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Non-Surgical Treatment Options for Female Incontinence

Author Ishaan Sangwan covers Non-Surgical Treatment Options for Female Incontinence on BackTable Urology

Ishaan Sangwan • Jul 7, 2021 • 42 hits

While surgical options are a highly effective female incontinence treatment, some patients may not want to or be able to undergo surgery. There are several non-surgical options for these patients, including pessaries, bulking agents, medications, and pelvic floor physical therapy. All of these treatments can be used to treat female incontinence in addition to or independent of surgery. However, some of these options, such as physical therapy, might not be accessible to some patients. When working up a patient, it is important to understand their goals and expectations to decide if non-surgical treatments are right for them.

Dr. Yahir Santiago-Lastra and Dr. Jose Silva discuss non-surgical treatment options for female incontinence, and what to consider when prescribing different treatment approaches. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.

The BackTable Urology Brief

• It is important to distinguish between stress incontinence and urgency incontinence while working up a patient. It is also important to understand a patient’s goals and expectations to decide which treatment is right for them.

• While slings are the most effective treatment for stress incontinence, pessaries and bulking agents can be considered for patients who don’t want to undergo surgery.

• Botox injections and cholinergics are options for treating overactive bladder that can be prescribed with and without sling surgery.

• Pelvic floor physical therapy is also a viable treatment option, but requires long term commitment and access to care.

Woman doing pelvic floor exercises for female incontinence treatment

Table of Contents

(1) Work-Up of Female Urinary Incontinence

(2) Procedures and Medications for Female Incontinence Treatment

(3) Pelvic Floor Physical Therapy for Female Incontinence Treatment

Work-Up of Female Urinary Incontinence

When working up female incontinence, it is important to distinguish between stress incontinence, which is leakage when one puts pressure on the bladder like during a cough or sneeze, and urgency incontinence, which is when the patient has an overactive bladder. Often, patients will have both, but one will be predominant. The diagnosis is usually based on self-reported symptoms, but Dr. Santiago-Lastra prefers to also perform a pelvic exam as part of the work-up. It’s also important to understand how the condition is affecting a patient’s life and what their expectations and goals are for treatment.

[Dr. Yahir Santiago-Lastra]
When women come into my clinic seeking care for urinary incontinence, it can be one of two main types. They either have stress incontinence which is leakage when they cough, laugh, sneeze, or exercise. Or they can have urgency incontinence or what we call overactive bladder and that is leakage that is associated with a strong urge with urinary frequency or incontinence associated with that urgency.

It is really important when I talk to women to do three important things. Number one is to get to know them and to understand how this problem is impacting their life because that factors into my decision making for them. Two is what their expectations are. Some women come into the office already knowing a little bit about what they want or don't want to do, so I don't want to patronize them or give them an option that doesn't fit into what they were expecting. Three, and probably most importantly, honestly, is to distinguish whether their problem is stress predominant or urgency predominant, because those two domains of incontinence are treated completely differently and you definitely don't want to get them mixed up or you're going to have a patient that is quite bothered. Most women have both, but there is usually one that is predominant over the other and so I try to distinguish that in my conversation with the women that I treat.

[Dr. Jose Silva]
And that is based purely on the complaints of the patient, which one you determine is more dominant?

[Dr. Yahir Santiago-Lastra]
Yeah. You know, I'm in an academic center, so one of the things that might distinguish my practice from someone who is in private practice, for example, is that we have really intense questionnaires. Patients don't always love them. They come into the clinic and they could spend maybe 10, 15 or 20 minutes filling out a questionnaire. So by the time I see them, I have a pretty good idea if they have stress incontinence, urgency incontinence, or a mixture of both. But, it is always important to talk to them because sometimes women may not want to fill out all the questionnaires or they may fill them out in a way that is perhaps a little misleading or doesn't answer their concerns perfectly. So, that's what I tend to do is sit down with them and distinguish those two and yes the symptoms are what distinguish one from the other.

[Dr. Jose Silva]
Yes, most of those patients are already frustrated going to other physicians, jumping from medication to medication, and not accurately knowing what they have or treating what they have. So they go to you, the specialist, and they want an answer or a solution immediately. So sometimes that is very tricky and I bet in your case to slow their pace down with the patients and say, "We are going to go through a process and see what's going on." and then offer a solution. Do you find that also in your practice?

[Dr. Yahir Santiago-Lastra]
Yes, that is 100% what I see. I tell my residents this a lot. I tell them it is very common in my practice for me to spend that first visit getting to know the patient and doing a pelvic exam. Whenever they come in with these complaints of urinary incontinence, I will do a pelvic exam. It is not mandated from a guidelines perspective, but most of the time it is going to be something in your toolkit that you will want to do so that you can strategically plan what kind of interventions you want for the patients.

I tell my residents and fellows all the time that, very often, we will have that first visit and the patient gets so much information and options to treat their problem that they can't really make a decision right then. So, I'll often schedule, especially now in the advent of telemedicine, I'll schedule phone calls or telemedicine visits in a few weeks after that initial visit, to go over those options that I talked to them about and to actually schedule either an intervention or therapy or something else. That may not be something convenient to everyone in practice. It really depends what kind of a practice you have, but that works really well for me.

Listen to the Full Podcast

Management of Pelvic Floor Dysfunction with Dr. Yahir Santiago-Lastra and Dr. Jose Silva on the BackTable Urology Podcast)
Ep 4 Management of Pelvic Floor Dysfunction with Dr. Yahir Santiago-Lastra and Dr. Jose Silva
00:00 / 01:04

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Procedures and Medications for Female Incontinence Treatment

Non-surgical options for treating female incontinence include pessary placement, injection of a bulking agent, and medications such as anticholinergics. While a sling is usually the best option for treating stress incontinence, and also mixed incontinence as the SISTEr trial has shown, some women may not want to undergo surgery. Medications like Ditropan and other anticholinergics can be used to treat overactive bladder, along with Botox injections to the bladder. These may also be used in addition to a sling surgery if treating mixed incontinence. Pessaries and bulking agents can be used to treat stress urinary incontinence.

[Dr. Yahir Santiago-Lastra]
I will go over all of the treatments from pelvic floor exercises to a pessary to a bulking agent to a sling, either made out of their own tissue or made out of synthetic polypropylene or mesh and let them decide for themselves. If they are really bothered by the urgency component and, for me, the women who have really bothersome nocturia, those women will really want to try to treat their overactive bladder first. I've really let the patient decide where they want to start. If I think they are going to be better off with one treatment or the other, I'll choose it for them and I'll explain to them why. But I ultimately let them decide for themselves.

[Dr. Jose Silva]
Those patients that might have an overactive bladder, but they need to go, for example, you said back to CrossFit, would you do a procedure and also give them Ditropan or any other anticholinergic or any medications or would you just try to treat the stress and see what happens with the urge?

[Dr. Yahir Santiago-Lastra]
I choose the latter. I typically will recommend that women treat their most bothersome component and then, within 12 weeks of their initial intervention, will circle back with the patient and then see how they are doing with their symptoms. One of the great things about clinical trials like the SISTEr trial which looked at outcomes of treating stress urinary incontinence in women is that a lot of women who had a lot of urgency symptoms found that those symptoms also improved after having a sling. In fact, there is currently a randomized controlled trial that we are recruiting for at UC San Diego where we are comparing first line sling treatment versus Botox for women who have mixed urinary incontinence. So, those women, through that clinical trial, will undergo urodynamics to confirm that they, in fact, have both of those parameters present and they don't have a contraindication to either of those two procedures. Then, we will randomize them to either a sling, which is a treatment for stress incontinence, or to Botox, which is a treatment for urgency incontinence. Those results, I think, will answer your question even better, but in my experience, a lot of women who have mixed incontinence and undergo a sling will find that a lot of their symptoms have improved enough that they don't need to try anticholinergics.

[Dr. Jose Silva]
Sometimes, even though you mention it to the patient that they could continue with the frequency, they say "Well, I'm not leaking but I'm still the same." So, definitely you treat one part but you still have the frequency so it is difficult. Depending on the patient, I usually give her the Ditropan and treat both at the same time to see how that goes.

Pelvic Floor Physical Therapy for Female Incontinence Treatment

Pelvic floor physical therapy is another important treatment option for women with urinary incontinence. Not only can it be used as a female incontinence treatment, but it can also improve sexual function. However, physical therapy requires a patient to be consistent with it for as long as they want to continue seeing the results. Access is also a barrier to physical therapy as many patients, especially those belonging to minority groups, may not live near a location where pelvic floor physical therapy is offered or they might be unable to afford it.

[Dr. Jose Silva]
You mentioned pelvic floor exercises. Do you send everybody, prior to the procedure if they have stress incontinence, everybody has to go to pelvic floor or there are patients that you decide "Hey, it might not work, let's just go into more invasive procedures or something else."

[Dr. Yahir Santiago-Lastra]
I'm a big believer in pelvic floor physical therapy. I think that it is really nice for women to learn to take care of their pelvic floor and to understand the muscles that are there. I think it can be really helpful, not just for incontinence, but also for their sexual function. But, I leave it up to the patient and I explain to the patients that, if you really want pelvic floor exercises to work, you have to dedicate yourself to that really for the rest of your life and you have to be committed to it. It is like undergoing any sort of therapy or exercise program, the more you put into it, the better results you are going to see. Some women are really honest with me and they will tell me, "Look, this is not something that fits in with my lifestyle." and that's totally fine. Some women do it and prefer to do that as opposed to going straight into surgery and they come back after the therapy, feeling like their symptoms have improved to the point where they don't feel like surgery is in the cards for them any longer and I consider that a success, as well.

[Dr. Jose Silva]
Yeah, definitely and also access to the pelvic floor. Not everybody... I'm in a community hospital and we don't have one, so they have to drive half an hour or 45 minutes to their appointments sometimes. Younger patients do tend to go. I have tried to push them that way first, but definitely older patients that might have problems driving and all that. I mean, I mention it to them and see what they think but most of the time, I end up doing a procedure.

[Dr. Yahir Santiago-Lastra]
Yes, I think my practice would be in line with that, too. Access to care for pelvic floor physical therapy is really problematic. I take care of a lot of minority patients and under-served patients and usually there's only one pelvic floor physical therapy location that's contracted with that insurance and so it can be really limiting for women who might be interested in doing it, but their insurance either won't cover it or won't offer them a location that's close to where they live. I am fortunate that now my institution has set up some internal pelvic floor physical therapy, but for now it is only in La Jolla. So, patients that live 45 minutes away in Bonita or in Chula Vista or somewhere else are limited to that location and it doesn't always work for them. I do get patients who end up choosing something else, just because they don't have that access which is definitely a disparity.

Podcast Contributors

Dr. Yahir Santiago-Lastra discusses Management of Pelvic Floor Dysfunction on the BackTable 4 Podcast

Dr. Yahir Santiago-Lastra

Dr. Yahir Santiago-Lastra is an associate professor of urology and the director of the Women's Pelvic Medicine Center at UC San Diego in California.

Dr. Jose Silva discusses Management of Pelvic Floor Dysfunction on the BackTable 4 Podcast

Dr. Jose Silva

Dr. Jose Silva is a board certified urologist practicing in Central Florida.

Cite This Podcast

BackTable, LLC (Producer). (2021, April 21). Ep. 4 – Management of Pelvic Floor Dysfunction [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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