Pelvic floor muscle training
An effective treatment for both UUI and SUI symptoms, pelvic floor muscle training (PFMT) leads to high degrees of patient satisfaction and improvement in quality of life.17 The presumed mechanisms of action of PFMT include improved urethral closure pressure and inhibition of detrusor muscle contractions.
Common exercise protocols recommend 3 sets of 10 contractions, held for 6 to 10 seconds per day, in varying positions of sitting, standing, and lying. While many women may be familiar with Kegel exercises, poor technique with straining and recruitment of gluteal and abdominal muscles can undermine the effect of PFMT. Clinicians can confirm successful pelvic muscle contractions by placing a finger in the vagina to appreciate contraction around and elevation of the finger toward the pubic symphysis in the absence of pushing.
Referral to supervised physical therapy and use of such teaching aid tools as booklets, mobile applications, and biofeedback can improve exercise adherence and outcomes.18,19 Systematic reviews report initial cure or improvement of incontinence symptoms as high as 74%, although little information is available about the long-term duration of effect.17
Vaginal pessaries
Vaginal continence support pessaries and devices work by stabilizing urethral mobility and compression of the bladder neck. Continence devices are particularly effective for situational SUI (such as during exercise).
The reusable medical grade silicone pessaries are available in numerous shapes and sizes and are fitted by a health care clinician (FIGURE 3). Uresta is a self-fitted intravaginal device that women can purchase online with a prescription. The Poise Impressa bladder support is a disposable intravaginal device marketed for incontinence and available over-the-counter, without a prescription (FIGURE 4). Anecdotally, many women find that menstrual tampons provide a similar effect, but outcome data are lacking.
In a comparative effectiveness trial of a continence pessary and behavior therapy, behavioral therapy was more likely to result in no bothersome incontinence symptoms (49% vs 33%, P = .006) and greater treatment satisfaction at 3 months.20 However, these short-term group differences did not persist at 12 months, presumably due to waning adherence.
UUI-specific nonsurgical treatments
Drug therapy
All medications approved by the US Food and Drug Administration (FDA) for UI are for the indications of OAB or UUI. These second-line treatments are most effective as adjuncts to behavioral modifications and PFMT.
A multicenter randomized trial that evaluated the efficacy of drug therapy alone compared with drug therapy in combination with behavioral modification, PFMT, urge suppression strategies, timed voiding, and fluid management for UUI found that combined therapy was more successful in achieving greater than 70% reduction in incontinence episodes (58% for drug therapy vs 69% for combined therapy).21
Of the 8 medications currently marketed in the United States for OAB or UUI, 6 are anticholinergic agents that block muscarinic receptors in the smooth muscle of the bladder, leading to inhibition of detrusor contractions, and 2 are β-adrenergic receptor agonists that promote bladder storage capacity by relaxing the detrusor muscle (TABLE 2). Similar efficacies lead most clinicians to initiate drug therapy based on formulary coverage and tolerance for adverse effects. Patients can expect a 53% to 80% reduction in UUI episodes and a 12% to 32% reduction in urinary frequency.22
Extended-release formulations are associated with reduced anticholinergic side effects (dry mouth, constipation, somnolence, dry eyes), leading to improved adherence. Notably, the anticholinergic medications are contraindicated in patients with untreated narrow-angle glaucoma, gastric retention, and supraventricular tachycardia. Mirabegron should be used with caution in patients with poorly controlled hypertension. 5 Due to concerns regarding the association between cumulative anticholinergic burden and the development of dementia, clinicians may consider avoiding the anticholinergic medications in older and at-risk patients.23
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