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Dr. Y.
Dr. Y., Urologist
Category: Urology
Satisfied Customers: 20141
Experience:  I am fellowship trained specializing in general urology and reconstructive urology.
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I need to stop wetting my pants

Customer Question

i need to stop wetting my pants
Submitted: 1 year ago.
Category: Urology
Expert:  Dr. Captain replied 1 year ago.

Hello!

Welcome to the JustAnswer.com chat dialog.

I am a Family Medicine doctor, board certified with active licenses and certification in Internal Medicine, Pediatrics, Obstetrics and Gynecology, as well as Integrative Medicine & Naturopathy, with advanced training in Neurology, Cardiovascular Medicine, Gastroenterology, Endocrinology, and Psychiatry. I am also well-trained in Functional Medicine. Perhaps most importantly, I consider myself a patient listener.

I have read your post and observations.

Would you prefer a summary answer to your question, or would you prefer more back-and-forth, where there will be a series of more questions and more details clarified?

Either way, I’ll do my best to take the appropriate time to help you.

Expert:  Dr. Captain replied 1 year ago.

Although I can try to address your question thoroughly, if you have immediate medical concerns, or feel like there is something urgently wrong, it is important to consult a doctor/nurse practitioner/physician's assistant, in person. There are aspects of your experience, features of the history you're telling me and some things that are left out (even unknowingly), and certainly features of a physical exam of your body that can't translate over this type of online communication. Unfortunately, because of the nature of this type of chat, some important concerns could be easily missed, and I could unwillingly get the wrong impression from you, or give you information based on incomplete information.

Expert:  Dr. Captain replied 1 year ago.

I'm more than happy to summarize my thoughts on the condition of incontinence, and various treatments, but my goal is really only for your satisfaction. Remember, specific questions are helpful for clear direct answers.

Expert:  Dr. Captain replied 1 year ago.

Here is a shortened summary up Uptodate resource information that I think summarizes the concerns and available treatments that you may find helpful. "Initial treatment includes lifestyle modifications and pelvic floor muscle exercise for all patients with urinary incontinence (stress, urgency, or mixed), along with bladder training in women with urgency incontinence and for some women with stress incontinence. We typically treat with these conservative therapies for six weeks before considering subsequent therapies. It is also reasonable to treat with conservative therapies for up to 12 weeks, particularly in women who would like to lose weight.

Weight loss – Obesity is a known risk factor for urinary incontinence, and weight loss in obese women appears to improve symptoms of urinary incontinence. Studies show greater benefits for stress incontinence than urgency incontinence. For example, one randomized trial of 338 overweight and obese women found that weekly incontinence episodes decreased in patients assigned to an intensive six-month weight loss program compared with a control group (47 versus 28 percent). While the difference in the groups was driven by a decrease in stress, but not urgency incontinence, more women in the intervention group had a ≥70 percent reduction in the frequency of all incontinence episodes.

Dietary changes – Some beverages may exacerbate symptoms of urinary incontinence. We ask patients to reduce consumption of alcoholic, caffeinated, and carbonated beverages. Women who are drinking excess amounts of liquids (>64 ounces of liquids) should normalize their fluid intake. We do not restrict fluid consumption below this level as this can lead to dehydration. We also ask women who complain of nocturia to decrease the amount of liquid consumed before bedtime.

Constipation – Constipation can exacerbate urinary incontinence and increase the risks of urinary retention. Constipation should be managed and avoided when possible.

Bladder training — Bladder training is most effective for women with urgency incontinence. Some women who have stress incontinence only at higher bladder volumes may also benefit from the timed voiding component to keep bladder volumes below that where stress incontinence occurs. Bladder training and pelvic muscle exercises are often used in combination.

Bladder training starts with timed voiding. Patients should keep a voiding diary to identify their shortest voiding interval. They are then instructed to void by the clock at regular intervals using the shortest interval between voids identified on their voiding diary as the initial voiding interval. Urgency between voiding is controlled with either distraction or relaxation techniques (eg, performing mental math, deep breathing, or by quick contractions of the pelvic floor muscles "quick flicks"). When the patient can go two days without leakage, the time between scheduled voids is increased. The intervals are gradually increased until the patient is voiding every three to four hours without urinary incontinence or frequent urgency. Successful bladder training can take up to six weeks. Patients often need reassurance to proceed despite initial lack of response.

Patients should be encouraged to void regularly even when outside of the home. Websites that give the locations of public restrooms are available for many major cities. Many such United States cities can be found at:www.americanrestroom.org/locate/index.htm.

Topical vaginal estrogen — We suggest a trial of vaginal estrogen therapy for peri- or postmenopausal women with either stress or urgency incontinence and vaginal atrophy. Vaginal atrophy can lead to symptoms of urinary frequency and dysuria and can contribute to incontinence. We use Premarin or Estrace cream 0.5 mg twice weekly, Vagifem 10 mcg twice weekly, or the Estring. The product choice is determined by patient preference and ease of use.

It may take up to three months for patients to notice benefits from treatment.

Systemic absorption is low with the recommended doses. The use of vaginal estrogen in women with a history of breast cancer is discussed separately.

A 2012 systematic review and meta-analysis of four randomized trials of postmenopausal women found that vaginal estrogen was associated with improved incontinence. Three of the four trials were restricted to patients with stress incontinence, and statistical heterogeneity between trials limit the confidence in the meta-analysis' conclusion.

We do not recommend systemic (oral hormone replacement therapy) estrogen therapy for urinary incontinence. Evidence suggests that systematic hormone therapy may worsen urinary incontinence.

STRESS INCONTINENCE — If initial treatments described above are not sufficient for patients with stress incontinence, pessaries may be effective as a next step. Patients without adequate relief should be referred for additional treatment options.

Pessaries – Continence pessaries may be used for women with stress incontinence as an adjunct or substitute for pelvic muscle exercises. Overall success rates are approximately 50 percent. We find them most useful for patients who have stress incontinence associated with specific activities or situations (eg, exercise or transient cough in the setting of upper respiratory infection). This treatment is discussed in detail separately.

Pharmacologic therapy – Multiple medications have been evaluated for stress incontinence in women. In the United States, no pharmacologic therapies have been approved by the US Food and Drug Administration (FDA) for treatment of stress incontinence.

Duloxetine – Duloxetine is a serotonin and norepinephrine reuptake inhibitor and may be effective for incontinence. We do not routinely use duloxetine as treatment for stress incontinence. However, if patients are already being treated for depression, it is reasonable to discuss the option of duloxetine a primary treatment for depression given this potential beneficial side effect.

Some studies have shown decreases in incontinence episode frequency compared with placebo, and it is used in Europe for treatment of stress incontinence. However, a 2012 systematic review of 24 studies (including six randomized trials) found that duloxetine was not more effective than placebo for stress incontinence.

Other medications – Alpha-adrenergic agonists (eg, phenylpropanolamine), which stimulate urethral smooth muscle contraction, had been used previously for the treatment of stress incontinence. They are no longer recommended because they are only mildly efficacious compared with placebo and have a high rate of adverse effects. There is insufficient evidence for the efficacy of imipramine in stress and mixed incontinence and side effects are significant.

Mechanical devices – Several devices have been developed over the years. They are placed within the urethra or vagina to prevent urinary leakage. Their use is limited by their high rates of urinary tract infections and lack of evidence regarding long-term safety and efficacy.

Surgery – Women without sufficient improvement with initial treatment and/or pessaries should be evaluated for surgical therapy. Surgery offers high cure rates for stress urinary incontinence (SUI), even in older women. A randomized trial comparing pelvic floor muscle training with surgery found improved overall outcomes with surgery, with nearly 50 percent of women assigned to conservative therapy crossing over to surgery.

Smoking cessation – Smoking has been associated with an increased risk for urinary incontinence. However, no studies have evaluated whether smoking cessation decreases urinary incontinence.

Pelvic floor muscle exercises (Kegel exercises) — We suggest pelvic floor muscle exercises for all women with urinary incontinence. In women who are able to isolate their pelvic floor muscles to stop urine flow, verbal instruction on timing and frequency of exercise is usually sufficient. For those with difficulty identifying the proper muscles, supplemental modalities can help women to perform these exercises properly.

Initial instruction — Pelvic muscle (Kegel) exercises strengthen the pelvic floor musculature to provide a backboard for the urethra to compress on and to reflexively inhibit detrusor contractions. As such, these can be effective for both stress and urgency incontinence. Systematic reviews of randomized trials have found that compared with no treatment, women treated with pelvic muscle exercises were more likely to report improvement or cure.

The basic regimen consists of three sets of 8 to 12 contractions sustained for 8 to 10 seconds each, performed three times a day. Patients should try to do this every day and continue for at least 15 to 20 weeks. Adequacy of pelvic floor muscle contraction can be assessed during the pelvic examination. The examiner places one or two fingers within the vagina and asks the patient to contract her pelvic floor using the same muscles she would use to stop urine flow or gas.

Patients have better outcomes with regular exercise and proper technique. For women who are able to isolate pelvic floor musculature, supplemental therapy may not be necessary. However, other patients may have difficulty because of poor muscle isolation, low motivation, or inability to properly contract the pelvic floor. For these patients, we use supplemental therapies such as supervised pelvic floor therapy, vaginal weighted cones, or biofeedback (based on patient preference, access, and availability)."

Expert:  Dr. Captain replied 1 year ago.

I hope I have been able to help, if so a positive rating would be appreciated and please return and ask for Dr Captain in the future. Thank you.