Stress Urinary Incontinence
"Your not alone" An estimated 10 million Americans suffer from urinary incontinence. There is hope!! A urologist is the specialized most qualified in evaluating you incontinence problem and offering advice on treatment option. You have come to the Although the evaluation of your problem might be a bit embarrassing it should be painless and usually is done right in the office. Once the problem is diagnosed a treatment plan can be developed specifically for you. Evaluation of your incontinence will include a precise history, a voiding diary , and a physical that includes a pelvic examination. Other in office tests or procedures will usually be necessary to further evaluate your incontinence.
Next we must determine what type of incontinence you experiencing. Basically there are 3 types to be aware of: urgency, stress , or overflow. You may be wet intermittently or nearly all the time.
* Urgency incontinence is defined as the impending sudden and often uncontrolled urge to urinate. Such things as hearing the sound of running water, standing up, coughing, or other stress may initiate a urge to urinate that you can not hold. This type of leakage is often due to a weak bladder.
* Stress Incontinence is the loss of urine due to abdominal pressure on the bladder created by coughing, sneezing, laughing, jumping, ect, that causes a gush of urine to leak from the bladder. This type of incontinence is usually due to weakness of the pelvic muscles that support the bladder. Child birth, aging, pelvic surgeries, obesity, or radiation can all cause stress incontinence.
* Overflow Incontinence This type of incontinence is die to a poorly emptying bladder resulting in retention of urine. This can be secondary to a poorly functioning bladder caused by diabetes, pelvic surgeries, radiation or chronic distention. Also though less frequent obstruction at the urethra can be present. This can be secondary to scarring, vaginal prolapse, mediations, or radiation.
* Mixed Incontinence Some individuals might have a a combination of both stress and urgency incontinence. This can result from many factors and often requires more extensive evaluation to delineate the causes and offer an appropriate treatment plan.
Evaluation:
To evaluate the incontinence it will be helpful to have a diary of your episodes of incontinence on a typical day. This diary will be given to you on your first visit to the office.
* A pelvic examination will be performed to assess pelvic anatomy for other problems. Many times associated with your incontinence will be relaxation of the vaginal muscles resulting in prolapse of the rectum, bladder, or even the uterus into the vaginal opening. These prolapes often will alter the recommendations offered to improve your incontinence.
* A urinalysis will be performed to check for infection and blood.
* A cystometrogram (CMG) will be done to check the bladder function and check the bladders ability to empty out (a residual urine check). This test is performed by placing a small tube into the bladder and filling the bladder with sterile water.
* A cystoscopy will usually be performed to delineate the internal bladder anatomy and check other potential bladder problems. Cystoscopy is performed by placing a small soft flexible telescope through the urethra into the bladder in order to view its interior.
* Occasionally X Ray studies to evaluate the upper urinary tract will be necessary and these will be performed at the hospital.
Management:
Should your incontinence be secondary to urgency from an unstable bladder (often found in individuals with urgency) then the treatment plan will be directed toward increasing your bladder capacity by a combination of bladder exercises and medications.
* Mediation: The usual medication used for treatment of an unstable bladder is oxybutynin( ditropan). This mediation will tend to increase your bladder holding capacity by reducing bladder tone. It's side effects include a dry mouth, or eyes and possible flush face, decreased sweating, or constipation. This side effects are more pronounced as you dosage of medication increases. It's use is contraindicated if you have wide angle glaucoma, rapid heart rate or severe constipation. Other medications are available and can be tried if ditropan doesn't work or can not be tolerated.
* Bladder Training: This is a program that will allow an individual more independence by gaining self improved bladder control. It requires active patient participation. The participant is required to !.
1. Resist or inhibit the sensation of urgency.
2. Void according to a timetable rather than by the urge to void.
3. Postpone voiding.
4. Restrict or reduce the amount of fluids imbibed during the day.
The individual must learn to time voiding at 2-3 hour intervals during the day. Although the capacity of the bladder will increase with the medication once a certain trigger point is reached your bladder will contract unavoidably.
* Pelvic Floor Exercises: Kegles improve urethral resistance by actively exercising the pelvic muscles that surround the urethra. This exercise is performed by drawing up the perivaginal muscles as if trying to control urination or defecation without tightening the abdominal or pelvic muscles. Emphasis is placed on contracting the muscles for up to 10 seconds performed 60-80 times per day for 6 weeks. Once control is obtained maintaince exercises must be performed.
* Vaginal Cones: These may be used as an adjunct to pelvic exercises. A number of cones the same shape and volume but different weight are placed intravaginal and retained for 15 minutes twice daily. The sustained action necessary to retain the cone improves pelvic muscle tone.
Surgical treatments for stress incontinence:
Certain individuals will not respond adequately to medical or behavioral therapy alone. Other individuals may have pelvic relaxation to such a great degree that success with conservative therapy will be limited. Surgeries to correct incontinence are directed to suspend the bladder from descending that occurs with increased abdominal pressures. The type of surgery advised for you will depend on the degree of pelvic relaxation. Should you have a large cystocele, rectocele or prolapsing uterus; surgery will be performed vaginally by buttressing the vaginal wall and supporting the bladder with abdominal stitches , the so called Modified Peyrera Raz and anterior bladder repair. As with all surgeries there is a small risk of infection, bleeding, vaginal tear, anesthetic complications or failure.
Failure of surgery is increased by patient factors such as chronic cough, obesity, prior pelvic surgery , advanced age, prior radiation therapy, and poor nutrition.
* Collagen Periurethral Injection: For patients identified to have urethral incompetence secondary to previous surgery, radiation or advancing age the instillation of a bovine collagen into the tissue surrounding the urethra maybe an optional therapy. It is nearly 75 % successful in appropriately chosen individuals. The advantage of this type therapy is that it can be performed in an out patient setting using local anesthesia. It can be repeated up to 5 times or until an appropriate response is obtained.
* Laparoscopic Bladder neck suspension: This new surgical approach to well established surgical procedure offers distinct advantages over traditional open surgery. The procedure is performed by placing small entrance ports in the lower abdominal cavity and performing the bladder suspension through these small ports. This less invasive approach results in a better cosmesis, earlier return to full activity and less post operative pain and hospitlization. Although preliminary results are encouraging with laparoscopy compared to traditional open surgery; its long term success is not yet known. Currently this is our preferred method of bladder suspension and followup to 1 1/2 years have been encouraging. Very few recurrrences of incontinence and minimal morbidity associated with the procedure have beeen noted.
Lakes Area Urology
