Urinary Incontinence is the accidental loss of urine. It affects over 17 million American men and women. Many people suffer in silence due to embarrassment. Most problems of incontinence can be managed or treated successfully.
There are many conditions which cause or contribute to incontinence problems.
- Urinary Tract or Vaginal infections
- Pelvic Muscle Weakness/Prolapse
- Obstruction (Prostate enlargement, Stricture)
- Neurological Diseases
- Pelvic Surgery
- Overactive Bladder
- Weakness of Sphincter Muscles
- Birth Defects
- Spinal Cord Injury
Types of Incontinence
- Stress Urinary Incontinence is the involuntary loss of urine that occurs with an increase in abdominal pressure caused by activities such as sneezing, coughing, laughing, getting out of a chair or lifting.
- Urgency Urinary Incontinenceis also known as overactive bladder. It is the involuntary loss of urine accompanied by a sudden, strong urge to urinate and an inability to get to the bathroom in time.
- Mixed Urinary Incontinence is the combination of urge and stress incontinence.
- Overflow Urinary Incontinence occurs when the bladder does not empty properly. Symptoms include frequency and dribbling.
After a complete medical history by the provider, a physical exam includes a pelvic and rectal exam to evaluate for correctable reasons for leakage. A urinalysis will screen for infection, blood, sugar, kidney disease and bladder cancer. Blood and urine tests will be taken as needed to evaluate for medical causes of incontinence.
A renal ultrasound or abdominal CT scan may be ordered to evaluate the anatomy of the kidneys and surrounding abdominal organs.
Cystoscopy and urodynamics (nerve study of the bladder may be indicated. The cystoscopy is a 20 minute procedure that requires passage of a rigid or flexible scope through the urine tube into the bladder to directly look at the bladder wall. The urodynamics test requires a tube to be placed in the bladder during water filling of the bladder to measure pressure and to look for bladder spasms or contractions.
Treatment of Incontinence
Treatment for Stress Incontinence in women begins with conservative management.
- Behavioral Therapy – techniques include fluid management, decrease bladder irritants such as tea, soda, coffee, carbonated drinks or acid foods, increase water intake over other fluids, timed voiding and double voiding to empty the bladder completely, avoidance of constipation, as well as Kegel (pelvic floor muscle) exercises daily. Symptoms of leakage may resolve with conservative management alone.
- Pelvic Floor Muscle Training – These discrete exercises done on a regular basis will strengthen the pelvic floor and sphincter muscles and improve urinary control. It is best not to perform these exercises during the act of voiding. For help in isolating the pelvic floor muscles techniques including biofeedback, electrical stimulation of the pelvic muscles and weighted vaginal cones and be done with a trained therapist or nurse or at home.
- Pessary Use – A pessary, special stess incontinence ring with knob, can be placed in the vagina giving support to the mid urethra and urinary sphincter. The pessary is temporary and needs to be removed and cleaned on a regular basis.
- Bladder Neck Implant – Several products are available to transurethral injection into The urethra for “bulking” and coaptation of the urethral mucosa. It is available for men and women. A rigid cystoscope and needle are used to inject material (i.e. contigen, beads, gel) under the lining of the urethra under local anesthesia. Success with reduction in leakage is common however multiple injections may be needed and there tends to be “settling” of the material within 1-2 years. This procedure does not keep other surgical methods from being used and may be used in combination with slings for bladder control.
- Radiofrequency of the Bladder Neck – Also a minimally invasive technique involves a urethral probe with 4 needles placed at the bladder neck sphincter in women. During treatment radiofrequency causes denaturation of protein and in effect ”shrink wrapping” the bladder outlet. This one-time 30 minute office procedure is done under local anesthesia with minimal risk.
- Midurethral Sling – Most of the suburethral slings performed today are known as the TVT (transvaginal tape) or the TOT (Transobturator Tape). A narrow strip of material from cadaveric tissue, autologous (from your own body), synthetic mesh, or natural biologics (cross linked protein tape grown in cell culture i.e. “new skin” can be place under the urethra to provide a hammock of support and improve urethral sphincter function. This procedure is minimally invasive and has a quick recovery time.
- Retropubic Colposuspension – An open surgery with the goal of fixing the vaginal or peri-urethral tissues to the pubic bone (i.e. M.M.K., Burch, para-vaginal repair). Long term results are good but require a more invasive approach. Laparoscopic suspensions are done but currently do not have the lasting results with control of stress incontinence as the open procedures.
- Male Slings – Male patients with stress incontinence (post-surgery, trauma or neuromuscular injury) may benefit from a urethral compression sling. An incision is made underneath the scrotum. Success rates are good with low volume incontinence.
- Artificial Urinary Sphincter – A silicone three piece device is implanted with a cuff around the urethra, a fluid filled pressure regulating balloon placed in the abdomen and a small pump placed in the scoturn or vulvar area to be controlled by the patient. fluid fills the cuff and provides compression to the urethra to prevent leakage. To urinate, the pump is squeezed which releases the fluid back to the abdominal balloon and opens the urethra to allow urine flow.
Urgency Urinary Incontinence
- Behavioral Management – The first step in treatment of urgency incontinence is fluid management (avoid dietary irritants, tea, soda, coffee and carbonated drinks), evening fluid restriction, timed voiding with regular emptying of the bladder.
- Medications Bladder – relaxants prevent the bladder muscle from contracting involuntarily. Side effects are dry mouth and constipation. There come in forms of pills, patch, and gel and can be very effective. Contraindications to the use of anticholinergics are narrow angle glaucoma and unrelieved urinary obstruction.
- Percutaneous Tibial Nerve Stimulation (PTNS) – A small needle is placed at the ankle in the office as the patient relaxes in a recliner. Electrical stimulation is delivered for 30 minutes before the needle is removed. Treatment in the office is Weekly for up to 12 weeks with a 75% reduction in urgency, frequency or urgency incontinence.
- Sacral Nerve Stimulation (SNS) – An electrode is temporarily placed in the patient’s for a 3 to 5 day trial. If a reduction of 50% or more in urge, frequency, urge incontinence and urinary retention occurs, a permanent electrode with pacemaker is implanted in the back and buttock.
Treatment Options for Incontinence
Stress Urinary Incontinence
- Decrease dietary irritants soda, tea, coffee, acidic foods and carbonated beverages.
- Timed Void – go every two hours during the daytime to keep the bladder at a small volume which is more controllable.
- Pelvic Muscle Exercises (Kegel exercise) Repeated contractions of the pelvic floor will increase muscle strength and coordination. The smallest tightening of the isolated muscles around the anus and urethra will be effective if done every day.
Bladder Neck Implant
- A bulking agent (Contigen, Duraspheres, Coaptite, or Macroplastique) can be injected by a needle into the bladder neck to bring the urethra together and provide resistance to urine leakage. This procedure can be done under local anesthesia
Sub urethral Slings
- Slings made from synthetic mesh or biologics are placed transobturator or transvaginal under local or general anesthesia to provide a hammock type support for the bladder neck and urethra.
Retro pubic culposuspension
- Is done through and abdominal incision or laparoscopic approach. The periurethral vaginal tissues are attached to the undersurface of the pubic bone.
Bladder Neck Needle Suspension
- Vaginal dissection of the bladder neck is performed and long needles pass from the anterior abdomen behind the pubic bone and transfer suspend sutures to tie over the abdominal fascia. This popular procedure in the 1990’s is less effective than the tension free suburethral slings and are rarely done today.