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Articles - Urinary Incontinence
NEW TREATMENTS AVAILABLE Most people believe that urinary incontinence, the involuntary leakage of urine, is a normal part of growing old. Advertisements abound to promote the use of disposable undergarments as an appropriate method for controlling this problem. Incontinence, however, is not normal at any age--5 or 85. It is a symptom of an underlying disorder that is treatable and even curable through the use of diet, exercise, medication, or as a last resort, surgery. Many are surprised to learn that there are at least 17 million Americans suffering from urinary incontinence. More surprising is that only one in four seek help. People are just too embarrassed or simply not aware that there is treatment available. At least 80 percent of those who suffer from this disorder can be cured or treated with significant improvement. A minority may choose absorbent padding, but most can be rid of the cost and inconvenience of these products through other options. TYPES OF INCONTINENCE Many women in their 40's who have given birth to children leak a small amount of urine with a laugh, cough, sneeze, or with exercise. This is called "stress incontinence" and is the most common type in this age group. This occurs from muscle weakness of the pelvic floor muscles that support a woman's bladder. Pregnancy and repeated childbirth can stretch these muscles. A lack of estrogen in post-menopausal women can aggravate the damage and lead to leakage. During exercise or sneezing, muscles are tugged downward and pressure around the bladder increases. The muscle of the bladder that controls emptying, called the urinary sphincter, relaxes in this situation and is not strong enough to keep the bladder shut, resulting in a urinary leak. Another type of incontinence is called "urge incontinence." This is more common in both sexes, usually over the age of 60. This is now commonly referred to as "overactive bladder" and causes an abrupt and unstoppable desire to urinate. It can result from an infection, an increase in bladder sensitivity, or even a bladder tumor causing the bladder to contract involuntarily. Some people have combination of incontinence called "mixed incontinence", a combination of both "stress and urge." Other people may have "overflow incontinence" which is produced by physical obstruction that prevents the bladder from emptying completely. In women, the blockage may be caused by a previous operation. In men, it may be caused by an enlarged prostate gland. DIAGNOSIS AND TREATMENT The first step is to recognize that this is a treatable disease and in most cases, curable. A physician who specializes in incontinence will try to determine the exact type of incontinence, the possible causes, and then offer a treatment program. The initial evaluation includes a carefully obtained history and physical examination. Use of prescription and over-the-counter medication is an important part of the evaluation as certain sedatives, antidepressants, diuretics, sleeping pills, and cold tablets can cause side effects including incontinence. Very often, just a change in medication can bring dramatic relief of urinary leakage. The use of caffeine is notorious for producing irritable bladder symptoms. A physical examination is performed to assess pelvic floor anatomy and muscle strength. An ultrasound of the bladder is typically performed to determine if the bladder empties normally, and urine testing is done to make sure a urinary tract infection is not present. Federal guidelines from the Department of Health and Human Services recommend behavioral treatments as a first option (such as a change in diet), then the use of drugs, and lastly, surgery. Other behavioral methods include bladder retraining, biofeedback techniques, and pelvic muscle rehabilitation. Conservative treatment of stress incontinence begins with the use of Kegel exercises. This helps to strengthen the muscles that control the stop and start of urination. These are done several times throughout the day, sometimes with weights inserted in the vagina. Other times, it can be properly taught using biofeedback techniques. In some situations, mild stress incontinence can be treated by the use of a tampon or a pessary. This causes compression of the urinary tract and can help restore support to the muscles surrounding the bladder. Unfortunately, there is no medication available for use in stress incontinence. A promising new medication called duloxetine (Cymbalta) is an antidepressant that has a beneficial action that improves symptoms of mild to moderate stress incontinence. Although it is fully approved in Europe, in the United States the FDA has only approved its use for depression. Therefore, using duloxetine for stress incontinence remains "off-label." If all conservative measures are ineffective, there are a variety of operations that are designed to place the support muscles of the bladder back in their proper position. Newer vaginal "tape" procedures can typically be done as an outpatient, while more complex repairs may require an overnight hospital stay. The success rate for these procedures is 80-90 percent. Overactive Bladder and urgency incontinence are usually treated in a 2-step approach. The first step involves behavioral changes that can be very effective. These include limiting caffeine products, monitoring water and intake, and modifying voiding schedules. Kegel exercises that are properly performed provide a powerful pelvic contraction and have been shown to inhibit bladder urgency. If behavioral therapy is unsuccessful, then medication that decreases the sensitivity of the bladder can be prescribed. This class of drugs offers about 50 – 60% improvement overall and has side effects of dry mouth and constipation. There are a variety of medications available (Detrol LA, Ditropan XL, Vesicare, Enablex) allowing a patient to find one that provides the best benefit with minimal side effects. Today, men with overflow incontinence who suffer from an enlarged prostate have a variety of treatment options. Many can be treated by prescription medications, including Proscar, Cardura, Hytrin, and Flomax. However, if an enlarged prostate does not respond to medication, prostate surgery is usually indicated. Because of the widespread use of medication, the number of men undergoing prostate surgery has dramatically fallen over the past ten years. Newer procedures utilizing microwave therapy can be performed in the doctor's office. Laser therapy is now available, which is essentially bloodless, can be done as an outpatient, and is rapidly replacing the "old-fashioned" prostate operation that required a 2 to 3 day hospitalization. The difficulty in treating urinary incontinence is basically a lack of awareness of the general public to the availability of newer, non-invasive treatments that control this often-debilitating problem. The media is currently targeting urinary incontinence. Articles routinely appear in magazines such as Good Housekeeping and Cosmopolitan. Consumer Reports has an excellent review article on urinary incontinence. This contemporary report states, "In recommending treatment for this disease, it is important to seek out a doctor, ideally a specialist. Relying only on absorbent padding deprives people of the change for longer term, more effective relief." Millions of people suffer needlessly from urinary incontinence. It is the hope that in time the public will understand the multitude of treatment options available to alleviate, and even cure, this disorder.
Bladder Training
The Purpose of This Program is to Gradually Increase Your Bladder Capacity and Decrease the Frequency of Urination. After an extended period of time of frequent urination the bladder sets its "thermostat" at a very low volume. This "thermostat" needs to be reset at a higher volume. Concentrated urine is "irritating" to your bladder and makes you feel like you need to urinate at lower volumes than dilute urine. Certain dietary factors can also be irritating to your bladder and make you feel the need to pass urine frequently. To encourage your bladder to hold larger volumes, the urine going into your bladder should be as dilute and "non-irritating" as possible. When you first start drinking more water, you may find that the frequent urination seems worse until your bladder starts to enlarge gradually. The best way to monitor your progress is to keep a voiding diary 1 or 2 days a week. Keep track of how much urine you pass and how often you pass it. Gradually you will see the volumes of urine that you pass increase. We have forms to help you keep track of this. To Start Your Bladder Training Program: 1) Eliminate Bladder Irritants:
2) Drink at least 1 quart of water per day, increasing gradually to 2 quarts a day 3) When you get the urge to void, try to hold it for 5 extra minutes before going to the washroom. Each week add 5 minutes to the length of time you hold the urine after you have the urge.
4)The goal is to hold 300-400cc in your bladder and urinate every 2-4 hours can decrease gradually your fluid intake to decrease the frequency of urination.
5) You should see improvement within 2-3 months
Biofeedback
The Purpose of this Program is to Gradually Improve Bladder Control by Increasing the Strength of the Pelvic Muscles. Bladder control problems are often caused by weakness of the muscles of the pelvis. For some patients the muscles may have been weak for years, and for others, the weakness has been worsened by childbirth or medical problems. The traditional way to strengthen these muscles is with Kegel exercises. With biofeedback therapy, some patients can be taught to grip and squeeze with the pelvic muscles. Repeated on a regular schedule over long periods, these exercises are often effective. However, many patients cannot grip well with these muscles and, for them, electrical stimulation can be used. Electrical stimulation uses skin pads placed on the abdomen and a small sensor placed in the vagina (rectum in a male) that passes a painless electric current into the tissues. As the current passes into the body's tissues, it can cause the nerves to stimulate the muscles to contract. By using repeated treatments, the muscles can be strengthened and bladder control improved. Six to eight weekly sessions with our nurse therapist are usually necessary. A durable result can only be obtained by regular strengthening of the pelvic muscles. After each session, the patient is encouraged to practice the Kegel exercise at home in a regular, routine manner.
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DeKalb Clinic Urology
217 Franklin St
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