Urinary Incontinence

Dr. Thomas Minnec and Dr. Andrew Wagner specialize in treating our patients with urinary incontinence.
In addition to office based treatment, they are specialists in surgical based options.

Introduction

Urinary incontinence (UI) is defined as the involuntary loss of urine which is objectively demonstrable and a social or hygienic problem

• UI has been reported to affect 10-23% of women under the age of 65, 15-30% of noninstitutionalized women over the age of 60, and more than 50% of nursing home residents
• It is reported to affect approximately 13-25 million people in the United States. This number is most likely a low estimation secondary to underreporting due to the embarrassing stigma associated with the disorder or a misperception that nothing can be done about it. Another reason may be women are raised to believe it is a natural part of the aging process, a consequence of giving birth or has no effective therapy. As the population continues to age, the number of female patients suffering from UI will increase.
• Urinary incontinence often has a devastating impact on people's lives; Americans spend more than $10 billion each year on products to help them cope with UI or to hide the problem without looking for ways to treat the cause. Unfortunately, only 1% of this amount was spent on the diagnosis and treatment of this disorder, while 60% was spent on palliative measures
• The condition is costly in a social and psychological context as well, as many people with UI avoid social contact and even become homebound due to the embarrassing nature of the ailment. Impaired sexual function was noted in 25% of women with UI in one study
• Incontinent individuals have been reported to be more likely to be depressed; they may be fearful about their appearance or the odor of urine. Further, loss of bladder control is one of the most frequent reasons for nursing home admission.

Etiology

Factors that contribute to the development of UI and pelvic organ prolapse include genetic factors; female sex; vaginal birth; white race; aging; menopause and lack of estrogen; obesity; underlying neurologic, gastrointestinal, or pulmonary diseases; and occupational and recreational factors such as smoking .

• Vaginal deliveries play a major causative role in pelvic floor dysfunction. It is unclear how much of the dysfunction is due to anatomical insult and how much is due to neurologic or vascular insult. It is known that active second-stage labor is associated with denervation, and damage can occur in as little as 1 hour in first-time moms
• Forceps and episiotomies appear to play an injurious role as well
• Lacerations after vaginal delivery, maternal age, and giving birth to large babies (birth weight > 9 pounds) also are important risk factors
• Damage from vaginal deliveries can also cause pelvic floor descent and change the anorectal angle, contributing to incontinence
• Urinary incontinence is much less common in males. There are several obvious reasons for this. Men do not bear children and have no space into which the pelvic organs can prolapse. The anatomic sphincter is bulkier and better able to maintain incontinence. Men do have prostates that enlarge over time and obstruct the flow of urine.
  

Stress Incontinence (SUI)

The involuntary loss of urine coincident with increased intraabdominal pressure (e.g., coughing, laughing, sneezing, walking). Its main cause is mechanical in nature, stemming from loss of pelvic support of the urethra, bladder, and the urethrovesical junction. This loss of support allows the urethra to be pushed outside the pelvis and be subjected to an inproportionate amount of pressure. In other words, an increase in pressure of the bladder occurs without an increase in pressure of the urethra resulting in incontinence.

Urge Incontinence/Detrusor Instability (DI)

The involuntary loss of urine associated with an abrupt, strong and uncontrollable desire to void (urgency). Urge incontinence is due to over activity of the detrusor muscle, the smooth muscle wall of the bladder, and is referred to as detrusor instability. Some patients may involuntarily void only a small amount, while others may loose a large volume if their bladder is full. Bladder spasms may be related to conditioning. For example, many people may be continent when they are out all day, but when they put the key in their front door, they are unable to control a sudden urge to void. The bladder contracts as a conditioned response, the result of many years of using the bathroom immediately upon arriving home. For a person with DI, even the sight of a bathroom or the sound of running water can trigger an accident.

Mixed Incontinence

The presence of both stress and urge incontinence symptoms together. This accounts for at least 40% on incontinence in women.

Overflow Incontinence

Common in women with a large cystocele, overflow incontinence is the accidental loss of urine from a chronically full bladder. It is associated with a small quantity of urine escaping when a woman stands, bends, exerts herself; however, the urge to void is absent. It may also be due underactivity of the detrusor muscle.

Other Conditions Causing Incontinence

Women with normally adequate bladder control may experience incontinence due to physical limitations, such as arthritis or mobility restrictions. This is called functional incontinence. Systemic or traumatic nervous system disorders may affect lower urinary tract dysfunction. These include spinal cord lesions, diabetes, Parkinson disease, and stroke.

Diagnosis of Incontinence

UI is not an ailment in and of itself; it is a symptom of an underlying problem. The purpose of the clinical evaluation of incontinence is to

1. Clarify the patient's symptoms,
2. Demonstrate the loss of urine objectively,
3. Determine the etiology of the incontinence using clinical testing, and
4. Identify women who require more sophisticated urodynamic or imaging studies.

History

A detailed medical and surgical history should be taken. A drug history is important because certain medications may precipitate incontinence. Using a urogynecologic questionnaire facilitates the evaluation.

Voiding Diary

A voiding diary is one of the most important aspects of a urogynecologic investigation. The patient is asked to record the time and volume of her spontaneous voids over a 24-72 hour period. Additional information regarding urgency prior to voiding, frequency of voiding, frequency of incontinent episodes, activity precipitating incontinence, and the type and volume of fluid intake may also be recorded.

Physical Examination

Following a general physical examination, clinical evaluation of the lower urinary tract should begin with a screening neurologic examination. Estrogen status should be determined. Evaluation of defects in genitourinary support (bladder, urethral, rectal, uterine or vaginal prolapse) is done.

Urinalysis and Culture

A clean catch midstream urine specimen should be obtained to determine infection is not present.

Stress Test

Since objective evidence of urinary leakage with stress is necessary to establish the diagnosis of stress incontinence, the stress test is an important part of the evaluation. The patient is asked to cough repetitively with a bladder volume of at least 300cc or a subjectively full bladder. Simultaneous loss of urine from the external urethral meatus during coughing is highly suggestive of genuine stress urinary incontinence.

Cystometrics

Cystometry indicates the pressure-volume relationship of the bladder during filling. The main diagnostic value of cystometry is its ability to detect detrusor overactivity.

Treatment

Therapy for urinary incontinence consists of behavioral modification, pharmacological treatment, and surgical management. Women with stress incontinence can be treated by using any one of these methods, while those with urge incontinence respond best to behavioral techniques or medications. A treatment plan should offer the least invasive approach first; surgical options should be reserved for women who decline or do not improve following conservative management

All incontinent women should avoid excess fluid intake, limiting their intake to approximately 2 L/d. Consumption of caffeine-containing beverages should be eliminated or reduced to no more than 8 oz/d.

Palliative

Some women may require protective perineal pads. While these products may provide the patient with a measure of security against visible leakage, they are costly, may decrease a patient's motivation to seek help, and may contribute to skin irritation and breakdown.

Behavioral Therapy

Behavioral therapy includes bladder training (retraining), timed voiding, prompted voiding, and pelvic muscle exercises. The effectiveness of pelvic muscle exercises may be enhanced by biofeedback techniques using pressure catheters in the vagina that provide visual or auditory feedback concerning bladder function or using weighted cones to aid in the performance of pelvic muscle exercises.

Pelvic Muscle Exercises

Kegel exercises facilitate improved urinary control in 40-75% of patients. The patient performs the exercise by contracting the pubococcygeous muscle, thus improving the tone of the voluntary external urethral musculature. Exercises are indicated in patients with either stress or urge incontinence. The success of pelvic muscle exercises depends on the patient's ability to correctly identify the muscles for the exercise and her commitment to performing the exercises.

Biofeedback

Biofeedback uses electrophysiologic signals or pressure readings to provide visual or auditory feedback to the patient regarding the status of her lower urinary tract function or pelvic floor musculature. Intravaginal, intraurethral, or intrarectal manometric devices can be used on a weekly basis during office biofeedback sessions to augment pelvic floor tone in women with incontinence.

Devices

Weighted vaginal cones are tamponlike devices that are progressively weighted. These have been found to be effective in decreasing the number of episodes of incontinence in premenopausal women. Vaginal pessaries or contraceptive diaphragms have been used to alleviate the symptoms of pelvic organ prolapse with or without concomitant urinary incontinence.

Pharmacotherapy

Pharmacotherapy for urinary incontinence is directed at either relaxing an overactive detrusor muscle in women with urge incontinence or augmenting intrinsic urethral tone in women with stress incontinence. These medications provide an alternative to behavioral therapy, with cure rates of 20-30% and reduction in the frequency of incontinent episodes of 10-80% in placebo-controlled trials. The side effects of drugs used for detrusor instability include dry mouth, constipation, or blurred vision. In postmenopausal women, estrogen replacement is recommended to treat either stress or urge incontinence. Estrogen appears to raise the sensory threshold for involuntary detrusor contractions, thus decreasing urinary urgency, frequency, and incontinence. Estrogen improves the urethral mucosal seal.

Surgery

The success rate of surgery to restore urinary continence declines with repeated attempts. Therefore, precise preoperative diagnosis and careful planning and execution of the procedure are essential. The best treatment for stress urinary incontinence resulting from hypermobility of the urethrovesical junction appears to be an abdominal retropubic urethropexy such as the Marshall-Marchetti-Krantz or Burch procedure. Objective cure rates for primary incontinence operations range from 70-90%. Surgical intervention for detrusor instability is associated with significant morbidity and should be reserved only for severely affected individuals.