Medications for Urinary Incontinence

Hi again, Bestie! Welcome back. Today I thought we could circle back to urinary incontinence (UI) and chat about medications for improving it. If you need a bit of a refresher on UI before we get started, find that here.

As we know, UI occurs when one has unwanted leakage of urine. This can be uncomfortable, embarrassing, and difficult to navigate. Previously, we’ve discussed how pelvic floor physical therapy (PFPT) can help to improve symptoms of UI. There are also medications one can take that can improve symptoms of certain types of UI. Let’s dig into it!

If I have UI, how do I know whether I am a candidate for medication?

If you are suffering from any kind of UI, talk with your healthcare provider about what could be going on. Your provider will help guide you toward the right treatment, whether that be medication, physical therapy, surgery, or a combination of the above.

To understand which types of medication for which you might be a candidate, you first need to understand which type of UI you are suffering from. Stress urinary incontinence (SUI) is typically the result of pelvic floor weakness or poor coordination. Because of this, it is best treated with physical therapy, injections, pessary placement, or surgery. However, there are a couple of medications that could be helpful for SUI. These include Duloxetine (Cymbalta), which is commonly prescribed in Europe, but not used as frequently in the US due to the lack of studies demonstrating its effectiveness. Also occasionally used for SUI treatment is estrogen. Studies on the use of topical estrogen have yielded mixed results and studies on oral estrogen have demonstrated its lack of effectiveness for treatment of SUI (1, 2). So, it is possible to find some relief from SUI symptoms from duloxetine or topical estrogen, but you are more likely to have success with the more commonly prescribed SUI treatments mentioned above.

Urge urinary incontinence (UUI), on the other hand, can be treated with medication. UUI is the involuntary loss of urine due to a feeling of urgency, or just not being able to hold the urine in any longer. In some cases, UUI is the result of overactivity in the bladder. Okay…so what does this mean? Let’s revisit the basics of how the bladder works.

The bladder is actually a muscle, called the detrusor muscle. Normally, when the bladder is relaxed, it is able to fill with urine. When it is time to urinate, your brain will send a signal to the detrusor to tell it that it is time to pee, and the detrusor will contract (squeeze) to push out the urine. The detrusor needs to be relaxed in order to be able to fill with urine. In instances of bladder overactivity, the bladder muscle may spasm as the bladder is filling, giving you the sensation that you have to pee. This might lead you to urinate increasingly often (maybe even every 15 minutes), or it might lead you to experience UUI. If you are suffering from overactive bladder (OAB) causing UUI, you might benefit from medication for UI.

What types of medication are available for OAB?

There are a few different medications that can help to reduce that bladder overactivity and therefore contribute to decreased instances of UUI. The most commonly prescribed medications for UUI and OAB are called antimuscarinics (sometimes also referred to as anticholinergics) (3). Note that, folks should trial physical therapy and lifestyle changes for treatment of their UUI/OAB symptoms prior to initiating medication (3). After three months with minimal changes in symptoms, it is appropriate to add in medication. Antimuscarinics, such as Oxybutynin or Ditropan, help to calm bladder contractions during the filling stage. This helps to reduce the feeling of urinary urgency. This medication is also relatively cheap and from my experience, typically covered by insurance. The downside of this medication is that it comes with a few side effects. These include dry mouth, constipation, drowsiness, blurred vision, and more. Because of these unwanted side effects, more than half of patients stop taking this medication after a year of treatment (4,5).

Next, we have a medication called Mirabegron, or Myrbetriq. This medication also improves bladder relaxation during filling and results in decreased sensation of urinary urgency and UUI (6). It can cause side effects including increased blood pressure, dry mouth, constipation, and urinary retention, but from my experience, these side effects are typically less common than they are in antimuscarinic drugs and much more tolerable (7). The downside of this medication is that it is more expensive than other types of medication for UUI and not always entirely covered by insurance. This means it is less accessible.  

Lastly, let’s talk about Botox. OnabotulinumtoxinA, otherwise referred to as Botox, is a neurotoxin that occurs in nature. You’ve probably heard of Botox before, and you might even associate it with improving or avoiding facial wrinkles. Botox works to reduce facial wrinkles by paralyzing the muscles in the face that form wrinkles. By decreasing the movements of these muscles, the skin lies flatter and doesn’t bunch up creating fine lines. Similarly, Botox can reduce muscle spasming in OAB. It is injected into the detrusor muscle and has been shown to improve symptoms of UUI and urinary urgency (8). Side effects include urinary retention and urinary tract infections (UTIs).

It is especially important to note that, while the medications mentioned have been proven to improve symptoms associated with UUI, they should be used in conjunction with PFPT (9). They work better when combined with PFPT and, as with most things pelvic floor, a well-rounded treatment plan is the best way to go.

Let’s chat soon :)

XOXO,

Your Pelvic Bestie

 References:

1.     Hendrix SL, Cochrane BB, Nygaard IE. Effects of estrogen with and without progestin on urinary incontinence. JAMA  2005; 293:935.

2.     Cody JD, Richardson K, Moehrer B, et al. Oestrogen therapy for urinary incontinence in post-menopausal women. Cochrane Database Syst Rev.  2009:CD001405.

3.     DuBeau CE. Treatment and prevention of urinary incontinence in women. In: UpToDate , Falk, SJ,Ed. Waltham, MA: UpToDate; 2014.

4.     Shamliyan T, Wyman JF, Ramakrishnan R. Benefits and harms of pharmacologic treatment for urinary incontinence in women: a systematic review. Ann Intern Med  2012; 156:861.

5.     Layton D, Pearce GL, Shakir SA. Safety profile of tolterodine as used in general practice in England: results of prescriptionevent monitoring. Drug Saf 2001;24(9):703- 13.

6.     Chapelle 2014: Chapple CR, Cardozo L, Nitti VW, Siddiqui E, Michel MC. Mirabegron in overactive bladder: a review of efficacy, safety, and tolerability. Neurourol Urodyn . 2014;33(1):17-30.

7.     Khullar V, Amarenco G, Angulo JC. Efficacy and tolerability of mirabegron, a β(3)-adrenoceptor agonist, in patients with overactive bladder: results from a randomised European-Australian phase 3 trial. Eur Urol 2013; 63:283.

8. Visco AG, Brubaker L, Richter HE. Anticholinergic therapy vs. onabotulinumtoxina for urgency urinary incontinence. N Engl J Med . 2012; 367:1803.

9. McAuley, J. Adrienne PT, DPT, MEd1; Mahoney, Amanda T. PT, DPT2; Austin, Mary M. PT, DPT3. Clinical Practice Guidelines: Rehabilitation Interventions for Urgency Urinary Incontinence, Urinary Urgency, and/or Urinary Frequency in Adult Women. Journal of Women's & Pelvic Health Physical Therapy 47(4):p 217-236, October/December 2023.

*The information contained in this article is for educational and informational purposes only and is not intended as health or medical advice. Always consult a qualified health provider regarding any questions you may have about a medical condition or health objectives.