Urinary Incontinence

Urinary Incontinence affects approximately one out of every four adult women in the United States, and is more prevalent than diabetes, hypertension, or depression. In over 90% of cases, incontinence will fall into one of the following types.

Stress Urinary Incontinence - the involuntary loss of urine which occurs during sudden increases of intra-abdominal pressure such as laughing, coughing, sneezing, lifting, or exercising.

Urge Urinary Incontinence - the "gotta go, gotta go" leakage which occurs with a sudden uncontrollable urge to pass urine, and is usually attributable to overactive bladder.

Mixed Urinary Incontinence - (combination of stress and urge)

Treatment options include three main categories: behavioral, pharmacological, and surgical.

Behavioral Therapy is a treatment approach by which women are able to improve or lessen the degree of incontinence thorough modification of diet and activity. For example, certain foods and beverages contribute to urgency, increased frequency, and urge incontinence, and by reducing or eliminating these items, women can decrease their symptoms dramatically. In addition, timed voiding and bladder retraining, which involve urinating on a set schedule during the day regardless of the need or urge to void, is often helpful. These options tend to be most useful in the mild to moderate forms of incontinence.

Pelvic Muscle Exercises

Pelvic Muscle Exercises (sometimes called "Kegel exercises") can be used for both mild stress and urge incontinence. When properly and consistently performed these exercises strengthen the sphincter muscles thereby lessening the degree of incontinence. The key to these exercises, as with most other exercise regimes, is that they must be done for as long as the patient desires benefit. Once the exercises are stopped, the involved muscles will weaken, and the incontinence will return. In many cases, the patient will need to perform these exercises for several weeks before she notices any improvement in her urine loss.

Biofeedback

Exercise and behavioral training can both be enhanced by biofeedback. During biofeedback training, a probe inserted into the patient's vagina sends images to a computer monitor, which allows patients to watch the muscles' response as they are squeezed. This visual feedback allows the patient to be sure she contracting the proper muscles and it helps guide the training sessions toward better muscle endurance.

Stress incontinence

Stress incontinence, the most common type of incontinence, accounts for roughly 75% of all urinary incontinence, and the cost has been estimated to be $26.3 billion annually. It can occur in any stage throughout a women's life: high school, college, pregnancy, following childbirth, and on into menopause. This condition results from a weakening of the pelvic supportive structures for the bladder, bladder neck, and urethra which can be due to pregnancy, childbirth, obesity, lack of hormonal support, and prior pelvic surgery.

The mainstay of treatment for significant stress urinary incontinence is surgery. In the past it was felt that most stress incontinence resulted from two distinct scenarios:

Urethral Hypermobility in which there was an unequal pressure-transmission ratio to the bladder and proximal urethra
Intrinsic Sphincter Deficiency (ISD)

Different surgeries were used to address each of these situations. For urethral hypermobility it was felt that a retropubic urethropexy would "re-establish" normal anatomy thus resulting in continence. In patients with intrinsic sphincter deficiency, a "sling" was use to provide added support to the deficient sphincter, and sometime obstruction. Recently the distinction between the two scenarios has become blurred and it is felt by many that intrinsic sphincter deficiency exists along a spectrum rather than being an "all or nothing" phenomenon. And as such, it is felt that all patients with stress urinary incontinence suffer from some degree of ISD. In accordance with this thinking and the development in the tension-free mid-urethral tape procedures over the last several years, slings have taken the forefront as the first-line surgical correction of stress urinary incontinence.

Less invasive surgeries for stress incontinence include peri-urethral bulking agents such as bovine collagen and carbon-coated beads. This treatment can be office-based, usually requires multiple injections and the results may last from 1-5 years.

Urge Incontinence

Patients with overactive bladders usually present with symptoms of urgency, frequency, and urge incontinence. Unlike women with simple stress incontinence whose urine loss is associated with strenuous activities that can be avoided or prepared for, the woman with the overactive bladder never knows when the incontinence will strike. Coughing, the sound of running water or hand/dish washing may trigger the urge incontinence. The causes of overactive bladder are many. An infection can irritate the bladder lining resulting in overactive bladder, the nerves that normally control the bladder can be overactive, and in a large majority of cases, the cause is unclear.

As with stress incontinence, behavioral therapy is the first-line of treatment, and when behavioral methods alone are unsuccessful, medication may be added. Although none of these medications are 100% successful in eliminating sign and symptoms of overactive bladder, they can provide substantial improvement. The medications which are most often used in the treatment of overactive bladder are the anticholinergics/antimuscarinics.

For patients with refractory overactive bladder or are unable to tolerate medical therapy, there is a minimally invasive, reversible surgical option called Interstim Therapy. Under fluoroscopic guidance a tined-lead is placed through the S3 foramen. The lead is then attached to a small medical device call an implantable pulse generator or IPG (which is also use in cardiac pacemakers). This device sends mild electrical impulses to the sacral nerve. Electrical stimulation can stimulate somatic nerve fibers without causing simultaneous contractions of the bladder. This may decrease the symptoms of urgency, frequency, urinary retention and urge incontinence. Recently there are some ongoing studies involving botox injections into the bladder wall (detrusor muscle)for the treatment of overactive bladder, but presently it is not recommend in the United States as standard treatment.