| * 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.
IS 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:
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
The Urinary System
system helps to maintain proper water and salt balance throughout
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 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
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
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
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.)
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.
IS STRESS INCONTINENCE AND ITS CAUSES?
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
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:
when the activity stops. If the condition persists, it is more likely
to be urge incontinence [ see Urge Incontinence below].
(Sometimes even standing can produce leakage.)
Incontinence in Women
In women, stress
incontinence is nearly always due to one or both of the following:
Many women are
prone to one or both of these problems, which can occur under the
- 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.)
(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:
had many children through vaginal deliveries. In such cases,
pregnancy and childbirth strain the muscles of the pelvic floor.
Complications of this operation may damage pelvic floor muscles,
the sphincter itself, or the nerves that enable the sphincter
muscles to contract.
of the urethra after menopause. Estrogen deficiencies can cause
the urethra to thin out
so that it may not close properly.
associated with urethral hypermobility is sometimes categorized
as Type 1 or Type 2.
- 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.
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:
- In the
less severe stress incontinence (type 1), bladder neck and urethra
remain incompletely closed. The urethra also becomes overly
- 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
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
- The bladder
neck is open during filling.
- The closing
pressure around the urethra is low.
Incontinence in Men
can impair the sphincter muscles. Such treatments are the major
causes of stress incontinence in men. They include the following:
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.
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.
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.
IS URGE INCONTINENCE AND ITS CAUSES?
All cases of
urge incontinence (also called hyperactive or irritable bladder)
involve an over-active bladder.
There are usually
one of two types:
- 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,
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.
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.
of Urge Incontinence
The primary symptom
of urge incontinence is the need to urinate frequently with subsequent
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:
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).
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.
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.
- The aging
disorders. Anxiety and possibly even depression have been associated
with urge incontinence.
IS 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.
of Overflow Incontinence
The causes of
the conditions leading to overflow incontinence include the following:
medications (anticholinergics, antidepressants, antipsychotics,
sedatives, narcotics, alpha-adrenergic agonists, beta-adrenergic
agonists, calcium channel blockers).
- Scar tissue.
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
IS FUNCTIONAL INCONTINENCE?
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:
physical disorders, such as in Parkinson's disease.
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.
depression. In such cases, people may become incontinent because
they are indifferent to self-control.
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.
in Children and Young People
in children over age five, one study reported that the following
children experienced incontinence:
when incontinence occurs, it is twice as common in boys as in girls.
- 10% of
- 5% of
- 1% of
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:
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.
- An overproduction
of urine at night.
- A lack
of ability to recognize bladder filling when asleep.
factors (indicated by a strong family history of bedwetting).
of diabetes, stroke, multiple sclerosis, and Parkinson's disease.
- High impact
exercise, particularly in young women.
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.
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:
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
- The urethras
in women are shorter than in men (around two inches versus ten).
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.
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:
- Two or
more urinary tract infections within a past year.
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.
in Temporary Incontinence
A number of conditions
can cause temporary incontinence, including the following:
Drugs are most often the cause of temporary incontinence.
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.
agonists, such as pseudoephedrine (found in some oral decongestants)
strengthen the muscles and may cause overflow incontinence in
blockers, such as propranolol (Inderal), prescribed for hypertension
and angina, relax the sphincter.
used for high blood pressure, often rapidly introduce high urine
volumes into the bladder.
blockers can cause overflow incontinence by relaxing the bladder
a drug used for gout, can cause urge incontinence.
medications and substances that increase the risk for incontinence
are caffeine, sedatives, antidepressants, antipsychotics, and
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.
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:
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:
- When the
of daily fluid intake.
- Use of
caffeine or alcohol.
and description of leakage or urine loss, including activity
at the time, sensation of urge to urinate, and approximate volume
of urine lost.
of urination during the night.
the bladder feels empty after urinating.
- Pain or
burning during urination.
starting or stopping the flow of urine.
of the urine stream.
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
For each incident
of incontinence, the log should also include the following:
eating and drinking habits.
- The times
and amounts of normal urination.
- The amount
of urine lost. (The patient is often asked to catch and measure
urine in a measuring cup during a 24-hour period.)
the urge to urinate was present.
the patient was involved in physical activity at the time.
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.
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
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.
about 50 mL or less of urine is left.
than 100 mL suggests an abnormality and requires further tests.
- More than
200 mL is a definite sign of abnormalities.
Ultrasound. Ultrasound is useful in determining the volume
Cystometry for Urge Incontinence
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.
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.
- 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.
water (usually at body temperature) is usually instilled through
the tube into the bladder
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
- 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 simple test used for stress incontinence.
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.
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:
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.
- 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
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:
The Q[max] level
does not necessarily coincide with a patient's perceptions of the
severity of his own symptoms.
flow varies widely among individuals as well as from test to
- 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.
Urethrocystoscopy, also called cystourethroscopy or cystoscopy,
detects structural abnormalities, inflammation of the bladder wall,
or masses that might not show up on x-ray.
is not without risks. Complications are uncommon but can include
allergic response to the anesthetic, urinary tract infection, bleeding,
and urine retention.
- The patient
is given a light anesthetic and the bladder is filled with water.
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.
Intravenous Pyelogram . Intravenous pyelogram (IVP) may be
used for urge incontinence. It uses a dye that shows up on x-ray:
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
- 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
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.
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.
sphincter testing, also referred to as electromyography (EMG), evaluates
two important factors:
Using a technique
similar to that of an electrocardiogram, the physician places electrodes
on the affected areas to observe electrical activity in the muscles.
- The function
of the nerves serving the sphincter and pelvic floor muscles.
- The patient's
ability to control these muscles.
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.
SERIOUS IS 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.
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
Among the negative emotional effects are the following:
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.
may eventually curtail social activities, or even give them
- Many people
with incontinence believe that they are unemployable.
of Daily Life
To prevent humiliation
due to wetness or odors, people with incontinence may have to totally
alter their way of life.
of Incontinence in Seniors
- Even errands
become very difficult and need advanced planning.
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.
Incontinence is particularly serious in elderly people:
can result in loss of independence and quality of life.
- It is
a major reason for nursing home placement.
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
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.
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.
ARE THE GENERAL GUIDELINES FOR MANAGING AND TREATING INCONTINENCE?
for Temporary Incontinence
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.
for Treating 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
Management techniques to improve the quality of life are part of
Approach for Treating Specific Forms of Incontinence
depending on whether the patient has stress or urge incontinence.
In people who have both, the treatment usually is aimed at the predominant
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:
For type 2 patients,
surgery is often beneficial.
that reduce urination (vaginal pessaries and others).
(Typically alpha-adrenergic drugs, also possibly tricyclic antidepressants.)
estrogen (creams, ointments, rings).
- If symptoms
do not improve, specialists may suggest surgery or other procedures.
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:
(Anticholinergics, antispasmodics, tricyclic antidepressants.)
floor electrical stimulation.
estrogen (in women).
ARE LIFESTYLE MEASURES FOR MANAGING URINARY INCONTINENCE?
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.
Clean. To avoid skin irritation and infection associated with
incontinence, it is important to always keep the skin clean:
or Reducing Odor. Certain methods or oral agents may help reduce
odor from accidents. They include the following:
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.
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.
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.
creams that contain miconazole nitrate are used for yeast infections.
tablets (eg, Derifil, Nullo, Devrom, Chlorofresh) that can be
taken orally or used in appliances are available. Most contain
- 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.
more water, not less, will also reduce odors and may not increase
the risk for urinary accidents [ see Dietary Considerations
- 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
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:
recommend drinking two to three quarts a day.
- The lining
of the urethra and bladder becomes irritated, which may actually
urine also has a stronger pungency, so drinking plenty of fluids
can help reduce odor.
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:
(including decaf) and tea and other caffeinated beverages or
fruits and juices.
and tomato-based foods.
- Milk and
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:
For men, the
following are available:
and even attractive looking washable underwear that contains
waterproof panels is available for women. Even stomach-control
panties are available for women with incontinence.
Even for men
and women with severe incontinence, disposable undergarments can
be purchased that have a normal look to them.
- 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.
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.
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 ].
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.
ARE URETHRAL AND VAGINAL DEVICES FOR BLOCKING URINE IN STRESS
Pad for Women
Foam pads (Miniguard,
UroMed, Softpatch) with an adhesive coating have been developed
for women with stress incontinence. They work as follows:
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.
- 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.
They should not be used by the following women:
with urinary tract or vaginal infections.
with urge or other forms of nonstress incontinence.
who have had surgery for incontinence.
and Vaginal Devices for Women
Shields or caps (CapSure, FemAssist) that fit over the urethral
opening are proving to be safe and effective in managing many forms
or Sleeves. Tubes or sleeves (Reliance Urinary Control Device, FemSoft)
that fit into the urethra are also available for female 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.
Devices that support the vaginal wall also help support the
urethra that is located next to it:
- 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
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.
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.
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
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
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.
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.
Floor Muscle (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:
The general approach
for learning and practicing Kegel exercises is as follows:
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.
Some notes of
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.)
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
- 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
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 ].
- 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.
can also tire muscles and cause more leakage.
will return to its original severity if these exercises are
discontinued, so commitment to the program must be high and
of Kegel exercises can be enhanced with the use of biofeedback,
which can help the patient gain control over involuntary urinary
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.
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
- 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.
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
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.
- The typical
set includes five cones of graduated weights ranging from 20
grams (less than one ounce) to 65 grams (slightly over two ounces).
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
is helpful for both stress and urge incontinence and is often used
in combination with Kegel exercises:
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.
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.
Magnetic Innervation Therapy for Stress Incontinence
A treatment called
extracorporeal magnetic innervation therapy stimulates pelvic muscles
to automatically perform Kegel exercises:
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.
- The patients
stay fully dressed and sit on a special chair during the treatment.
focused magnetic fields penetrate the pelvic area to stimulate
are twice a week for about six weeks, although it may take more
than eight weeks to build up the muscles.
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.
for Urge Incontinence
agents, such as oxybutynin (Ditropan), hyoscyamine (Levbid, Cytospaz),
and tolterodine (Detrol) have the following advantages:
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.
- They inhibit
the involuntary contractions of the bladder.
- They increase
capacity of the bladder.
- They delay
the initial urge to void.
Side Effects. Side effects of anticholinergic agents include
In rare cases,
anticholinergics may precipitate glaucoma.
- 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.
for Urge Incontinence
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:
- Dry mouth.
Agonists for Stress Incontinence
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:
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.
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:
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.
- 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.
cream particularly desensitizes the bladder, helping those with
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.
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.
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.
ARE THE SURGICAL PROCEDURES FOR TREATING STRESS INCONTINENCE?
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
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.
(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
The three most common procedures are the following:
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:
Burch colposuspension (sometimes called colpocystourethropexy)
is intended to improve on the MMMK procedure:
- It requires
a wide abdominal incision.
- The surgeon
then elevates the urethra and bladder neck using sutures.
structures are then secured and anchored in nearby cartilage.
It is more effective
in premenopausal than postmenopausal women and may not be appropriate
for all women.
- 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.
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.)
in urinating from surgical overcorrection (which may require
- Poor wound
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.
Needle Suspension. Transvaginal suspension is a newer procedure.
There are many variations including the Pereyra, Stamey, Raz, and
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.
- 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.
working through the abdominal incision, the surgeon ties the
sutures to the abdominal or pelvic walls.
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.
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.
of the 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
- 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.
- 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
- 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.
for Loss of Sphincter Function
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:
Stimulated graciloplasy is an interesting investigative alternative
for severe sphincter incompetence:
If the implant malfunctions, the surgery must be performed again.
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
are promising, the risk of infection with this procedure may be
lower, but further study is needed.
- A muscle
from the thigh (the gracilis muscle) is repositioned to create
a natural sphincter.
- An electrode
- The patient
uses a magnet to draw current from the electrode, which opens
the new sphincter.
the magnet stops the current and closes the sphincter.
materials that provide bulk to help support the urethra are proving
to be beneficial for certain patients:
(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.
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
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
- 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
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
- The procedure
may not be appropriate for patients with certain cardiac conditions.
ARE ELECTRICAL AND MAGNETIC STIMULATION PROCEDURES FOR URGE INCONTINENCE?
Stimulation of the Pelvic Floor for Urge Incontinence
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.
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.
- The procedure
uses a probe inserted into the anus or vagina.
- It produces
a contraction in the pelvic floor muscles.
- 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,
- It is
often not covered by insurance.
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
Sacral Neuromodulation. The sacral nerve stimulation system
(InterStim) sends electrical pulses to the sacral nerves to help
It is completely
reversible, does not cause nerve damage, and can be removed at any
- 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.)
Some studies have reported improvement in three major areas:
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.
- The number
- The volume
of urine per void.
- The intensity
of the urgency before voiding.
Complications include the following:
Stoller Afferent Nerve Stimulation. The percutaneous stoller
afferent nerve system (PerQ SANS System) has also been approved
for urge incontinence.
- Pain at
the implant site.
are promising, but more research is needed.
- 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.
electrical stimulation is applied for 30 minutes once a week
for about three months.
that, depending on the patient's response, treatments are given
every week to every other week.
ARE CATHETERS AND COLLECTION DEVICES BE USED FOR URINARY INCONTINENCE?
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.
report that they can maintain an active life with no significantly
increased risk for infection with some simple precautions:
insert the catheter tube into their urethras, generally every
three to four hours.
Catheterization. People who are mentally or physically incapable
of self-catheterization may need permanent catheterization.
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.
is not painful, but there is a substantial increased risk of infection.
Many experts feel that the catheter is overused, especially in the
- 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.
drains to an external collection device, which is generally
strapped to the leg and must be emptied periodically.
Condom catheters are available that are much more satisfactory
than standard catheters for many male patients, although there is
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.
- The condom
is worn all day.
- At night
it is removed and washed for reuse the next day.
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
ELSE CAN HELP BE OBTAINED FOR URINARY INCONTINENCE?
for Continence (NAFC), Box 8310, Spartanburg, SC 29305-8306, 800-BLADDER,
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,
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)
AUA journal www.jurology.com
American Urogynecologic Society
This organization is concerned with urologic and gynecologic problems
that coincide in women. Site gives names of professionals in specific
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
Sponsored site with some excellent information.
Sponsored site with good information.
Provides information on urine collections devices and has no financial
interest in the products.
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
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
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
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