Urinary Incontinence

June 22, 2011

Elias Hsu, M.D.

Eight questions you may – or may not – have wanted answered about urinary incontinence…

How common is incontinence?

Incontinence is defined as the inability to control the evacuative functions of urination. At the most basic level, it is the leakage of urine from the bladder without control. Incontinence is a very common condition, with reports indicating that 15-45 percent of women will experience some form of urinary leakage during their lives. Most studies report that nearly one in every four women experience incontinence starting in middle age. This number increases over time, with nearly half of all nursing home residents dealing with some type of incontinence.

What are the different types of incontinence?

There are several different types of incontinence, which vary in incidence. These include stress incontinence, urge incontinence, mixed incontinence, overflow and total incontinence. Stress incontinence and urge incontinence are the most common types of incontinence.

Stress incontinence is leakage associated with activities such as exercise, sneezing, laughing or coughing. Urge incontinence is leakage from a strong urge to go to the bathroom (e.g. bladder spasm) that is not associated with any activity. Overflow incontinence is leakage associated with a bladder that is filled to capacity and cannot hold any more urine. Total incontinence is leakage without association with activities or urgency. This type of incontinence can be a sign of a fistula (communication between the urinary system and the vagina).

What is urodynamics?

Urodynamics is a test that urologists will commonly order for a patient with incontinence. It is a test that involves placing a small catheter into the bladder and rectum. The pressure in your bladder is measured as it fills with fluid.

The severity of stress incontinence can be measured when you are asked to cough and bear down, which can help determine what treatment might be needed.

Urodynamics can also help detect urge incontinence from bladder spasms. This test measures the capacity of the bladder before you are able to void, allowing your medical team to see how strongly your bladder contracts and how well you empty your bladder.

How do we treat stress incontinence?

Physical therapy with Kegel and core exercises is the first and easiest treatment for stress incontinence. Exercises can help strengthen the urethral and pelvic floor muscles. This works well for people who have mild incontinence (leaking less than one-two pads per day). Patients should continue to do exercises to keep the incontinence from recurring.

Unfortunately, although at one point there was some promise with certain medications (e.g. estrogen creams, alpha agonists, and selective serotonin reuptake inhibitors), they generally do not work well for the treatment of stress incontinence. For this reason, surgery is often recommended. Sling surgeries are the mainstay of treatment for stress incontinence, which conceptually tighten the urethral opening from the bladder. Originally, harvested (from a patient during surgery or decellularized and decontaminated porcine or cadaveric tissue) tissue was used as sling material. Although this is sometimes recommended, urologists typically use synthetic mesh materials because of their durability and ease of use. Sling surgery is usually an outpatient procedure that involves a short recovery time.

How do we treat urge incontinence?

Like stress incontinence, conservative exercises such as bladder drills or timed voiding/urge suppression exercises can be used to retrain a bladder that is overactive or has urge incontinence.

Medications are the most common strategy used to treat urge incontinence. More than half a dozen medications, including pills, patches and gels, are currently on the market with more coming out every year. Their common bothersome side effects include dry mouth, constipation and blurry vision.

Neuromodulation is an alternative to medications for urge incontinence. By stimulating the nerves until they turn off, bladder spasms and urge incontinence can be controlled. There are two types of neuromodulation – posterior tibial nerve stimulation (PTNS) and interstim sacral nerve stimulation. Posterior tibial nerve stimulation involves placing a small acupuncture sized needle by a nerve in the ankle that communicates with the bladder. This stimulation is performed in the office once a week for 12 weeks, before being tapered off to do maintenance protocol. Interstim sacral nerve stimulation is performed in two stages. A testing is performed with a temporary lead that is placed in the back to stimulate the sacral nerve that innervates the bladder. If this testing is effective, then a permanent generator is placed into the buttock, which is like a “pacemaker for your bladder”. Botox is also an effective, but off label use, for overactive bladder and urge incontinence. This type of treatment provides minimal risk, but unfortunately will only last six months to one year before it needs to be repeated.

What if I have both symptoms?

Many women have elements of both stress and urge incontinence. Typically, one type is more bothersome. Treatment will focus on the predominant component, but many patients will often receive multiple strategies to improve their symptoms.

What about total and overflow incontinence?

Overflow incontinence is associated with urinary retention. When someone cannot hold any more fluid in their bladder, it “overflows” and leaks out. This can often be associated with an obstruction or blockage of the urethra that needs to be corrected to improve the leakage.

Total incontinence secondary to a fistula or communication between the bladder and vagina usually needs to be fixed with surgery to close the hole.

What do I do now?

The great news is that treatments for incontinence have been consistently improving over the past few years. You can attempt conservative therapies at home, but if you have questions and would like to come in for a consultation, please visit www.tucc.com or call 303.825. TUCC (8822).