Incontinence

Bladder control is a common yet complex problem that can seriously affect a person’s life. Fortunately, with today’s high-tech procedures and powerful drugs, a diagnosis may simply mean the road to bladder control is challenging, rather than impossible. So read below to learn more about the available treatment options so you are better prepared when talking with your urologist.

What can be expected under normal conditions?

The urinary tract is similar to a plumbing system, with special pipes that allow water and salts to flow through them. The urinary tract includes the kidneys, two ureters, the bladder and the urethra.

The kidneys act as a filtration system for the blood, cleansing it of poisonous materials and retaining valuable glucose, salts and minerals. Urine, the waste product of the filtration, is produced in the kidney and flows through two 10- to 12-inch long tubes called the ureters, which connect the kidneys to the bladder. The ureters are about one-fourth of an inch in diameter and their muscular walls contract to make waves of movement that force the urine into the bladder. The bladder is expandable and stores the urine until it can be conveniently disposed of. It also is a one-way flap valve that allows unimpeded urinary flow into the bladder but prevents urine from flowing backward (vesicoureteral reflux) into the kidneys. It also closes passageways into the ureters so that urine cannot flow back into the kidneys. The tube through which the urine flows out of the body is called the urethra.

What is urinary incontinence?

Urinary incontinence is the involuntary loss of urine. It is not a disease but rather a symptom that can be caused by a wide range of conditions. Incontinence can be caused by diabetes, a stroke, multiple sclerosis, Parkinson’s disease, some surgeries or even childbirth. More than 15 million Americans, mostly women, suffer from incontinence. Although it is more common in women over 60, it can occur at any age. Most health-care professionals classify incontinence by its symptoms or circumstances in which it occurs. In the normal population, the incidence of incontinence in the female over 65 is more than 25 percent and in the male it is about 15 percent.

What are the various types of urinary incontinence?

Stress incontinence: Stress urinary incontinence is the most common type of leakage. This occurs when urine is lost during activities such as walking, aerobics or even sneezing and coughing. The added abdominal pressure associated with these events can cause urine to leak. The pelvic floor muscles, which support the bladder and urethra, can be weakened, thus preventing the sphincter muscles from working properly. This can also occur if the sphincter muscles themselves are weakened or damaged from previous childbirth or surgical trauma. Menopausal women can also suffer from small amounts of leakage as a result of decreased estrogen levels. In men, the most common cause of incontinence is surgery on the prostate. This is more frequent after radical prostatectomy for cancer than after transurethral surgery for BPH.

Urge incontinence: Also referred to as “overactive bladder,” urge incontinence is another form of leakage. This can happen when a person has an uncontrollable urge to urinate but cannot reach the bathroom in time and has an accident. At other times, running water or cold weather can cause such an event. Some people have no warning and experience leakage just by changing body position (e.g., getting out of bed). Overactive bladder is also associated with strokes, multiple sclerosis and spinal cord injuries.

Overflow incontinence: This type of incontinence occurs when the bladder is full, is unable to empty and yet leaks. Frequent small urinations and constant dribbling are symptoms. This is rare in women and more common in men with a history of surgery or prostate problems.

Functional incontinence: This type of incontinence is the inability to access a proper facility or urinal container because of physical or mental disability.

Mixed incontinence: Mixed incontinence refers to a combination of types of incontinence, most commonly stress and urge incontinence.

How is the diagnosis made?

As with any medical problem, a good history and physical examination are critical. A urologist will first ask questions about the individual’s habits and fluid intake as well as their family, medical and surgical history. A thorough pelvic examination looking for correctable reasons for leakage, including impacted stool, constipation and hernias will be conducted. Usually a urinalysis and cough stress test will be conducted at the first evaluation. If some findings suggest further evaluation, other tests may be recommended — such as a cystoscopy or even urodynamic testing. This outpatient test is usually done with a tiny tube in the bladder inserted through the urethra and sometimes with a small rectal tube, as well.

What are some treatment options for each type of incontinence?

In most cases of incontinence, minimally invasive management (fluid management, bladder training, pelvic floor exercises and medication) is prescribed. However, if that fails, surgical treatment can be necessary.

Stress incontinence: One of the surgical treatments for this condition in males is the use of urethral injections of bulking agents to improve the function of the sphincter. The injections are done under local anesthesia and can be repeated. Unfortunately, the cure rate is only 10 to 30 percent. Another alternative is to perform a urethral compression procedure with the use of a vascular graft or a segment of cadaveric tissue to compress the urethra in the area between the scrotum and the rectum. The results are very preliminary and at this time only experimental. The most effective treatment for male incontinence is implantation of an artificial sphincter. The device is inserted under the skin and consists of a cuff around the urethra, a fluid-filled, pressure-regulating balloon in the abdomen and a pump in the scrotum which is controlled by the patient. The fluid in the abdominal balloon is transferred to the urethra cuff, closing the urethra and preventing leakage of urine.

Stress incontinence in the female is treated at the beginning with behavior modification and pelvic exercise. Sometime techniques like biofeedback or electrical stimulation of the pelvic muscles can help. But when the symptoms are more severe and conservative measures are not helping the treatment is surgery. In selected cases bulking agents can be used to increase continence. The operation is done under local anesthesia and is minimally invasive but the cure rates are lower compared to open surgical procedures.

Anterior repair (Kelly plication) is a common option used by gynecologists but has not given good long-term results. Another option is abdominal surgery (Burch suspension) in which the vaginal tissues are affixed to the pubic bone. The long-term results are good but the surgery requires longer recuperation time and is generally only used when other abdominal surgeries are also required. The most common and most popular surgery for stress incontinence is the sling procedure. In this operation a strip of tissue is applied under the urethra to provide compression and improve urethral closure. The operation is minimally invasive and patients recuperate very quickly. The tissue used to create the sling can be a segment of the patient’s abdominal wall, specially treated fascia, skin from a cadaver or a synthetic material.

Urge incontinence: For urge incontinence there is a large array of treatment options available. The first step should be behavior modification — drinking less fluids; avoiding caffeine, alcohol or spices; not drinking at bedtime and urinating around the clock and not at the last moment. Exercising the pelvic muscle (Kegel exercises) also helps. It is important to keep a log on the frequency of urination, number of accidents, the amount lost, the fluid intake and the number of pads used if required. The mainstay of treatment for overactive bladder is medication. This consists of the use of bladder relaxants that prevent the bladder from contracting without the patient’s permission. The most common side effect of the medication is dryness of the mouth, constipation or changes in vision. Sometimes, reduction of medication takes care of the side effects.

Other alternatives can be considered in patients who fail to respond to behavior modification and/or medication. A new and exiting technology is the use of a bladder pacemaker to control bladder function. This technology consists of a small electrode that is inserted in the patient’s back close to the nerve that controls bladder function. The electrode is connected to a pulse generator and the electrical impulses control bladder function. There is more than 60 to 75 percent cure or improvement with this technology. In more difficult cases, the bladder can be made bigger using a segment of small intestine. This operation, called augmentation cystoplasty, is very successful in curing incontinence but its main drawback is the need in 10 to 30 percent of the patients to perform self-catheterization to empty their bladder.

Overflow incontinence: For overflow incontinence, the treatment is to completely empty the bladder and prevent urine leakage. Patients with diabetic bladder or patients with prostatic obstruction often develop this type of incontinence. Overflow incontinence due to obstruction should be treated with medication or surgery to remove the blockage. If no blockage is found, the best treatment is to instruct the patient to perform self-catheterization a few times a day. By emptying the bladder regularly the incontinence disappears and the kidneys are protected.

What can be expected after treatment?

The goal of any treatment for incontinence is to improve quality of life for the patient. In most cases, great improvements and even cure of the symptoms are possible. Medical therapy is usually effective, but not if the patient sips fluids all day and does not time their urination. Similarly, large shifts in weight gain and activities that promote abdominal and pelvic straining put any repair to the test and cannot be expected to stand the test of time. Positive, long-term outcomes can almost be assured with common sense, proper body mechanics and care.

Medical treatment of overactive bladder (urgency and urge incontinence) can be very successful, but factors like prior surgery, lack of hormones, neurological conditions and age may make the treatment less effective. There are mild complications from medications, including constipation and dryness of the mouth that some patients cannot tolerate. Surgery, like the insertion of a bladder pacemaker, can result in 50 to 70 percent cure or great improvement of the symptoms. Enlargement of the bladder using a segment of intestine may cure the urgency incontinence in more than 80 percent of the cases but the main drawback is the need in 10 to 30 percent of the patients to perform self-catheterization for the rest of their life. It is sometimes the only choice when other treatments fail.

Surgery for urinary incontinence in the male like the artificial sphincter can cure or greatly improve more than 70 to 80 percent of the patients. Prior radiation, bladder malfunction and/or scar tissue in the urethra may result in a deterioration of the results. Being a mechanical device, it may require modification over time.

Surgery for urinary incontinence (stress incontinence) in the female is in general very successful, but choosing the proper procedure is important. Many patients with stress incontinence also have other conditions like bladder prolapse, rectocele or uterine prolapse that must be treated at the same time. The combination of urgency incontinence symptoms requires medical treatment first to try to improve the symptoms. The procedure of choice will depend on multiple factors, like the need for abdominal surgery for other conditions, the degree of incontinence, the degree of mobility of the urethra and bladder and the surgeon’s personal experience. For simple stress incontinence with mild to moderate urethral incontinence, a sling is the procedure of choice. The patient can expect more than 80 to 90 percent cure or great improvement. Injectables can cure 30 percent of patients but may require multiple applications.