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* Please note that most treatment modalities listed below are based on conventional medicine. PreventDisease.com does not advocate the use of any pharmaceutical drug treatments. Long-term drug therapy is very detrimental to human health. All drug information is for your reference only and readers are strongly encouraged to research healthier alternatives to any drug therapies listed.

Urinary Incontinence


WHAT IS URINARY INCONTINENCE?



Urinary Incontinence


Urinary incontinence is the inability to control urination. It may be temporary or permanent and can result from a variety of problems in the urinary tract. Urinary incontinence is generally divided into four groups according to the malfunction involved:
  • Stress.

  • Urge.

  • Overflow.

  • Functional incontinence.
Often, more than one type of incontinence is present. Approximately 40% of all incontinence cases fall into more than one of the four categories. A variety of disease and medical problems may contribute to each of the four major types of incontinence. Because incontinence is a symptom rather than a distinct disease, it is often difficult to determine a definite cause.


NORMAL URINATION



The Urinary System


The urinary system helps to maintain proper water and salt balance throughout the body:
  • The process of urination begins in the two kidneys, which process fluids and dissolved waste matter to produce urine.

  • Urine flows out of the kidneys into two long tubes called ureters.

  • Ureters empty into the bladder, which rests on top of the pelvic floor . This is a muscular structure similar to a sling running between the pubic bone in front to the base of the spine.

  • The bladder is enclosed in a powerful muscle called the detrusor.

  • The bladder stores the urine, which is then eliminated from the body via another tube called the urethra, which is the lowest part of the urinary tract. (In men it is enclosed in the penis. In women it leads directly out.)

  • The connection between the bladder and the urethra is called the bladder neck.

  • Strong muscles called sphincter muscles encircle the bladder neck (the smooth internal sphincter ) and urethra (the fibrous external sphincter ).


The Act of Urination


The act of urination itself is a combination of automatic and conscious voluntary muscle actions. There are two phases: the filling and storage phase and the emptying phase.

The Filling and Storage Phase.
  • When a person has completed urination, the bladder is empty. In response, the brain signals the detrusor muscle , which surrounds the bladder, to relax.

  • This signaling process uses pathway of nerve cells and neurotransmitters (chemical messengers) called the cholinergic and adrenergic systems.

  • As the muscles relax, the bladder expands and allows urine to flow into it from the kidney.

  • As the bladder fills to its capacity (about 8 to 16 oz of fluid) the nerves in the bladder send back signals of fullness to the spinal cord and the brain.

  • As the bladder swells, brain produces a conscious sensation of fullness. In response, the individual voluntarily contracts the external sphincter muscles (the muscle group surrounding the urethra). (During the toilet training process, people learn to control these muscles, which allow both voluntary and involuntary actions.)
The Emptying Phase
  • At the point when a person is ready to urinate, the nervous system initiates the voiding reflex. In this case, the spinal cord (not the brain) sends the nerve signals that initiate this event.

  • The voiding reflex is an automatic process in which nerves signal the detrusor muscles around the bladder to contract. At the same time, nerves are also signaling the internal sphincter (a strong muscle encircling the bladder neck) to relax. These muscles are involuntary; they require no conscious effort for contraction or relaxation.

  • With the bladder muscles squeezing and its neck is open, the urine flows out of the bladder into the urethra.

  • Once the urine enters the urethra a person consciously relaxes the external sphincter muscles, which allows urine to pass out.

  • Urine is then completely drained from the bladder and the process of filling and storing begins again.


WHAT IS STRESS INCONTINENCE AND ITS CAUSES?


Stress incontinence occurs when the internal sphincter does not close completely. (This is the muscle that surrounds the urethra, the last part of the urinary tract.) In both men and women, the aging process causes a general weakening of the sphincter muscles and a decrease in bladder capacity. Causes of stress incontinence, however, may differ depending on gender.


Symptoms of Stress Incontinence


The primary symptom is leakage from activities that apply pressure to a full bladder. High-impact exercise certainly poses the greatest risk for leaking. But stress incontinence can occur with even minor activities, such as the following:
  • Coughing.

  • Sneezing.

  • Laughing.

  • Running. (Sometimes even standing can produce leakage.)

  • Lifting.
Leakage stops when the activity stops. If the condition persists, it is more likely to be urge incontinence [ see Urge Incontinence below].


Stress Incontinence in Women


In women, stress incontinence is nearly always due to one or both of the following:
  • The urethra fails to close (called urethral hypermobility ).

  • The muscles around the bladder neck weaken (called intrinsic sphincteric deficiency, or ISD ). Some experts believe that this problem is present to some degree in nearly all women with stress incontinence. (ISD can also occur in anyone from an inborn disorder or injury from surgery or radiation.)
Many women are prone to one or both of these problems, which can occur under the following circumstances:
  • Having had many children through vaginal deliveries. In such cases, pregnancy and childbirth strain the muscles of the pelvic floor.

  • Hysterectomy. Complications of this operation may damage pelvic floor muscles, the sphincter itself, or the nerves that enable the sphincter muscles to contract.

  • Thinning of the urethra after menopause. Estrogen deficiencies can cause the urethra to thin out so that it may not close properly.
Urethral Hypermobility (Type 1 and 2). Urethral hypermobility is a condition in which the urethra does not close properly and it is too moveable. It typically occurs from weakened pelvic floor muscles in women. In general, urethral hypermobility effect occurs during the following events:
  • The weakened pelvic floor muscles stretch.

  • This allows the bladder to sag downward within the abdomen.

  • The sagging bladder pulls on the muscles surrounding the bladder neck ( internal sphincter ), which are connected to the urethra.
Stress incontinence associated with urethral hypermobility is sometimes categorized as Type 1 or Type 2.
  • In the less severe stress incontinence (type 1), bladder neck and urethra remain incompletely closed. The urethra also becomes overly moveable.

  • In type 2, the angle of the bladder neck shifts. The urethra and bladder neck opening are closed, and the urethra is still overly movable. In addition, in such cases cystocele may occur. In this condition, the bladder muscles bulge (herniates) into the vaginal wall.
Intrinsic sphincteric deficiency (ISD). Intrinsic sphincter deficiency, or type 3, is the other major cause of stress incontinence in women, it occurs when the bladder neck muscles are damaged or weakened. The result is twofold:
  • The bladder neck is open during filling.

  • The closing pressure around the urethra is low.
This is the most severe stress incontinence in women (sometimes referred to as type 3) and usually occurs in women who have undergone previous surgeries for incontinence.


Stress Incontinence in Men


Prostate treatments can impair the sphincter muscles. Such treatments are the major causes of stress incontinence in men. They include the following:
  • Surgery or radiation for prostate cancer. Incontinence occurs in nearly all male patients for the first three to six months after radical prostatectomy. After a year of the procedure, most men retain continence, although leakage can occur.

  • Surgery for benign prostatic hyperplasia. Stress incontinence occurs in 1% to 5% of men after transurethral resection of the prostate (TURP), the standard treatment for severe benign prostatic hyperplasia.
It should be noted that incontinence after prostate procedures is often a combination of urge and stress. In fact, because studies often combine the two types of incontinence, it is not always clear which predominates.


WHAT IS URGE INCONTINENCE AND ITS CAUSES?


All cases of urge incontinence (also called hyperactive or irritable bladder) involve an over-active bladder.
  • In such cases, the detrusor muscle, which surrounds the bladder, contracts inappropriately during the filling stage.

  • When this occurs, the urge to urinate cannot be voluntarily suppressed, even temporarily.
There are usually one of two types:
  • Detrusor Instability. In this type, the nerves serving the bladder have signaled the brain appropriately that the bladder is full, but the detrusor muscles are unable to be suppressed.

  • Detrusor Hyperreflexia. With this type, a neurologic abnormality impairs the signaling systems between the bladder and the central nervous system, and the brain is unable to inhibit the detrusor muscles controlling urination.


Symptoms of Urge Incontinence


The primary symptom of urge incontinence is the need to urinate frequently with subsequent leakage.


Causes of Urge Incontinence


Very often, the cause of detrusor instability and bladder hyperactivity is unknown. Some conditions that can produce the disorders leading to urge incontinence include the following:
  • Benign prostatic hyperplasia (BPH). Detrusor instability occurs in about 75% of men with BPH and causes frequency, urgency, and urination during the night (although incontinence itself occurs only in very severe cases).

  • Prostate surgical procedures. Either prostatectomy for prostate cancer or transurethral resection of the prostate (TURP) for BPH can cause detrusor instability. As with stress incontinence, prostatectomy poses a much higher rate than with TURP, which is very low.

  • Damage to the central nervous system. Certain neurologic disorders or injuries can disrupt the passage of nerve messages between the urinary tract and central nervous system. Among the many conditions that cause this are stroke, multiple sclerosis, spinal cord or disk injury, and Parkinson's disease.

  • Infections.

  • The aging process.

  • Emotional disorders. Anxiety and possibly even depression have been associated with urge incontinence.


WHAT IS OVERFLOW INCONTINENCE?


Overflow incontinence happens when there is an impediment to the normal flow of urine out of the bladder and the bladder cannot empty completely. Overflow incontinence can be due to a number of conditions:
  • A partial obstruction. In this case the urine cannot flow completely out of the bladder, so it never fully empties.

  • An inactive bladder muscle. In contrast to urge incontinence, the bladder is less active than normal, not more. It cannot empty properly and so becomes distended, or swells. Eventually this distention stretches the internal sphincter until it opens partially and leakage occurs.


Causes of Overflow Incontinence


The causes of the conditions leading to overflow incontinence include the following:
  • Tumors.

  • Certain medications (anticholinergics, antidepressants, antipsychotics, sedatives, narcotics, alpha-adrenergic agonists, beta-adrenergic agonists, calcium channel blockers).

  • Benign prostatic hyperplasia.

  • Scar tissue.

  • Nerve damage. In such cases, nerves in the bladder are damaged so that they are not sensitive to fullness and so do not trigger contraction. Damage can be caused by spinal cord injuries, previous surgery in the colon or rectum, and pelvic fractures. Diabetes, multiple sclerosis, and shingles can also affect nerves in this way.


WHAT IS FUNCTIONAL INCONTINENCE?


In functional incontinence, the patient has mental or physical disabilities that impair urination, although the urinary system itself is normal. Conditions that can lead to function incontinence include the following:
  • Severe physical disorders, such as in Parkinson's disease.

  • Mental diseases, including Alzheimer's disease and other forms of dementia. Mental confusion may prevent both recognition of the need to void and locating a bathroom.

  • Severe depression. In such cases, people may become incontinent because they are indifferent to self-control.


WHO HAS URINARY INCONTINENCE?


About 17 million adults experience incontinence at some point. This figure, however, may underestimate the problem because most patients are reluctant to discuss incontinence with their doctors. In fact, research has shown that a number of patients will not admit to having the problem even when questioned directly.


Incontinence in Children and Young People


While uncommon in children over age five, one study reported that the following children experienced incontinence:
  • 10% of 5-year-olds.

  • 5% of 10-year-olds.

  • 1% of 18-year-olds.
Before puberty, when incontinence occurs, it is twice as common in boys as in girls.

Most young people who experience nighttime wetting do not have any serious physical or emotional disorders. Many cases probably result from a combination of factors, including one or more of the following:
  • Slower physical development.

  • An overproduction of urine at night.

  • A lack of ability to recognize bladder filling when asleep.

  • Anxiety.

  • Inherited factors (indicated by a strong family history of bedwetting).

  • Complications of diabetes, stroke, multiple sclerosis, and Parkinson's disease.

  • High impact exercise, particularly in young women.
Bedwetting in children is not considered to be incontinence. Of interest, however, one study reported that adult women who regularly wet their bed when they were six years old were more likely to have urge incontinence than were women who did not bedwet during childhood.


Incontinence in the Elderly


All older adults are susceptible to incontinence. About half of the elderly who are house bound or in nursing homes are incontinent; between 25% to 30% of older adults experience incontinence after hospitalization from a serious illness. Urge incontinence accounts for two-thirds of incontinence cases in the elderly.


Incontinence in Women


Six out of every seven cases of adult incontinence occur in women. Between 15% and 30% of women experience incontinence during their lifetimes.

Major Biologic Gender Differences. Younger women are generally more at risk for urinary incontinence than younger men because of two important biologic differences:
  • The urethras in women are shorter than in men (around two inches versus ten).

  • Women bear children. The more children a woman has the greater the risk for incontinence, however, the risk is highest with the first child, and there is an increased risk in women who have their first child over age 30.
Women Who Used Oxytocin During Labor. Women who used the drug oxytocin for inducing labor also appear to be at higher risk for urinary incontinence later on. Such medically induced labor tends to subject the muscles and nerves in the pelvis to greater force than does natural labor.

High-Impact Exercisers. Women who engage in high-impact exercise are susceptible to urinary leakage, particularly women with a low foot arch. Shock to the pelvic area is increased as the foot makes impact with hard surfaces. Those at highest risk for urinary leakage are gymnasts, followed by softball, volleyball, and basketball players.

Smokers. One study of 600 women indicated that smokers and former smokers are twice as likely to develop incontinence than women who never smoked.

Medical Factors in Older Women. Urge incontinence is reported to be more common among older postmenopausal women with one or more of the following:
  • Diabetes.

  • Two or more urinary tract infections within a past year.

  • Obesity.


Incontinence in Men


In older men, prostate problems and their treatments affect the urinary tract. In fact, these problems are so common in older men, that as people age incontinence rates in men and women even out.


Factors in Temporary Incontinence


A number of conditions can cause temporary incontinence, including the following:
  • Urinary tract infections.

  • Excess fluid intake.

  • Constipation.

  • Severe depression.

  • Restricted mobility.
Drugs. Drugs are most often the cause of temporary incontinence.
  • Drugs that affect the adrenergic system, a nerve-cell and hormonal pathway that regulates the sphincter muscle, are common causes incontinence. For example, alpha-adrenergic blockers, such as terazosin (Hytrin), used for benign prostatic hypertrophy, can cause incontinence by over-relaxing the muscles. On the other hand, men with enlarged prostates who suffer from urinary problems may be helped by the increase of urine flow after using terazosin.

  • Alpha-adrenergic agonists, such as pseudoephedrine (found in some oral decongestants) strengthen the muscles and may cause overflow incontinence in susceptible people.

  • Beta-adrenergic blockers, such as propranolol (Inderal), prescribed for hypertension and angina, relax the sphincter.

  • Diuretics, used for high blood pressure, often rapidly introduce high urine volumes into the bladder.

  • Calcium-channel blockers can cause overflow incontinence by relaxing the bladder detrusor muscles.

  • Colchicine, a drug used for gout, can cause urge incontinence.

  • Other medications and substances that increase the risk for incontinence are caffeine, sedatives, antidepressants, antipsychotics, and antihistamines.


HOW CAN URINARY INCONTINENCE BE DIAGNOSED?


Less than half of patients who have urinary incontinence report the condition to their doctor. And, in spite of the commonness of this problem, two thirds of physicians never ask their older patients if they experience incontinence. In one survey, many physicians claimed they did not have the time to treat the patient. Many also have no knowledge of treatments and did not realize that therapies are available that can help about two-thirds of people with incontinence. Patients are often unaware of the nature of their condition or are too embarrassed to seek help for it. In many cases, patients simply felt that incontinence was part of the aging process and didn't want to bother their physicians. Some doctors are as embarrassed about incontinence as patients. It is important, however, for both the physician and the patient to raise the issue.


Medical History


The first step in the diagnosis of incontinence is a detailed history, including any medical conditions and patterns of urination. Patients should report the following information to their doctor:
  • When the problem began.

  • Frequency of urination.

  • Amount of daily fluid intake.

  • Use of caffeine or alcohol.

  • Frequency and description of leakage or urine loss, including activity at the time, sensation of urge to urinate, and approximate volume of urine lost.

  • Frequency of urination during the night.

  • Whether the bladder feels empty after urinating.

  • Pain or burning during urination.

  • Problems starting or stopping the flow of urine.

  • Forcefulness of the urine stream.

  • Presence of blood, unusual odor or color in the urine.

  • A list of major surgeries with their dates, including pregnancies and deliveries, and other medical conditions.

  • Any medications being taken.
Voiding Diary. In order to provide this information to the physician, the patient might find it helpful to keep a diary for three to four days before the office visit. This diary, sometimes referred to as a voiding diary or log, should be a detailed record of the following:
  • Daily eating and drinking habits.

  • The times and amounts of normal urination.
For each incident of incontinence, the log should also include the following:
  • The amount of urine lost. (The patient is often asked to catch and measure urine in a measuring cup during a 24-hour period.)

  • Whether the urge to urinate was present.

  • Whether the patient was involved in physical activity at the time.


Physical Examination


The office visit should consist of a thorough physical examination, checking for abnormalities or enlargements in the rectal, genital, and abdominal areas that may cause or contribute to the problem.


Measuring Postvoid Residual Urine Volume


One of the important measurements for urinary incontinence is the postvoid residual urine volume (PVR). This is the amount of urine left in the bladder after urination:
  • Normally, about 50 mL or less of urine is left.

  • More than 100 mL suggests an abnormality and requires further tests.

  • More than 200 mL is a definite sign of abnormalities.
Use of a Catheter. The most common method for measuring PVR is with a catheter, a soft tube, which is inserted into the urethra within a few minutes of urination. The advantage of the catheter is that it can also collect urine for analysis.

Ultrasound. Ultrasound is useful in determining the volume of urine.


Filling Cystometry for Urge Incontinence


Cystometry measures the bladder's ability to retain urine at different capacities and pressures. It is a basic test for urge incontinence.

Cystometry employs a catheter and so can be performed at the same time as the PVR test.
  • The patient empties the bladder as much as possible.

  • A catheter (a thin tube) is inserted into the urethra until it reaches the bladder. Measurements are taken of any residual urine and the pressure of the bladder.

  • Sterile water (usually at body temperature) is usually instilled through the tube into the bladder

  • During this process the pressure in the bladder is continuously measured. A fluid-inflatable balloon may be inserted into the rectum for a second measurement. This reflects any contribution that abdominal pressure is making.

  • Also during the process, the patient informs the physician about any changes in the need to urinate, differences in temperature, or other sensations.

  • When the urge to urinate is strong, the physician stops this portion of the test.

  • The patient urinates and measurements are made of pressure, volume, and the flow rate of the urine.

  • A calculation is then made using bladder and abdominal pressure measurements. The result provides an accurate assessment of detrusor contractions.
A normal bladder will not contract during filling. Severe contractions at low amounts of administered fluid (less than 200 mL) indicate urge incontinence. If results are uncertain, the test may be repeated to provoke bladder response by having the patient stand, by increasing the speed of the filling time, or by using ice-cold water.


Cystometry


Cystometry is a simple test used for stress incontinence.
  • After the bladder is filled, the patient coughs forcefully while lying down on the back.

  • If there is leakage, stress incontinence is indicated.

  • If there is no leakage, and stress incontinence is still suspected, the physician then places his or her fingers on each side of the urethra and tilts it up. The patient coughs again.

  • The test is then repeated with the patient standing. No leakage at this point indicates that the patient is probably continent.


Uroflowmetry


To determine whether the bladder is obstructed, the speed of urine flow is measured electronically using a test called uroflowmetry. The test cannot determine the cause of obstruction, which can be due not only to BPH, but possibly also to abnormalities in the urethra, weak bladder muscles, or other causes. The test involves the following steps:
  • The patient is instructed not to urinate for several hours before the test and to drink plenty of fluids so he or she has a full bladder and a strong urge to urinate.

  • To perform this test, a patient urinates into a special toilet equipped with a uroflowmeter.

  • It is important that patients remain still while urinating to help ensure accuracy, and that they urinate normally and do not exert strain to empty their bladder or attempt to retard their urine flow.
Many factors can affect urine flow (such as straining or holding back because of self-consciousness) so experts recommend that the test be repeated at least twice.

Q[max]. The rate of urine flow is calculated as milliliters of urine passed per second (mL/s). At its peak, the flow rate measurement is recorded and referred to as the Q[max]. The higher the Q[max], the better the patient's flow rate. Men with a Q[max] of less than 12 mL/s have four times the risk for urinary retention than men with a stronger urinary flow.

The Q[max] measurement is sometimes used as the basis for determining the severity of obstruction and for judging the success of treatments. It is not very accurate, however, for a number of reasons:
  • Urine flow varies widely among individuals as well as from test to test.

  • The patient's age must be considered. Flow rate normally decreases as men age, so the Q[max] typically ranges from more than 25 mL/s in young men to less than 10 mL/s in elderly men.
The Q[max] level does not necessarily coincide with a patient's perceptions of the severity of his own symptoms.


Imaging Tests


Urethrocystoscopy. Urethrocystoscopy, also called cystourethroscopy or cystoscopy, detects structural abnormalities, inflammation of the bladder wall, or masses that might not show up on x-ray.
  • The patient is given a light anesthetic and the bladder is filled with water.

  • Next, a thin flexible tube called a cystoscope is inserted through the urethra into the bladder.

  • The end of the cystoscope contains a tiny microscope-like instrument.

  • The physician uses the cystoscope to look for abnormalities in the interior of the bladder.
The procedure is not without risks. Complications are uncommon but can include allergic response to the anesthetic, urinary tract infection, bleeding, and urine retention.

Intravenous Pyelogram . Intravenous pyelogram (IVP) may be used for urge incontinence. It uses a dye that shows up on x-ray:
  • The dye is injected through a vein and is processed by the kidneys.

  • A series of x-ray pictures are taken of the kidneys, ureter, and bladder as the dye passes through them. This provides a dynamic picture of the relationship between the patient's urinary system and urinary functioning.
IVPs can detect structural abnormalities, urethral narrowing, or incomplete emptying of the bladder. This test should not be used on pregnant women or patients with kidney failure. There is a risk for an allergic reaction to standard dyes, although newer less allergenic ones are becoming available.

Chain Cystogram. In cases of stress incontinence, a chain cystogram may also be performed. With this procedure, a beaded chain is positioned in the bladder and urethra. The x-ray image of the chain reveals the angle of the bladder neck. This test should also not be performed on pregnant women.


Video Urodynamics


Video urodynamics combines a computer reading of bladder pressures and pictures of the bladder itself. It is most useful in cases where the more standard tests have not yielded satisfactory results.


Electrophysiologic Sphincter Testing


Electrophysiologic sphincter testing, also referred to as electromyography (EMG), evaluates two important factors:
  • The function of the nerves serving the sphincter and pelvic floor muscles.

  • The patient's ability to control these muscles.
Using a technique similar to that of an electrocardiogram, the physician places electrodes on the affected areas to observe electrical activity in the muscles.


Urethral Pressure Profile


Urethral pressure profile is used to investigate urethral blockage. A probe is placed in the urethra to determine pressure at different points along this pathway during urination and the exact location of any obstruction in the urethra.


HOW SERIOUS IS INCONTINENCE?


Incontinence is rarely life threatening. In most cases, and if treated promptly, complications are no more serious than external skin irritation or the occasional infection in the urinary tract.


Emotional Effects


Urinary incontinence can have severe emotional effects. A number of studies of prostate cancer patients have reported that incontinence is a much more distressing side effect for men than impotence (also a side effect of prostate cancer treatment).

Among the negative emotional effects are the following:
  • Because little public attention has been paid to this problem, the incontinent person often feels alone. Up to one third of people with incontinence do not even seek medical advice for the problem. In one survey of physicians, nearly all of them reported that a patient's embarrassment and reluctance to discuss bladder problems is a major barrier to successful treatment.

  • Many people experience a sense of personal failure, a child-like shame.

  • They often feel helpless and angry.

  • Patients may eventually curtail social activities, or even give them up entirely.

  • Many people with incontinence believe that they are unemployable.


Disruption of Daily Life


To prevent humiliation due to wetness or odors, people with incontinence may have to totally alter their way of life.
  • Even errands become very difficult and need advanced planning.

  • Public bathrooms are often scarce and difficult to locate. The problem is particularly severe for those with urge incontinence who have little time to reach a bathroom and have large volume spills.
Specific Effects of Incontinence in Seniors

Incontinence is particularly serious in elderly people:
  • Incontinence can result in loss of independence and quality of life.

  • It is a major reason for nursing home placement.

  • Severe incontinence may require catheterization. This the insertion of a tube that allows urine to continually pass into an external collecting bag. In such cases, complications are common, particularly infections.

  • There is a strong association between urge incontinence and falls and injuries. In one large study, over half of women who reported incontinence experienced at least one fall over a three-year period. This high incidence of falls may be due in part to the rush to the toilet in the middle of the night. Keeping a pan or portable commode near the bed may prevent injuries as well as improve sleep and general convenience.


Financial Cost


It is estimated that the cost of incontinence to the elderly alone is $11 billion annually. While medical evaluations and treatments are often covered (at least in part) by insurance, the individual often bears the cost of absorbent pads or pants, and also of unconventional treatments such as biofeedback.


WHAT ARE THE GENERAL GUIDELINES FOR MANAGING AND TREATING INCONTINENCE?



Treatments for Temporary Incontinence


The treatment for temporary incontinence can be rapid, simple, and effective. For example, if urinary tract infections are the cause, they can be treated with antibiotics. Any related incontinence will often clear up in a short time. Medications that cause incontinence can be discontinued or changed to halt episodes.


Guidelines for Treating Chronic Incontinence


Chronic incontinence may require a variety of treatments, depending on the cause. Treatment options include the following. They are listed in the order in which they are usually tried, from least invasive to most.

1. Behavioral techniques (Kegel exercises and bladder training). While the physician will determine the regimen most suited to the type of incontinence, as well as the individual patient's needs, it is common to try behavioral techniques first.

2. Medications. Drugs are tried next.

3. Surgery. Surgery is the last resort; there are many procedures available and the patient must discuss all options thoroughly with the physician.

Management techniques to improve the quality of life are part of all treatments.


General Approach for Treating Specific Forms of Incontinence


Treatments vary depending on whether the patient has stress or urge incontinence. In people who have both, the treatment usually is aimed at the predominant form.

Treating Stress Incontinence. The general goal for women with stress incontinence is to strengthen the pelvic muscles.

Typical steps for treating women with type 1 stress incontinence is as follows:
  • Kegel exercises.

  • Weighted vaginal cones.

  • Devices that reduce urination (vaginal pessaries and others).

  • Medications. (Typically alpha-adrenergic drugs, also possibly tricyclic antidepressants.)

  • Topical estrogen (creams, ointments, rings).

  • If symptoms do not improve, specialists may suggest surgery or other procedures.
For type 2 patients, surgery is often beneficial.

And for type 3 patients, whose conditions are often caused by previous surgical failure, a repeat sling procedure of collagen injections may be helpful.

General Approach to Urge Incontinence. The goal of most treatments for urge incontinence is to reduce the hyperactivity of the bladder.

The typical steps for treating people with type 1 stress incontinence are as follows:
  • Bladder training.

  • Medications. (Anticholinergics, antispasmodics, tricyclic antidepressants.)

  • Pelvic floor electrical stimulation.

  • Extracorporeal magnetic innervation.

  • Topical estrogen (in women).

  • Sacral nerve stimulation.


WHAT ARE LIFESTYLE MEASURES FOR MANAGING URINARY INCONTINENCE?


Maintaining good hygiene and diet are key components in sustaining a high quality of life. Many products are now available that help patients avoid embarrassment and, in some cases, prevent leakage. With recent improvements in paper technology, pads are now thin enough to be worn undetected, and a spare can be carried in a purse or pocket.


Hygiene Tips


Keeping Skin Clean. To avoid skin irritation and infection associated with incontinence, it is important to always keep the skin clean:
  • After a urinary accident, clean any affected areas right away.

  • When bathing, use warm water and don't scrub forcefully; hot water and scrubbing can injure the skin.

  • Keeping the area around the urethra clean without causing it to dry out is key.

  • A number of cleansers are available that are specially created for incontinence and allow frequent cleansing without over-drying or causing irritation to the skin. Most do not have to be rinsed off; the area is simply wiped with a cloth.

  • After bathing, a moisturizer plus a barrier cream should be applied. Barrier creams include petroleum jelly, zinc oxide, cocoa butter, kaolin, lanolin, or paraffin. These products are water repellent and protect the skin from urine.

  • Anti-fungal creams that contain miconazole nitrate are used for yeast infections.
Preventing or Reducing Odor. Certain methods or oral agents may help reduce odor from accidents. They include the following:
  • Deodorizing tablets (eg, Derifil, Nullo, Devrom, Chlorofresh) that can be taken orally or used in appliances are available. Most contain chlorophyll.

  • Some people report that taking a vitamin C supplement helps reduce odor. High doses of this supplement may have adverse effects. Patients should discuss this with their physician.

  • Some people have reported that taking an alfalfa pill four times a day reduces odor and does not interfere with any other medications. Alfalfa is a common grass and some people with seasonal allergies may experience an allergic reaction.

  • Drinking more water, not less, will also reduce odors and may not increase the risk for urinary accidents [ see Dietary Considerations below ].

  • To remove odors from mattresses, some experts recommend using a solution of equal parts vinegar to water. Once the mattress has dried, baking soda can be applied on the stain, rubbed in, and then vacuumed.


Dietary Considerations


Weight Control. I n women, pelvic floor muscle tone weakens with significant weight gain, so women are urged to eat healthful foods in moderation and to exercise regularly.

Fluid Intake. A common misconception among people with incontinence is that drinking less water will prevent accidents. In reality, limiting fluid intake has the following effects:
  • The lining of the urethra and bladder becomes irritated, which may actually increase leakage.

  • Concentrated urine also has a stronger pungency, so drinking plenty of fluids can help reduce odor.
Some experts recommend drinking two to three quarts a day.

Drinking plenty of cranberry juice may be particularly helpful. It is known to help prevent urinary tract infections. (Low calorie juices are available.)

People with incontinence, however, should stop drinking beverages two to four hours before going to bed, particularly those who experience leakage or accidents during the night.

Fiber-Rich Foods. Constipation can exacerbate urinary incontinence, so diets should be high in fiber, fruits, and vegetables. A diet rich in these foods is highly recommended anyway for overall well-being.

Fluid and Food Restrictions. A number of foods and beverages have been reported to increase the incidence of incontinence. Some experts suggest that people who eat or drink the following items should try eliminating one a day over a 10-day period and check to see if removing them improves continence:
  • Coffee (including decaf) and tea and other caffeinated beverages or medications.

  • Carbonated beverages.

  • Alcoholic beverages.

  • Citrus fruits and juices.

  • Tomatoes and tomato-based foods.

  • Spicy foods.

  • Chocolate.

  • Sugars and honey.

  • Artificial sweeteners.

  • Milk and milk products.


Absorbent Undergarments


A variety of absorbent pads and undergarments are quite effective in catching spills and leaks. Many undergarments developed for incontinence are almost indistinguishable from regular briefs and underpants. The following are some examples:

For women, the following are available:
  • Normal and even attractive looking washable underwear that contains waterproof panels is available for women. Even stomach-control panties are available for women with incontinence.
For men, the following are available:
  • Drip collectors are available which can be worn under briefs and are not noticeable under normal clothing. Lined with absorbent material, the pouch-like collector surrounds the penis or scrotum and is fastened with a belt or pins.

  • Washable briefs made from polyester (Sir Majesty) are available that have a fully functional fly and waterproof panel and look and feel like normal underwear. Boxer shorts are also available that look regular but have a protective pouch.
Even for men and women with severe incontinence, disposable undergarments can be purchased that have a normal look to them.

All absorbent undergarments should be changed when wet to limit problems of chafing or infection. Some manufacturers names and numbers are included in this report [ see Where Else Can Help Be Obtained For Urinary Tract Incontinence? below ].


Personal Urinals


A specially shaped plastic urinal (Feminal) is available for women. It avoids the use of a bed pan, and can be used while the woman is lying down, seated, or even standing.

Urinals for men are available that attach to athletic-like supporters.


WHAT ARE URETHRAL AND VAGINAL DEVICES FOR BLOCKING URINE IN STRESS INCONTINENCE?



Adhesive Pad for Women


Foam pads (Miniguard, UroMed, Softpatch) with an adhesive coating have been developed for women with stress incontinence. They work as follows:
  • The pad is placed over the opening of the urethra where it creates a seal, preventing leakage.

  • It is removed before urinating and replaced with a new one afterwards.

  • The pad can be worn up to five hours a day and through the night.

  • It can be used during physical activity, although it may change position during vigorous exercise.

  • It should not be worn during sexual intercourse.
In one study, the average number of leaks dropped from 14 a week to five. Women with more severe incontinence (an average of 34 leaks a week) had only 10 events, and when leakage occurred, it was slight.

They should not be used by the following women:
  • Women with urinary tract or vaginal infections.

  • Women with urge or other forms of nonstress incontinence.

  • Women who have had surgery for incontinence.


Urethral and Vaginal Devices for Women


Urethral Shields. Shields or caps (CapSure, FemAssist) that fit over the urethral opening are proving to be safe and effective in managing many forms of incontinence.
  • In a study of patients with stress incontinence, CapSure reduced urine loss by 96% within a week, and 82% of patients were completely dry. Side effects include irritation and urinary tract infections, although they are not severe.

  • In another study, 47% of women who used FemAssist reported complete continence, and 33% of the women reported continence was improved by more than half. FemAssist offered equal benefits for women with stress, urge, or mixed incontinence.
Urethral Tubes or Sleeves. Tubes or sleeves (Reliance Urinary Control Device, FemSoft) that fit into the urethra are also available for female incontinence.
  • The Reliance Urinary Control Device for women is a small tube inserted into the urethra using a reusable syringe. The device must be prescribed by a physician, who measures the woman's urethra to determine the right size. The tip of the tube contains a balloon that is inflated against the urethra and blocks urine, preventing leakage. Every time a women urinates, she pulls a string that deflates the balloon, then throws the old device away and replaces it with a new one. It is effective, but carries a high risk for urinary tract infections and most women report discomfort and irritation.

  • FemSoft is a silicone tube insert surrounded by a liquid-filled sleeve. When the tube is inserted into the urethra, the sleeve conforms to its shape and creates a seal at the bladder neck, preventing leakage. It is intended for one-time use and is replaced after voiding. This is a new product and information is lacking on its comfort and risk for urinary tract infections.
Vaginal Devices. Devices that support the vaginal wall also help support the urethra that is located next to it:
  • Tampons. Even simple tampons may be helpful. Mild stress incontinence in women, particularly when induced by exercise, may be managed by using a tampon. As tampons push on the vaginal wall, it compresses the urethra. The following are some considerations about using tampons: covering tampons with K-Y jelly helps prevent the cotton fibers from sticking. Tampons can only be worn for short periods. In one study, 86% of women with mild incontinence remained continent during exercise sessions when using tampons. Out of this group, however, only 29% with severe incontinence remained dry.

  • Vaginal Pessaries. Vaginal pessaries are devices inserted into the vagina that support the inside of the vaginal walls. Pessaries are usually made of silicon and come in various forms, including donut or cube-shapes. They must be fitted by a health professional and are effective for vaginal prolapse or other vaginal structural problems.

  • Introl Bladder Neck Support. The Introl bladder neck support prosthesis is a flexible ring that is inserted into the vagina and has two ridges that press against the walls, supporting the urethra. Sizing the Introl is difficult, but success rates of 83% have been reported in women with stress incontinence. It can be left in during urination but must be removed and cleaned afterward. Introl can cause vaginal or urethral infections and may also be uncomfortable.


WHAT ARE THE BEHAVIORAL METHODS FOR TREATING STRESS INCONTINENCE?


With the exception of functional incontinence, most cases of incontinence will almost always improve with behavioral techniques. There are a variety of methods, but the focus is usually on strengthening or retraining the bladder. Studies indicate that such exercises are very effective, even for men recovering from surgery for prostate cancer.


Crossing the Legs


In a small study, 73% of women with stress incontinence were helped by an absurdly simple and obvious movement: crossing the legs whenever a cough or sneeze was coming on prevented urine leakage almost completely.


Pelvic Floor Muscle (Kegel) Exercises


Kegel exercises are designed to strengthen the muscles of the pelvic floor that support the bladder and close the sphincters. Dr. Kegel first developed these exercises to assist women before and after childbirth, but they are very useful in helping to improve continence for both men and women. Kegel exercises are particularly useful for the following:
  • Stress incontinence. Some experts believe that Kegel exercises should be the primary treatment for stress incontinence.

  • Urge incontinence. They can also be helpful for urge incontinence in cases that are not caused by nerve damage.
The general approach for learning and practicing Kegel exercises is as follows:
  • Since the muscles are sometimes difficult to isolate, the best method is to first learn while urinating. The patient begins to urinate and then contracts the muscle in the pelvic area with intention of slowing or stopping the flow of urine. Women should contract the vaginal area as well.

  • An alternate approach is to isolate the muscles used in Kegel contractions by sensing then squeezing and lifting the muscles in the rectum that are used in passing gas. (Again, women should contract the vaginal muscles as well.)

  • Patients should place their the hands on their abdomen, thighs, and buttocks to make sure there is no movement in these areas while exercising.

  • In order to achieve success, some experts recommend performing two exercises that have different timing for the hold and release of the contraction. Both should be done regularly.

  • The first method is used for strengthening the pelvic floor muscles. The patient slowly contracts and lifts the muscles and holds for five seconds, then releases them. There is a rest of 10 seconds between contractions.

  • The second method is simply a quick contraction and release. The object of this exercise is to learn to shut off the urine flow rapidly.

  • In general, patients should perform five to 15 contractions, three to five times daily.
Some notes of caution:
  • Once learned, Kegel exercises should not be performed while urinating more than about twice a month, since this practice may eventually weaken the muscles.

  • In women, incorrect or overly vigorous exercises may cause vaginal muscles to tighten excessively, resulting in pain during sexual intercourse.

  • Over-exercise can also tire muscles and cause more leakage.

  • Incontinence will return to its original severity if these exercises are discontinued, so commitment to the program must be high and possibly life-long.
It may be several months before the patient sees significant improvement. Kegel exercises do not usually cure incontinence, and so estimates of the effectiveness of Kegel exercises fall into a broad range. Nevertheless, between 50% and 75% of patients who do them report a substantial improvement in their symptoms, including elderly people who have had the problem for years. One study suggested that they were more effective than electrical stimulation and vaginal cones for women with stress incontinence [ see below ].


Electronic Biofeedback


The effectiveness of Kegel exercises can be enhanced with the use of biofeedback, which can help the patient gain control over involuntary urinary function:
  • Biofeedback uses a vaginal or rectal probe inserted by the patient to relay information to monitoring equipment.

  • The patient isolates the pelvic floor and bladder muscles and performs Kegel exercises.

  • The monitor emits auditory or visual signals that indicate how strongly the patient is contracting the proper pelvic floor muscles and how effectively the bladder muscles are being released.

  • The apparatus is designed for home use.
Like the Kegel exercise regimen, it must be tried for several months before it is effective. One 2000 study reported that it was more effective than manual Kegel exercises. And another 2000 study reported that after four months 43% of women were dry and 36% experienced more than 50% improvement.


Vaginal Cones


This system uses a set of weights to improve the effectiveness of Kegel exercises for women. The cones are inexpensive, relatively simple to use, and have led to a substantial improvement in 70% of female patients monitored:
  • The typical set includes five cones of graduated weights ranging from 20 grams (less than one ounce) to 65 grams (slightly over two ounces).

  • Starting with the lightest, the woman places the cone in her vagina while standing and attempts to prevent the cone from falling out. The muscles used to hold the cone are the same ones needed to improve continence.
As with standard Kegel exercises, frequent repetition is required, but most women will eventually be able to use the heavier weights and build up the ability to prevent stress and urge incontinence.


Bladder Training


Bladder training is helpful for both stress and urge incontinence and is often used in combination with Kegel exercises:
  • Patients are also put on a specific, graduated schedule for urinating. Patients start by planning short intervals between urinations and then gradually progressing with a goal of voiding every three to four hours.

  • If the urge to urinate arises between scheduled voidings, patients should remain in place until the urge subsides. At that point, they move slowly to a bathroom.

  • For incontinent patients who are in nursing rooms, regular reminders to urinate and checks for dryness may be needed to enhance bladder training.
As an extra tip for older people with severe incontinence, keeping a pan or portable commode near the bed may prevent injuries from falling as well as improve general convenience.


Extracorporeal Magnetic Innervation Therapy for Stress Incontinence


A treatment called extracorporeal magnetic innervation therapy stimulates pelvic muscles to automatically perform Kegel exercises:
  • The patients stay fully dressed and sit on a special chair during the treatment.

  • Highly focused magnetic fields penetrate the pelvic area to stimulate the nerves.

  • Sessions are twice a week for about six weeks, although it may take more than eight weeks to build up the muscles.
Studies are reporting that patients experience fewer leaks, need fewer pads, and have fewer voiding episodes throughout the day and night. One study comparing groups with magnetic therapy and a "dummy" treatment reported no differences in their effects. More studies are needed to determine whether extracorporeal magnetic innervation therapy has any value.


WHAT ARE MEDICATIONS FOR INCONTINENCE?


A number of medications are available that increase sphincter or pelvic muscle strength or relax the bladder, thus increasing its capacity to hold urine. Medications can be prescribed for all kinds of incontinence, but they are generally most helpful for urge incontinence.


Anticholinergics for Urge Incontinence


Anticholinergic agents, such as oxybutynin (Ditropan), hyoscyamine (Levbid, Cytospaz), and tolterodine (Detrol) have the following advantages:
  • They inhibit the involuntary contractions of the bladder.

  • They increase capacity of the bladder.

  • They delay the initial urge to void.
These drugs are most useful in treating urge incontinence, but most have distressing side effects that limit their use, and compliance is poor. Newer extended-release versions of oxybutynin (Ditropan XL) and tolterodine (Detrol LA) that only need to be taken once a day may improve these experiences, however. Early results suggest they will have less severe side effects, including dry mouth, than the short-term versions. Oxybutynin delivered through other means is being tested, including the use of a skin patch and a reservoir bag implanted into the bladder. Early trials are promising, showing a reduction in adverse effects compared to the immediate release oral form.

Side Effects. Side effects of anticholinergic agents include the following:
  • Dry eyes. Dryness in the eyes is a particular problem for people who wear contact lenses. Patients who wear contacts may wish to start with low doses of medication and gradually build up.

  • Dry mouth.

  • Headache.

  • Constipation.

  • Rapid heart rate.

  • Confusion.
In rare cases, anticholinergics may precipitate glaucoma.


Antispasmodics for Urge Incontinence


Antispasmodic drugs help relax the bladder muscle and are used for urge incontinence. Before bladder relaxants are prescribed, a thorough evaluation for obstructions in the ureter must be performed to avoid excessive urine retention. The two antispasmodics most commonly prescribed include flavoxate (Urispas) and dicyclomine (Bentyl). They also have anticholinergic properties. They have been used for years, although studies suggest that Urispas has very little benefits for most patients with urge incontinence.

Side Effects. Possible side effects reported with use of antispasmodic drugs include:
  • Weakness.

  • Dizziness.

  • Drowsiness.

  • Hallucinations.

  • Insomnia.

  • Dry mouth.

  • Impotence.

  • Restlessness.


Alpha-Adrenergic Agonists for Stress Incontinence


Alpha-adrenergic agonists are used to strengthen the smooth muscle that opens and closes the internal sphincter. They are most effective in patients with mild stress incontinence not caused by nerve damage.

These are common ingredients in numerous over-the-counter decongestants and appetite suppressants. Alpha-adrenergic agonists include ephedrine, pseudoephedrine, and phenylpropanolamine (PPA). (Products containing PPA have been taken off the market because of reports of a higher risk for stroke in some women who took it.)

Side effects include the following:
  • Agitation.

  • Insomnia.

  • Anxiety.
The may have adverse effects on the heart in people with existing heart problems. People with glaucoma, diabetes, hyperthyroidism, heart disease, or high blood pressure should avoid alpha-adrenergic agonists.


Estrogen Replacement Therapy


The drop in body estrogen levels brought on by menopause may contribute to both stress and urge incontinence. Research shows that estrogen applied as a vaginal cream, rings, or patches may help restore continence in the following manner:
  • It helps restore the urethral lining, which thins from estrogen deficiency. The thinner lining can increase the risk for stress incontinence by impairing the urethra's ability to close.

  • Estrogen cream particularly desensitizes the bladder, helping those with urge incontinence.
Full benefit may take a year, although some improvement often occurs in six weeks. One device called a vaginal estrogen ring (Estring) is inserted into the vagina every three months.

Oral estrogen may not have the same benefits as estrogen creams, ointments, or patches for urinary incontinence. In fact, a 2001 study reported that oral hormone replacement therapy (HRT) that contained both estrogen and progesterone actually worsened urinary incontinence. This is the most common HRT for postmenopausal women, since estrogen alone increases the risk for uterine cancer.


Antidepressants


Evidence indicates that urge incontinence may be related to altered levels of serotonin, a neurotransmitter important in depression.

Tricyclic Antidepressants. Agents known as tricyclic antidepressants have been helpful in the treatment of incontinence. These antidepressants, particularly imipramine (Janimine, Tofranil) provide multiple benefits for both urge and stress incontinence. They act as anticholinergic agents [ see Anticholinergics above ], relax the bladder, and strengthen the internal sphincter.

These drugs should be used carefully. They pose some risk for adverse effects on the heart and possibly the lungs, and they have other severe side effects in older adults. These antidepressants produce side effects similar to anticholinergic drugs, and may cause drowsiness. They may also back-fire and actually cause overflow incontinence in some people.

Investigative Antidepressants. Specially designed antidepressants are under investigation. For example, duloxetine is an antidepressant now in late clinical trials that is aimed specifically at treating both depression and urinary incontinence.


Other Drugs


Desmopressin. Studies have reported that desmopressin (DDAVP), a drug used for bedwetting in children, may be helpful in the treatment of urinary incontinence in adults that occurs during sleep.

Capsaicin and Analogs. Studies have reported beneficial effects from instillation of capsaicin, a component of hot red chili peppers, into the bladder of people with hyperactive and hypersensitive bladders. Temporary adverse effects, however, can be distressing. A more powerful agent called resiniferatoxin, which is a capsaicin analog may have fewer side effects and is under investigation.


WHAT ARE THE SURGICAL PROCEDURES FOR TREATING STRESS INCONTINENCE?



General Guidelines for Surgical Treatment


There are nearly 200 procedures for incontinence. Most of these procedures are designed to restore the bladder neck and urethra to their anatomically correct positions in patients with stress incontinence.

The American Urological Association suggests that surgery should actually be considered as initial therapy for women with severe stress incontinence. It is an effective and safe alternative when conservative treatments fail. Many of the procedures are safe even for women up to 80 years old who do not have serious medical conditions. Potential complications of all procedures include obstruction of the outlet from the bladder, causing difficulty in urination and irritation.

The choice of procedure is a difficult one and often depends on whether particular anatomical abnormalities are involved, or other factors causing the incontinence. It should be noted that a hysterectomy must not be performed as a cure for incontinence.

In general, patients should weigh all options carefully in order to pick the best procedure possible. The patient should discuss the situation with their physician, and also inquire about their surgeon's experience. As a general rule, the more times a procedure has been successfully performed by the surgeon, the better. Patients are also advised to research success rates on any procedure used for the condition in question.


Standard Retropubic Surgery


Retropubic suspension (also called bladder neck suspension or bladder suspension) procedures are used in mild to moderate stress incontinence. These procedures correct the position of the bladder and urethra by sewing the bladder neck and urethra directly to the surrounding pelvic bone or nearby structures. There are many variants, but in general, they are effective only for women whose incontinence is caused by urethral hypermobility. Most procedures require a general or spinal anesthetic and a two-day hospital stay.

The three most common procedures are the following:
  • Marshall-Marchetti-Krantz (MMMK).

  • Burch colposuspension.

  • Transvaginal suspension.
Long-term success rates can range from 80% to 97% with MMMK or Burch colposuspension. Transvaginal suspension is a newer procedure.

Marshall-Marchetti-Krantz. The MMMK approach is one of the most time-tested and reliable:
  • It requires a wide abdominal incision.

  • The surgeon then elevates the urethra and bladder neck using sutures.

  • These structures are then secured and anchored in nearby cartilage.
Burch Colposuspension. Burch colposuspension (sometimes called colpocystourethropexy) is intended to improve on the MMMK procedure:
  • In stead of anchoring the urethra and bladder neck to nearby cartilage, the surgeon secures them with the sutures to thick bands of muscle tissue running along the pubic bones.
It is more effective in premenopausal than postmenopausal women and may not be appropriate for all women.

Postoperative Considerations. Following most standard procedures, patients usually leave the hospital on the second or third day, but will require a urinary catheter for about ten days. Complications after surgery include the following:

Some risk of damage to the surrounding nerves or vessel. This can result in internal sphincter deficiency. (In some cases it may already have been present before the operation.)
  • Difficulty in urinating from surgical overcorrection (which may require additional surgery).

  • Poor wound healing.

  • Vaginal abnormalities (prolapsed vagina). One study of 264 women who underwent surgery for stress incontinence reported that there was a high incidence (42%) of pelvic organ prolapse repair and vaginal reconstruction among this group.


Newer Retropubic Surgeries


Transvaginal Needle Suspension. Transvaginal suspension is a newer procedure. There are many variations including the Pereyra, Stamey, Raz, and Gittes procedures:
  • It typically requires only a small abdominal incision.

  • The surgeon works through the vagina and places sutures through the vaginal walls to areas near the bladder neck and urethra.

  • Then, working through the abdominal incision, the surgeon ties the sutures to the abdominal or pelvic walls.
Transvaginal suspension is effective only if the walls of the vagina are strong enough to withstand the procedure. Transvaginal needle suspension is also showing poor long term results. Poor wound healing rates appear to be high. In one study, only 35% of patients who had transvaginal suspension were continent after about six years, and in another, failure rate was 83% after four to five years. In one study 20% of women reported worse sexual function after the procedure.

Laparoscopy. Newer less invasive procedures use laparoscopy, which require only one or two incisions over the pubic bone that are less than an inch long. Early results were very encouraging. However, long term studies are reporting very low success rates (about 30%) and failure rates occur at an average of 18 months. Nevertheless increasing experience may improve these results. For example, some 2001 studies are reporting high satisfaction rates after three and four years (even without complete cures) in women who have had laparoscopic versions of Burch colposuspension.


Sling Procedure


A sling procedure may be the best option for severe stress incontinence in women with either intrinsic sphincter deficiency or urethral hypermobility. Studies suggest that it may be useful for managing urge incontinence in certain women.

The Basic Sling Procedure.
  • The surgeon uses a piece of fasci (a layer of tissue that covers muscle fibers) taken from a cadaver to perform this procedure. (New synthetic slings made of polypropylene mesh are proving to be effective alternatives.)

  • The piece of muscle fiber or material is attached under the urethra and bladder neck, somewhat like a hammock, and secured to the abdominal wall and pelvic bone.

  • This sling then compresses the urethra back to its original position. The sling must be supportive without being too tense, which can cause urinary obstruction.

  • The procedure is usually performed through a small incision in the abdomen. A newer outpatient procedure that uses no incisions and is performed through the vagina is showing promise and has the potential to reduce the risk for urge incontinence afterward. Studies show, however, that success rates are still lower than with the standard sling procedure.
Variations of the Sling Procedure.
  • One minimally invasive sling procedure called a tension-free vaginal tape employs a special gauze tape covered by a polypropylene coating, which is attached on each side of the urethra. The patient is conscious and asked to cough during the procedure so that the surgeon can determine if the tape is being placed properly. Early studies show good results for both its safety and its effectiveness.

  • For some men who have prostatectomy-induced incontinence, a procedure called the bulbourethral sling may be a good option. One version involves placing three Gore-Tex covered tubes across the urethra attached to the abdominal muscles. In one early study, 79% reported that they were dry and uninfected after the procedure. In a follow-up study, over half the men complained about persistent numbness or discomfort in the anal region. It is also less effective in men who have had radiation therapy.


Treatments for Loss of Sphincter Function


Artificial Sphincter. In cases of sphincter incompetence, or complete lack of sphincter function, an artificial internal sphincter may be implanted. This silicone device must be opened manually by the patient; it closes automatically several minutes later. The two drawbacks of the internal sphincter implant are the following:
  • Malfunction. If the implant malfunctions, the surgery must be performed again.

  • Infection. Infection is more serious as it can cause erosion of the urethra or bladder neck underneath the implant. Such infections not only require removal of the device, but also may worsen the incontinence. In men, the surgeon may be able to implant a new sphincter around the bladder neck if the original implant was fixed around the urethra. In women, a new implant may not be possible. Fortunately, techniques have improved so that infection is uncommon.
Dynamic Graciloplasty. Stimulated graciloplasy is an interesting investigative alternative for severe sphincter incompetence:
  • A muscle from the thigh (the gracilis muscle) is repositioned to create a natural sphincter.

  • An electrode is implanted.

  • The patient uses a magnet to draw current from the electrode, which opens the new sphincter.

  • Removing the magnet stops the current and closes the sphincter.
Initial results are promising, the risk of infection with this procedure may be lower, but further study is needed.


Bulking Material Injections


Injections of materials that provide bulk to help support the urethra are proving to be beneficial for certain patients:
  • Women (even the elderly) with severe stress incontinence caused by intrinsic sphincter deficiency alone or with urethral hypermobility. Such patients must still have good pelvic muscle support and functional bladders. According to one study, success rates average 56% in women; other studies report higher rates.

  • Men who have slight incontinence caused by prostate surgery. Men who have bulking injections after TURP (transurethral resection of the prostate) have an equal success rate to women. After radical prostatectomy (removal of the prostate gland in prostate cancer), collagen injections can achieve some level of continence in up to nearly half of men. Collagen injections are not beneficial after radiation therapy.
The Procedure.
  • First, bladder instability or hyperactivity should be medically treated and managed to control muscle activity before having the procedure. Otherwise it is likely to fail.

  • The basic procedure involves injecting bulking material into the tissue surrounding the urethra.

  • The material used is usually animal or human collagen. (Collagen is the basic protein in bones, muscles, and all connective tissue.) Synthetic bulking agents, such as carbon-coated beads, are also being used.

  • The physician passes the collagen-containing needle through a cystoscope, a tube that has been inserted into the urethra. The collagen can also be injected into the skin next to the sphincter.

  • The injected collagen tightens the seal of the sphincter by adding bulk to the surrounding tissue.

  • The procedure takes about 20 to 40 minutes and most people can go home immediately afterward.
Postoperative Care. People may experience immediate improvement followed by a temporary relapse after a week or so. Patients must be taught to use a catheter tube for withdrawing urine for a few days following the procedure. In general, it takes about a month for the full benefits to be apparent. Collagen is absorbed over time, so injections generally need to be repeated every six to 18 months. (Ear collagen and synthetic materials are being studied that may last longer than collagen from other sources.)

Complications.
  • There is a risk for infection and urinary retention, although these conditions are temporary.

  • An increase in autoimmune disease has been reported in a small number of cases.

  • The procedure may not be appropriate for patients with certain cardiac conditions.


WHAT ARE ELECTRICAL AND MAGNETIC STIMULATION PROCEDURES FOR URGE INCONTINENCE?



Electrical Stimulation of the Pelvic Floor for Urge Incontinence


Electrical stimulation of the pelvic floor muscles has been a common treatment for years. Success rates range from 6% to 90% for stress incontinence and 50% to 90% for urge incontinence.
  • The procedure uses a probe inserted into the anus or vagina.

  • It produces a contraction in the pelvic floor muscles.
Studies are reporting that is more effective than sham devices in patients with urge incontinence. It is not clear if it has advantages for women with stress incontinence.

Disadvantages.
  • It requires frequent physiotherapy visits.

  • It takes between two to three months before the benefits are felt.

  • Side effects can be distressing and include abdominal cramps, diarrhea, bleeding, and infection.

  • It is often not covered by insurance.


Sacral Nerve Stimulation for Urge Incontinence


The sacral nerves are located in the tail bone and appear to play an important role in regulating bladder control. Therapies have been devised that stimulate these nerves to help control the bladder in patients with urge incontinence.

Sacral Neuromodulation. The sacral nerve stimulation system (InterStim) sends electrical pulses to the sacral nerves to help retrain them.
  • The procedure employs a stopwatch-size device that is implanted under the skin in the abdomen.

  • A wire connected to it runs to the sacral nerves in the lower back.

  • The device is actually a battery-operated generator and produces the electrical pulses that are sent to these nerves.

  • The electrical pulses help offset the hyperactivity of the bladder.

  • The sensation of the electrical pulse is similar to a slight pulling sensation in the pelvic area. Some times it can cause a small jolt or shock if the patient changes posture quickly. It should not cause pain. (If it does, then something is wrong with the device.)
It is completely reversible, does not cause nerve damage, and can be removed at any time.

Some studies have reported improvement in three major areas:
  • The number of urinations.

  • The volume of urine per void.

  • The intensity of the urgency before voiding.
Studies report complete dryness in 40% to 47% of patients, with about 75% of patients experiencing relief from heavy leaking, and 47% of all patients were completely dry. Not all patients are candidates. And even in those who are, about 50% have an unsuccessful trial-run response to the test, which further reduces the number of appropriate users.

Complications include the following:
  • Infection.

  • Lower back pain.

  • Pain at the implant site.
Percutaneous Stoller Afferent Nerve Stimulation. The percutaneous stoller afferent nerve system (PerQ SANS System) has also been approved for urge incontinence.
  • In this therapy, a very thin needle is inserted a short distance above the ankle bone.

  • The needle is applied to the tibial nerve in the ankle, which connects with the sacral nerve complex.

  • Low-frequency electrical stimulation is applied for 30 minutes once a week for about three months.

  • After that, depending on the patient's response, treatments are given every week to every other week.
Short-term results are promising, but more research is needed.


HOW ARE CATHETERS AND COLLECTION DEVICES BE USED FOR URINARY INCONTINENCE?



Catheterization


A catheter is a slim flexible tube inserted into the urethra. They are mainly used for cases of severe urge incontinence.

Intermittent Catheterization. For people who are still active, catheterization is often very distressing. If possible, intermittent or temporary catheterization is usually the best choice. This type of catheterization carries few risks and empties the bladder completely.
  • Patients insert the catheter tube into their urethras, generally every three to four hours.
Some patients report that they can maintain an active life with no significantly increased risk for infection with some simple precautions:
  • Sterilize catheters at home.

  • Use a Zip Lock plastic bag to carry them in when leaving home.

  • Use another plastic bag for antiseptic cleansing solution.

  • When using public bathrooms, wash before and after catheterization. Touch as few places in the bathroom as possible.
Permanent Catheterization. People who are mentally or physically incapable of self-catheterization may need permanent catheterization.
  • The permanent catheter is inserted by a doctor or nurse into the opening of the bladder and a cuff is inflated to hold the tube in place.

  • Urine drains to an external collection device, which is generally strapped to the leg and must be emptied periodically.
The procedure is not painful, but there is a substantial increased risk of infection. Many experts feel that the catheter is overused, especially in the elderly.


External Collection Devices


Condom Catheters. Condom catheters are available that are much more satisfactory than standard catheters for many male patients, although there is more spillage.
  • The condom is worn all day.

  • At night it is removed and washed for reuse the next day.
Collection Devices Attached to the Leg. For chronic or severe incontinence , collective devices drain urine into a bag that is attached to the lower leg and emptied periodically. These are generally more successful for men, in which urine can be funneled into the tube by a pouch surrounding the penis. The positioning of the collecting device is difficult for women, and more accidents occur.

For both men and women, irritation of the area around the urethral opening is a problem, since urine is in contact with the area for long periods.


WHERE ELSE CAN HELP BE OBTAINED FOR URINARY INCONTINENCE?


National Association for Continence (NAFC), Box 8310, Spartanburg, SC 29305-8306, 800-BLADDER, www.nafc.org
An excellent organization. Paid membership includes the quarterly newsletter: Resource Guide (a very comprehensive directory of products and services for the incontinent) and referrals to physicians who specialize in continence. Also offers an audio tape and manual to teach and coach patients learning pelvic floor muscle exercises. Helpful for men recovering from prostate surgery and women with stress and urge incontinence. Acts as an advocate for the incontinent with governmental agencies, insurance companies, and health organizations.


The Simon Foundation for Continence, Box 835, Wilmette, IL 60091, 800-23-SIMON, www.simonfoundation.org, Offers newsletters, books (including Managing Incontinence , a useful collection of articles from professionals and incontinence sufferers), and videos. Provides help in finding devices and products for incontinence. Promotes awareness, research, and education.


National Kidney and Urologic Diseases Information Clearinghouse, 3 Information Way, Bethesda, MD 20892-3580, 800-891-5388, www.niddk.nih.gov


American Foundation for Urologic Disease, 1128 North Charles Street, Baltimore, MD 21201, 800-242-2383 or 410 468-1800, www.afud.org


American Urological Association (AUA)
www.auanet.org, AUA journal www.jurology.com or www.drylife.org


American Urogynecologic Society
202-857-5329), www.augs.org, This organization is concerned with urologic and gynecologic problems that coincide in women. Site gives names of professionals in specific locations.


Digital Urology Journal
300 Longwood Avenue, Hunnewell 3, Boston, Massachusetts 02115, www.duj.com,
An online journal with research articles on urologic problems.



Useful Internet Sites


https://www.urologychannel.com/ Sponsored site with some excellent information.

https://www.incontinet.com, Sponsored site with good information.

https://www.kegel-exercises.com/

https://www.diapersbedamned.com. Provides information on urine collections devices and has no financial interest in the products.


Products


The following are manufacturers or distributors of products or devices that may help patients with urinary incontinence. These products or services have not been reviewed by our editors and the list is by no means comprehensive.

Mailorder supplier of incontinence products. https://www.brucemedical.com/incontinent.html

Kimberly Clark Corporation (Depends): 800-558-6423 or www.depend.com.

Procter and Gamble Company: 800-543-0480.

TransAqua: 800-769-1899 or www.coastresources.com.

UroSurge, Inc. : Manufactures both AcuTrainer, a device that aids bladder retraining by signaling and tracking voiding times, and the PerQ SANS System, a sacral nerve stimulation device. 800-658-5965 or www.urosurge.com.

Neocontrol: Manufacturer device that performs extracorporeal magnetic innervation therapy. Website describes procedure and provides center locations. 800-717-0714 or www.neocontrol.com.

Medtronics. Information on Interstim, the neural sacral stimulation therapy. https://www.medtronic.com/patients/bladder.html

DesChutes Medical Products, Inc. : Medical products for urinary incontinence including the FriaSystem for women, a hand-held Kegel trainer. 800-383-2588 or https://www.deschutesmed.com.

Uroclean of Georgia, Inc. : Uroclean system for men, an alternative to catheters, involves reusable latex-free sheaths and seals to block leakage and a strap-on urine receptacle. 877-990-4090 or email uroclean@bellsouth.net.


 

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