Collaborative for Education on Urinary Incontinence and Women's Health (ceUIwh)

Clinical Consult

Each month, a question dealing with urinary incontinence will be selected and answered comprehensively by one of our Steering Committee members. Previously answered questions will be archived each month for your reference. If you wish to submit a question, click here.

To view archived responses, click here.

How do the treatment options for stress urinary incontinence (SUI) and urge urinary incontinence (UUI) differ?

Response by Jean F. Wyman, PhD, APRN-BC, GNP, FAAN, posted 12/29/2005:

Distinguishing between SUI and UUI is important because the underlying differences in pathophysiology affect treatment options. SUI is the involuntary loss of urine during an increase in intra-abdominal pressure created by actions such as coughing, laughing, sneezing, or exercising.^1,2 SUI is due to either intrinsic urethral sphincter incompetence or loss of normal anatomic supports of the bladder neck resulting in the urethra not being able to provide enough compression to prevent urine loss.¹

UUI is involuntary urine loss preceded by or accompanied by a strong desire to void, whether or not the bladder is full.^1,2 Urinary urgency with or without UUI is one of the symptoms in the clinical syndrome of overactive bladder (OAB).³ OAB symptoms are associated with involuntary contractions of the detrusor (bladder) muscle.³ A diagnosis of both SUI and UUI is called mixed urinary incontinence (mixed UI).¹

When treating SUI, methods to strengthen anatomic support include rehabilitation of the pelvic floor muscles through Kegel exercises (pelvic floor muscle training), which can be taught with or without biofeedback; vaginal weights; pelvic floor electrical or magnetic stimulation; and/or intravaginal support devices (pessaries).^1,4,5 To increase outlet resistance, periurethral bulking agents such as collagen and other inert substances have been used.⁵ Lifestyle changes, such as weight loss⁶ and smoking cessation⁷, may be helpful in reducing the magnitude of pressure on the bladder during exertional events (eg, coughing). Several off-label drugs, including estrogen, have been used in SUI treatment, but these have not been found effective in clinical trials.⁵ Surgery may be a viable option when other treatments fail.^1,5 Duloxetine, a balanced dual serotonin and norepinephrine reuptake inhibitor, is an investigational agent being evaluated for the treatment of SUI.⁸ By increasing the levels of serotonin and norepinephrine, sphincter muscle contraction and bladder capacity can be increased, allowing urine to be stored.⁸ Studies have shown that duloxetine can decrease the frequency of SUI episodes and increase the intervals between voiding.^8-10

In OAB, overactivity of the detrusor muscle due to involuntary contractions can result in urinary urgency or UUI, depending on sphincter response.³ Acetylcholine, which interacts with the muscarinic receptors on the detrusor muscle, is responsible for stimulating the contractions.³ Therefore, treatment options for UUI include antimuscarinic agents to relax the bladder smooth muscle. These agents include tolterodine, oxybutynin, trospium, solifenacin, and darifenacin.³ Other treatment options for UUI include lifestyle interventions, such as caffeine and fluid modifications, weight loss, smoking cessation, and/or constipation prevention; and behavioral therapy, such as bladder training and biofeedback.¹¹ Treatment for mixed UI should focus on the symptom that is most bothersome to the patient.¹

Because of the differences in the pathophysiology of SUI and UUI, a careful differential diagnosis is necessary to choose the appropriate treatment options. For instance, medications that target the bladder smooth muscle are commonly prescribed for UUI but are ineffective for the treatment of SUI.¹⁰ With correct diagnosis and effective treatment, both SUI and UUI can be successfully managed.

References

Culligan PJ, Heit M. Urinary incontinence in women: evaluation and management. Am Fam Physician. 2000;62:2433-2444, 2447, 2452.
Abrams P, Cardozo L, Fall M, et al. The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourol Urodyn. 2002;21:167-178.
Ouslander JG. Management of overactive bladder. N Engl J Med. 2004;350:786-799.
Gray M. Stress urinary incontinence in women. J Am Acad Nurse Pract. 2004;16:188-197.
Miller KL. Stress urinary incontinence in women: review and update on neurological control. J Womens Health. 2005;14:595-608.
Subak LL, Whitcomb E, Shen H, Saxton J, Vittinghoff E, Brown JS. Weight loss: a novel and effective treatment for urinary incontinence. J Urol. 2005;174:190-195.
Bump RC, McClish DM. Cigarette smoking and pure genuine stress incontinence of urine: a comparison of risk factors and determinants between smokers and nonsmokers. Am J Obstet Gynecol. 1994;170:579-582.
Thor KB. Serotonin and norepinephrine involvement in efferent pathways to the urethral rhabdosphincter: implications for treating stress urinary incontinence. Urology. 2003;62(suppl 4A):3-9.
Dmochowski RR, Miklos JR, Norton PA, Zinner NR, Yalcin I, Bump RC, for the Duloxetine Urinary Incontinence Study Group. Duloxetine versus placebo for the treatment of North American women with stress urinary incontinence. J Urol. 2003;170:1259-1263.
Norton PA, Zinner NR, Yalcin I, Bump RC, for the Duloxetine Urinary Incontinence Study Group. Duloxetine versus placebo in the treatment of stress urinary incontinence. Am J Obstet Gynecol. 2002;187:40-48.
Wyman JF. Behavioral interventions for the patient with overactive bladder. J Wound Ostomy Continence Nurs. 2005;32(suppl 1): S11-S15.