Beat the Bladder Blues: Strength, Beauty and Power

Given the nature of the condition, few of us feel comfortable bringing up the subject of urinary incontinence, let alone discussing treatments at length. Who can blame us? The thought of it conjures visions of absorbent underwear, catheters, and dehydration.
However, that does not have to be the case. In 2024 we don’t have to settle for 1924 solutions!

Calm an Overactive Bladder

The first line of defence against bladder mishaps is lifestyle changes. Making certain choices can significantly help the symptoms of an overactive bladder (OAB) and stress incontinence (SUI). Changes can include reducing caffeine intake, avoiding liquids immediately before bedtime, weight management, bladder retraining, pelvic floor strengthening exercises.¹

Even sticking to a Mediterranean diet, characterized by anti-inflammatory foods and low red meat content, has been effective in easing an OAB.² Interestingly, emerging research suggests that eating less protein may relieve nighttime urine production.³

What’s New?

So, you’ve already tried all that, but things aren’t getting better. Don’t worry, we have you covered! Let’s take a quick tour of next generation urinary incontinence therapies.

Menopause and Medications

Hormonal changes linked with menopause often cause an increase in the need to urinate. Good news, hormone replacement therapy can help. Your doctor can prescribe vaginal estrogens to counter urogenital epithelium atrophy. Urogenital epithelium atrophy is a relaxation of your bladder and urethra’s supportive tissue. Loss of strength in your urogenital epithelium is what causes those unexpected urges. A meta-study of 33 clinical trials including over 19,000 participants showed that topical hormone application for epithelial atrophy works well for some women.⁴ Your doctor might offer you Ospemifene or dehydroepiandrosterone.5 A notable finding of the evidence review was that oral estrogen makes urinary incontinence worse in more cases than it helps. Moreover, in England and Wales, the National Institute for Health and Care Excellence (NICE) explicitly states that oral estrogen should not be offered for urinary incontinence.⁶

Antidepressants in the Arsenal

Certain antidepressants can cause a tightening of the urethral muscles, making it more difficult to relieve yourself. While for most patients this would be an annoying inconvenience, people dealing with a weak pelvic floor could find this a distinct advantage. For example, doctors usually prescribe duloxetine for mood regulation, but it can cause the side effect of urethral sphincter contraction.⁷ Similarly, Litoxetine is another selective serotonin reuptake inhibitor (SSRI) that enhances bladder capacity and urethral sphincter function.⁸ While results of clinical trials show that these can be useful for some women, many find that the side effects outweigh the benefits.⁶

The Microbiome Connection

Did you know that there is a link between urinary incontinence and gut bacteria diversity?⁹ Emerging research suggests a connection between the microbiome and urinary incontinence. Specifically, individuals with OAB had less microbiome variety compared to those without the condition. This relationship, however, is still under investigation. 

Streamlining Strength: Exercises for Incontinence Independence

We’ve talked a lot about “pelvic floor”, but not in the context of using it. Pelvic floor exercises specifically aim to fortify the muscles around the bladder. Kegel exercises, specifically, are highly recommended for postmenopausal women seeking to manage urinary incontinence.¹⁰ Research suggests that these workouts give better results in postmenopausal women than their premenopausal counterparts.¹⁰ Nonetheless, an ounce of prevention is better than a pound of cure. Given that pelvic floor exercise can help delay pelvic organ prolapse, it’s worth doing!

Build Up Your Bladder

Weakness in the muscles and connective tissue that hold the bladder up or squeeze the urethral opening closed, is often the culprit behind stress incontinence. Treatments that build and strengthen muscle and collagen are an ideal way to improve a weak pelvic floor and calm an overactive bladder. Luckily for us advances in cosmetic medical technology that use just those principles, have inspired a new generation of incontinence interventions.

Nerve Stimulation

Using neuromodulation to get your bladder under control might sound like space-age technology, but in fact, this idea goes all the way back to 19th-century Vienna.¹¹ While the victorian take on the technique wasn’t one you’d want to try these days, in 1976 Giles Brindley and colleagues successfully used electrical stimulation of nerves to treat a patient’s incontinence. ¹²

Percutaneous tibial nerve stimulation (PTNS) can be a great option for some women with OAB. In this case, a therapist uses a tiny needle to stimulate a neurone in your ankle. This percutaneous tibial nerve goes all the way up the leg to the spinal cord. An electric pulse is sent to the spinal cord giving an imperceptible zap to the area that receives messages from your bladder. This tiny stimulus can damp down the signals from your urinary system giving respite from an overactive bladder. Meta-studies show that this can be a helpful intervention for an overactive bladder with a 60% success rate.¹³

More recent strategies have targeted the pelvic floor in patients with stress incontinence. Many clinics are offering what they call a “Kegel Throne”. This is a chair with a neuromodulation device in the seat. The device can stimulate the nerves in your pelvic floor while you sit in it. Some women say they have found it helpful, however, meta-analyses and systemic reviews have shown that the evidence that it works is weak. ¹⁴

Laser Technology

While neuromodulation might not be good for stress incontinence, meta-analysis of clinical trial data shows that laser therapy could be a great alternative. ¹⁵

You’ve heard about laser treatments for facial rejuvenation, but did you know doctors can use it to strengthen the connective tissue that supports your urethra? The laser disrupts collagen molecules in the connective tissue of the vaginal wall. Then, when the collagen reorders itself after the treatment, it triggers new collagen production resulting in a thicker, stronger layer of supportive tissue. This helps the muscles that open and close your urethra to stand firm against the pressure applied by sneezing or bending.¹⁶ Laser treatments, such as microablative fractional carbon dioxide (CO2) laser and non-ablative Er: YAG laser, are proving to be transformative in managing the condition.

Botox: Not Just for Beauty

Beyond its cosmetic applications, Botox holds promise in managing urinary incontinence. Its muscle-paralyzing properties that relax wrinkles can also effectively reduce bladder muscle contractions. A frozen bladder muscle will be less prone to unexpected emptying.¹⁷

Platelet-Rich Plasma (PRP)

Treating urinary incontinence takes another aesthetic approach with platelet-rich plasma (PRP). The benefits of PRP have recently been investigated in other areas. By extracting, centrifuging, and reinjecting blood plasma, this procedure aims to rejuvenate urethral tissue. Preliminary trial results for stress incontinence have been encouraging. More work needs to be done to show whether it’s effective, but so far no side effects or complications have been reported. ¹⁸

Conclusion

A diverse range of innovative treatments offers hope to those affected—from Botox to antidepressants. Urinary incontinence need not stay an unspoken burden; solutions are all around and available for those who seek them.

References

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2. Bozkurt YE, Temeltaş G, Müezzinoğlu T, Üçer O. Mediterranean Diet and Overactive Bladder. Int Neurourol J. 2022;26(2):129-134. doi:10.5213/inj.2142118.059
3. Alwis US, Delanghe J, Dossche L, et al. Could Evening Dietary Protein Intake Play a Role in Nocturnal Polyuria? J Clin Med. 2020;9(8):2532. doi:10.3390/jcm9082532
4. Cody JD, Richardson K, Moehrer B, Hextall A, Glazener CM. Oestrogen therapy for urinary incontinence in post‐menopausal women. Cochrane Database of Systematic Reviews. 2009;(4). doi:10.1002/14651858.CD001405.pub2
5. Shin JJ, Kim SK, Lee JR, Suh CS. Ospemifene: A Novel Option for the Treatment of Vulvovaginal Atrophy. J Menopausal Med. 2017;23(2):79-84. doi:10.6118/jmm.2017.23.2.79
6. Recommendations | Urinary incontinence and pelvic organ prolapse in women: management | Guidance | NICE. Published April 2, 2019. Accessed January 2, 2024. https://www.nice.org.uk/guidance/ng123/chapter/Recommendations
7. Maund E, Guski LS, Gøtzsche PC. Considering benefits and harms of duloxetine for treatment of stress urinary incontinence: a meta-analysis of clinical study reports. CMAJ. 2017;189(5):E194-E203. doi:10.1503/cmaj.151104
8. Dmochowski RR, Haab F, Robinson D. A randomized, placebo-controlled clinical development program exploring the use of litoxetine for treating urinary incontinence. Neurourol Urodyn. 2021;40(6):1515-1523. doi:10.1002/nau.24690
9. Karstens L, Asquith M, Davin S, et al. Does the Urinary Microbiome Play a Role in Urgency Urinary Incontinence and Its Severity? Frontiers in Cellular and Infection Microbiology. 2016;6. Accessed January 2, 2024. https://www.frontiersin.org/articles/10.3389/fcimb.2016.00078
10. Park SH, Kang CB. Effect of Kegel Exercises on the Management of Female Stress Urinary Incontinence: A Systematic Review of Randomized Controlled Trials. Advances in Nursing. 2014;2014:e640262. doi:10.1155/2014/640262
11. Ultzmann R: Die Krankheiten der Harnblase, Stuttgart, F. Enke. 1890, pp 343-356.
12. Brindley GS. History of the sacral anterior root stimulator, 1969–1982. Neurourology and Urodynamics. 1993;12(5):481-483. doi:10.1002/nau.1930120506
13. Burton C, Sajja A, Latthe P m. Effectiveness of percutaneous posterior tibial nerve stimulation for overactive bladder: A systematic review and meta-analysis. Neurourology and Urodynamics. 2012;31(8):1206-1216. doi:10.1002/nau.22251
14. Stewart F, Berghmans B, Bø K, Glazener CM. Electrical stimulation with non-implanted devices for stress urinary incontinence in women. Cochrane Database Syst Rev. 2017;12(12):CD012390. doi:10.1002/14651858.CD012390.pub2
15. Hafidh B, Baradwan S, Latifah HM, et al. CO2 laser therapy for management of stress urinary incontinence in women: a systematic review and meta-analysis. Ther Adv Urol. 2023;15:17562872231210216. doi:10.1177/17562872231210216
16. Ruffolo AF, Braga A, Torella M, et al. Vaginal Laser Therapy for Female Stress Urinary Incontinence: New Solutions for a Well-Known Issue-A Concise Review. Medicina (Kaunas). 2022;58(4):512. doi:10.3390/medicina58040512
17. Sahai A, Khan MS, Gregson N, Smith K, Dasgupta P. Botulinum toxin for detrusor overactivity and symptoms of overactive bladder: where we are now and where we are going. Nat Rev Urol. 2007;4(7):379-386. doi:10.1038/ncpuro0839
18. Grigoriadis T, Kalantzis C, Zacharakis D, et al. Platelet-Rich Plasma for the Treatment of Stress Urinary Incontinence-A Randomized Trial. Urogynecology (Phila). 2024;30(1):42-49. doi:10.1097/SPV.0000000000001378