Treatment of Refractory Urinary Urgency, Frequency, and Incontinence in Pregnancy

Abstract

The prevalence of urinary symptoms such as urgency, frequency, and urge incontinence is high in pregnancy and often becomes more bothersome further in pregnancy. First-line treatment often includes behavioral modifications such as avoidance of caffeine and timed voiding. Treating incontinence refractory to these first-line measures poses a challenge to the clinician given the concern for fetal harm, miscarriage, and preterm labor from current treatment modalities. The purpose of this review article is to summarize the most up-to-date literature of second- and third-line treatment options for urge incontinence in pregnancy as well as address the known and theoretical risks. The etiology of urge incontinence in pregnancy remains poorly understood and is likely multifactorial. Pelvic floor physical therapy, oral medications, and sacral neuromodulation have been used during pregnancy with some efficacy and outcome reporting. The use of percutaneous tibial nerve stimulation or intradetrusor onabotulinum toxin A injections specifically for the treatment of overactive bladder in pregnancy has not been reported. The current data is limited and comes mostly from case studies/series and registry data. With the exception of pelvic floor physical therapy, limited evidence exists to recommend one treatment modality over another in pregnancy. The safety prolife of oral medications, onabotulinum toxin A injections, and neural modulation in pregnancy has not been conclusively established. The decision to use one of these treatments during pregnancy must weigh the known and theoretical risks against the potential benefits and include informed decision making with the patient.