Mixed Incontinence in Women
Treatment

Treatment for mixed incontinence can include combinations of therapies prescribed for either stress or urge related incontinence. These treatments are described below.

Behavioral Treatments

Behavioral treatments are simple, self-directed, have no side effects and are often used in conjunction with other treatment options. They have proven effective for many women and work well for certain types of incontinence. They include:

• Bladder Training — The goals of bladder training are to increase the intervals between emptying your bladder and the amount of fluid your bladder can hold. This training can help diminish the sense of urgency and leakage.
  
  Bladder training requires adhering to a fixed voiding schedule, whether or not you feel an urge to urinate. If you feel the urge to urinate before the assigned interval, you should use urge suppression techniques, such as relaxation and Kegel exercises. As success is achieved, the interval is lengthened in 15- to 30-minute increments until you can remain comfortable for three or four hours. This goal can be adjusted to suit each woman's needs and desires.
• Pelvic muscle exercises — Pelvic muscle exercises, also known as Kegels, are an essential part of improving incontinence and preventing it from worsening. They can also help you suppress the urge to urinate. The exercises strengthen and tone the muscles that support the pelvic organs. These muscles contract and relax under your command to control the opening and closing of the bladder. Achieving results requires commitment and regular exercise. Correct technique is also very important.
• Biofeedback — Biofeedback has been proven effective in numerous research studies for the treatment of urinary incontinence. It can help you learn to control and strengthen your pelvic floor muscles, which play an important role in bladder control. Because you cannot see the pelvic floor muscles, you may find it difficult to locate them or to determine if you're doing pelvic muscle exercises correctly. Biofeedback therapy uses computer graphs and audible tones to show you the muscles you are exercising. It also allows the therapist to measure your muscle strength and individualize your exercise program.
• Urge Suppression — Urge suppression is a way to help control the sudden urge to urinate, so that going to the bathroom is not an emergency. Running to the bathroom is the worst thing you can do, as it increases bladder irritability and interferes with your ability to concentrate on controlling your bladder.

Electrical Stimulation

Pelvic floor electrical stimulation uses low-grade electrical current to stimulate weak or inactive pelvic muscles to contract. A tampon-like sensor that connects to a handheld adjustable device is inserted in the vagina. The patient then increases the current to the level of a comfortable tingle. Regular electrical stimulation sessions can supplement or augment your pelvic muscle exercise regime. Units are available for home use and may be covered by medicare or insurers.

Percutaneous Tibial Nerve Stimulation (PTNS)

Normal voiding depends not only on the normal function of organs and muscles, but also on nerves that deliver appropriate signals regarding urination. In urge incontinence, the nerves regulating the bladder can become hyper-reactive, sending strong signals to empty before the bladder is full. Nerve stimulation therapies "jam" the pathways that transmit these abnormal messages.

In PTNS, a small acupuncture needle is placed in the ankle along the tibial nerve. A handheld device connects to the needle to deliver mild electrical impulses to the nerve. These travel up the tibial nerve to the sacral nerve plexus, which regulates the bladder. PTNS sessions are painless, last 30 minutes and are repeated weekly for 12 weeks. All sessions take place in a medical office.

Sacral Neuromodulation Therapy (Interstim)

Sacral neuromodulation therapy also uses electrical impules applied directly to the sacral nerves. Wires are threaded through openings in the pelvic bones along the sacral nerves. This is done in an operating room using local anesthesia. The wires are attached to a small external generator. If a two week test using the external device shows improvement in symptoms, a permanent device, called Interstim, is implanted under the skin. This procedure requires general anesthesia.

Botox Bladder Injections

Botulinum toxin A, better known as botox, is used to treat patients with urge incontinence that does not improve with medications or other conservative therapies. It works by paralyzing bladder muscle, which helps decrease unwanted bladder contractions. Maximum relief is usually seen seven days after injection and normally lasts six to 12 months. Repeat injections are often needed.

Vaginal Inserts

Vaginal inserts and pessaries are frequently used to treat bladder and pelvic support problems. These devices are placed into the vagina to provide support for the uterus, bladder, urethra and rectum. A number of types are available, and the inserts are fit to meet your needs and anatomy.

Surgery

Surgery is performed to restore the normal position of the bladder neck and urethra. There are two main types of operations for incontinence: bladder neck suspension procedures and sling procedures. Within the medical community, the comparative effectiveness of these procedures is still being debated, and it is important that your decision is based on your individual circumstances.

Medications

There are currently no medications marketed specifically for the treatment of stress urinary incontinence. However, there are several experimental medications in development. Medications for this condition should be available in the near future.

In urge incontinence or overactive bladder, medications can help relax the bladder. These medications do not cure incontinence, but they can be very useful in reducing or eliminating problems of bladder control. They can be used alone or in combination with behavioral treatments.

Estrogen replacement therapy taken in pill or skin patch form has not been shown to be an effective treatment for female urinary incontinence. Vaginal estrogen (creams, vaginal rings or vaginal pellets) have helped reduce recurrent urinary tract infections in postmenopausal women, but their effectiveness for incontinence is unknown.

Reviewed by health care specialists at UCSF Medical Center.