Urinary Incontinence

What is incontinence?

Urinary incontinence is the involuntary loss of urine. There are several different types of incontinence. Some of the more common include:

1. Stress Incontinence: Loss of urine with coughing, sneezing, laughing or anything that increases abdominal pressure. In stress incontinence, the urethral sphincter doesn't stay closed to prevent urine from exiting the bladder. This is caused by weakness of the muscles that support the bladder and urethra (the tube through which urine exits the body), allowing the urethra to drop into an abnormal position, which makes it unable to function properly. This type of incontinence usually, but not always, occurs as a result of pregnancy.
2. Urge Incontinence or Over-Active Bladder (OAB): A sudden, irresistible urge to void. In urge incontinence, the bladder muscles contract when they should not. Usually the cause of urge incontinence is not known but is attributed to age-related changes in the urinary tract or to bladder irritation from infection, cancer, or inflammation. Urge incontinence can also be caused by neurological problems, such as stroke or multiple sclerosis.
3. Overflow Incontinence: Overflow incontinence occurs if something is blocking the urethra and preventing the normal flow of urine. When the bladder gets full, urine leaks around the obstruction. This is a common cause of incontinence in men with enlarged prostates, but is rarely seen in women.
4. Mixed Incontinence: It is not unusual to have both stress incontinence and urge incontinence. Successful treatment depends on treating the major component, and in some cases, both components.

 

By age 65, 30% of people (mostly women), have at least some problems with incontinence. However, from a medical standpoint, incontinence should not be considered a normal part of aging.

In-office evaluation of incontinence:

We will know a great deal about what type of incontinence you have by just talking to you about the problems you have been experiencing and by doing a physical examination. We may ask you to keep a "diary" for about a week. The diary will keep track of when you experience incontinence and whether there may be any factors that may cause stress incontinence, such as coughing. Urodynamic testing is the most precise way to measure how the bladder is functioning and can be used to confirm a diagnosis. This is done with specialized electronic equipment that takes readings from a catheter inserted into the bladder.

Urodynamic Testing

Urodynamics is a study that assesses how the bladder and urethra are performing their job of storing and releasing urine. Urodynamic tests help us determine how well your bladder and sphincter muscles work and help explain symptoms such as:

1. Incontinence
2. Frequent urination
3. Sudden, strong urges to urinate
4. Problems starting a urine stream
5. Painful urination
6. Problems emptying your bladder completely
7. Recurrent urinary tract infections

 

Preparing for the Test

Prior to testing, a urinalysis and urine culture must be obtained no longer then two weeks prior to the test to ensure there is no infection. You should arrive at our office will a full bladder and should not urinate until you are in the testing suite and asked to do so.

Taking the Test

Most urodynamic testing focuses on the bladder's ability to empty steadily and completely. It can also show whether the bladder is having abnormal contractions that cause leakage, if  you have difficulty starting a urine stream, how hard you have to strain to maintain it, whether the stream is interrupted, and whether any urine is left in your bladder when you are done. 

Uroflowmetry (Measurement of Urine Speed and Volume)

A uroflowmeter automatically measures the amount of urine and the flow rate, or how fast urine comes out. You will be asked to urinate privately into a toilet that contains a collection device and scale. This equipment creates a graph that shows changes in flow rate from second to second so that we can measure the peak flow rate and how many seconds it took to get there. Results of this test will be abnormal if the bladder muscle is weak or urine flow is obstructed.

Measurement of Postvoid Residual

After you have finished urinating, you may still have some urine, usually only an ounce or two, remaining in your bladder.The remaining urine is called the postvoid residual.  To measure this postvoid residual, the doctor or nurse may use a catheter, a thin tube that can be gently glided into the urethra. A postvoid residual of more than 200 mL, about half a pint, is a clear sign of a problem. Even 100 mL, about half a cup, requires further evaluation. However, the amount of postvoid residual can be different each time you urinate.

Cystometry (Measurement of Bladder Pressure)

A cystometrogram (CMG) measures how much your bladder can hold, how much pressure builds up inside your bladder as it stores urine, and how full it is when you feel the urge to urinate. The doctor or nurse will use a catheter to empty your bladder completely. Then a special, smaller catheter will be placed in the bladder. This catheter has a pressure-measuring device called a manometer. Another catheter may be placed in the vagina to record pressure there as well. Your bladder will be filled slowly with warm water. During this time you will be asked how your bladder feels and when you feel the need to urinate. The volume of water and the bladder pressure will be recorded. You may be asked to cough or strain during this procedure. Involuntary bladder contractions can be identified.

Measurement of Leak Point Pressure

While your bladder is being filled for the CMG, it may suddenly contract and squeeze some water out without warning. The manometer will record the pressure at the point when the leakage occurred. This reading may provide information about the kind of bladder problem you have. You may also be asked to apply abdominal pressure to the bladder by coughing, shifting position, or trying to exhale while holding your nose and mouth. These actions help us evaluate your sphincter muscles.

Pressure Flow Study

After the CMG, you will be asked to empty your bladder. The catheter can measure the bladder pressures required to urinate and the flow rate a given pressure generates. This pressure flow study helps to identify bladder outlet obstruction that men may experience with prostate enlargement. Bladder outlet obstruction is less common in women but can occur with a fallen bladder or rarely after a surgical procedure for urinary incontinence. 

Getting the Results

Results and possible treatments will be discussed with you immediately after the test. 

Treatment of Incontinence

Treatment is completely dependent on the type of incontinence; therefore, a proper diagnosis is the key to success. Depending on the type and severity of incontinence, treatment might involve pelvic muscle training, medication, and/or surgery.

The first step in the treatment of stress incontinence is often an attempt to strengthen and train the muscles that support the urethra and bladder. This can be done using biofeedback or bladder training techniques with a pelvic physical therapist. An experienced pelvic therapist is instrumental in the success of pelvic muscle strengthening techniques.

A pessary is a rubber device placed in the vagina which lifts and supports weakened tissues. It is useful in the woman with a dropped bladder, urethra or uterus, and is appropriate for women who would like to avoid surgery, or who are medically unable to have surgery. Pessaries come in a variety of shapes and sizes and must be carefully fitted.

Drugs are not useful in the treatment of stress incontinence, and should not be prescribed unless there is also a component of urge incontinence (mixed incontinence).

Surgery for Stress Incontinence

Surgery is usually the best option for women with pure stress incontinence. The surgical method depends on what defect is causing the problem. All incontinence surgeries attempt to correct inadequate urethral support. Since the basic problem is weakened supporting tissue that has caused the urethra to drop, the goal of surgery is to put the urethra back in its proper position. Successful surgeries can provide relief of symptoms for 10-12 years and sometimes significantly longer. Most surgeries are outpatient but sometimes require an overnight stay.

Sling Procedures - Sling procedures use various materials to create a "hammock" to lift and support the urethra. The most commonly done sling procedure is known as a Tension-Free Vaginal Tape (TVT) procedure and is done as an outpatient procedure using local anesthesia. The surgery is done vaginally but requires two tiny incisions inside the inner thigh. While long-term studies are pending, the cure rate is over 90%, the complication rate very low, and the recovery short. TVT procedures are considered by many to be the best first surgery to do for the woman with stress incontinence. You can visit the website, www.gynecare.com, prior to your visit for further information about this procedure.

Treatment of Urge Incontinence

Treatment of urge incontinence is never surgical, unless there is also a component of stress incontinence.

The first course of treatment, which is usually highly successful, is behavior modification. This includes bladder-training techniques in which there is a schedule of urination so that the bladder "learns" how to fill and empty appropriately. Biofeedback and pelvic physical therapy are also useful in the treatment of urge incontinence. Certain drugs are also commonly prescribed and can be quite beneficial.

Watch Dr. Streicher talk about incontinence on NBC's In the Loop with iVillage.

Hear Dr. Streicher talk about urinary incontinence.