Incontinence is a familiar condition among providers, but not all providers agree on the best treatment order. As patients have different needs and treatment goals, real-world practice varies considerably. While that variation isn’t necessarily negative or harmful, clinical guidelines continually recommend conservative therapies as first-line treatment for urinary incontinence. These treatments are low-risk, non-invasive, and often effective in improving symptoms.
Guidelines also recommend that only after first-line treatments fail should other options be considered in a stepwise approach. This style of evidence-based sequencing helps you make clinical decisions that are most likely to produce positive outcomes using the least invasive and most cost-effective route.
Understanding the Types of Urinary Incontinence
Urinary incontinence affects both males and females and tends to be more common in older adults, though it can also affect young people.
There are five key categories of urinary incontinence:
- Stress incontinence: Urine leakage results from abdominal pressure and a weak urinary sphincter or pelvic floor.
- Urge incontinence: Leakage is caused by increased bladder contractions that lead to sudden urgency, which may result from a neurological condition or bladder irritation.
- Mixed incontinence: Leakage is due to a combination of stress and urge incontinence.
- Functional incontinence: Leakage is caused by physical or situational barriers to toileting.
- Overflow incontinence: Problems with bladder contractility or obstruction in the bladder outlet cause bladder overfilling and leakage.
Urinary incontinence may be bothersome and embarrassing for patients, affecting their overall quality of life. In the case of overflow incontinence, it may lead to long-term kidney and bladder damage.
What “First-Line Treatment” Really Means
As the term suggests, first-line treatment is the first treatment offered for a condition. First-line does not mean basic. Instead, this is foundational care based on evidence that demonstrates its efficacy.
First-line treatment generally meets a few key criteria and is a starting point before moving on to more advanced therapies or procedures. These initial treatments are known as conservative management and are typically:
- Low-risk
- Well-tolerated
- Non-invasive
- Accessible to most patients
These principles are evident in urinary incontinence guidelines, which prioritize safety and patient adherence. These guidelines take into account systematic reviews of evidence and consider benefits and potential harm to patients, as well as the cost-effectiveness of a treatment in relation to its outcomes. Bladder training, for example, is a free, home-based treatment that may be more effective for overactive incontinence than certain medications — and with fewer adverse effects.
If initial approaches fail, treatment moves in a stepwise approach from first-line to higher-risk and more invasive therapies, such as medication or surgery. While generally safe and effective, medications and procedures have inherent risks and the potential for patient harm.
Core First-Line Treatments Recommended by Guidelines
The American Urological Association issues urinary incontinence guidelines for a few types of incontinence. The treatment specifics vary based on the type and underlying issue. However, a few core first-line treatments are recommended and are the standard of care across multiple specialties.
Conservative management of incontinence includes several non-surgical treatments for urinary incontinence. These guidelines recommend lifestyle changes that reduce the need to urinate or lower potential irritation.
Lifestyle modifications that are low-risk and inexpensive include:
- Restricting fluids at night
- Reducing total fluid intake
- Increasing physical activity
- Losing weight
- Avoiding or reducing bladder irritants, like coffee, alcohol, tea, and soda
- Increasing fiber and reducing dietary fat
The guidelines also recommend behavioral therapies and non-invasive treatment, such as:
- Pelvic floor muscle training (PFMT)
- Suppressing urges through muscle control
- Core exercises
- Muscle strengthening, like Kegels
- Manual therapy to release muscle tension
- Re-training muscles to brace during a cough or sneeze
- Bladder training
- Timed voiding
- Double voiding
- Delayed voiding
Where Traditional First-Line Approaches Fall Short
First-line treatments do have some shortcomings and challenges, however. Even when you make recommendations that fall in line with clinical guidelines and have the best evidence available, it’s ultimately up to the patient to implement the prescribed treatment. If they struggle to do so, it will likely impact their treatment outcomes.
For instance, patients may find it challenging to adjust their lifestyle habits or have trouble performing the exercises correctly. Additionally, bladder training and pelvic floor muscle therapy typically require dedicated time and consistency to see changes. Patients may have physical difficulties or other barriers that interfere with therapy and training, including forgetfulness, lack of time, and limited caregiver support.
Also, patients can benefit from physical therapy and regular follow-ups, but they also may struggle to follow through for many of the same reasons. The problem, in these cases, isn’t the treatment or the recommendation. Unfortunately, it’s more often patient acceptance and adherence to treatment.
Bridging the Gap: Enhancing First-Line Care
One way to counteract these challenges is to enhance care with technology-assisted therapies that align with non-invasive pelvic floor therapy first-line treatment.
Such therapies include:
- Magnetic muscle stimulation
- Electrical muscle stimulation
- Transvaginal electrical stimulation
- Transcutaneous tibial nerve stimulation
These technologies send electrical impulses to nerves and cause the muscles to contract, activating and strengthening pelvic floor muscles and bladder control. Whether using a patch applied to the lower abdomen for short treatment sessions, a needle, or a chair, such tools provide advanced muscle stimulation and consistency that is hard to produce with other therapies like Kegels.
What This Means for Modern Clinics
Technology offers you an opportunity to position your practice within clinical guidelines and provide options that are easier for patients to carry out. Stimulating the muscle from within delivers consistent and high-intensity treatment that encourages better control and improved patient outcomes.
Technologies like the ReStora EMS chair are compact, mobile, and convenient. They fit well into a busy workflow and allow you to manage several patients at once. For instance, you can set up one patient, then see another patient or catch up on charting during that session time.
These types of treatments require minimal staff time and no major clean-up or downtime. Patients may find these technology-assisted treatments to be more convenient as well, allowing them to receive advanced care with noticeable improvement in symptoms in a short period of time.
The Patient Perspective: Why First-Line Still Matters
More invasive treatments have risks and complications. Surgery, for example, can lead to infections, device failure or migration, organ prolapse, and painful urination. Medications may also have uncomfortable side effects. Many patients prefer to use first-line and non-invasive options to avoid these risks.
Urinary incontinence leaves patients feeling uncomfortable and often dealing with liners, pads, and diapers. Skin may also break down and lead to dermatitis, another aspect that affects quality of life. For these patients, simple first-line treatments that improve symptoms and enhance comfort and dignity are essential.
Technology-assisted therapy can offer patients a comfortable experience with no downtime and little disruption to their life. With these types of advanced therapies, patients can recover control over time and regain their confidence in the process.
Aligning Evidence, Outcomes, and Practice Growth
First-line treatments are clinically recommended for many reasons. Backed by evidence, they are effective therapies with little risk. However, patient adherence is a real challenge for patients and providers.
Modern clinics can bridge this gap by incorporating non-invasive and technology-assisted therapies that are aligned with clinical guidelines. With these types of therapies, you can give patients comfortable, convenient access to first-line treatments that can bring symptom relief and improved outcomes.
