the detrusor and reduce its contractility. Combining behavioural therapy with drug therapy can be more effective than either alone.²⁷ Wein AJ 2003

Several anticholinergic/antimuscurinic brand medications are available.  The NICE (2006) guidelines recommend the use of Oxybutinin as a first-line non-proprietary drug treatment for OAB or mixed stress and urinary incontinence.  In the event of a patient being unable to tolerate oral Oxybutinin, a transdermal Oxybutinin patch or antimuscurinic drug may be tried.²⁵ NICE 2006 CG40  

Intravesical installation of Oxybutinin is another form of treatment intended as a means of increasing bladder capacity, lowering pressures and decreasing episodes of incontinence in patients with  neuropathic detrusor overactivity. However, this has been shown to be more effective when combined with oral Oxybutinin.³⁴ Rolle U,Geyer C, Lehnert T, Weißer M & Till H (2007)

Surgery

Sacral Nerve stimulation
Should surgery be necessary due to a lack of response to conservative measures, sacral nerve stimulation is recommended.²⁵ NICE 2006 CG40    This procedure involves the implantation of an electrical stimulator into the sacral nerves, and is effective for up to two thirds of patients who may either achieve continence or experience substantial improvement compared to other treatments.  However, life-long follow-up is recommended. ²⁵ NICE 2006 CG40    

Botulinum toxin type A (BoNT/A)
Botulinum toxin type A (BoNT/A), although a relatively new addition to bladder treatments, has now become an established second-line method of management for those with refractory AOB and/or detrusor overactivity who have not responded to antimuscurinics and conservative measures.³⁵  Seth, Dowson et al (2013)  BoNT/A is a powerful toxin injected into the detrusor muscle under local anaesthetic. The toxin can be effective in reducing unwanted involuntary bladder contractions but its effects are relatively short-lived lasting between six and twelve months.³⁵ Seth JH, Dowson C et al (2013)  However, Botox treatment can be repeated. It appears to be more effective in patients with neuropathic detrusor overactivity, although non-neuropathic patients have also been treated with success.³⁶ (Leippold et al, 2003) Although there are side-effects such as generalised muscle weakness, fatigue and blurred vision, these are generally uncommon³⁶ (Leippold et al, 2003) The greatest risks appear to be urinary tract infection and difficulty in bladder emptying necessitating intermittent catheterisation.³⁵ Seth JH, Dowson C et al (2013)    Patients, particularly those with neuropathic detrusor overactivity, must be informed of these risks before consenting to the procedure.

Surgical Treatment of Refractory OAB
Surgery remains the last resort in the treatment of OAB and has become less common due to the success of other options previously discussed. In cases of refractory OAB that has not adequately responded to medication therapy, a surgical procedure that may be performed is a Detrusor Myectomy or Autoaugmentation.  This involves removal of the detrusor muscle from the vault of the bladder to create a ‘bulge’ (diverticulum) with the objective of increasing bladder capacity and lowering bladder pressure.³⁷ Glinsky 2007

Mixed Urinary Incontinence (MUI)
For MUI as with SUI, pelvic floor muscle exercises undertaken daily for a trial period of 3 months are a safe and effective option.²⁵ NICE 2006 CG40    (See Stress Urinary Incontinence above).  Bladder training undertaken for a minimum period of 6 weeks is another conservative treatment that can be effective for patients with mixed urinary incontinence and urge incontinence.²⁵  NICE 2006 CG40 (See Urge Urinary Incontinence above).

Nocturnal Enuresis (NE)
In cases of Nocturnal Enuresis it has been suggested that children who are frequent bedwetters (ie more than 3 times per week) have a higher chance of persistent enuretic symptoms later in life. Whether for primary or secondary NE, the main treatment options include lifestyle changes, non pharmacologic interventions and medications that suit the needs of the child, teenager or adult.

Lifestyle Modification:

These include a wide array of interventions and advice.  For example, reassuring the individual that this is not his/her fault; educating the family and sufferer about the condition and offering assessment, support and treatments bearing in mind their ability to cope.   Advising on correct toileting postures and regular voiding, (4-7 times per day), along with optimal fluid intake (6-8 reasonably sized drinks spread evenly throughout the day). The avoidance of caffeinated drinks, particularly in the evening, can be beneficial, as can treatment and prevention of further episodes of constipation.³⁸⁺³⁹Deshpande et al 2012 & Norfolk & Wooten 2011 Reward systems with positive rewards for agreed behaviour that is within the child’s control, rather than rewards for dry nights, may be implemented alongside other treatments.³⁹ Norfolk & Wooten 2011

Enuresis Alarms

As an initial treatment these can be useful for children who have difficulty in waking in response to bladder sensations. However, they should not be used on children who have developmental delay.  The sensor alarm that is sensitive to moisture, (usually a small body worn one or a bed and bell alarm) should be used until the child experiences 14 consecutive dry nights.  Their use is credited with a long-lasting effect once alarm usage has ceased.⁴⁰  Darci & Kiddoo 2012  In the event of a lack of response to the alarm, a combination of the alarm with desmopressin may be tried.  Desmopressin alone may be given if the alarm is no longer acceptable or there has been a partial response to the combination of both.¹³NICE 2010 CG111

Desmopressin (DDAVP)
Desmopressin a synthetic analogue of human vasopressin with an anti-diuretic effect on the renal collecting tubule causing increased water reabsorption. This reduces nocturnal urine production and is the most commonly used drug in the treatment of nocturnal enuresis.  According to the NICE Guidelines CG111 (2011)¹³ CG111 desmopressin can be offered to children from age 5, if this is the main priority of treatment and if an enuresis alarm is inappropriate or undesirable, and from age 7 should a rapid onset or short-term improvement be required.

Desmopressin can also be offered to adults up to the age of 65 years with primary nocturnal enuresis.  It is contraindicated in cases of cardiac insufficiency and other conditions requiring treatment with diuretic agents.  Hypertension and the diagnoses of psychogenic polydipsia and alcohol abuse should be excluded.

Taken as either as a tablet or sublingual melt 1-2 hours before bedtime, this should be combined with a restriction of fluid intake at least one hour before bedtime.  A break of a week every 3 months should be implemented to ascertain whether or not treatment should continue.¹³ CG111 Although desmopressin is largely effective and does improve quality of life, there is a high rate of relapse once stopped.⁴⁰ Darci & Kiddoo 2012  However, a relapse may be prevented by the implementation of a structured withdrawal programme.³⁹  Norfolk & Wooten (2011)

Some individuals may have an overactive bladder (OAB). The symptoms of urgency, frequency and urge incontinence may be experienced during the day.  At night nocturia and enuresis caused by an OAB is a significant problem.  It is estimated that 70-80% of individuals with primary nocturnal enuresis also have an OAB.⁴¹ B&BF 2012 Nocturnal Enuresis

The treatment of enuresis associated with an OAB is usually anticholinergic medication which should only be given if daytime symptoms are also experienced.
In some instances, and following further assessment, anticholinergic medication may be combined with desmopressin.  Instances when this combination should be considered are when bedwetting has partially responded to desmopressin alone, or has not responded at all to desmopressin, or, when bedwetting has not responded to a combination of an alarm and desmopressin.¹³ NICE 2010 CG111

In some instances, Imiprimine, a tricyclic antidepressant agent, which by its actions on the complex neural control of the lower urinary tract may improve bladder storage function,⁴²  Hunsballe & Djurhuus (2001) could be prescribed if there is no response to other treatments for AOB, but not usually as an initial pharmaceutical treatment before desmopressin.  Imipramine should never be combined with desmopressin.¹³ NICE 2010 CG111

Post-Micturition Dribble (PMD)

Treatment for PMD in men varies and depends on the aetiology of the condition.  Before commencing treatment, it is necessary for a patient assessment to be undertaken as well as a digital rectal examination.¹⁹ Dorey G 2008
Since pelvic floor muscle weakness is one of the causes of  PMD, it stands to reason that pelvic floor muscle strengthening exercises (PFME’s) should be undertaken.  Men can be taught how to do these in the same way as for females with PFM weakness, specifically targeting the bulbocavernosis and ishiocavernosis muscles with the aim of increasing pelvic muscle tone. These have been shown to be effective in males with PMD who have had a  transurethral resection of the prostate.  Whilst voiding the male can encourage bladder emptying and increase abdominal muscle tone by simultaneously applying muscle pressure in this area.  At cessation of voiding, the individual should be taught to lift the pelvic floor muscle in a similar way to trying to stop the passing of flatus so that the muscles can act as a post-void ‘squeeze out’ or ‘post void milking mechanism.’  Alternatively, after urinating the patient can be taught to place his fingers behind the scrotum and gently massage the bulbar urethra in a forwards and upwards direction in order to ‘milk’ the remaining urine from the urethra. ⁴³ Robinson J 2008  PFME’s  alone has been found to be more effective than just ‘milking’ in reducing urinary dribble.  However, both were deemed to be more effective than just counselling.⁴⁴ Patterson J 1997
Feeling of Incomplete Emptying
A feeling of incomplete bladder emptying in both men and women is due to retention of urine for a variety of reasons.  Causes can be classified as bladder outflow obstruction, detrusor failure (flaccid bladder muscle), neurological cause or a side effect of drug therapy.²⁰  Jassim Y & Almallah Z (2009) Retention of urine is verified following a post voiding bladder ultrasound prior to further testing to identify the underlying cause.

When the bladder is distended, and the need for drainage has been confirmed by an ultrasound bladder scan and urological advice, catheterisation can be performed intermittently by passing a urethral catheter in and out of the bladder.  Alternatively, and only  if appropriate, an indwelling urethral or suprapubic catheter can be introduced which is retained in the bladder.  The indwelling catheter can drain continuously into a urine collection bag or a catheter valve may be fitted which can be intermittently released for drainage purposes.⁴⁵ Jindal T et al (2012)

Note: it is important that you ask your patients' whether they have a known latex allergy or sensitivity.

Wilson M (2012) noted that “despite over a quarter of a century of experience in the use of indwelling catheterisation, problems still occur, causing disruption, discomfort to the patient and increasing workload for the nurse whose responsibility it is to find the solution.”⁴⁶ Wilson M 2012 Problems of catheter associated urinary tract infection and encrustation associated with the use of these catheters remain despite many approaches to alleviate them such as changes to the materials and catheter coatings.  Innovative research continues to find a solution that not only provides direct benefits to catheter users with regards to comfort and superior performance, but also assists with a reduction in patient care costs.⁴⁷ Lawrence EL & Turner IG (2005)    In the meantime, healthcare professionals can still do much to prevent unneccessary complications.

You can read more about catheterisation and Harm Free Care by clicking here or on the CATHETERS AND CATHETERISATION

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