Interventions/treatment

Incontinence can usually be treated, and if it is not treatable then it can be managed. The treatment will depend on the type of incontinence, how severe it is and what is causing it. Sometimes it will require a combination of treatments.

Bladder incontinence

Initially, treatment focuses on approaches that don't involve medication or surgery. These include:

  • lifestyle changes – such as reducing caffeine intake (including green tea), stopping smoking and losing weight
  • pelvic floor muscle training – this technique strengthens the pelvic floor muscles and is an effective treatment for stress incontinence, especially if the muscle has been damaged.
  • bladder training – bladder training involves learning techniques to increase the length of time between feeling the need to urinate and passing urine. The course usually lasts for at least six weeks and can be combined with the Kegel exercises. Some individuals may find that timed toileting is helpful, particularly people with a learning disability or cognitive impairment.

Medication

Medication can be used to ease and treat symptoms of urinary incontinence. Oxybutynin, Tolterodine, Solifenacin are anticholinergics which block signals that trigger abnormal bladder contractions associated with overactive bladder.

Mirabegron relaxes the bladder muscle and increases the amount of urine the bladder muscle can hold.

Duloxetine is sometimes used for stress incontinence in place of surgery.

Desmopressin reduces urine production at night.

All drugs should be used with caution, particulary in older people.

A number of products are available to help with the management of incontinence. These include:

  • handheld urinals (urine collection bottles)
  • a catheter, a thin tube that is inserted into the bladder to drain urine. It may be used intermittently or on a long-term basis
  • devices that are placed into the vagina or urethra to prevent urine leakage, for example during exercise
  • urinary sheath
  • absorbent products, such as incontinence pants or pads

Surgery and procedures

A number of surgical procedures can be undertaken if other treatments are unsuccessful.

Tape procedure
A vaginal tape procedure is an operation to help women with stress incontinence. A 1cm synthetic tape is inserted through an incision in the vagina and threaded behind the urethra (the tube that allows urine to pass outside the body). The middle part of the tape supports the urethra, thereby preventing leakage. The tape stays in place permanently.

Colposuspension
Colposuspension involves making an incision in the lower abdomen, lifting up the neck of the bladder and stitching it in this lifted position. It can help prevent involuntary leaks in women with stress incontinence.

There are two types of colposuspension:

  • an open colposuspension – where surgery is carried out through a large incision
  • a laparoscopic (‘keyhole’) colposuspension – where surgery is carried out through one or more small incisions using special, small surgical instruments.

Sling procedures

Sling procedures involve making an incision in the lower abdomen and vagina so a sling can be placed around the neck of the bladder to support it and prevent accidental urine leaks.

The sling can be made of:

  • a synthetic material
  • tissue taken from another part of the body (an autologous sling)
  • tissue donated from another person (an allograft sling)
  • tissue taken from an animal (a xenograft sling), such as cow or pig tissue.

Urethral bulking agents
An urethral bulking agent is a substance that can be injected into the walls of the urethra in women with stress incontinence. This increases the size of the urethral walls and allows the urethra to stay closed with more force.

Artificial urinary sphincter
The urinary sphincter is a ring of muscle that stays closed to prevent urine flowing from the bladder into the urethra. An artificial urinary sphincter is a device fitted to relieve urinary incontinence. It replaces the damaged sphincter to restore control of the flow of urine.
It tends to be used more often as a treatment for men with stress incontinence and is only rarely used in women.

An artificial sphincter consists of three parts:

  • a circular cuff that is placed around the urethra – this can be filled with fluid when necessary to compress the urethra and prevent urine passing through it
  • a small pump placed in the scrotum (when used in men) that contains the mechanism for controlling the flow of fluid to and from the cuff
  • a small fluid-filled reservoir in the abdomen – the fluid passes between this reservoir and the cuff as the device is activated and de-activated.

Botulinum toxin A injections

Botulinum toxin A (Botox) can be injected into the sides of the bladder to treat urge incontinence and overactive bladder syndrome (OAB). This medication can sometimes help relieve these problems by relaxing the bladder. The effect can last for several months and the injections can be repeated if they help.

Sacral nerve stimulation
The sacral nerves are located at the bottom of the back. They carry signals from the brain to some of the muscles used when urinating, such as the detrusor muscle that surrounds the bladder.

During the operation, a medical device is inserted under the skin near one of the sacral nerves, usually in one of the buttocks. An electrical current is sent from the device to the sacral nerve. It should improve the way signals are sent between the brain and the detrusor muscles, and so reduce the urge to urinate and restore the normal function of the bladder.

Posterior tibial nerve stimulation
The posterior tibial nerve runs down the leg to the ankle. It contains nerve fibres that start from the same place as nerves that run to the bladder and pelvic floor. It is thought that stimulating the tibial nerve will affect these other nerves and help control bladder problems, such as urge incontinence.

The treatment targets the tibial nerve in the ankle and modifies the nerve impulses sent to the bladder, which contribute to the development of urgency. A fine needle is inserted into the tibial nerve just above the ankle and an electrode is placed on the foot. A mild electric current is passed through the needle to stimulate the tibial nerve.

Augmentation cystoplasty
This procedure involves making the bladder bigger by adding a piece of tissue from the intestine into the bladder wall. The aim is to increase bladder capacity and reduce the effect of the contractions of the bladder.

After the procedure, a catheter may be put in place. The difficulties passing urine can also mean that people who have augmentation cystoplasty can experience recurrent urinary tract infections.

Urinary diversion
A urinary diversion is a procedure to release urine from the body when urination is not possible because the urinary system is damaged or not working. Any problem in the bladder that blocks the flow of urine and causes it to accumulate in the ureters (the tubes that lead from the kidneys to your bladder) may result in the need for a urinary diversion.

A urinary diversion may mean a urostomy, which requires a pouch to be worn outside the body, or a continent diversion, which involves the creation of a pouch or bladder inside the body, usually using part of the digestive tract.

Clean intermittent catheterisation
Clean intermittent catheterisation (CIC) is a technique that can be used to empty the bladder using a small catheter tube at regular intervals, thus reducing overflow incontinence (also known as chronic urinary retention).

In a CIC procedure, a catheter (a thin, hollow tube) is inserted through the urethra into the bladder to help the individual urinate. Urine flows out of the bladder, through the catheter and into the toilet. Good hygiene is extremely important in CIC as it reduces the risk of developing a bladder infection, which is unpleasant and can sometimes lead to more widespread infection.

Indwelling catheterisation
An indwelling catheter is designed to be left in place for a prolonged period. Patients should only be offered an indwelling catheter once all other options have been considered.

Bowel incontinence

Treatment for bowel incontinence depends on underlying cause and the pattern of the symptoms.

Trying the least intrusive treatments first, such as dietary changes and exercise programmes, is often recommended. Medication and surgery are usually only considered if other treatments haven't worked.

Treatment that can help with bowel incontinence includes:

Dietary changes
Bowel incontinence associated with diarrhoea or constipation can often be controlled by making changes to the diet.

Diarrhoea
NICE provides the following dietary advice to people with diarrhoea associated with bowel incontinence:

  • limit fibre intake from wholegrain breads, bran, cereals, nuts and seeds (except golden linseeds)
  • avoid skin, pips and pith from fruit and vegetables
  • limit fresh and dried fruit to three portions a day and fruit juice to one small glass a day (make up the recommended ‘five a day’ with vegetables)
  • reduce consumption of fizzy drinks and drinks containing caffeine
  • avoid foods high in fat, such as chips, fast foods and burgers.

Constipation
A high-fibre diet is usually recommended for most people with constipation-associated bowel incontinence. A GP can confirm whether a high-fibre diet is suitable. Fibre can soften stools, making them easier to pass. Foods that are high in fibre include:

  • fruit and vegetables
  • beans
  • wholegrain rice
  • wholewheat pasta
  • wholemeal bread
  • seeds, nuts and oats
  • Fluids can help to soften stools and make them easier to pass.

Pelvic floor muscle training
Pelvic floor muscle training is a type of exercise programme used to treat cases of bowel incontinence caused by weakness in the pelvic floor muscles.

Bowel retraining
Bowel retraining is used to treat people with reduced sensation in their rectum as a result of nerve damage, or for those who have recurring episodes of constipation.

There are three goals in bowel retraining:

  • to improve stool consistency
  • to establish a regular time to empty the bowels
  • to find ways of stimulating the bowels to empty themselves

Biofeedback
Biofeedback is a bowel retraining exercise that involves placing a small electric probe into the anus. The sensor relays detailed information about the movement and pressure of the muscles in the rectum to an attached computer.

The individual is asked to perform a series of exercises designed to improve bowel function. The sensor checks that the exercises are being performed in the right way.

Anal plugs are one way to prevent involuntary soiling. An anal plug is made of foam and designed to be inserted into the anus.

If the plug comes into contact with moisture from the bowel, it expands and prevents leakage or soiling. Anal plugs can be worn for up to 12 hours, after which time they are removed using an attached string.

Disposable body pads are contoured pads that soak up liquid stools and protect the skin. They can be used in cases of mild bowel incontinence.

Single-use silicone inserts, which form a seal around the rectum until the next bowel movement, are also being investigated as a treatment option for moderate to severe bowel incontinence.

Medication
Medication can be used to help treat soft or loose stools or constipation associated with bowel incontinence.

Loperamide is a medicine widely used to treat diarrhoea. It works by slowing down the movement of stools through the digestive system, allowing more water to be absorbed from the stools.

Laxatives are used to treat constipation. They loosen stools and increase bowel movement. Bulk-forming laxatives are usually recommended as they help the stools to retain fluid. This means they’re less likely to dry out, which can lead to faecal impaction.

Suppositories and enemas
Suppositories and enemas are used when other treatments are deemed ineffective. Suppositories are small and bullet-shaped and are used to deliver medication to soften hard faeces blocking the rectum. Enemas work in a similar way but the medication is delivered through a small tube inserted into the rectum.

Rectal irrigation

Rectal irrigation is used when bowel incontinence is caused by faecal impaction and other treatments have failed to remove the impacted stool from the rectum. The procedure involves placing a small tube in the anus and injecting a medicine in fluid form to wash out the rectum.

Surgery

Sphincteroplasty
A sphincteroplasty is an operation to repair damaged sphincter muscles. The surgeon removes some of the muscle tissue and the muscle edges are overlapped and sewn back together. This provides extra support to the muscles, which makes them stronger.

Sacral nerve stimulation
Sacral nerve stimulation is a treatment used for people with weakened sphincter muscles. Electrodes are inserted under the skin in the lower back and connected to a pulse generator. The generator releases pulses of electricity that stimulate the sacral nerves, which causes the sphincter and pelvic floor muscles to work more effectively.

Tibial nerve stimulation
Tibial nerve stimulation is a fairly new treatment for bowel incontinence. A fine needle is inserted into the tibial nerve just above the ankle and an electrode is placed on the foot. A mild electric current is passed through the needle to stimulate the tibial nerve.

It’s not known exactly how this treatment works, but it is thought to work in a similar way to sacral nerve stimulation.

Bowel

Injectable bulking agents
Bulking agents, such as collagen and silicone, can be injected into the muscles of the sphincter and rectum to strengthen them.

Endoscopic heat therapy
Endoscopic radiofrequency (heat) therapy is a relatively new treatment for bowel incontinence.

Heat energy is applied to the sphincter muscles through a thin probe, to encourage scarring of the tissue. This tightens the muscles and helps to control bowel movements.

Artificial sphincter
An artificial sphincter may be implanted if bowel incontinence has been caused by damage to the sphincter muscles. The operation involves placing a circular cuff under the skin around the anus. The cuff is filled with fluid and sits tightly around the anus, keeping it closed.

A tube is placed under the skin from the cuff to a control pump. In men, the pump is placed near the testicles, in women it’s placed near the vagina. A special balloon is placed into the abdomen, and this is connected to the control pump by tubing that runs under the skin.

The pump is activated by pressing a button located under the skin. This drains the fluid from the cuff into the balloon, so the anus opens and stools can be passed. When the stool is passed, the fluid slowly refills the cuff and the anus closes.

Colostomy
A colostomy is usually only recommended if other surgical treatments are unsuccessful. A colostomy is a surgical procedure in which the colon (lower bowel) is cut and brought through the wall of the stomach to create an artificial opening. Stools can then be collected in a bag, known as a colostomy bag, which is attached to the opening.

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