(Ideally 1-2 Months After Visit #2)

1. Evaluate Response to Therapy
   
   
2. Consider Intervention by Incontinence Expert if Not Sufficiently Improved

I. Evaluate Response to Therapy.

1. For patients on behavioral therapy alone:
   • If necessary, review strategies described in patient handouts (change in voiding frequency, strategies to prevent urine loss, e.g., urge suppression or squeezing pelvic floor muscles during a cough or sneeze.
     
     
   • Encourage continued compliance with behavioral therapy to maintain efficacy.
     
     
   • For patients who have not responded to behavioral therapy after two or three visits, refer to a continence center or a nurse practitioner or physical therapist skilled in pelvic floor muscle rehabilitation/biofeedback.
     
     
   • Consider adding a medication for patients with OAB/urge UI who have not responded favorably to behavioral therapy alone (See Table 6).
   
   
2. For patients with OAB/urge UI on combined behavioral therapy and medications:
   • If UI controlled, consider reducing the dose or discontinuing the medication.
     
     
   • Adjust dose as needed to maximize efficacy and minimize side effects.
     
     
   • If the patient becomes worse on a certain drug or dose, discontinue the drug or decrease the dose. Once symptoms return to baseline, consider rechallenge with previous medication/dose or an alternative drug. OAB medications can also elevate PVR, worsening symptoms (See Table 5 for management of elevated PVR).
   
   
3. For patients with OAB/urge UI on medication alone:
   • Adjust dose as needed to maximize efficacy and minimize side effects, as above.
     
     
   • Consider adding Behavioral Therapy if not sufficiently improved.

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II. Consider Intervention by Incontinence Expert if Not Sufficiently Improved.

• If the patient has not improved after a trial of behavioral treatment and/or medication, refer to an incontinence expert or clinic for advanced evaluation and treatments such as biofeedback, electrical stimulation, devices, or surgery.
  • Biofeedback - a training technique that provides the patient with visual or auditory monitoring of physiologic activities, such as pelvic floor muscle activity, abdominal muscle activity, and bladder pressure. It allows the patient to locate and control appropriate muscles, improve pelvic floor muscle exercise technique, and reduce detrusor overactivity.
    
    
  • Electrical Stimulation -
    • Pelvic floor muscle electrical stimulation - an anal or rectal probe stimulates pudendal nerves resulting in maximal pelvic floor muscle contraction and detrusor relaxation. It can be useful for patients with very weak pelvic muscles or with overactive bladder that doesn't respond to behavioral or pharmacologic therapies. Electrical stimulation can be done in office visits 2-3 times per week or daily at home with a unit that can be rented or purchased. One month is a typical course.
      
      
    • Sacral nerve stimulation - a surgically implanted stimulator that reduces bladder overactivity and can decrease incomplete bladder emptying. (13)
    
    
  • Pessaries - Pessaries come in various sizes and shapes and are placed vaginally to reduce pelvic prolapse. Patients can insert and remove the device themselves or return to the office periodically for removal, cleaning, and replacement if they are unable.
    
    
  • Penile Clamps - For post-prostatectomy leakage, these are worn in waking hours or during certain activities that precipitate leakage and removed for voiding and at bedtime. Not for patients with urge incontinence.
    
    
  • Surgical Intervention - Surgery may be indicated for patients who have not responded to behavioral therapy, pharmacotherapy, or devices (e.g., pessary, clamp), or for those who choose surgery as their desired form of treatment.
    • Bladder suspension surgeries such as the Burch retropubic colposuspension for stress incontinence in women have approximately 90-95% early cure rates and 61-80% long-term cure rates. (14)
      
      
    • Pubovaginal sling procedures for stress incontinence have short-term success rates similar to the Burch, although long-term data are lacking. The sling material can be autologous (fascia lata or rectus fascia), cadaveric, or synthetic. A new sling procedure, the tension-free transvaginal tape or TVT, can be performed with less invasive surgery. TVT has excellent short-term results, but there is no data on long-term results. (15,16)
      
      
    • Periurethral bulking agents can be injected under the mucosa of the proximal urethra in patients with stress or mixed incontinence. Collagen is the most well studied bulking agent. In women the injections can be performed in the outpatient setting using local anesthesia; regional anesthesia may be used for men. Collagen has an overall short-term success rate of approximately 80% for women and 15% for men, and can be repeated when it fails. (17, 18)

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