Urinary incontinence is a common problem, affecting approximately 80 per cent of women at some point in their lives. Forty per cent of women deal with incontinence regularly. Many women are either too afraid or too embarrassed to seek help for their condition, or simply believe it is a normal part of aging and they need to just “live with it”. One need only look at the sales of incontinence pads and Depends to understand the impact of incontinence on society. Because information is the key to overcoming fear, we should begin by developing a basic understanding of incontinence. The bladder and urethra together have two functions: urinary storage and emptying of urine. Failure of either the bladder or urethra to perform properly results in either a failure to store or a failure to empty.
TYPES OF INCONTINENCE:
Many women are surprised to learn that there are different types of incontinence, with different causes and therefore different treatments. This is a fundamentally important fact to understand before considering a treatment option. While some types of incontinence may be treated surgically, other types may be totally inappropriate for surgical treatment. Part of our job as clinicians is to ascertain the type of incontinence and then formulate an appropriate treatment plan for the individual.
STRESS INCONTINENCE: This is a “failure to store” (see above) – ie: leakage – that occurs with physical exertion such as coughing, sneezing, laughing, or exercise. THIS IS AN ANATOMIC PROBLEM. It is usually a result of a somewhat weakened urethral sphincter muscle combined with a loosening of the support of the urethra, which then results in the upper urethra and neck of the bladder descending with physical exertion. Because the abdominal pressure exceeds the pressure holding the urethra closed, leakage occurs when the urethra descends. Sometimes, the urethral sphincter muscle is so weak that even if the urethra does not descend during exertion, leakage occurs anyway. This is a special case called “Intrinsic Urethral Sphincter Deficiency”, or ISD. Stress incontinence is more common in women who have had vaginal deliveries, have a family history of stress incontinence or prolapse, are obese, menopausal or have a weak pelvic floor for other reasons.
URGE INCONTINENCE: This is a “failure to store” (again, see above) that occurs with the urge to urinate. The urge becomes uncontrollable but is not associated with a specific physical activity. THIS IS A PHYSIOLOGIC PROBLEM. However, it often occurs as a result of conditioning, so women often complain that as soon as they drive into the driveway, or put their hands in water, or see the bathroom door, or hear water running (etc), they feel an uncontrollable urge and may begin to leak. They usually notice that the faster they run, the more likely they are to leak on the way. It is often associated with a frequent need to urinate, and may be associated with nighttime awakening due to a need to urinate. Usually, women will report that they are simply unable to stop the urine from coming out no matter how hard they try to “squeeze”. It is related to the information passing between the bladder, spinal cord, and brain. There is a center in the brain (the Pontine Micturition Center) which sends signals to the bladder via the spinal cord to empty. The thinking part of the brain (the cerebral cortex) can inhibit those signals (that is how we are all “potty trained”, by learning to activate that center). When something goes wrong in the signaling/control pattern, urge incontinence may result.
ANATOMIC VS. PHYSIOLOGIC:
I like to give the analogy of a chair and sitting. Form vs function = anatomy vs physiology.
If the chair is broken, we might rebuild it to fix it. The act of sitting down requires coordination between the brain and the muscles. If you have trouble sitting down in a chair, we need to work on your strength and coordination, but we wouldn’t shorten your leg or try to move your butt around.
Even though it is just a little more complex than that, I think it helps to differentiate between the two problems and leads us to understanding how to approach treatment logically.
BOTH types of incontinence can be significantly improved in the majority of cases simply through physical therapy and bladder training. If a woman is overweight, even a small loss of weight can result in a significant improvement in symptoms. Because the pelvic floor is a “big bowl of muscles”and connective tissue, working with a trained physical therapist can lead to significant improvement in strength, tone, and control of the tissues in the pelvis, including the urethral muscles and supporting muscles for the bladder, vagina, rectum, and urethra. This training also builds awareness of the pelvic floor muscles which helps with proper interpretation of signals from the bladder as it fills.
If the response to physical therapy and bladder training is not satisfactory, there are other options for treatment. Nonsurgical options include FemSoft (R) inserts, which are placed by a woman for a specific activity (such as dancing or exercise) known to cause leakage, and worn for a short period of time. The insert is highly effective, with a slight increased risk for bladder infection. There is no surgical risk. Another option is an incontinence pessary, which is worn in the vagina and has a special knob that juts against the urethra to keep it elevated and closed during activity. It may be inserted and removed by the woman or her doctor/practitioner, depending upon the situation. Next on the scale of invasiveness is urethral bulking using a special material such as gel or microbeads. The gel is injected around the urethra near the bladder side to “tighten” the urethra a bit. It has an initial 60-70 per cent success rate, which falls over 2 years. It may be repeated if necessary, and the procedure is done under a local anesthetic, often in the office setting. There is little to no “downtime”, with 10 per cent of women having initial difficulty voiding requiring the use of a catheter, rarely for more than one day. Complications are rare but may include unusual allergic reaction to the material or migration of the material into other parts of the body. If these measures are ineffective or not desired, then surgical treatment may be an option. Today, the most common surgery in the world for incontinence is a suburethral sling using a small, thin mesh tape. The most-studied of this sort is the “TVT” or tension-free vaginal tape. The Cochrane Library www.CochraneLibrary.com has a large review of the data regarding this procedure. Modifications of this device such as the “TOT” or trans-obturator tape, or the “mini-sling”, are newer and less well studied, with current evidence suggesting they may be slightly less effective at least in certain circumstances (particularly the mini-sling). It is considered one of the “gold standard” procedures, despite the fact that it is a synthetic mesh. Advantages include less likelihood of difficulty emptying the bladder, so women usually do not need to go home after the procedure with a catheter. Disadvantages include the fact that it is a synthetic mesh and therefore carries an erosion risk of 5-10 per cent. It can also be used for the “ISD” mentioned previously, which can be especially difficult to treat. Another form of sling is the fascial sling, made of a woman’s own natural tissue, harvested from her hip or abdomen. This is a retropubic fascial sling. It is also “gold standard” having high effectiveness persisting for 5 years after the procedure. This procedure was first described about 100 years ago and has undergone a few modifications, but is very similar to what was first described long ago. Its advantage is primarily that there is no risk for erosion or synthetic-materials-related complications. Disadvantages include greater difficulty emptying the bladder initially, with virtually all women going home with a catheter and wearing the catheter for at least one week. It may take a few months to void normally in some women. 10 per cent of women may develop more urgency symptoms following a fascial sling. It also involves another incision to harvest the tissue used in creating the sling, thus increasing slightly the risk of infection or complications related to that incision. This procedure can also be useful for ISD. The third “gold standard” procedure is the Burch procedure, described over 40 years ago and modified to its current most standard technique over 30 years ago. It was originally done with an open abdominal incision, however, studies reviewing the technique performed laparoscopically (through tiny holes in the abdomen) reveal that it is at least as effective when done in this way. The advantages include no artificial material (except for suture material), no graft harvesting, and similar longterm efficacy to the sling procedures. Disadvantages include the need for catheterization (usually about a week) afterwards, some reduced activity during healing to allow for scar tissue formation to hold the tissue into place, and an increased risk (about 5 to 10 per cent) of increasing urgency symptoms. Surgical risks for any of the procedures just described include infection, bleeding, scarring, damage to bowel, bladder, ureters, major vessels, need for reoperation or more extensive surgery, as well as common surgical risks for any pelvic surgery.
WHAT DOESN’T WORK? Anti-incontinence medications.
If the response to physical therapy and behavior modification is not satisfactory, then there are medications which may be helpful to treat symptoms. The original class of medications include “anticholinergics” (they work on the nerves which tell the bladder to contract and empty). Although much work has been done to try to refine the effects and limit them to the bladder, those chemicals affect other parts of the body such as the colon, salivary glands, and lens muscles in the eye. Some of these types of medications include oxybutynin, Detrol, Gelnique, Vesicare, Enablex, Toviaz, Sanctura, among others. Some women will find they do better on one versus another medication. Some women simply can not tolerate the side effects. Still others find that the medications are not effective enough to control their symptoms. A new class of medications, the beta3 agonists, has been developed, and there is one approved medication in that class: Myrbetriq. Because it works on a totally different system, the side effects of the anticholinergics are not a problem. In addition, because only the bladder contains the beta 3 receptors, it is a much more specific medication. However, because of its relationship with other chemicals in its class, it is to be used with extreme caution in poorly controlled high blood pressure. It is a welcome addition to the treatment options for overactive bladder. If medications do not work or can not be tolerated, there are additional options. One option is injections of Botox (R) into the bladder. Because this chemical creates a mild paralysis of the bladder, the spasms do not occur and the urgency symptoms are usually significantly improved. There is an approximately 10 per cent risk of needing to self-catheterize after the procedure due to inability to adequately empty the bladder. Also, the injections wear off after 12-18 months, and have to be repeated. The injections can be performed in the office with some local anesthetic. Another option is called neuromodulation. A device called InterStim is used. This is something akin to a “pacemaker” for the bladder, as it sends an electrical signal to the nerves coming from the bladder to the spinal cord in order to regulate the information and allow the bladder to store and empty more normally. It can be highly effective in treating refractory urgency incontinence and is also effective for treating fecal incontinence. Risks include infection, pain, in rare cases nerve damage or bleeding. Once the device is implanted, the wearer (as with a pacemaker) is prevented from having an MRI below the neck.
Well, this was a pretty long post. If you want more information regarding incontinence treatments, speak with your doctor, or if you desire a consultation, call 561-701-2841.
Linda Kiley, MD
Dr. Kiley is a Board Certified subspecialist in Female Pelvic Medicine and Reconstructive Surgery, and is also Board Certified in general Obstetrics and Gynecology.