Urinary incontinence is defined as the accidental loss of urine. More than 15 million American men and women suffer from this disease. Many of these people suffer in silence unnecessarily, and are prevented from doing activities they enjoy and living the life they want to lead. Since incontinence can be managed or treated, the following information should help you discuss this condition with your urologist and what treatments are available to you. For millions of Americans, incontinence is not just a medical problem. It is a problem that also affects emotional, psychological and social well-being. Many people are afraid to participate in normal daily activities that might take them too far from a toilet. So it is particularly important to note that the great majority of incontinence causes can be treated successfully.
Incontinence Signs & Symptoms
Coordinated activity between the urinary tract and the brain controls urinary function. The bladder stores urine because the smooth muscle of the bladder (detrusor muscle) relaxes and the bladder neck and urethral sphincter mechanism are closed. The urethral sphincter is a circular muscle that wraps around the urethra. During urination, the bladder neck opens, the sphincter relaxes and the bladder muscle contracts. Incontinence occurs if closure of the bladder neck is inadequate (stress incontinence) or the bladder muscle is overactive and contracts involuntarily (urge incontinence).
Multiple factors have been found to be associated with urinary incontinence. Yet, the leading culprits of incontinence have been neurologic disease, prostatic disease and obstetric factors.
Studies have found that pregnancy, mode of delivery and parity (the number of children a woman has had) are all factors that can increase the risk of incontinence. Women who delivered babies (via cesarean section or vaginal delivery) have much higher rates of stress incontinence than women who never delivered a baby. Women who developed incontinence during pregnancy or shortly after delivery have higher risk of sustained incontinence than those who did not. Increased parity (having more babies) also increases the risk.
Age is also known to be a factor. As the human body ages, muscle loss and weakness occur and the urinary tract is not spared. Menopausal women can also suffer from urine loss as a result of decreased estrogen levels. Interestingly, replacement estrogen has not been found to help the symptoms. Many medications have been associated with urinary incontinence. These include diuretics, estrogen, benzodiazepines, tranquilizers, antidepressants, hypnotics, and laxatives. Poor overall general health has been associated with incontinence. Specifically, diabetes, stroke, high blood pressure, smoking history, Parkinson’s, back problems, obesity, Alzheimer’s, and pulmonary disease have all been associated with incontinence.
As with any medical problem, a good history and physical examination are critical. A urologist will first ask questions about the individual’s habits and fluid intake as well as their family, medical and surgical history. A thorough physical examination looking for correctable reasons for leakage, including impacted stool, constipation, prostate disease and prolapse or hernias will be conducted. Usually a urinalysis and cough stress test will be performed at the first evaluation. If findings suggest further evaluation is necessary, tests such as cystoscopy or urodynamics may be recommended.
Cystoscopy is performed by placing a small scope or camera through the urethra and into the bladder. Urodynamics is an outpatient test that is done with a tiny tube in the bladder inserted through the urethra and often with a second small tube in the rectum. The bladder is filled and the patient is asked to void while pressure measurements are recorded.
Treatment for incontinence is depends not only on the type of incontinence a person has, but also the gender of the patient. Certain treatment options are optimal for men while others are better suited for females. Below are the various treatment options for both men and women.
Behavioral Modification: Mild to moderate stress incontinence in the female is treated initially with behavior modification. Decreasing the volume of fluid ingested as well as eliminating caffeine and other bladder irritants can help significantly. Timed voiding can be helpful in preventing accidents by scheduling frequent trips to the toilet before leakage occurs.
Pelvic Floor Muscle Training: Strengthening or Kegel exercises can fortify the pelvic floor and sphincter muscles and improve urinary control. These exercises include repeated contractions of isolated muscles several times a day. Sometimes techniques including biofeedback, electrical stimulation of the pelvic muscles, and weighted vaginal cones can be helpful in teaching the patient how to isolate these muscles.
Botox Injections: One of the surgical treatments for this condition, used in both males and females, is urethral injections of bulking agents to assist the closing of the urethral mucosa. The injections are done under local anesthesia with the use of a cystoscope and a small needle. Botox is injected into the urethral sub mucosal layer under direct vision.
Sub urethral Sling Procedures: The most common and most popular surgery for stress incontinence is the sling procedure. Today, most of these procedures are being called by the names TVT or TOT. In this operation a narrow strip of material is used either from: cadaveric tissue (from a cadaver), autologous tissue (from your own body), or soft mesh (synthetic material). It is applied under the urethra to provide a hammock of support and improve urethral closure. The operation is minimally invasive and patients recuperate very quickly. For many years it was thought that biologic materials, the patient’s own fascia or cadaveric fascia, would create better more sustainable outcomes. We have found however, that synthetic meshes have both the ease of use with no need for harvest, as well as superior long term results.