Incontinence

Incontinence: What is urinary incontinence?

Urinary incontinence (UI) is the loss of bladder control. This condition is much more common in women because it is often related to childbirth. Vaginal deliveries can stretch and tear the nerves and muscles that support and control bladder function. These injuries are not always noticed until menopause when estrogen levels drop and the tissues weaken even further. Straining from constipation or a chronic cough may cause the problem to become worse. Though many women develop UI as they grow older, this disorder is not a normal part of aging.

Since there are many different causes for loss of bladder control, obtaining an accurate diagnosis is critical in providing an effective treatment.

A complete medical history is an essential part of a good evaluation. Because many medications have a profound effect on the bladder, a list of all current prescription and over-the-counter medications should be provided during the history-taking process.

Types of Urinary Incontinence

The history will guide your physician in diagnosing your problem. Just as there are different causes of UI, there are also different types of UI.

The bladder acts as a reservoir to store urine. It has two functions, to store and to empty urine. Urinary incontinence is the result of failure of one of those functions.

Stress urinary incontinence (SUI)

It occurs when increases in abdominal pressure force open the bladder outlet (urethra) and urine spurts out. This usually happens when weak pelvic floor muscles fail to support the bladder and urethra during coughing, sneezing, lifting, or other strenuous activity.

Childbirth is most often the cause of poor pelvic floor muscle tone. A weakening in the urethral tube that drains the bladder may also cause SUI. Women with SUI typically experience the loss of a few drops of urine during an accident.

Urge incontinence (OAB)

A condition in which the bladder is overactive and empties without one's permission. The bladder is supposed to store urine until there is a socially acceptable time and place to empty it. Then, and only then, the bladder muscle squeezes down to empty. People with urge incontinence may experience a sudden, strong urge to urinate, but fail to make it to the bathroom without leaking.

Bladder infections and lack of astrogen can cause urge incontinence.

Any condition that affects the nervous system such as spinal injuries, stroke or Parkinson's disease may also cause urge incontinence. Women with urge incontinence often urinate very frequently and lose moderate to large amounts of urine when they leak.

Mixed incontinence

Especially common in older women, this condition occurs when symptoms of both stress and urge types of incontinence are present. Symptoms of one type of incontinence may be more severe than the other. Treatment will depend on which symptom is more bothersome to the patient. Stress, urge, and mixed incontinence - each is a failure of the bladder to store urine.

Overflow incontinence

Overflow incontinence is a failure of the bladder to empty completely. As the bladder becomes overfilled, frequent dribbling occurs to release pressure. Overflow incontinence may happen when pelvic organs drop and block the urethra or when certain medications cause the bladder to stop contracting. Swelling of pelvic tissues after childbirth or surgery, injured nerves, or a bladder that is habitually overstretched may also result in overflow incontinence.

Incontinence from surgery is a temporary condition that follows such operations as hysterectomies, caesarean sections, lower intestinal surgery, or rectal surgery. Incontinence can also occur due to other reversible factors, often outside of the urinary tract, such as restricted mobility.

Mobility aids can help remove barriers to self-toileting on a timely basis. Other factors such as arthritis may interfere with managing zippers, buttons, and articles of clothing - or moving quickly enough to reach the toilet.

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Treatments

Bladder control issues can be a taboo subject, even for women who are open with their friends and medical professionals. Many women of a variety of ages live with the daily fear of wetting through their clothes, having an odor or having bladder issues that will interrupt their daily routine and sexual lives.

Many women endure bladder leakage issues for years before they finally talk to their doctor. Once they do, there is significant relief in learning that there are many options – from behavior modification to surgery – that can help them to return to a normal life with vigor and confidence.

Choose a treatment below to learn more about your treatment options. Our physicians would be happy to meet with you to discuss these solutions further.

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Conservative Therapies

Dietary Modification
Timed Voiding
Bladder Retraining
Physical Therapy
Pelvic Floor Exercises (Kegel Exercises)
Biofeedback
Oral Medication
Urge Suppression
Bladder Instillation

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Office Treatments

Bulking agents
Renessa
Botox Injections
Neuromodulation
Urgent PC Percutaneus Tibial Nerve Stimulation
Sacral Nerve Stimulation
InterStim II

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Urinary Incontinence Surgeries

Mini-Slings
Transobturator slings
Suprapubic slings

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Conservative Therapies

Dietary Modification

Certain foods and beverages have been shown to contribute to urgency, frequency or urge incontinence. Caffeine and alcohol are big offenders. Many people are unaware of how much caffeine they ingest in a single day. They often just remember the one or two cups of coffee that they drank in the morning, forgetting the cola they drank with lunch and the cup of tea in the afternoon. Foods, beverages and products which should be avoided: tea, coffee, alcohol, chocolate and nicotine.

Women with mild or intermittent symptoms may require only reassurance and simple measures such as decreased fluid intake and avoidance of the above irritants. The majority of patients will require further treatment.

Timed Voiding

Timed voiding is urinating on a set schedule during the day regardless of the need or urge to void. For example, a patient would urinate every two hours during the waking hours. This is an attempt to pre-empt the urge incontinence episodes before they occur. However, there is no goal at increasing the interval between voids. This form of behavioral therapy is useful in older adults or other individuals for whom bladder retraining is not an option. This is one way of treating urge incontinence.

Bladder Retraining

Many people with urge incontinence, urgency, frequency and incontinence can be helped through the use of bladder re-training. Bladder re-training involves urinating on a set schedule during the day. The patient goes to the bathroom by the clock only, not the urge to void. For example, if the patient normally goes to the bathroom every hour or less during the day, they would start this technique by voiding every hour. After one week one should increase the time interval between voids by 30 minutes so one is now voiding every 1 hour and 30 minutes. After one week the interval is increased by another 30 minutes. This exercise is continued until the interval between voids is 3-4 hours. The patient may void at anytime during sleeping hours. This retraining program encourages the bladder to retain more urine without bladder urgency or spasms.

Pelvic Floor Exercises (Kegel Exercises)

This is treatment for urinary incontinence which, when done faithfully and correctly, can help decrease the urgency a patient may have and help with both urge incontinence and stress incontinence. The pelvic floor muscle is like a hammock that stretches from the pubic bone in the front to the tailbone in the back. This set of muscles supports the organs of the pelvic region, which include the bladder, large intestines and uterus. Since this muscle is often not exercised, it is generally weak to begin with, which contributes to urinary symptoms.

Childbirth will weaken this muscle more because during vaginal delivery, the child's head and body push under the pelvic floor muscle and stretches it extensively, which causes temporary additional damage/weakening. Learning to do these exercises can help with incontinence; however, to perform these incontinence treatment exercises effectively, the patient must first identify the correct muscles.

Two methods of identifying the correct muscles:

  • While urinating stop the flow of urine by tightening the pelvic floor muscles. Do not perform the incontinence treatment exercises while urinating, since this can lead to difficulty in voiding. Stopping and starting the stream as a person voids is a popular misnomer and should not be done. Patients may elect to try to stop the stream once or twice to check for contraction of the correct muscle.
  • Place a finger in the vaginal opening and attempt to squeeze the finger. Upon squeezing, the patient should feel a tightening around her finger. She has identified the correct muscles that are to be exercised.

One key point is that patients do not want to use other muscles, such as the abdomen, legs or buttocks. While doing bladder incontinence treatment, it is important to isolate the muscles only to further increase their strength. If you are moving these muscles or holding your breath, you are probably trying too hard. When performing incontinence treatments, concentrate just on the pelvic floor muscles and do the best you can. This contraction will get easier with practice.

One exercise program is described below:

  • Attempt to contract and hold the muscle squeeze for 10 seconds
  • Relax for a period of 10 seconds
  • Perform 10-15 contractions and relaxation
  • Perform this regimen 3-4 times a day

It may take awhile to work up to a 10 second hold. In the beginning, you will probably not be able to hold for more than five or six seconds and that is all right. Between each contraction, relax for 10 seconds. This allows the muscle to rest adequately to be able to perform well for the next contraction. If you do not relax the muscle well enough, the muscles will tire quickly. By faithfully doing your Kegel exercises, you should see an improvement in your symptoms starting in four to six weeks.

Biofeedback

This term refers to a variety of techniques that teach patients bladder and pelvic muscle control by giving positive feedback when the patient performs the desired action. This feedback can be from an electronic device or directly from a health professional.

Medication

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 overactive bladder and urge incontinence — a bladder control problem marked by sudden, intense urinary urges and urine leakage. There are fewer options for stress incontinence — urine leakage prompted by a physical movement or activity, such as coughing, sneezing or heavy lifting.

Which drugs can help control urinary incontinence?
The major types of medications used to manage urinary incontinence are anticholinergics and estrogen. Other options include the antidepressant imipramine and the synthetic hormone desmopressin, which is more commonly used for bed-wetting in children.

The most common medications (and their possible side effects):

Anticholinergics

Overactive bladder, one of the causes of urge incontinence, 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 sends the signals that trigger these contractions.

Several drugs fall under this category, including:
Oxybutynin (Ditropan)
Tolterodine (Detrol)
Darifenacin (Enablex)
Solifenacin (Vesicare)
Trospium (Sanctura)
Fesoterodine (Toviaz)

Some are available in an extended-release form, meaning you take them once a day. These may have fewer side effects than the immediate-release versions, which are usually taken multiple times a day. 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 cream or skin patch that delivers a continuous amount of medication.

Side effects

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, rapid heartbeat (tachycardia), 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.

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 low-dose, topical 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.

In general, there's not a lot of scientific evidence to support using topical estrogen to treat urinary incontinence, but many women report that it's helpful for their urinary symptoms. Estrogen may have a role when used in combination with other therapies, such as pelvic floor muscle training.

Combination hormone replacement therapy (estrogen plus progestin) isn't the same as topical estrogen and is no longer used for urinary benefits. Oral estrogen replacement is also not the same as topical estrogen, and it may actually worsen incontinence symptoms.

Side effects

When topical estrogen therapy is used correctly, it doesn't usually cause side effects. However, topical estrogen is usually paired with another medication or therapy to treat incontinence.

Imipramine

Imipramine (Tofranil) is a tricyclic antidepressant. 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).

Side effects

Serious side effects are rare but can include cardiovascular problems, such as irregular heartbeat and dizziness or fainting from reduced blood pressure when you stand up quickly. Children and older adults 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. Research suggests that desmopressin may also reduce urinary incontinence in adult women.

Side effects

Although it's uncommon, there is a risk of water retention and sodium deficiency in the blood (hyponatremia), which has in rare cases led to seizures, brain swelling and death. Be sure your doctor knows your full medical history and is aware of all the medications you are taking before you begin using this drug. Researchers are looking into new drugs and therapies, including botulinum toxin type A.

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See your doctor

When talking to your doctor, carefully review all the medications you're taking, including over-the-counter drugs or herbal remedies. Some medications increase bladder control problems. Others may interact with incontinence medications in a way that increases symptoms. Your doctor can help you decide if you need medicine to treat your bladder control problem, and if so, which one may be best for you.

Urge Suppression

Patients get the urge to urinate as the bladder signals the brain by sending a message through the spinal cord. This is just a message about the filling status of the bladder; it is not a direct order to urinate. Believe it or not, a patient can and in fact, should wait, to void. The worst possible time to try to get to the bathroom "in time" is when one really has to go. A lot of people will leak especially the closer that they get to the bathroom. In an attempt to suppress the urge, patients should contract their pelvic floor muscles (i.e. Kegel exercise). Tightening and relaxing the pelvic floor muscle in rapid succession will help until the urge subsides. This will help to kick in a natural reflex that quiets down the bladder.

Bladder Instillation

This procedure may also be called a bladder wash or bath. During a bladder instillation, the bladder is filled with a solution that is held for varying periods of time, from a few seconds to 15 minutes, before being drained through a narrow tube called a catheter. Treatments are given every week or two for 6 to 8 weeks, and repeated as needed. Most people notice improvement of symptoms 3 or 4 weeks after the first 6- to 8-week cycle of treatments.

The procedure is effective because the solution passes into the bladder wall and may more effectively reach tissue to reduce inflammation and block pain. It may also prevent muscle contractions that may cause pain, frequency, and urgency. A bothersome but relatively insignificant side effect is a garlic-like taste and odor from the breath and skin. This may last up to 72 hours after a treatment.

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Office treatments

Bulking agents

Bulking agents are materials, such as collagen, that are injected into tissue surrounding the urethra to help keep the urethra closed and reduce urine leakage.

A bulking agent procedure — usually done in a doctor's office — requires minimal anesthesia and takes about five minutes. The downside of the procedure is that most available bulking agents lose their effectiveness over time, and repeat injections are usually needed every six to 18 months. New bulking agents are being developed, as well as new ways to make the injection process easier and more efficient.

The standard method of injecting a bulking agent is through a needle, which is inserted in different positions with the assistance of a cystoscope — a slender, tube-like instrument that allows the surgeon to view the urethral area.
Materials used as bulking agents include:

Collagen. Collagen is a natural fibrous protein found in connective tissue, bone and cartilage of humans and animals. Collagen can produce an allergic reaction in some people. For this reason, your doctor is required to give you a skin test before performing the procedure to see if you have a reaction. Over time, collagen tends to deteriorate within your body. Often, multiple repeat injections are required.

Carbon-coated zirconium beads. Carbon-coated zirconium beads consist of synthetic, nonallergenic material, which means they don't carry the risk of causing an allergic reaction. So far, carbon-coated zirconium beads appear to be as effective as collagen. Scientists hope that this bulking agent will last much longer than does collagen and require fewer repeat injections.

Coaptite. This commonly used synthetic material is injected and permanently implanted in the body. It's similar to collagen injections but may be more durable. Allergic skin tests are not required.

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Macroplastique

Macroplastique is an injectable soft-tissue urethral bulking agent. It is made up of two parts – the water-soluble gel (polyvinylpyrrolidone) that is absorbed and removed from the body in urine and the man-made, rubber-like, silicone elastomer implant material that is permanent and not absorbed by the body. It is this permanent material that causes the bulking effect around the urethra after implantation.

One material isn't necessarily better than another. If you try one and it doesn't seem to help, your doctor may suggest trying another.

Renessa

The RenessaTM treatment uses a small probe which a physician passes through the urethra. The treatment can be performed in the convenience of a physician's office or other outpatient setting. There are no incisions, bandages or dressings required. Recovery is rapid and comfortable, with minimal post-procedure limitations.

The Renessa procedure uses radiofrequency energy (RF) to generate controlled heat at low temperatures in tissue targets within the lower urinary tract. The heat denatures collagen in the tissue at multiple small treatment sites. Upon healing, the treated tissue is firmer, increasing resistance to involuntary leakage at times of heightened intra-abdominal pressure, such as laughing, coughing or during exercise, thereby reducing or eliminating SUI episodes.

The treatment is rather simple. Once the patient has received the appropriate anesthetic (either local anesthesia or conscious sedation), her physician passes the Renessa probe through the urethral opening and the urethra into the bladder. With the end of the probe positioned within the bladder, a small balloon is inflated to maintain the probe in its proper position during treatment. With the probe in place, radiofrequency energy is delivered from a compact RF generator to four small needles which are deployed from the probe into the tissue of the bladder neck and upper urethra. No visualization of the treatment site is required. RF is delivered for 60 seconds, heating small areas of tissue around the needle tips to a temperature at which collagen undergoes a structural change (denatures). The probe is located and repositioned using a series of simple maneuvers and RF is delivered for 60 seconds a total of nine (9) times, thus denaturing collagen at 36 tissue sites.

Benefits of the Renessa treatment include:

  • Non-surgical, in-office procedure
  • Single treatment
  • No incisions, bandages, or dressings
  • Excellent safety profile, well tolerated
  • Can be performed using local anesthesia + oral sedation
  • Rapid recovery with minimal limitations

Botox injections

Injections of botulinum toxin type A into the bladder muscle may benefit people who have an overactive bladder. Botulinum toxin type A blocks the actions of acetylcholine and paralyzes the bladder muscle.

Studies have found that botulinum toxin type A significantly improves symptoms of incontinence and causes few side effects. Benefits can last up to nine months. Botulinum toxin type A may be helpful for people who haven't responded to other medications. The Food and Drug Administration (FDA) has not yet approved this drug for incontinence.

The FDA warns that adverse reactions including respiratory arrest and death may occur following the use of botulinum toxin type A for both approved and unapproved uses.

Neuromodulation

Many people have urinary problems that are difficult to control by non-surgical means. Most surgical treatments are for people with stress incontinence only. Implants that provide continuous electrical stimulation to the nerves that control the bladder have been used in people with other types of incontinence. These devices are expensive, the surgery is invasive, and many people need another operation. It is not clear how best to use these devices. However, implantable stimulators that provide continuous electrical stimulation to the nerves or nerve roots supplying the bladder and pelvis, or to the peripheral nerves that share the same nerve roots, can benefit carefully selected patients with difficult-to-control urinary problems.

Urgent PC Percutaneus Tibial Nerve Stimulation

The Urgent PC Neuromodulation System is a nerve stimulator that generates a specific kind of electrical impulse that is delivered to the patient. Using a needle electrode placed near the ankle as an entry point, the stimulator’s impulses travel along the tibial nerve to the nerves in the spine that control pelvic floor function.

Sacral nerve stimulation

Sacral nerve stimulation inhibits messages sent by an overactive bladder to your brain signaling a need to urinate. Sacral nerve stimulation works by continuously sending small, electrical impulses to the nerves that control urination. The impulses are generated by a small, pacemaker-like device surgically placed under the skin, usually in your buttock. Attached to the device — called a stimulator — is a thin, electrode-tipped wire that passes under your skin, carrying these impulses to the sacral nerve.

Because sacral nerve stimulation doesn't work for everyone, you can try it out first by wearing the stimulator externally, after the attached wire is placed under your skin in a minor surgical procedure. If the stimulator substantially improves your symptoms, then you can have it implanted.

Surgery to implant the stimulator is an outpatient procedure done in an operating room under local anesthesia and mild sedation. You may be advised to limit activities for three or more weeks as your incisions heal. Once the stimulator is implanted, it functions for several years. After that, it can be replaced during an outpatient procedure. Your doctor can adjust the level of stimulation with a hand-held programmer, and you also have a control to use for adjustments. The stimulation doesn't cause pain and may improve or successfully treat more than half the people with difficult-to-treat urge incontinence or urinary retention leading to overflow incontinence. The device can be removed at any time.

InterStim II

A sacral nerve stimulator for the management of chronic functional disorders of the pelvis and lower urinary tract or intestinal tract, including overactive bladder, urinary retention, fecal incontinence and constipation.

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Urinary Incontinence Surgeries

Mini-Sling

In this procedure, the urogynecologist attaches a piece of fascia or mesh around the bladder neck to keep urine in, even under stress. Only one incision is needed and the procedure can be completed in as little as 5-10 minutes under local anesthesia. Only one small incision is needed in the vagina. No incisions are needed in the groins or the abdomen and no needles are needed to pass through the abdomen or groins. This decreases the risk of injury, however the sling still is able to go in the same position. Since there is no need for needle passage through the groins or abdomen, the procedure can very easily be done under local anesthesia, in an outpatient type setting or even in an office procedure room setting in as little as 10 minutes. Many patients state that they didn’t even use any pain medication after having the procedure completed.

Advantages of the Single Incision Mini-Sling include:

  • Safer, faster, more efficient, less pain
  • Decreased risk of: Bowel Injury, Bladder Injury and Major Bleeding
  • No Retropubic Needle Passage
  • No Groin needle passage
  • No Abdominal or Groin Incisions
  • More Anatomic Position of Tape

Transobturator slings

Tension-free slings (tvt sling) are used to treat stress urinary incontinence. In this approach, the vaginal sling (flat, tough, tendon-like material) is held in place by the friction between the mesh and the tissue canals created by the metallic needle passers. Scar tissue later fixes the mesh, preventing movement. Because the sling is not anchored to the pubic bone, ligaments, or rectum, it is considered "free of tension."

Advantages of Transobturator Approach

  • Safer, faster, more efficient
  • Decreased risk of: Bowel Injury, Bladder Injury, Major Bleeding
  • No Retropubic Needle Passage
  • No Abdominal Incisions
  • More Anatomic Position of Tape

During the procedure, very small incisions are placed in the groins (one on each side) and the same small incision is made in the vagina under the urethra, allowing the mesh tape to be placed under the urethra in the correct position without having to pass needles blindly through the retropubic space and the abdominal wall. There is essentially NO risk of major bleeding (no major blood vessels), bowel, bladder or nerve injury.

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Suprapubic slings

Adjustable slings

The surgeon makes a small vaginal incision and a small abdominal incision to insert the sling. After the sling is placed and while the person is awake, the doctor tests and adjusts the sling's tension according to the person's needs. Adjustments can continue to be made months or years later and require only a local anesthetic to access the adjustable portion. Longer study is needed to determine how effective adjustable slings are over time.

Laparoscopic Burch Procedure

The Laparoscopic Burch involves placing permanent suture material adjacent to the neck of the bladder on each side and attaching them to a strong ligament attached to the pelvic bone. The reported advantages include improved visualization of the retro-pubic anatomy, minimal blood loss, shorter hospitalization, and faster recovery.

Laparoscopic Burch offers a number of benefits, including:
• 3 or 4 tiny scars instead of one large abdominal incision
• shorter hospital stay (you may leave the same day or next day)
• reduced post-operative pain
• faster return to work
• shorter recovery time

da Vinci Robotic Burch procedure

This surgical robot-assisted Laparoscopic Burch involves placing permanent suture material adjacent to the neck of the bladder on each side and attaching them to a strong ligament attached to the pelvic bone. The reported advantages include improved visualization of the retro-pubic anatomy, minimal blood loss, shorter hospitalization, and faster recovery.

Laparoscopic Burch offers a number of benefits, including:
• 3 or 4 tiny scars instead of one large abdominal incision
• shorter hospital stay (you may leave the same day or next day)
• reduced post-operative pain
• faster return to work
• shorter recovery time

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