Urinary incontinence affects millions of women of all ages. One in three women experience bladder leakage during some point in their lifetime. Understandably, one’s quality of life diminishes in proportion to the severity of incontinence. Not only can it be socially embarrassing, but it can result in social isolation, avoidance of physical activities, and additional costs (loss of work, pads, laundry, etc).
The evaluation of urinary incontinence begins with a thorough history taking. Medical problems such as spinal cord injury, multiple sclerosis, and Parkinson’s disease may trigger or worsen incontinence. Certain medications such as diuretics may also impact bladder control. It is equally important to understand the severity and impact on a patient’s daily activities and the patient’s goals.
The evaluation then proceeds to examining the urine specimen and performing a physical examination. The urinalysis is useful to check for a urinary tract infection or the presence of blood, which would require further evaluation. The next step is to categorize the type of incontinence. There are four categories of incontinence:
- Stress urinary incontinence: leakage associated with activities such as laughing, coughing, sneezing, exercise, lifting, and sex.
- Urgency urinary incontinence: leakage associated with a sudden urge sensation that is difficult to postpone. This is often described as an inability to get to the bathroom quick enough to avoid leakage. It is not uncommon for patients to need to know where bathrooms when they are away from home (“toilet-mapping”).
- Mixed urinary incontinence: a combination of stress and urgency incontinence.
- Overflow urinary incontinence: leakage due to the inability to empty the bladder properly. Dr. DuPont refers to this as the “cup runneth over.”
Conservative treatment may begin with bladder and pelvic floor retraining exercises (Kegels), fluid management, and avoidance of dietary irritants. Caffeinated, alcoholic, and carbonated beverages can worsen bladder control. We work closely with a number of excellent physical therapists who provide additional support to help patients learn mechanisms to improve bladder and fecal incontinence. Besides Kegels exercises, placement of a tampon or use of a pessary with a knob may offer relief from stress urinary incontinence.
When a patient is not satisfied with the results of conservative measures, further evaluation of her incontinence needs to take place. A bladder diary is typically elicited that is a record of fluid intake (quantity as well as type of fluid), number of voids (and possibly measured volume of each void), number of pads/diapers used, and number of incontinent episodes. Additional testing may be necessary that would include urodynamics and/or cystoscopy. These tests are very commonly used for further evaluation. They are performed in the office setting and no preparation is needed.
Urodynamics testing is composed of several components that measure how well the bladder and sphincter muscles function. Essentially, the test measures how much your bladder holds, how well it stores fluid, and how well the bladder empties. It also gives information on the urinary flow (speed, pattern, and voiding time). The EMG component tests the electrical activity of the nerves and muscles of the pelvic floor. The urodynamics study can be thought of as the “EKG for the bladder.”
Cystoscopy looks at anatomy. Through a small telescope with magnified lenses, the urethral and bladder lining are visualized. This is typically a simple 5 minute evaluation that allows evaluation of the bladder muscle and urethra. Bladder muscle thickening, diverticula, strictures, polyps, inflammation, stones, and tumors can be identified through visualization. Local anesthetic may be administered for this test.
What Is Stress Urinary Incontinence (SUI)?
SUI is the loss of urine associated with activity. Women report loss of urine with coughing, sneezing, laughing, lifting, jumping, running, and sex. It is the most common type of urinary incontinence in women. It is linked to vaginal deliveries, obesity, and aging. Older patients often will comment that it is normal at their age to have this problem. SUI is more common in older patients but it is not normal at any age.
How Is SUI Treated?
- Kegels (pelvic floor muscle strengthening exercises)
- Timed Voiding (going to the bathroom at set intervals)
- Weight Loss
- Biofeedback and Electrical Stimulation
- Vaginal pessaries
- Tampons or the Poise Impressa
Intraurethral Bulking Agent Injections
- Filler is injected in the urethral wall. This results in a narrowing of the urethral channel by increasing mucosal coaptation (urethral wall thickness). Thus, greater resistance to leakage is created. Several fillers have been used for this purpose. They include collagen, calcium hydroxyapatite (Coaptite), pyrolytic carbon coated beads (Durasphere EXP), and a silicone elastomer (Macroplastique). Dr. DuPont uses Macroplastique due to its durability.
- Minimally invasive, office setting procedure
- One third dry and two thirds improved at one year post-injection.
- Repeat injections typically required at intervals
- Pubovaginal Slings (Retropubic, Transobturator, MiniSlings). Pubovaginal slings have been in existence over 100 years. The sling consists of synthetic, biomaterial, or the patient’s own tissue. The technique was revolutionized in 1994 by a Swedish gynecologist who developed the Tension Free Vaginal Tape (TVT). Dr. DuPont was one of the first surgeons to use and teach the technique in the United States. The band is made of synthetic suture material, prolene. It is placed under the urethra to restore a backboard of support lost by weakened pelvic floor muscles. The transobturator approach was developed in France and Belgium.
- High success rate of ~90% five year.
- High patient satisfaction rate of 92%
- Minimally invasive, outpatient.
- Takes less than 20 minutes
- Minimal postoperative discomfort
What Is Urgency Incontinence?
It is a sudden, intense, urge to urinate that is difficult to postpone and results in an involuntary loss of urine. Simply stated, it is when the bladder contracts (spasms) without your permission and you cannot prevent urinary leakage.
What Are the Risk Factors?
- Neurological Disease (stroke, Multiple Sclerosis, Parkinson’s Disease, spinal cord injury)
- Bladder/prostate malignancy
- Urinary tract infection
- Pelvic Surgery
What Treatments Are Available for Urgency Incontinence?
- Avoid dietary bladder irritants (e.g., caffeinated beverages, carbonated beverages, alcohol)
- Bladder and pelvic floor muscle retraining exercises (Kegels)
- Timed voiding at intervals
- Losing weight
- Anticholinergics (Detrol, Toviaz, Ditropan, Enablex, Sanctura) work by blocking the neurotransmitter, acetylcholine.
- Beta-3 adrenergic agonists (Myrbetriq): These agents have relaxing effects on bladder smooth muscle by binding to beta-3 receptors.
Percutaneous Tibial Nerve Stimulation
- Office based treatment
- Electrical impulse is applied to the tibial nerve above the ankle
- 61 to 80% success
- Least invasive form of neuromodulation used to treat urinary frequency, urgency, and urgency incontinence.
- Treatment protocol requires 12 weekly treatments, 30 minutes per session. Improvements may be seen by the 6th treatment. Maintenance treatments are once every 4 weeks to sustain improvement.
Dr. DuPont was the first to offer intravesical Botox for the treatment of overactive bladder and urgency incontinence in the Washington DC area.
- Injected in the bladder muscle to calm the spasms
- Office procedure under local anesthetic
- Reduces leakage episodes by at least 50%
- Dry rate ~25%
Medtronic Sacral Neuromodulation
- Indicated for the treatment of overactive bladder, urgency incontinence, fecal incontinence, urine retention
- A neurostimulator is surgically implanted to stimulate the sacral nerve and a programmer is used to control the electrical pulse.
What Is Overflow Urinary Incontinence
Dr. DuPont typically describes this to patients as “the cup runneth over.” The bladder is not emptying properly, it over fills, and urine leaks or dribbles out. Typically, it results in a weak urine stream, dribbling, and a feeling of fullness. Urinary tract infections may also result when the bladder does not empty. Overflow incontinence occurs secondary to the bladder muscle not contracting properly or a blockage of the lower urinary tract.
Causes of Overflow Urinary Incontinence
- Neurological Disease (multiple sclerosis, diabetes, pelvic surgery, spinal cord injury, Parkinson’s Disease, spina bifida)
- Cystocele (prolapse of bladder)
- Stricture (scar tissue in the urethra)
- Medications (e.g., anticholinergics, narcotics, sedatives, etc.)
- Acute, post-operative urine retention due to medication or anesthesia
How Can Overflow Urinary Incontinence Be Treated?
- Remove any obstruction to flow if one exists
- Intermittent Self-Catheterization to Treat Overflow Urinary Incontinence
- Safe, effective method to empty the bladder through intermittent insertion of a short, female catheter.
- Self-catheterization interval is every 3 to 8 hours, depending on fluid intake.
- Sacral Neuromodulation (InterStim)
- Device that delivers electrical impulses to correct miscommunication in the nerve network between the bladder and the brain. Similar in appearance to a pacemaker.
- Typically implanted in the upper buttock.
- 77% of patients achieved clinical success with 61% able to eliminate the use of catheters. 16% experienced 25% reduction in catheterized urine volume.
- InFlow Device for Women
- FDA approved non-surgical, intra-urethral device that pumps urine out of the bladder
- Must be replaced 29 days in the office setting
- Indicated for women that have impaired bladder contractility due to neurogenic origin