|
Illnesses We Treat
Female Urinary Incontinence
What does this mean?
- Women with urinary incontinence have difficulty controlling the
passage of their urine.
- Urinary incontinence affects millions of women.
- Some women have leakage every day and others have occasional
episodes.
- This problem bothers some women more than others
In general, there two types of urinary incontinence:
- Stress urinary incontinence (SUI)
- Urge urinary incontinence (UUI)
Women who have both components are said to have mixed
incontinence. Women who are not sure which component they have are
said to have unaware incontinence.
Facts about stress urinary incontinence (SUI)
- SUI is an involuntary loss of urine that occurs during physical
activity, such as coughing, sneezing, laughing, or exercise.
- It occurs in all age groups.
- Sometimes, SUI is accompanied by a weakening in the entire pelvic
floor resulting in the herniation of the bladder (cystocele), rectum
(rectocoele) or uterus (uterine prolapse) into the vagina.
- A weak urethral sphincter or a malfunction in the urethral
sphincter may cause SUI.
- Previous childbirth and pelvic surgery are the most common risk
factors.
Facts about urge urinary incontinence (UUI)
- Leakage that is accompanied by a strong urge to
urinate.
- The bladder contracts without the woman’s control and she is unable
to suppress it long enough to make it to the bathroom.
- Running water or excessive cold may trigger UUI.
- The problem for some women may be greater at night or when they
first wake up in the morning.
- More common in older adults
Possible causes:
- Neurological injuries (such as spinal cord injury or stroke),
neurological diseases (such as multiple sclerosis), infection,
inflammation, or bladder outlet obstruction.
- In most cases the cause cannot be identified
Diagnosis and workup
Incontinence is sometimes easy to diagnose based on a history and
physical exam. Patients who only leak with a cough or laugh or who
demonstrate leakage with a full bladder most likely have SUI. Other
patients may need further testing (see below) to find the cause of their
leakage. Many patients will require one or more of these tests during
their initial evaluation.
- Post void residual is measurement of the amount of urine left in
the bladder after urinating. Patients who do not empty their bladders
will sometimes have leakage from urine overflow.
- Urinalysis and urine culture are performed to look for a
urinary tract infection.
- A pad test in which the patient
collects her pads over a 24-hour period is used to determine the severity
of the incontinence.
- Video urodynamics is a test where a small catheter is placed in
the bladder which is filled with a water-based dye that can be seen on
x-ray. Pressures in the bladder are measured during filling and voiding
and x-rays are taken at various points in the study. A bladder stress
test is performed to see if there is SUI.
- Cystoscopy is an endoscopic look inside the
bladder.
Management and Treatment
Incontinence is a personal problem that must have an individualized
solution. Incontinence is not dangerous; rather it affects a women’s
quality of life. Women who are not bothered by it or who have adjusted
their lifestyles accordingly may not elect to treat it. In these cases, it
is usually unnecessary to undergo major diagnostic testing to find a
cause. On the other hand, women who are unhappy about their incontinence
can be comforted by the fact that there are many effective options for
treatment. Treatment of symptoms can be done without major diagnostic
testing. For more definitive treatments, such as a surgical procedure, it
is usually necessary to have bladder testing to make sure that the
treatment is indicated.
Treatment for SUI
- Behavioral therapy such as decreasing fluid intake and
increasing voluntary trips to the bathroom.
- Diet changes to reduce alcohol and caffeine can decrease the
number of incontinent episodes.
- Kegels or pelvic floor exercises to strengthen the
muscles involved with continence can be moderately helpful for women
with lower degrees of incontinence. For women who have difficulty
locating their pelvic floor muscles to do the exercises, a dedicated
biofeedback regimen with a nurse or physiatrist can sometimes be
helpful.
- Medications
- Sudafed, which is used to treat cold symptoms,
has been prescribed to treat the condition. However, the dosage required
to obtain the desired effect is often very high and can be accompanied
by unwanted side effects like elevated blood pressure.
- Imiprimine, a drug that is used in the treatment
of depression, is mildly effective in stress incontinence.
- Newer medications more specific to the treatment of SUI are on the
horizon but are not yet FDA approved
- Periurethral injection therapy. This is an office
procedure in which collagen or a similar agent is injected into the
urinary sphincter through a cystoscope. It is relatively easy to do,
but it is more likely to produce improvement in symptoms rather than
cure. Also, most patients will require multiple injections to improve
and will need maintenance injections at least once a year. Because
collagen can produce an allergic reaction in some patients, it is
necessary to perform a collagen skin test at least one month prior
to injection
- Surgeries
- Bladder neck suspension - a small bikini-line incision
is made. The urethra is lifted toward the pubic bone to recreate the
normal urethral angle. It requires at least two overnight stays in
the hospital.
- Sling procedure - uses a person’s own tissue as
a piece of material underneath the urethra. The procedure is done
through two incisions, one in the vagina and one at the bikini line.
Recently, newer materials have been utilized including tissues from
animals and synthetics. It requires an overnight stay and patients
will sometimes have difficulty urinating afterward.
- The TVT (Tension-free Vaginal Tape)
is a sling procedure that was developed in Europe in the pastdecade.
It is an outpatient procedure that takes approximately 30 minutes
to perform. The recovery period following the procedure is short,
and patients experience few complications. It's also 96 percent
effective at seven years. This procedure can also be done through
a thigh approach, which virtually eliminates the possibility of
a bladder, bowel or vascular injury. The data on this procedure
is as good as for the traditional TVT, but the follow up is only
one year long.
Treatment for UUI
- Behavioral therapy - diet modification and decreasing fluid
intake as well as pelvic floor exercises and biofeedback are somewhat
effective.
- Medications such as anticholinergics - these drugs
work by relaxing the bladder and decreasing involuntary bladder contractions.
With the trade names of Ditropan® XL, Detrol®
LA and Oxytrol® , which differ mostly upon their delivery systems,
these drugs are effective in about 60 percent of patients. Their most
common side effects are dry mouth and constipation. They should not
be used in patients with certain types of glaucoma or in Alzheimer’s
disease.
- Neuromodualtion or Interstim® therapy -
is a technique used in the treatment of refractory urgency, frequency
and urge incontinence as well as chronic pelvic pain. A pacemaker-like
device is inserted to stimulate the nerves leading to the bladder and
pelvic floor muscles. A test stimulation is performed before the device
is implanted to see if there is a benefit.
- Botox injection - Botox therapy has been used for the treatment
of refractory UUI. Most of the studies so far have been on patients with
neurologic problems and it is not yet FDA approved for use in the
bladder although there will soon be clinical trials.
- Bladder augmentation - an operation to enlarge the size of the
bladder using a piece of bowel. It is a last resort treatment for
patients who are severely debilitated by their problem as it is a major
operation with obvious risks. Furthermore, after such an operation, most
patients will not be able to urinate on their own and will need to
perform self-catheterization in order to empty their bladders.
For further information or to schedule an appointment, contact:
Nicole B. Fleischmann, M.D.
Thomas Grimaldi, M.D.
5 East 98th
Street, Box 1272
New York, NY 10029
Tel: (212) 241-4812
|
