What is Continence?

Continence means control, specifically control over your urination or defecation. If you are continent of urine, it means that you can hold your urine until you make it to the toilet. If you are incontinent of urine, you cannot hold your urine and either experience leakage or full blown wetting accidents.

What types of Urinary Incontinence are there?

Stress Urinary Incontinence (SUI) is loss of urine from the bladder with activities such as coughing, sneezing, laughing, or jumping etc. Stress refers to pressure on your bladder, not mental stress.
Urgency Urinary Incontinence (UUI) is loss of urine with a sudden uncontrollable desire to urinate. Women describe having to rush to the bathroom but not quite making it there, or putting the keys in the door, turning the lock and losing their bladder control right there on the doorstep.

Mixed Urinary Incontinence (MUI) is a combination of both stress and urgency urinary incontinence. It is common for women to have mixed symptoms.

Overflow Urinary Incontinence is urine loss that occurs as a result of the bladder becoming overly full and occurs in women who have problems with emptying their bladders. Overflow incontinence may occur in the diabetic woman a result of diabetic nerve damage. It may also be seen in the woman who has loss of bladder stretch as a result of pelvic radiation. It may also occur due to obstruction after surgery to correct stress urinary incontinence.

Is Urinary Incontience Common?

Approximately 1 in 3 women experiences urinary incontinence in her lifetime. However, the actual prevalence of urinary incontinence in women is not known. Most women who experience urinary incontinence never seek or receive treatment. Existing estimates are based on the number of women who are treated for incontinence, and do not account for the millions more who do not seek treatment. Therefore, the real number of women who experience urine leakage may be much higher. As the US population ages, the number of women with urinary leakage will likely increase. 

What causes SUI?

There are multiple risk factors for the development of SUI, and usually several are possible in any woman who suffers from this type of leakage. Some of these risks women have no control over such as: gender, race, and genetic factors. Other risks are related to lifestyle and may be in a woman’s ability to change such as: smoking, chronic cough, chronic constipation, and obesity.

In a woman’s life, some things happen to her pelvis that can incite SUI such as: childbirth, hysterectomy, vaginal surgery, radical pelvic surgery, radiation and pelvic injuries. Although urinary incontinence is not a normal part of aging, as we age problems such as dementia, debility, disease, and medications may lead to decompensation of the brain and/or bladder which in turn can cause urinary incontinence.

How does SUI Happen?

SUI happens due to problems in the things that are supposed to keep the urethra (the tube that connects the bladder to the outside of our body) closed during activities. The urethra is supported by a “hammock” of tough tissue. This hammock is also dependent on ligaments that attach the urethra to our part of the pelvic bone and a muscle of the pelvic floor called the pubococcygeus. The urethra itself is composed of several layers of muscle, blood vessels, and other tissue that is also important for maintaining control of leakage. When there are activities that cause an increase in the pressure in the abdomen (what is meant by “stress”) the urethra gets closed by the hammock. However, if the strength of any of these components (hammock, ligaments, pubococcygeus, urethra itself) is poor, urine leakage may occur during certain activities.

How is Stress Urinary Incontinence Treated?

A number of treatment options exist for SUI and range from conservative nonsurgical treatments to surgical treatments.

Behavioral therapy is the least invasive therapy. It includes education about healthy bladder habits and urinary incontinence, keeping fluid intake and urinary output diaries (bladder diaries), performance of bladder training regimens, pelvic floor muscle exercises (also called Kegel exercises), and possible pelvic floor physical therapy.

Medications are not used commonly for SUI because there are no effective medications available specifically for SUI.

Incontinence pessaries are plastic devices that are worn in the vagina to compress the urethra to prevent leakage during activities. They are a barrier method that does not correct leakage, but helps to control it. Pessaries must be removed and cleaned regularly.

Urethral patches and inserts are also barrier devices that are for temporary or occasional use. Urethral inserts are more occlusive than patches but are associated with a higher rate of urethral irritation and infection.

Urethral Bulking Agents are a minimally invasive option for SUI. They are materials that are injected with a cystoscope (bladder scope) beneath the lining of the urethra. Once injected, the bulking agent works by increasing the resistance within the urethra. In some cases the injections are performed in the doctor’s office with the use of local anesthesia, meaning just a shot of lidocaine similar to getting a shot before a dental procedure. Often a series of injections delivered over time is necessary to get the best results. The injections are usually well tolerated and while there may be some decreased urinary flow for 24 hours, there is no risk of permanent inability to urinate. Success rates with bulking agents vary, and seeing improvement in leakage is a more likely outcome than getting completely dry. Studies suggest 25% of women will get dry, and 50% will be improved. The remaining 25% fail to get any response to bulking agents. Unfortunately, it is not possible to determine how a woman will respond to bulking agents before using them. Bulking agents are temporary. They will lose their effect over time and require retreatment. Bulking agents fill an important need for the woman who cannot have a larger surgery or who cannot afford the recovery time associated with any surgery.
Surgery is the most invasive treatment option for stress urinary incontinence, but it is also the most effective. It is the most likely to make a woman dry. However, it is associated with greater risk than the nonsurgical options. The most common surgery performed today is a synthetic sling procedure. Slings are strips of tissue or material that are placed beneath the urethra to act as a support for the urethra. Not all slings are the same. Some may be made of synthetic or man-made material while others may be made out of biologic tissue such as the patient’s own tissue known as an “autologous fascial sling” or tissue from a pig (porcine dermis) or a cadaver.

Midurethral synthetic slings: Even among synthetic slings, there are several types available: retropubic, transobturator, or “mini- sling.” Retropubic slings have a good rate of cure in the short term, with about 94% of women being dry at 1 year. The rates of dry drop in the longer term to about 85% of women being dry beyond 10 years; however, this is still a better dry rate than can be achieved with other treatments. Transobturator slings have not been used quite as long as the retropubic ones, but published studies suggest that they are as good as the retropubic type. Mini-slings are the newest, and data on them is looking promising, but we have not been using them long enough to compare to the others. ‘The type of sling may not matter, but it is important that the synthetic sling be made of Type I mesh. Midurethral synthetic slings have become popular because of their good results, short operative time, and easier recovery than more invasive procedures. Patients will go home after a midurethral sling surgery most of the time.

Autologous fascial slings: These procedures have been the traditional gold standard surgery for stress urinary incontinence but are associated with a longer recovery time and slightly increased postoperative pain.  Most patients stay at the hospital overnight and are discharged the next day. The same potential risks exist for this sling as for the synthetic ones. Additionally, the harvest site has its own set of risks such as hematoma, seroma, pain, hernia. A delay in the time to onset of normal voiding is greater with an autologous sling than the synthetic ones, but the rates of urinary retention requiring intervention are the same. In most cases, an autologous sling will be chosen for the patient who has a very fixed urethra or very poor/thin vaginal tissues, multiple failed procedures, or a complication from mesh in the past.

Retropubic bladder suspension: This procedure, also known as a “Burch procedure” is another operation with good cure rates. It is performed less frequently because it is more invasive than current synthetic slings and has a longer recovery time. It remains a good procedure, and may most commonly be chosen if  an an abdominal hysterectomy is being done.

Whether a sling or a retropubic bladder suspension is chosen, the risks of surgery are very much the same. The risks include: infection, bleeding, damage to adjacent organs such as bowel, bladder, urethra or blood vessels, failure to control the stress leak, the development of bladder overactivity, or urinary retention, need for other surgery due to complications, pain, pain with intercourse, extrusion of the sling in the vagina, or erosion of the sling into the urinary tract. The rates of these risks are low.

What causes Urgency Incontinence?

Urgency incontinence is usually caused by a bladder spasm or involuntary bladder contraction. The uncontrollable spasm causes a sudden urge to urinate that cannot be ignored or suppressed which then leads to a gush of urine leakage. Classically a woman describes leakage as she “ puts the keys in her door at home” or as she is “ pulling her pants down at the toilet.” However, urge leakage can occur at any time.

Why involuntary bladder contractions occur in the otherwise healthy woman is not known. The mechanism of what causes the spasm to occur is not clear. Prevailing theories target both the bladder muscle and nerves. In cases of men and women with brain or spinal cord disorders such as stroke, multiple sclerosis or spinal cord injury the impaired central nervous system causes the lack of control over the bladder muscle.

What are the treatments for Urgency Incontinence

Since we do not know exactly what causes urgency incontinence or involuntary bladder spasms, we do not have a cure. Instead, our treatments suppress the symptoms and spasms.

Medications are standard first-line treatment for urgency incontinence. They relax the bladder muscle allowing it to hold more before giving the person the sensation of needing to urinate, preventing unwanted bladder contractions that might cause leakage and giving the person more time to get the bathroom. The most common side effects caused by these medications include dry mouth, constipation, and blurry vision. Occasionally the side effects are bothersome enough that a medication will be changed. Rarely, a patient is allergic to these medications. When medications do not control the patient’s urgency incontinence or the patient cannot tolerate them, other options are available.

Pelvic Floor Muscle Exercises are used for urinary urgency, frequency and urgency incontinence as well as for stress urinary incontinence. Although we usually describe these exercises as strengthening the muscles around the urethra that control our urine flow, exercising these muscles also helps to calm the bladder by sending a feedback message to the brain through the nervous system. This feedback message to the brain is, “Keep the bladder quiet!” Exercising the pelvic floor muscles is helpful not only for stress urinary incontinence but urgency incontinence too.

Sacral neuromodulation , marketed under the name of Interstim, has been FDA approved since 1997 for urge incontinence and since 1999 for urinary retention and urgency-frequency. It is effective therapy in many patients even some who did not do well with or could not tolerate medications. InterStim therapy is a proven neuromodulation therapy that targets the communication problem between the brain and the nerves that control the bladder. If those nerves are not communicating correctly, the bladder will not function properly. The InterStim system uses an external device during a trial assessment period and an internal device for long-term therapy. In most cases patients will undergo a testing phase. During this testing phase two small wires are placed into the lower back near the tailbone. Patients are very comfortable with just local anesthesia for this testing phase. The wires are connected to an external stimulator that looks similar to a beeper. Over 3 to 5 days, patients record their urinary symptoms with the stimulator turned on. If they experience a positive response during the test, the device is surgically implanted at a later date. Complications with the implant are rare but include infection, pain at the site, failure to fully control symptoms, malfunction or lead migration, and need for revision for other reasons.

Bladder Botox injections (off label Botulin toxin) is not currently FDA approved for use in the bladder. Botox is a neurotoxin, and the same one that causes botulism. In controlled doses it has been used for spastic muscles in the eye and extremity, and its use in the bladder for bladder spasm is well recognized among urologists. It is injected into the bladder muscle through a cystoscope under either local anesthesia or intravenous sedation. A usual dose is between 100- 200 units which can be injected in 10-20 sites on the bladder wall. Injections may take as few as 15 minutes to complete, and the duration of effect is from 6 to 9 months. Potential risks of injection include infection, bleeding, failure to control symptoms, or urinary retention.

Copyright © 2014 Harriette Scarpero and PrattWebSolutions