There is no single treatment option for urinary incontinence. Self-care measures can make a substantial difference for the patient and consist of lifestyle changes (avoiding coffee, tea, citrus fruits, and alcohol), bladder training (holding urine), and pelvic floor muscle exercises (it's always best to learn these with a pelvic floor specialist). Only when self-care measures are ineffective will medication be necessary, and surgery as a last resort.
Pharmacological treatment of urinary incontinence.
Drug treatment will depend on the severity and type of incontinence. A specialist will determine the best option.
The main drugs The drugs used to treat urinary incontinence are muscarinic receptor antagonists, mirabregon, estrogens, desmopressin, and duloxetine.
- Muscarinic receptor antagonists:
These medications are commonly used to treat urinary incontinence due to overactive bladder. They help relax the bladder muscle wall by blocking the nerve impulses that cause the bladder to contract involuntarily and empty. This relaxation allows the bladder to increase its urine storage capacity. These medications can also be used to reduce nighttime urination (nocturia).
- Mirabegron
This drug is a beta-3 agonist and relaxes the bladder wall muscle through a different mechanism than muscarinic receptor antagonists, helping to increase bladder capacity and thus facilitate greater urine retention.
- Estrogens:
Estrogens improve blood flow and nerve function. They also help maintain the health and flexibility of the tissues of the urethra and vagina. These hormones play an important role in urinary continence. Estrogen therapy is indicated for postmenopausal women who experience urinary incontinence. It can be administered as a cream, pill, vaginal ring, or even a pessary. This treatment may be prescribed in combination with other medications.
- Desmopressin:
It is a medication that limits the amount of urine produced by the kidneys. It is specifically indicated for treating nighttime urinary incontinence. Its effect lasts four hours, so the patient takes it right before going to sleep. It is not recommended for long-term use because it improves symptoms but does not cure them. Furthermore, it can cause side effects such as fluid retention and altered sodium levels in the body.
- Duloxetine
It is a medication that increases the muscle tone of the sphincter and reduces the nerve signals that cause urine leakage. It is recommended for moderate to severe incontinence and should only be taken temporarily because it can also cause side effects such as nausea and vomiting, which may limit its tolerability.
When drug treatment does not work, the doctor may recommend incontinence surgery for both men and women.
Surgery of the urinary incontinence in women
The options for stress urinary incontinence that a specialist can recommend are diverse, but factors such as age, severity of the disease, level of impact on the patient's quality of life and finally, general health status will always be taken into account.
The options are:
1.-Mesh or ribbons
Slings or belts are the most common treatment for stress urinary incontinence. They support the pelvic floor muscles and help the urethra withstand the pressure of a full bladder. They can be synthetic or made of natural materials, such as a graft from the patient's own body or manufactured from animal tissue. They are anchored under the urethra, supporting it like a sling.
The procedure is usually done with local anesthesia, but that will depend on the circumstances of each patient.
To insert the mesh, the specialist makes an incision in the anterior vaginal wall and places the ends of the tape on each side, securing the urethra below the urethra in a hammock-like shape. The correct tension is applied, and the ends of the tape are secured to the surrounding tissue.
2.- Burch Colposuspension
This surgery is indicated for stress or mixed urinary incontinence. Its objective is to reposition the bladder neck so that it can better withstand filling.
This procedure requires general or spinal anesthesia. The upper part of the vagina is attached to a ligament behind the pubic bone. This elevates the bladder neck and reduces urinary leakage. The procedure can be performed using open surgery or minimally invasive techniques (laparoscopy or robotic surgery). Recovery after colposuspension can take up to six weeks.
3. Space-occupying agents:
This treatment is indicated for stress urinary incontinence and involves injecting substances into the urethral wall that help compress the urethra, allowing it to withstand the pressure of a full bladder. The injections can be of synthetic material or collagen of animal origin, which is injected in liquid form and hardens over time.
It is a procedure performed under local anesthesia. Endoscopically, the specialist guides the needle toward the urethral wall and infiltrates both sides of the urethra.
4. Artificial urinary sphincter
It is a treatment for moderate to severe stress urinary incontinence. It consists of a cuff with several inflatable cushions that is placed around the urethra, a pump that controls the cuff's inflation, and a saline reservoir. This device allows the patient to control leakage during activities such as coughing, running, or laughing.
The patient uses the pump to control the filling of the cuff located around the urethra. This allows the patient to decompress the cuff when they wish to urinate, and it refills, compressing the urethra again to prevent leakage, briefly after urination is complete.
This procedure is performed under general anesthesia. The specialist makes an incision in the abdomen and places the cuff around the urethra. The reservoir and pump are then inserted between the labia. The entire device is connected, except for the cuff, which is attached by the doctor several weeks later.
In the weeks following surgery, the patient may continue to experience urinary leakage until the device is fully activated. The patient will not resume a "normal" life for four to six weeks afterward and may experience discomfort when urinating or in the pelvic area, which will gradually subside.
Surgery of the Urinary incontinence in men
As with female urinary incontinence, the surgical treatment chosen by the specialist will depend on the severity of the patient's leakage and the impact it has on their quality of life.
1.-Mesh or ribbonSlings help the urethra withstand the pressure created by a full bladder. They also support the weight of the pelvic floor muscles. There are several types of slings available: two-arm, four-arm, and adjustable. As with slings for women, they can be made of synthetic or natural materials. These slings are also indicated for men after a prostatectomy, if necessary.
Under local or general anesthesia, the specialist makes a small incision in the perineum to place the mesh.
In the case of two-arm meshes, the arms are fixed to the obturator membrane and pass under the urethra, like a hammock, improving urinary continence.
In the four-armed ones, two ends are placed in the tissue around the pubic bone and the other two remaining arms are hooked or fixed to the groin.
Finally, in the adjustable ones, the specialist makes two small incisions in the lower abdomen through which he inserts an adjustment device.
2. Artificial compression balloons: This type of surgery is recommended when other alternatives or treatments have failed. It is recommended for stress urinary incontinence.
Through an incision in the perineum and guided by imaging, the doctor inserts a first balloon into one side of the urethra, under the prostate. A second balloon is then placed on the other side, also under the prostate. If the patient has undergone a radical prostatectomy (removal of the prostate gland), the balloons will be placed under the bladder neck. After the balloons are in place, a titanium device is inserted to connect them to the scrotum, allowing the patient to inflate them.
3. Artificial urinary sphincter: It is a treatment for moderate to severe stress urinary incontinence. It consists of an inflatable cuff that goes around the urethra, a pump that controls the cuff, and a saline reservoir. This technique allows the patient to control leakage during activities such as coughing, running, or laughing.
Using a pump, the patient controls a cuff placed around the urethra. This allows the patient to compress and decompress the cuff, thus controlling bladder flow. The system is exactly the same as in women, except that the pump is placed in the scrotum, not on the labia.
The first incision is made in the perineum. Through this opening, the inflatable cuff is placed around the urethra. Next, through an incision in the abdomen, the reservoir is inserted and connected to the cuff. The procedure concludes with the placement of the control pump in the patient's scrotum, allowing them to control the device as needed.
4.- Injections of space-occupying agents
This treatment is indicated for stress urinary incontinence and involves injecting substances into the urethral wall to improve the tightness of the urethral sphincter, allowing it to withstand the pressure of a full bladder. The injections can be of synthetic material or collagen of animal origin, which is administered in liquid form and hardens over time.
It is a procedure performed under local anesthesia. Using an endoscopic approach, the specialist guides the needle to the urethral wall and infiltrates both sides of the urethra.
