Urinary Incontinence

Often called overactive bladder, urinary incontinence is the involuntary loss of urine

Millions of Americans, mostly women, suffer from incontinence.

Urinary incontinence is the involuntary loss of urine. It is not a disease but rather a symptom that can be caused by a wide range of conditions.

Millions of Americans, mostly women, suffer from incontinence. Although it is more common in women over 60, incontinence affects all ages, both sexes and people of every social and economic level.

SOME POSSIBLE CAUSES AND CONTRIBUTING FACTORS OF INCONTINENCE

  • urinary tract or vaginal infections
  • effects of medications
  • constipation
  • weakness of certain muscles in the pelvis
  • blocked urethra due to an enlarged prostate
  • diseases and disorders involving the nervous system
  • some types of surgery
  • diabetes
  • delirium
  • dehydration
  • pregnancy and childbirth

Other causes can be longer lasting, even permanent. These include such conditions as an overactive bladder, weakness of the muscles holding the bladder in place, weakness of the sphincter muscles surrounding the urethra, birth defects, an enlarged prostate, spinal cord injuries, surgery or diseases involving the nerves and/or muscles (e.g., multiple sclerosis, Parkinson's Disease, spinal cord injury and stroke). In some cases, more than one factor causes incontinence in a single individual.

Urgency incontinence, often referred to as overactive bladder (OAB), occurs when the bladder contracts without you wanting it to. You may feel as if you can't wait to reach a toilet and you may lose urine on the way. At times, you may leak urine without any warning at all. A bladder can become overactive because of infection that irritates the bladder lining. The nerves that normally control the bladder can also be responsible for an overactive bladder. In other cases, the cause may be unclear. Risk factors include aging, obstruction of urine flow, inconsistent emptying of the bladder and a diet high in bladder irritants (e.g., coffee, tea, cola, chocolate and acidic fruit juices).

Stress incontinence or effort related incontinence may be due to weakened pelvic floor muscles as well as a weak or damaged sphincter or an abnormal urethra. This condition allows urine to leak when you do anything that strains or stresses the abdomen, such as coughing, sneezing, laughing, exercising, lifting, straining, getting out of chair, bending over or even walking. The major risk factor for stress incontinence in women is damage to pelvic muscles that may occur during pregnancy or childbirth. The major risk factor for men is prostate surgery with damage to the sphincter.

Mixed incontinence is a combination of urge and stress incontinence.

Overflow incontinence occurs when the bladder does not empty properly and the amount of urine produced exceeds the capacity of the bladder. It is characterized by frequent urination and dribbling and happens when bladder weakness or a blockage prevents normal emptying. An enlarged prostate (the male gland surrounding the urethra) can result in such blockage. For this reason, overflow incontinence is more common in men than in women. Bladder weakness can develop in both men and women, but it happens most often in people with diabetes, heavy alcohol use or decreased nerve function. It is also seen in women who have a "dropped" (prolapsed) bladder or uterus.

Environmental incontinence (sometimes called functional incontinence) occurs when people cannot get to the toilet or get a bedpan when they need it. The urinary system may work well, but physical or mental disabilities or other circumstances prevent normal toilet use.

Nocturnal enuresis (called bedwetting in children) is incontinence that occurs during sleep and is common in children. For adults, this is usually but not always associated with daytime incontinence.

Transient incontinence is leakage that occurs because of a temporary condition (e.g. medication, infection). When individuals have two or more types of incontinence, the causes of each must be found and considered in planning appropriate treatment.

Depending upon the type and suspected causes of your particular incontinence, some of the following tests may be performed to help your health care provider choose a treatment that is right for you.

  • Urinalysis. You will be asked to collect a sample of your urine, which will be examined for the presence of infection, bacteria, blood or other abnormalities.
  • Post-void residual measurement. This test may be performed to see whether any urine remains after you have attempted to empty your bladder completely. No more than one or two ounces should remain after urinating (voiding). Measurements may be made by inserting a small, soft tube, called a catheter, into the bladder to drain the remaining urine or by using sound waves, called ultrasound, to look at the bladder. When these special sound waves are directed at an organ, such as the bladder, shadow-like images are produced. These images can determine the amount of urine present in the bladder.
  • Stress test. While your bladder is full, you may be asked to cough, stand and do other activities to find out whether these stresses on the bladder cause leakage.
  • Urodynamic testing. Urodynamic tests examine bladder and sphincter muscle function. Using several such tests, your health care provider can find out whether you have normal bladder sensations and capacity and whether your bladder fills and empties in a normal manner. An X-ray test may be used to establish the degree of change in the position of the bladder and urethra during normal urination, coughing or straining.
  • Cystoscopy. A thin telescope-like instrument, called a cystoscope, is inserted into the bladder through the urethra. This test allows a view of the inside of the bladder and visually checks for problems and rules out cancer and stones.
  • Ultrasound. This technique can be used to determine the size and shape of the kidneys, bladder and prostate.

MANY TYPES OF TREATMENT ARE AVAILABLE FOR INCONTINENCE.

Fluid and diet management: This option consists of increasing or reducing your daily fluid intake. Incontinent patients may need to reduce the amount of caffeine or other dietary irritants (e.g., as acidic fruit juices, colas, coffee and tea), while at the same time increase water intake to produce an adequate amount of non-irritating, non-concentrated urine. A recommended water intake is six to eight glasses per day. Reducing or eliminating certain foods (e.g., chocolate, citrus fruits) may also help.

Bladder training: A diary is the starting point for bladder training. You will be instructed to record fluid intake, urination times and when your urinary accidents occur. The diary allows you to see how often you actually urinate and when incontinence occurs. The diary is also used to set time intervals for urination. If you urinate infrequently you will be told to do "timed urination" where you urinate by the clock every one to two hours during waking hours. By achieving regular bladder emptying you should have fewer incontinent episodes. Timed urination may be effective in patients with both urge and stress incontinence.

Bladder retraining: Bladder retraining is used for patients with urinary frequency. The goal of retraining is to increase the amount of urine that you can hold within your bladder. You will be told to keep a diary to determine your urination interval. You will be asked to gradually increase your urination interval by 15 to 30 minutes. The goal is to have you urinating every two to four hours while awake with less urgency and less incontinence. You can use things like deep breathing at the time of urgency to relax your bladder. This will allow you more time to get to the bathroom.

Pelvic floor muscle exercises: Also known as Kegel exercises, this type of treatment focuses on strengthening the external sphincter muscle and the pelvic muscles. If you are able to contract and relax your pelvic floor muscles, you can improve your strength by doing the exercises regularly. You may require help from a health care provider to learn how to contract those muscles. Biofeedback and electrical stimulation can be used to aid you in doing these exercises. During electrical stimulation, a small amount of stimulation from a sensor placed in the vagina or rectum is delivered to the muscles of the pelvic floor. Like any exercise program, you must continue to do the exercises to maintain the benefit. Patients with stress incontinence benefit from pelvic floor muscle exercises by increasing the closure of the urethra and by increasing the strength of the pelvic floor muscles. You can contract the pelvic muscles with certain activities like coughing and prevent stress incontinence. Pelvic floor muscle exercises are effective for urge incontinence, since a contraction of the pelvic floor can interrupt a contraction of the bladder smooth muscle and stop or delay a urinary "accident" or leakage.

Drug therapy: Stress incontinence may be treated with drugs that tighten the bladder neck.

Urgency incontinence is most commonly treated with drugs that have anticholinergic properties. Anticholinergics allow for relaxation of the bladder smooth muscle. A commonly used anticholinergic is oxybutynin chloride. This drug works well to treat urge incontinence but has side effects including dry mouth, confusion, constipation, blurred vision and an inability to urinate. New drugs or new formulations of older drugs have been developed in an effort to reduce side effects. Oxybutynin is newly formulated in a slow-release tablet taken once a day. The slow release of this new drug allows for a steady level of the drug in your blood and fewer side effects. Oxybutynin also comes in a skin patch where the drug is delivered through the skin. Tolterodine tartrate is another anticholinergic that is different than the older ones in that it has less effect on the salivary glands and therefore causes less dry mouth. It is also available in a slow-release, one-a-day form. Three more anticholinergics drugs are now available. They include trospium chloride, solifenacin and darifenacin. All of these drugs have various side effects.

Surgical treatment: In most cases of incontinence, minimally-invasive management (fluid management, bladder training, pelvic floor muscle exercises and medication) is prescribed. The best results are when these treatments are used together. However, if that fails, surgical treatment may be necessary.

One of the surgical treatments for stress incontinence in men and women is the use of urethral injections of bulking agents to improve the function of the sphincter. The injections are done under local anesthesia and can be repeated. Unfortunately, the cure rate is only 20 to 50 percent and may require multiple injections.

Another surgical alternative for men is to perform a urethral sling procedure to compress the urethra in the area between the scrotum and the rectum. The InVance and AdVance sling systems offer a minimally invasive option for men with mild to moderate stress incontinence. However, the most effective treatment for more severe male incontinence is implantation of an artificial sphincter-it can cure or greatly improve more than 70 to 80 percent of the patients. The device is inserted under the skin and consists of a cuff around the urethra, a fluid-filled, pressure-regulating balloon in the abdomen and a pump in the scrotum. When the man squeezes the scrotal pump, fluid in the cuff is transferred to the balloon, opening the urethra for voiding. After a delay, the system automatically pushes fluid back to the cuff closing the urethra and preventing leakage of urine.

In women, surgery for urinary incontinence (stress incontinence) is generally very successful, but choosing the proper procedure is important. Many women with stress incontinence also have other conditions like bladder prolapse, rectocele or uterine prolapse that must be treated at the same time. The procedure of choice will depend on multiple factors, like the need for abdominal surgery for other conditions, the degree of incontinence, and the degree of mobility of the urethra and bladder.

The most common and most popular surgery for stress incontinence is the sling procedure-which has more than 80 to 90 percent cure or greater improvement. In this operation a strip of tissue is applied under the urethra to provide compression and improve urethral closure. The operation is minimally invasive and patients recuperate very quickly. The tissue used to create the sling can be a segment of the patient's abdominal wall, specially treated fascia, skin from a cadaver or a synthetic material.

For urge incontinence an exciting technology is the use of a bladder pacemaker to control bladder function. This technology consists of a small electrode that is inserted in the patient's back, close to the nerve that controls bladder function. The electrode is connected to a pulse generator and the electrical impulses control bladder function.

In more difficult cases, Botox injections can be used to paralyze a portion of the bladder. In addition, the bladder can be enlarged using a segment of small intestine. This operation, called augmentation cystoplasty, is very successful in curing incontinence-more than 80 percent of the cases-but its main drawback is the need in 10 to 30 percent of the patients to perform self-catheterization to empty their bladder.

The goal of any treatment for incontinence is to improve your quality of life. In most cases, great improvements and even cure of the symptoms are possible. Medical therapy is usually effective, but not if the patient sips fluids all day and does not time their urination. Similarly, large shifts in weight gain and activities that promote abdominal and pelvic straining put any surgery to the test and cannot be expected to stand the test of time. Positive, long-term outcomes can almost be assured with common sense, proper body mechanics and care.


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