Bladder control problems

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.