Second-line Treatment for Urgency Urinary Incontinence
Sometimes self-management or the drugs your doctor prescribed do not improve your urgency urinary incontinence (UUI). In these cases, other treatment options are available. Together with your doctor you can decide which approach is best for you.
Common second-line treatment options for UUI are:
- Botulinum toxin bladder injection
- Nerve stimulation, also known as neuromodulation
- Surgery to increase bladder volume
This section offers general information and situations can vary from country to country.
Botulinum toxin is widely known by one of its trade names, Botox® and is often used in cosmetic surgery. For UUI, the toxin is injected into the bladder wall to reduce the activity of the nerves which cause the symptoms. This treatment may improve frequency of urinating, and urgency incontinence.
For botulinum toxin injections, you will generally receive local anaesthesia. Sometimes other forms of anaesthesia are used. The doctor uses a type of endoscope, known as a cystoscope, to enter your bladder through the urethra. The cystoscope has a small camera to show a high-quality image of your bladder on a video monitor. The doctor injects a small dose of botulinum toxin into different areas of your bladder wall (Fig. 1).
The effect of the procedure will wear off with time and after 4-9 months you will need to undergo repeat treatment. Some people (less than 10%) may have difficulty urinating after a botulinum toxin injection, and may need a catheter. Botulinum toxin injections may increase the risk of urinary tract infection and your doctor may prescribe antibiotics.
Nerve stimulation, also known as neuromodulation, is a treatment which uses electrical pulses to stimulate the sacral nerves, which control the bladder. There are two types of nerve stimulation:
- Tibial nerve stimulation uses a needle at the level of the ankle (Fig. 2).
- In sacral nerve stimulation a device is implanted in your lower back (Fig. 3).
Tibial nerve stimulation
For tibial nerve stimulation, your doctor will place a needle with electric current near your ankle. The needle passes through the skin and stimulates the tibial nerve, which runs from the inner part of the ankle along the leg up to the sacral nerves (Fig. 2).
A treatment course for tibial nerve stimulation generally lasts 12 sessions. A treatment session is done once a week at a clinic and usually lasts 30 minutes. The effect will wear off with time and you will likely need more treatment courses.
Sacral nerve stimulation
The sacral nerve stimulation procedure is done in two stages. First, the doctor places an electrode though the skin and tests whether or not your bladder responds to nerve stimulation. If there is a response, you will receive surgery to implant a programmable pulse generator above your pelvic bone. The electrode connects the generator to the area of stimulation of the sacral nerves (Fig. 3). This device will control the electrical stimulation on the nerves that reach the bladder. When the stimulation is altered, it reduces bladder over-activity. Sacral nerve stimulation can greatly improve your symptoms.
After surgery there is a low risk of infection and you may experience temporary pain in the area of implantation. Over time, the generator or the electrode may move, causing discomfort. It is also possible that the generator stops working if it moves. After several years, the generator battery will die. When this happens you will need further surgery to replace it. Make sure to discuss any of your concerns about these risks with your doctor.
In case your symptoms have not improved with drug or other treatments, you may need surgery on your bladder. The goal of the procedure is to increase the capacity of the bladder. This will reduce the pressure in the bladder as it fills so that it can hold more urine.
The doctor makes an incision in your lower abdomen and uses a piece of your bowel to increase the size of the bladder. This procedure is called bladder augmentation or cystoplasty, and is rarely performed nowadays (Fig. 4). If this surgery is recommended, you will need to discuss its implications and side effects with your doctor because they can be significant.