Urinary incontinence, or the involuntary leakage of urine is one of the most common problems treated in female urology. It is important for the clinician to realize that there are several different types of urinary incontinence, each with a different cause and potential treatment options. These include stress incontinence ( not related to psychologic stress ) , urge incontinence, overflow incontinence (bladder too full ) , mixed incontinence (simultaneous stress and urge incontinence), total incontinence and functional incontinence.
Improper diagnosis of the type of urinary incontinence is probably the most common reason for treatment failure.
Evaluation:
A detailed history and physical examination is of paramount importance in the proper diagnosis and sub typing of urinary incontinence. In select cases, urodynamic testing or cystoscopy may be useful. A neurologic history and physical examination should be obtained in order to rule out neurogenic bladder. Patients who have had multiple pregnancies, prolonged labor, are overweight ,or have had previous pelvic surgeries are the most at risk.
Patients with “pure” stress urinary incontinence report activity-related urinary leakage which interferes with their quality of life. Any increase in abdominal pressure such as coughing, sneezing, laughing, exercising, jumping, running, or event sexual activity may precipitate urinary leakage. This discourage patients from exercising.
Stress incontinence may or may not co-exist with pelvic organ prolapse ( Dropped bladder ) . In most cases urethral hypermobility is noted with rotational descent of the urethra upon straining. The need for treatment is largely dictated by the degree that it affects the quality of life of the patient . Pad usage and pad weight are sometimes used to gauge disease severity.
The current most popular surgical treatment to treat stress urinary incontinence is the sub-urethral sling. This is a simple minimally invasive outpatient vaginal surgery. Transurethral bulking agent is another less successful and shorter duration treatment option. The suburethral sling can be performed using a synthetic mesh or biologic allograft, or your own tissue (rectus fascia) . Abdominal procedures such as Burch urethropexy are effective but remain more invasive than the transvaginal sling procedures.
Currently, there is no approved medication for stress urinary incontinence. There is no evidence that estrogen therapy is effective in the management of stress urinary incontinence. Patients with urge urinary incontinence report involuntary urinary leakage with bladder spasm and strong urges to void. Urge incontinence is one of the symptoms associated with overactive bladder. More than 33 Million women are affected. The treatment algorithm of urge is very different from that of stress incontinence.
Behavioral therapy, fluid management, timed voiding, avoiding bladder irritants, pelvic floor exercises, Kegel exercises are useful in many cases. In more severe cases, anticholinergic medications can be used. Anticholinergics are plagued with adverse side effects such as dry mouth, constipation, cognitive side effects, and potential for urinary retention. In cases refractory to oral medications or if patients are unable to tolerate medications, intraderusor injection of onabotulinum toxin A (Botox) offers new hope to affected patients. The procedure is minimally invasive and can be performed in the office without general anaesthesiaThe usual dosage is 100 Units of Botox in patient with idiopathic urge incontinence refractory or intolerant to medications . This option is FDA approved in the USA.
Another option is Implant of sacral nerve stimulator. It is possible to stimulate the third (S3) sacral nerve via an implantable neuro-stimulator. Medtronic (Interstim) manufactures the most popular device. The procedure is performed under local anaesthesia with the patient awake.
Conclusion:
Although urinary incontinence is a common problem in women , most patients can be helped with minimally invasive procedures or treatments.
Angelo E. Gousse, MD
Clinical Professor of Urology – Herbert Wertheim College of Medicine – FIU
Voluntary Professor of Urology – University of Miami , Miller School of Medicine
Director of Fellowship:Female Urology,Voiding Dysfunction, Reconstruction
Memorial Hospital Miramar, South Broward Hospital District
1951 SW 172 Avenue, Suite 305,
Miramar, FL, 33029
Tel: 954-362-2720 Fax: 954-362-2761
www.bladder-health.net