The treatment recommended will depend on the type of incontinence as well as the severity of the problem. Treatments may include:

• Behavioral therapy
• Medications or estrogen
• Minimally invasive surgery
• Traditional surgery

Regardless of your type of incontinence, the initial treatment will likely involve behavioral therapy.

Read general tips for incontinence management

Behavioral Therapy

Behavioral therapy is safe, easy to learn, and has no side effects. Up to 80 percent of patients who regularly adhere to behavioral therapy will see improvement in their bladder control.

The results may take several months to achieve and results will differ from person to person. It is important to be compliant with the therapy and have realistic expectations.

Behavioral therapy includes:

• Pelvic muscle rehabilitation (based on Kegel exercises)
• Bladder training programs
• Fluid and dietary modification

Pelvic muscle rehabilitation

The pelvic floor muscles are the most important tool that women have to improve their bladder control. Many women with incontinence are unable to isolate nor contract their pelvic floor muscles and so have no defense mechanisms when stress or urgency threaten to cause incontinence.

Your pelvic floor muscle function will be assessed during your vaginal examination and you will be taught how to strengthen and use these muscles when incontinence threatens.

Learn more about pelvic floor muscle exercises

Bladder training

A number of different techniques may be recommended to you, depending on the nature of your problem and a variety of other factors. These include:

Timed/prompted voiding. This technique is usually advised in the elderly population, who may have associated problems that preclude the use of bladder retraining. The goal of this simple technique is not to 'cure' the incontinence, but simply to deal with it. The patient voids “by the clock” at intervals of one, two, or three hours, and often needs a caregiver to prompt them.

Bladder retraining. In the patient with an overactive bladder, the sudden urge to void is usually met with a sudden rush to the restroom, and often with urinary leakage along the way. Bladder retraining attempts to give the patient back control of this situation by teaching defense mechanisms, which rely considerably on pelvic floor muscle function.

It is important to recognize that contraction of the pelvic floor muscles not only stops the flow of urine, but also “switches off” the bladder, making the urge go away.

This program of urge control relies upon the patient first gaining control of the pelvic floor muscles, as described earlier.

Once this has been mastered, the bladder retraining program will involve one of two techniques:

1. Challenged voiding. Using this technique the patient challenges the sudden urge to void, does not rush to the restroom, but instead:
   
   • Stops what she is doing
   • Rapidly contracts and relaxes the pelvic floor muscles
   • Breathes deep
   • Walks to the restroom in a controlled manner once the urge has gone away
   This program relies on the fact that the pelvic floor muscles can inhibit the bladder.
2. Timed interval voiding. Using this technique the patient challenges the urge to void using the same methods detailed above, but instead of heading for the restroom once the urge is under control, the patient resumes normal activities and only goes to void once their “time is up.”
   
   The time to void is laid out by the program in intervals that increase by 15 minutes each time the patient graduates to the next level. The initial interval between voids will be determined by examining the bladder diary of normal bladder events, and the program will likely require some adjustment of fluid intake, and certainly will require that the patient’s fluid intake be spread out evenly over the day.
   
   By way of example, the program may commence with voids restricted to every 45 minutes, then graduating to every one hour, then one hour and 15 minutes, then one and a half hours. The progress is continued until four hour intervals are achieved.
   
   This program requires considerable fortitude, as the patient is constantly challenged, and always feels as though she needs to void. However once the four hour interval is achieved, any shorter interval feels comfortable. The goal is not to make four hours the expected interval between voids but to challenge the bladder so that acceptable intervals of one to three hours are easy. Ideally the patient should not wear incontinence protection during the program, giving added incentive to be successful.

Fluid and dietary modification. Most patients with voiding problems, urinary incontinence, and pelvic organ prolapse give very little consideration to their fluid intake and to their bowel habits. The bladder diary will give us considerable insight into factors that can be changed to improve your condition. In general advice will include:

• Decrease or eliminate caffeinated and alcoholic beverages. Other foods and beverages are also thought to contribute to bladder leakage, although their affect on the bladder is not always understood. The patient may want to decrease their intake of citrus juices and fruits, highly spiced foods, sugar and artificial sweetener, milk and milk products, and carbonated beverages.
• Avoid constipation by adding high fiber foods and by not restricting water intake. Cranberry, apple, and grape juice do not irritate the normal bladder and makes the urine more acid, thus preventing the spread of bacteria.
• No smoking.
• Drink a total of six to eight 8-ounce glasses of fluid per day. Too little allows for a concentrated urine which can irritate the bladder. Too much only aggravates an urgent bladder.

Medications

Medications may include:

• Estrogen therapy
• Anticholinergics
• Antispasmodics
• Tricyclic antidepressants (medication to treat urge incontinence)

These medications do not cure incontinence but may help "relax" the bladder. In particular they may increase the interval between voids but tend not to increase the warning time. There are many medications on the market and all are similarly effective. Some may have fewer side effects.

Estrogens may be very helpful for women with both stress and urge incontinence and those with pelvic organ prolapse symptoms.

There are many brands of oral estrogen therapy and all are similarly effective. Estrogen can also be delivered by a skin patch. To directly treat the vaginal tissue, vaginal estrogen cream is available. A newer way to deliver estrogen is by wearing a device in the vagina. This ring is placed in the vagina by your doctor and changed every three months. Estrogen given orally allows for the systemic benefits of estrogen.

If you have a uterus, a hormone called progesterone must be given along with the estrogen. This hormone is commonly given orally. If the patient does not have a uterus, then estrogens may be taken alone. When a uterus is present, bothersome side effects can include vaginal bleeding. This problem can often be treated by changing the dosage. Estrogen is contraindicated in some patients, such as those with a history of breast cancer.

Minimally Invasive Surgery

Neuromodulation (InterStim) may be beneficial in selected patients with symptoms of urgency, frequency, and urge incontinence who have found behavioral and medical treatments ineffective. The technique electrically stimulates the sacral nerves that influence the behavior of the bladder, urinary sphincter and pelvic floor.

The first stage of this treatment is a test stimulation that involves a minimally invasive procedure performed in the office. A stimulation wire is temporarily placed through the skin near one of the bladder nerves and is secured to stay in place for several days. This allows the patient to temporarily experience stimulation and the effect it has on controlling the incontinence or frequency of urgency episodes.

If the test stimulation is deemed successful, the second stage is the actual surgical implantation of the continence control system. This is performed in the operating room as an outpatient procedure.

To find out more and read patient testimonials you can visit Medtronics' InterStim Web site.

Minimally invasive procedures for stress incontinence

For some patients with activity-related (stress) urinary incontinence, the urethral competence can be improved by the injection of a bulking agent into the wall of the urethra.

Currently the most favored product for injection is collagen (Contigen), although others are available and in development. The procedure is performed in the clinic as an outpatient procedure, under local anesthetic. It is virtually painless, and results are known within weeks. The procedure often needs to be repeated at periodic intervals to maintain the effect.

Traditional surgery

In some cases of intractable urge incontinence, the behavior of the bladder can be modified by the removal of some of the bladder muscle (detrusor myectomy), or by the addition of an intestinal 'patch' to the bladder (enterocystoplasty).

These techniques can be quite successful in carefully selected cases, but they do require a surgical procedure of moderate magnitude (three to seven days of hospitalization), and may result in urinary elimination problems as the price that is paid for being dry.

There is no consensus regarding which is the best procedure to treat stress incontinence.

Operations may be performed vaginally or through an abdominal incision. At Duke, in more than 95 percent of cases, surgeons prefer the vaginal approach. When one considers the very many variables in the patients who have such surgery, it is evident that the results are not really comparable, and that the better operations performed by the better surgeons in the better hospitals carry similar results.

While some women are “cured” by surgery, this may not be a realistic expectation for everyone. At Duke, the goal is to achieve dramatic improvement in bladder control. However, many patients may still expect to wear protection on occasion, and particularly during energetic activity.

At Duke, the pubovaginal sling is the preferred procedure in the majority of cases, and it proves to be quite successful in treating incontinence, regardless of severity.

The procedure takes less than one hour to perform and does not require hospital admission in most cases. Most women will require a week of recuperation at home and will return to most prior activities after one month.

There are many variables in the way in which the sling may be performed. The sling material used varies, and while some have a long history of successful use, others are new, and their long-term outcome remains unknown.

The Burch colposuspension is a popular operation that is performed abdominally. It has good results in selected cases.

Unlike the sling, it does not address all types of stress incontinence. In addition, because it is performed through the abdomen, it requires hospitalization and does not facilitate the repair of vaginal prolapse that commonly accompanies incontinence.