At Signature Women’s Healthcare, we understand that many of our patients suffer silently from bladder problems and are often very reluctant to discuss this issue with anyone. This is unfortunate, as involuntary loss of urine is a very common condition that can often be corrected. There are many causes of urinary incontinence and the choice of treatment is dependent on the correct diagnosis. Signature Women’s Healthcare uses state-of-the-art equipment, including multichannel cystometrics, to assist in this evaluation. Please contact us at your convenience to discuss any bladder problems you may have.
What is Urinary Incontinence?
Urinary incontinence is the accidental loss of urine. More than 15 million Americans suffer from this condition. Many of these people suffer in silence unnecessarily, and are prevented from doing activities and living the life they want to lead. Since incontinence can be managed or treated, the following information should help you discuss this condition and what treatments are available to you with one of our doctors. For millions of Americans, incontinence is not just a medical problem. It is a problem that also affects emotional, psychological and social well-being. Many people are afraid to participate in normal daily activities that might take them too far from a toilet, so it is particularly important to note that the great majority of incontinence causes can be treated successfully.
What happens under normal conditions?
Coordinated activity between the urinary tract and the brain controls urinary function. The bladder stores urine because the smooth muscle of the bladder (detrusor muscle) relaxes and the bladder neck and urethral sphincter mechanism are closed. The urethral sphincter is a circular muscle that wraps around the urethra. During urination, the bladder neck opens, the sphincter relaxes and the bladder muscle contracts. Incontinence occurs if closure of the bladder neck is inadequate (stress incontinence, or SUI) or the bladder muscle is overactive and contracts involuntarily (urge incontinence, also known overactive bladder or OAB).
What causes Urinary Incontinence?
Below are a list of conditions and diseases that contribute and/or cause urinary incontinence:
- urinary tract or vaginal infections
- effects of medications
- weakness of certain muscles in the pelvis
- blocked urethra
- Diseases and disorders involving the nervous system muscles (e.g., multiple sclerosis, Parkinson’s disease, spinal cord injury and stroke).
- some types of surgery
- pregnancy and childbirth
- overactive bladder
- weakness of the muscles holding the bladder in place
- weakness of the sphincter muscles surrounding the urethra
- spinal cord injuries
Multiple factors have been found to be associated with urinary incontinence, yet the leading culprits of incontinence have been neurologic disease, and obstetric (or birth) trauma.
Studies have found that pregnancy, type of delivery and the number of children a woman has had are all factors that can increase the risk of incontinence. Women who delivered babies (via cesarean section or vaginal delivery) have much higher rates of stress incontinence than women who never delivered a baby. Women who developed incontinence during pregnancy or shortly after delivery have higher risk of sustained incontinence than those who did not. Increased parity (having more babies) also increases the risk.
Age is also known to be a factor. As the human body ages, muscle loss and weakness occur and the urinary tract is not spared. Menopausal women can also suffer from urine loss as a result of decreased estrogen levels. Interestingly, replacement estrogen has not been found to help the symptoms. Many medications have been associated with urinary incontinence. These include: diuretics, estrogen, benzodiazepines, tranquilizers, antidepressants, hypnotics, and laxatives. Poor overall general health has been associated with incontinence. Specifically, diabetes, stroke, high blood pressure, smoking history, Parkinson’s, back problems, obesity, Alzheimer’s, and pulmonary disease have all been associated with incontinence.
What are the different types of urinary incontinence?
Stress urinary incontinence: Stress incontinence is leakage that occurs when there is an increase in abdominal pressure caused by physical activities like coughing, laughing, sneezing, lifting, straining, getting out of a chair or bending over. The major risk factor for stress incontinence is damage to pelvic muscles that may occur during pregnancy and childbirth.
Urgency incontinence: Also referred to as “overactive bladder,” this type of incontinence is usually accompanied by a sudden, strong urge to urinate and an inability to get to the toilet in time. Frequently, some patients with urge incontinence may leak urine with no warning. Risk factors for urge incontinence include aging, obstruction of urine flow, inconsistent emptying of the bladder and a diet high in bladder irritants (such as coffee, tea, colas, chocolate and acidic fruit juices).
Mixed urinary incontinence: Mixed incontinence is a combination of urge and stress incontinence.
Overflow urinary incontinence: Overflow incontinence occurs when the bladder does not empty properly and the amount of urine produced exceeds the capacity of the bladder. It is characterized by frequent urination and dribbling. Poor bladder emptying occurs if there is an obstruction to flow or if the bladder muscle cannot contract effectively.
How is Urinary Incontinences Diagnosed?
As with any medical problem, a good history and physical examination are critical. Your doctor will first ask questions about the individual’s habits and fluid intake as well as their family, medical and surgical history. A thorough physical examination looking for correctable causes of leakage, including impacted stool, constipation and prolapse or hernias, will be conducted. A urinalysis and cough stress test may be performed at the first evaluation. If findings suggest further evaluation is necessary, tests such as cystoscopy or urodynamics may be recommended.
Cystoscopy is performed by placing a small scope or camera through the urethra and into the bladder. Urodynamics is an outpatient test that is done with a tiny tube in the bladder inserted through the urethra and often with a second small tube in the rectum. The bladder is filled and the patient is asked to void while pressure measurements are recorded.
How is Urinary Incontinence Treated?
Treatment for incontinence depends on the type of incontinence a person has.
What are the treatment options for stress incontinence?
In most cases of incontinence, conservative or minimally-invasive management is the first line of treatment. This may include fluid management, bladder training or pelvic floor exercises. However, when the symptoms are more severe, when conservative measures are not helpful or are unsatisfactory the next best treatment option is surgery.
Behavioral Modification: Mild to moderate stress incontinence in the female is initially treated with behavior modification. Decreasing the volume of fluid ingested as well as eliminating caffeine and other bladder irritants can help significantly. Timed voiding can be helpful in preventing accidents by scheduling frequent trips to the toilet before leakage occurs.
Pelvic Floor Muscle Training: Strengthening or Kegel exercises can fortify the pelvic floor and sphincter muscles and improve urinary control. These exercises include repeated contractions of isolated muscles several times a day. Sometimes techniques including biofeedback, electrical stimulation of the pelvic muscles, and weighted vaginal cones can be helpful in teaching the patient how to isolate these muscles.
Periurethral Injections: One of the surgical treatments for this condition, used in both males and females, is urethral injections of bulking agents to assist the closing of the urethral mucosa. The injections are done under local anesthesia with the use of a cystoscope and a small needle. Bulking material is injected into the urethral sub mucosal layer under direct vision. Unfortunately, the cure rate with this treatment is only 10 to 30 percent despite multiple formulations on the market for use. This treatment can be repeated and sometimes acceptable results are seen after multiple injections. The operation is minimally invasive but the cure rates are lower compared to the other surgical procedures.
Sub urethral Sling Procedures: The most common and most popular surgery for stress incontinence is the sling procedure. You may hear them referred to as TVT or TOT. In this operation, a narrow strip of soft mesh (synthetic material) is used. It is applied under the urethra to provide a hammock of support and improve urethral closure. The operation is minimally invasive and patients recuperate very quickly. For many years it was thought that biologic materials, the patient’s own fascia or cadaveric fascia, would create better and more sustainable outcomes. However, synthetic meshes have been found to have the ease of use with no need for harvest as well as superior long term results.
Anterior Vaginal Repair: Sutures are placed in the periurethral tissue and fascia in order to elevate and support the bladder neck. This procedure is sometimes performed along with a TVT or TOT if the bladder has dropped significantly (a cystocele has formed).
What are the side effects associated with the corrective surgeries for stress incontinence?
The potential adverse outcomes of surgical treatment include bleeding, infection, pain, urinary retention or voiding difficulties, de novo urgency, pelvic organ prolapse, and failure of surgery to fix leakage. With the use of mesh materials there is a very small risk of erosion of the material into the bladder, urethra or vagina.
What are the treatment options for urge incontinence?
For urge incontinence there are also multiple treatment options available. The first step is behavior modifications including drinking less fluid, avoiding caffeine, alcohol and spicy foods, not drinking at bedtime, and timed voiding. Exercising the pelvic muscle (Kegel exercises) can also help. It is important to keep a log on the frequency of urination, number of accidents, the amount of fluid lost, the fluid intake and the number of pads used. This helps the urologist tailor treatment to your specific needs.
Medications: The mainstay of treatment for overactive bladder and urge incontinence is medication. This consists of use of bladder relaxants that prevent the bladder from contracting without the patient’s intention. The most common side effect of the medication is dryness of the mouth, constipation or changes in vision. Sometimes, reduction of medication takes care of the side effects. Combinations of medications can also be used in some situations.
Neuromodulation: Other alternatives can be considered in patients who fail to respond to behavior modification and/or medication. A new and exciting technology is the use of a bladder pacemaker to control bladder function. This technology consists of a small electrode that is inserted in the patient’s back close to the nerve that controls bladder function. The electrode is connected to a pulse generator and the electrical impulses stimulate the bladder nerves and control bladder function. The exact mechanism of action remains unknown.
What are the treatment options for overflow incontinence?
The treatment for overflow incontinence is complete emptying of the bladder. When the bladder is allowed to cycle properly with filling and emptying on a regular basis urine loss is usually prevented. Patients with neurologic conditions, diabetic bladder, or patients with obstruction secondary to organ prolapse can develop this type of incontinence. Overflow incontinence due to obstruction should be treated with surgery to remove the blockage. This may include repair of pelvic organ prolapse. If no blockage is found, the best treatment is to instruct the patient to perform self-catheterization a few times a day. By emptying the bladder regularly, the incontinence often disappears.
What can I expect after treatment?
The goal of any treatment for incontinence is to improve quality of life for the patient. In most cases, great improvements and even cure of the symptoms is possible. Treatments are usually effective, as long as the patient is careful with fluid intake and urinates regularly. Large weight gain and activities that promote abdominal and pelvic straining may cause problems with surgical repair over time. Using common sense and care will help ensure long-term benefit from these surgical procedures.