Incontinence

What is Urinary Incontinence?

Urinary incontinence is the accidental loss of urine. More than 15 million American men and women suffer from this disease. 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 your urologist. 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
• constipation
• weakness of certain muscles in the pelvis
• blocked urethra due to an enlarged prostate
• Diseases and disorders involving the nervous system muscles (e.g., multiple sclerosis, Parkinson’s disease, spinal cord injury and stroke).
• some types of surgery
• diabetes
• delirium
• dehydration
• pregnancy and childbirth
• overactive bladder
• weakness of the muscles holding the bladder in place
• weakness of the sphincter muscles surrounding the urethra
• birth defects
• enlarged prostate
• spinal cord injuries

Multiple factors have been found to be associated with urinary incontinence, yet the leading culprits of incontinence have been neurologic disease, prostatic disease, and obstetric factors.

Studies have found that pregnancy, mode of delivery and parity (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. A urologist 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, prostate disease and prolapse or hernias, will be conducted. Usually a urinalysis and cough stress test will 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 not only on the type of incontinence a person has but also the gender of the patient. Certain treatment options are optimal for men while others are better suited for females. Below are the various treatment options for both men and women.

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. Today, most of these procedures are being called by the names TVT or TOT. In this operation, a narrow strip of material is used either from: cadaveric tissue (from a cadaver), autologous tissue (from your own body), or soft mesh (synthetic material). 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.

Retropubic Colposuspension:

Another option is abdominal surgery in which the vaginal tissues or periurethral tissues are affixed to the pubic bone. The long-term results are positive, but the surgery requires longer recuperation time and is generally only used when other abdominal surgeries are also required. This procedure can also be performed laparoscopically, however long-term results are typically not as good as with the open procedure.

Bladder Neck Needle Suspension:

A long needle is used in these procedures to thread sutures from the vagina to the abdominal wall. The suture incorporates paraurethral tissue at the level of the bladder neck. These procedures were found to be less effective than open retropubic suspensions and slings and as a result are rarely done today.

Anterior Vaginal Repair:

Sutures are placed in the periurethral tissue and fascia in order to elevate and support the bladder neck. This procedure has also fallen out of favor for inferior long-term outcomes compared to open retropubic suspensions and slings.

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 additional treatment options are available for stress incontinence in men?

Men should also initially be managed with behavioral modifications and pelvic floor exercises. Periurethral injections can be used in men as well. If these measures fail, surgical options are available, which are different from those performed in women.

Male Sling:

In male patients with stress incontinence, an alternative is to perform a urethral compression procedure, called a male sling. This is done with the use of a segment of cadaveric tissue or soft mesh to compress the urethra against the pubic bone. It is placed through an incision in the perineum (the area between the scrotum and the rectum). The results show decent success rates in patients with low volume incontinence, poor success is seen with severe incontinence. Long-term data is not currently available.

Artificial Urinary Sphincter:

The most effective treatment for male incontinence is implantation of an artificial urinary sphincter. This device is made from silicone and has three components that are implanted into the patient. The cuff is the portion that provides circular compression of the urethra and therefore prevents leakage of urine from occurring. This is placed around the urethra after an incision is made in the perineum. A small fluid-filled pressure-regulating balloon is placed in the abdomen and a small pump is placed in the scrotum, to be controlled by the patient. The fluid in the abdominal balloon is transferred to the urethral cuff, closing the urethra and preventing leakage of urine. When the patient needs to urinate he presses the scrotal pump which releases the fluid back to the abdominal balloon opening the urethra and allowing the patient to void.

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 prostate disease or organ prolapse can develop this type of incontinence. Overflow incontinence due to obstruction should be treated with medication or surgery to remove the blockage. This may include resection of prostatic tissue or urethral stricture or 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.

Because many of the incontinence treatments deal with implants and/or medical devices, adjustments and modifications may be required over time. Ask your doctor about typical follow-up procedures.

Reference:

Urology Care Foundation. The Official Foundation of the American Urological Association. http://www.urologyhealth.org/urology/index.cfm?article=143