Medication To Treat Urinary Incontinence - Treating Urinary Incontinence: Bladder Conditions

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Medication to treat urinary incontinence

Prescription medications are an increasingly common way of treating urge incontinence and urinary urgency and frequency. Although medication has been available for decades, older drugs often had disappointing results or intolerable side effects. Changes have made several drugs for urge incontinence much easier to use (see Table 2).

Although there are no medications designed specifically to treat stress incontinence, certain drugs occasionally help with the symptoms, and others are useful for both urge and stress symptoms. In men who have overflow incontinence caused by an enlarged prostate, medications to shrink the prostate may help. Patients and clinicians can work together to find the medication that results in the fewest side effects, at the lowest dose that eases symptoms. This may take some trial and error.

Before starting any new medication, inform your doctor about any other drugs you are taking. Some medications may be unsafe or ineffective when combined with an incontinence medication. Before prescribing a medication for incontinence, your doctor will also want to make certain that no other drug you are taking could be causing your symptoms (see Table 1). If so, changing that prescription might solve the problem without introducing a new medication.

Alpha-adrenergic agonists. Found in some popular cold medicines, these drugs are not designed specifically to treat incontinence. But women with stress incontinence and some men who have undergone prostate removal may find these medications help relieve their symptoms. Alpha-adrenergic agonists mimic the effects of the neurotransmitter norepinephrine, which, among other things, stimulates the muscles around the bladder neck and urethra to contract and form a tighter seal to keep urine in.

One alpha-adrenergic agonist, pseudoephedrine, is an ingredient in cold and allergy remedies such as Sudafed. Some people take pseudoephedrine occasionally to minimize stress incontinence. Side effects such as dry mouth and headache may make it unacceptable for everyday use.

Alpha-adrenergic antagonists. Alpha-adrenergic antagonists are prescribed to men who develop overflow incontinence because an enlarged prostate interferes with normal urine flow. Also known as alpha blockers, these drugs have the opposite effect of alpha-adrenergic agonists — they relax the smooth muscle of the urethra. They include doxazosin (Cardura), tamsulosin (Flomax), and terazosin (Hytrin).

These medications lower blood pressure and may make you prone to a sudden drop in blood pressure when you change position from lying down to sitting or standing (called postural hypotension). To minimize this symptom, your doctor may suggest taking the medication at bedtime. Some doctors are hesitant to prescribe alpha blockers for men who are already on another blood pressure medication. Other side effects may include dizziness, lack of energy, or swelling of the ankles.

Anticholinergic medications. For women, these are the mainstay of treatment for urge incontinence caused by detrusor instability. Anticholinergics block the effects of the transmitter acetylcholine, which causes the detrusor muscle to contract. These are used to quiet the spasms of the bladder muscle that cause frequency, urgency, and urge incontinence.

Anticholinergics such as darifenacin (Enablex), oxybutynin (Ditropan XL), solifenacin (VESIcare), tolterodine tartrate (Detrol LA), and trospium (Sanctura) are available in an extended-release form that minimizes side effects. Some people taking the drugs experience side effects such as dry mouth and dry eyes, headache, constipation, and blurred vision. You may need to try more than one medication to discover which works best and causes the fewest side effects. About 80% of people are able to tolerate one of these drugs — a big improvement over older anticholinergics.

In 2003, the FDA approved Oxytrol, a patch changed twice weekly to deliver a constant level of oxybutynin through the skin. The most common side effects are skin irritation at the site of the patch. You should not use anticholinergics if you have narrow-angle glaucoma, myasthenia gravis, or severe ulcerative colitis. Men should not use the drugs to relieve symptoms in lieu of getting a proper prostate evaluation.

Antidepressants. An older category of antidepressant drugs known as tricyclic antidepressants can be useful for treating men and women whose primary complaint is that they wake up at night to urinate (a condition called nocturia). Drugs such as amitriptyline and imipramine combine both anticholinergic and alpha-adrenergic agonist actions. Low doses are sometimes prescribed either alone or in combination with anticholinergics to treat urge incontinence.

Because they can cause drowsiness, these antidepressants can help people sleep through the night without getting up to urinate. Tricyclic antidepressants interact with a number of common medications, so your physician should be aware of all the medications you use (including over-the-counter or alternative remedies) before prescribing them. Antidepressants in the class known as the selective serotonin reuptake inhibitors (SSRIs), such as Prozac, are not effective in treating incontinence.

Duloxetine (Cymbalta) is an antidepressant that is both a serotonin and norepinephrine reuptake inhibitor. By altering the concentration of these neurotransmitters, the drug seems to increase the contraction of the urethral sphincter. However, this drug is not FDA-approved for the treatment of incontinence, and it is not covered by most health insurance plans.

Antidiuretic hormone. This synthetic hormone can be useful for men or women who are primarily troubled by the need to urinate during the night. Vasopressin, an antidiuretic hormone produced by the pituitary gland, signals the kidneys to reduce urine production while you sleep. The synthetic version, called desmopressin (DDAVP), works in the same way. If you have a medical condition that would be worsened by fluid retention (such as high blood pressure or congestive heart problems), your doctor is unlikely to prescribe antidiuretic hormone. Your electrolytes need to be carefully monitored when starting this medication, as it can cause dangerous hyponatremia.

Cholinergics. Cholinergics such as bethanechol (Duvoid, Urecholine) strengthen the contractions of the bladder muscle and may be prescribed to men and women who have overflow incontinence because of a weak bladder muscle (not a blockage). Side effects can include shortness of breath, blurry vision, sweating, and dizziness. The medication is usually taken an hour or two before meals to prevent stomach upset. Bethanechol will not be prescribed if you have asthma, an overactive thyroid, or Parkinson's disease, or if you have recently had surgery on your urinary system or gastrointestinal tract.

Estrogen. Estrogen is sometimes prescribed as an oral pill or vaginal supplement to improve the strength of tissues in the urinary tract of women who show signs of deficiency. However, in the large multicenter trial known as the Women's Health Initiative, oral conjugated equine estrogen (Premarin), both alone and combined with a progestin (as Prempro, the most commonly prescribed formulation) worsened stress and urge incontinence in postmenopausal women who already had incontinence, and increased the risk that incontinence would develop in women who were continent at the beginning of the study. Few studies demonstrate any benefit of vaginal estrogen therapy in treating incontinence. In one Italian study, women who received vaginal estrogen after a sling procedure developed fewer symptoms of urge incontinence after surgery than those who received no estrogen.

Without proof of a benefit in treating incontinence, you and your doctor will need to make a decision about using estrogen in light of your menopausal symptoms and the increased risk for breast cancer, heart disease, and stroke reported by the Women's Health Initiative. Hormone therapy is generally recommended only for the short-term treatment of menopausal symptoms. However, using vaginal estrogen cream or suppositories one to three times a week is probably safe over the long term because the estrogen does not enter the bloodstream in significant amounts.

Other agents

Botulinum toxin (Botox), best known for its ability to smooth a furrowed brow by paralyzing forehead muscles, is sometimes used to relieve urge incontinence by weakening the detrusor muscle's ability to contract. Your physician passes a cystoscope through the urethra into the bladder, then injects the toxin directly into the detrusor muscle in many locations. In randomized, controlled trials in people who have detrusor overactivity due to spinal cord injury or multiple sclerosis, botulinum toxin injections have been well tolerated and effective for 24 weeks. Trials are under way to determine whether botulinum toxin injections are safe and effective in people with urge incontinence without a specific neurological origin.

Two neurotoxins — capsaicin (the chemical that makes chili peppers hot) and a similar but more potent drug called resiniferatoxin — are being tested for their ability to deaden nerve endings in the bladder and thus increase bladder capacity in people with urge incontinence who have not responded to other drugs. To administer the drugs, the physician inserts a catheter and removes urine from your bladder, places the drug within the bladder for about half an hour, then drains it out. If you have normal sensation, you must receive anesthesia to tolerate capsaicin; resiniferatoxin does not cause bladder pain. Symptoms may worsen for a few weeks before any benefits are apparent.

Last updated:	September 05, 2008