Bladder control problems: Medications for treating urin...

Bladder control problems: Medications for treating urinary incontinence

Explore the different types of medication that work to treat bladder control problems, plus discover promising new medical therapies for treating urinary incontinence.

You've given up coffee and soda. You've followed your doctor's suggestions for bladder retraining. But bladder control remains a problem. What else can you do? Ask your doctor about medication options.

Effective medication has long been available for people with urge incontinence — a bladder control problem marked by sudden, intense urinary urges and urine leakage. Now new medications are becoming available for stress incontinence — urine leakage prompted by a physical movement or activity, such as coughing, sneezing or heavy lifting — and for overactive bladder — sudden urges to urinate that are difficult to suppress. These new medications tend to be easier to take and have fewer side effects than the older ones.
Which drugs can help control urinary incontinence?

The major types of medications used to manage urinary incontinence are anticholinergics, alpha-adrenergic agonists and estrogen. Other options include the antidepressant imipramine and the synthetic hormone desmopressin, which is more commonly used for bed-wetting in children.
How the drugs work

Here's an overview of the most common medications, along with possible side effects of each drug or group.

Anticholinergics
Overactive bladder is characterized by abnormal bladder contractions, which make you want to urinate even when your bladder isn't full. Anticholinergic drugs block the action of a chemical messenger — acetylcholine — that's instrumental in sending the signals that trigger these contractions.

Two commonly prescribed anticholinergics are oxybutynin (Ditropan) and tolterodine (Detrol). Both are available in an extended-release form, which has two advantages over the immediate-release forms. You need to take them only once a day instead of several times a day, and they have fewer side effects. Still, the immediate-release form may be helpful if you experience incontinence only at certain times, such as at night, or if you want to take a medication only at certain times, such as when you travel. Oxybutynin is also available as a skin patch that delivers a continuous amount of medication.

The most common side effect of anticholinergics is dry mouth. To counteract this effect, you might suck on a piece of candy or chew gum to produce more saliva. Other less common side effects include constipation, heartburn, blurry vision, urinary retention and cognitive side effects such as impaired memory and confusion.

The most common side effect of the oxybutynin skin patch is skin irritation. To remedy this, your doctor may recommend that you rotate the location of your patch.

Alpha-adrenergic agonists
Instead of blocking a chemical messenger, as anticholinergic drugs do, alpha-adrenergic agonists mimic a different chemical messenger, norepinephrine. The norepinephrine-like properties of these drugs stimulate alpha-adrenergic receptors. This has the effect of contracting the urethral smooth muscle, thus tightening the urinary sphincter and the muscular valve that prevents urine from leaking.

Examples of alpha-adrenergic agonists include ephedrine and pseudoephedrine. These drugs aren't designed specifically for incontinence, but are commonly found in over-the-counter cough medicines, antihistamines and appetite suppressants. Although these drugs may be helpful for mild cases of stress incontinence, their use in such cases has decreased because of potentially dangerous side effects.

Side effects include agitation, insomnia, anxiety, dry mouth and headache. Avoid the use of alpha-adrenergic agonists if you have glaucoma, diabetes, hyperthyroidism, heart disease or high blood pressure.

Estrogen
A woman's bladder and urethra contain receptors for the hormone estrogen. Estrogen helps maintain the strength and flexibility of tissues in this area. After menopause, a woman's body produces less estrogen. The theory is that this drop in estrogen contributes to the deterioration of the supportive tissues around the bladder and urethra, which makes these tissues weak and may aggravate stress incontinence.

Estrogen is known to improve blood flow, enhance nerve function and correct tissue deterioration in the urethra and vaginal areas. Applying estrogen in the form of a vaginal cream, ring or patch may help tone and rejuvenate these areas and relieve some of the symptoms of stress incontinence or urge incontinence. Oral estrogen may not have the same benefits as vaginal estrogen for urinary symptoms.

In general, there's not a lot of scientific evidence to support the use of estrogen for treating urinary incontinence, but many women report it to be helpful for their urinary symptoms. Estrogen may have a role when used in combination with other therapies, such as pelvic floor muscle training.

Taking combination hormone replacement therapy (estrogen plus progestin) may cause a slight increase in the risk of heart disease, stroke and breast cancer — but many additional factors, such as how long you're on this therapy and at what age you started it, contribute to the balance of risks and benefits. Systemic hormone therapy is no longer prescribed specifically for urinary benefits, but vaginal estrogen may sometimes be recommended. Most experts agree that the localized effects of vaginal estrogen don't carry the same health risks as systemic estrogen therapy.

Imipramine
Imipramine (Tofranil) is a tricyclic antidepressant that has both anticholinergic and alpha-adrenergic effects. It makes the bladder muscle relax, while causing the smooth muscles at the bladder neck to contract. As such, it may be used to treat mixed — urge and stress — incontinence. Imipramine may cause drowsiness, so it's often taken at night. Because of this, imipramine may be useful for nighttime incontinence, as well. It may also be helpful for children who bed-wet at night (nocturnal enuresis).

Imipramine can cause serious cardiovascular side effects, such as irregular heartbeat and dizziness or fainting from reduced blood pressure when you stand up quickly. Children may be especially susceptible to these side effects. Other side effects, including dry mouth, blurry vision and constipation, are similar to those of anticholinergics. Tricyclic antidepressants interact with many different medications, so make sure your doctor knows which medications you're taking before you begin taking imipramine.

Desmopressin
Desmopressin is a synthetic version of a natural body hormone called anti-diuretic hormone (ADH). This hormone decreases the production of urine. Your body normally produces more ADH at night, so the need to urinate is lower then. In children, bed-wetting may be caused by a shortage of nighttime production of ADH. Desmopressin is commonly used to treat bed-wetting in children and is available as a nasal spray or pill for use before bedtime.

Research suggests that desmopressin may also reduce urinary incontinence in adult women. Side effects are uncommon, but there is a risk of water retention and sodium deficiency in the blood (hyponatremia), particularly in older women.
Promising new drugs

Researchers are looking into new drugs that may have longer lasting benefits and fewer side effects. Here are some examples:

* Selective anticholinergics. One of the limitations of current anticholinergic drugs is that they affect multiple parts of the body in addition to the bladder. Their effect on the salivary glands, for example, can produce dry mouth, and their effect on the central nervous system, can cause dizziness. Darifenacin (Enablex), solifenacin (Vesicare) and trospium (Sanctura) are three more recently approved anticholinergics that target the bladder specifically in order to treat overactive bladder, without affecting other organs and systems.
* Capsaicin. Some studies have shown that instilling an extract of capsaicin, the spicy component of hot chili peppers, numbs a hypersensitive bladder. The extract is placed in the bladder through a thin tube (catheter) inserted through the urethra. At first, it stimulates the sensory nerves of the bladder, but after a while, it produces a long-term resistance to sensory activation, which may last for two to seven months. Capsaicin has been used successfully as a treatment for overactive bladder associated with nerve disorders, such as multiple sclerosis or spinal cord injuries. Temporary side effects include discomfort and a burning sensation in the pubic area when the capsaicin is instilled. Instilling the local anesthetic lidocaine before the capsaicin can help alleviate this problem. You also might experience a temporary worsening of your symptoms before they get better. However, at this time, capsaicin isn't readily available — due in part to the severe bladder pain it can cause — and is rarely used outside of clinical studies.
* Resiniferatoxin. Resiniferatoxin, an extract from a cactus-like plant, has effects similar to those of capsaicin, but a thousand times more potent. Remarkably, though, burning sensations do not occur when resiniferatoxin is infused in the bladder. Studies of resiniferatoxin have found that it doesn't produce the temporary worsening of bladder symptoms seen with capsaicin, and its beneficial effects may last up to three months. Resiniferatoxin is still under investigation and available only to those in clinical studies at this time.
*

Botulinum toxin type A. Injections of botulinum toxin type A (Botox) into the bladder muscle may benefit people who have an overactive bladder. Botox blocks the actions of acetylcholine and paralyzes the bladder muscle.

Preliminary studies have found that Botox significantly improves symptoms of incontinence and causes few side effects. Benefits can last up to nine months. Scientists speculate that in cases of severely overactive bladder unrelated to a neurological condition, Botox may be helpful for people who haven't responded to other medications.

See your doctor

When talking to your doctor, carefully review all other medications you're taking, including over-the-counter drugs or herbal remedies. Some medications increase bladder control problems. Others may interact with incontinence medications in a way that increases symptoms. Your doctor can help you decide if you need medicine to treat your bladder control problem, and if so, which one may be best for you.

1998-2008 Mayo Foundation for Medical Education and Research (MFMER)
May 8, 2007