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Urinary incontinence in aging females: When can medications help?

The Bottom Line

  • There are two types of urinary incontinence - stress incontinence and urgency incontinence. Aging women may develop one or both types.

  • The scientific evidence shows that many non-drug interventions, such as lifestyle changes (e.g., losing excessive weight and exercising) or conservative treatments (e.g., pelvic floor muscle training and   bladder training) are effective. 

    These non-drug treatments can help you achieve complete continence or improve your symptoms. These should be the first choice for women with any type of incontinence. 

  • Currently there is limited scientific evidence that duloxetine or estrogen is an effective or a safe option to manage stress-related incontinence. 

  • The scientific evidence shows that several medications for urgency incontinence may benefit women who have not achieved optimal continence with non-drug interventions. 
    • However, well-studied drugs that work by stopping sudden bladder muscle contractions (antimuscarinic drugs) increase the risk of common harms including dry mouth and eyes, constipation, blurred vision or headaches.
    • Newer drugs (beta-three adrenergic agonist drugs) have shown no bothersome harms in clinical studies but we do not know about the long-term safety of these drugs.
  • The decision to select one drug over others should depend on a careful balance between benefits and harms. Each woman should discuss with incontinence professionals the most troubling harms specific to each drug.

Why is urinary incontinence a health issue?

Urinary incontinence is a very common problem in aging women (1). When women leak urine during exercise, sneezing, or coughing, doctors call this type of incontinence stress-related (2). When women have strong urges to urinate and have trouble holding urine until getting to the bathroom, they may have what is known as urgency incontinence (2). Although most women have one or the other type of incontinence, older women often have both types. Incontinence hurts women's self-confidence, interferes with their ability to enjoy their favorite activities, and decreases the quality of their lives (1).

What is the evidence for effective treatments for urinary incontinence?

Women have several options to manage their urinary incontinence and these primarily include either drug or non-drug treatments. Many studies have shown that the majority of women improve their symptoms using non-drug conservative interventions and these include:

  1. specialized pelvic floor muscle exercises,
  2. normalizing weight (decreasing excess weight),
  3. scheduling when they drink (fluid intake) and when they go to the bathroom (voids)(3).

Intra-vaginal electrical or magnetic stimulation may help some women with incontinence (3). However, some women do not benefit from these non-drug treatments, or they are unable to access these treatments, or make the necessary lifestyle changes. In this case, doctors may suggest the use of drugs to help with incontinence problems. We review the current scientific evidence about the effectiveness of these drugs to help manage incontinence.

Drugs for urgency urinary incontinence

Health Canada and the Food and Drug Administration in the United States have approved several medications from two drug classes for adult women with frequent urges to urinate (overactive bladder with or without urgency incontinence).

Drugs stopping sudden bladder muscle contractions (antimuscarinic drugs)

Six approved antimuscarinic drugs work because they block nerve signals regulating bladder muscle contractions; the drugs help to relax the bladder muscle and to decrease urges to void. Several studies have shown that these drugs resolve urinary incontinence in one woman among every eight or nine treated (3). These drugs include:

  • Darifenacin (Enablex™) (4;5),
  • Fesoterodine (Toviaz™) (6-10),
  • Oxybutynin(Ditropan™) (11),
  • Solifenacin (VESIcare™) (5;12),
  • Tolterodine(Detrol™) (6;10;11;13-16),
  • Trospium (Sanctura™) (11;17).

However, these drugs, especially oxybutynin, may cause adverse effects which may include:

  1. dry mouth and eyes,
  2. constipation,
  3. blurred vision or headaches, and
  4. other less common harms (or side effects).

For oxybutynin, one out of every 16 women stopped using it because of intolerable side effects.

When researchers compared the benefits and harms across these six different antimuscarinic drugs, they found that although these drugs demonstrate similar benefits, the potential for adverse effects was not the same (3). Women should discuss with their doctor what adverse effects are the most troubling for them. They can then choose the medication with the least risk for those specific side effects.

Unfortunately, none of the clinical studies evaluated the long-term safety of these antimuscarinic drugs. All drugs were tested in older women (+65) (3;18). However, we do not know long-term safety of these drugs in real-life geriatric settings. Future research should look at long-term safety in older women who are also taking several medications because of other chronic diseases.

Limited evidence shows that pelvic floor exercises or bladder training have similar effectiveness but less harms when compared with drug treatments for women with urgency incontinence (3).

Drug increasing bladder capacity to hold urine (beta-three adrenergic agonist drugs)

Two medications, in the beta-three adrenergic agonist class of drugs, have been studied in women with urgency incontinence. These medications work by improving the bladder's capacity to hold urine and therefore increase the time between "urgent" trips to the toilet.

Mirabegron (Myrbetriq®) (13-16;19;20) and solabegron (21) are newer drugs and have been designed to resolve urgency urinary incontinence without causing bothersome harms. However, fewer clinical studies have examined these drugs. Future research will help us to know more about the long-term safety of mirabegron and solabegron.

Drugs for stress-related urinary incontinence

Health Canada and the FDA have not yet approved drugs specifically for stress-related incontinence (2). To date, the research on drugs or hormones used in women with stress-related incontinence is limited (few studies with small numbers of patients) and shows that they are not beneficial.

In Europe and the United States, some specialists were using duloxetine (an antidepressant) to treat women with stress-related incontinence. This practice should stop because of the potential for side effects and the studies have shown very little benefit. In several clinical trials duloxetine improved symptoms of incontinence in only 1 out of 13 women. In addition, these studies showed that 1 out of 8 women stopped taking this drug because of intolerable side effects (3). Currently, clinical guidelines do not recommend the use of duloxetine for women with stress incontinence (22;23).

There are some studies that have used hormones, specifically estrogens in a cream or tablet form to treat stress-related incontinence. At this time there is not enough scientific evidence to conclude with confidence that topical estrogen is effective and safe for most women(3). Currently, clinical guidelines do not recommend the use of topical estrogen for treating stress-related incontinence.

What are important things to know about urinary incontinence and medications?

We need to remember that drugs are not free of consequences and that they always increase our risk for unwanted side effects. First, women who want help with their incontinence problems should seek to make lifestyle changes such as exercising more and losing excessive weight. The earlier in our lives we adopt such healthy behaviors, the better we will be when we get older (1). Keeping with these healthy behaviors is a key for success when dealing with incontinence. However, for some women, lifestyle changes may not be enough and they may wish to discuss the use of drugs to manage their incontinence. If you are considering asking your doctor about the use of drugs, go prepared. Women should inform themselves about the specific benefits, harms, and costs of the medications. Together women and their doctors can make the best choice and select the optimal balance between the benefits and potential harms of medications for treating incontinence.

What is the bottom line about this health issue?

If you have trouble with leaking urine, know that you are not alone; many women suffer from urinary incontinence. There is no shame in discussing this problem with your doctor or an incontinence professional (nurse, physiotherapist). The real harm is in ignoring incontinence. Non-drug treatments, such as healthy lifestyle changes or pelvic floor exercises, should be the first choice. Once you start adopting healthy behaviors, sticking to these good habits will serve you well in the long run.

Currently there are no effective medications for women with stress incontinence. In contrast, women with urgency incontinence have good evidence that several medications can be helpful. There are eight drug choices available and women can make informed decisions with their doctors. We "urge" you to take into account the balance between benefits and harm for each of eight available drugs and to make informed treatment decisions after discussions with incontinence professionals.


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References

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DISCLAIMER: The blogs are provided for informational purposes only. They are not a substitute for advice from your own healthcare professionals.

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