Urinary Incontinence in Women: It's Not Normal

Female Urology Center

Urinary Incontinence in Women: It's Not Normal

Urinary incontinence implies unwanted and unintentional leakage or loss of urine producing wet clothing, wet undergarments, wet absorbent pads or wet diapers. Millions of Americans have this problem and the majority of them are women. The total financial cost of this problem is colossal with more than 16 billion dollars spent annually in the U.S.. Unfortunately, most of this expenditure goes for pads and diapers and only a small portion of these dollars are used for treatments which have been shown to alleviate the problem. This socially stigmatizing problem is treatable in all cases and curable in most!

Millions of women silently endure continuously wet undergarments or pads. A rash may develop; the adult equivalent of diaper rash. Affected women are often concerned about the continuous odor of leaking urine which makes them uneasy near other people that might detect the odor. Scientific reports and clinical experience shows that incontinence is associated with urinary tract infections, falls, fractures, embarrassment, stigmatization, depression and even risk of institutionalization (in nursing homes). Some women even become reclusive, refusing to go out in public for fear of wetting themselves when there is no restroom nearby. Otherwise healthy women who become incontinent may find that they are no longer socially, physically or even sexually active and some become progressively more isolated.

"Approximately 45 percent of mature women develop incontinence of urine, however, less than one woman in 25 will seek medical advice."

Approximately 45 percent of mature women develop incontinence of urine, however, less than one woman in 25 will seek medical advice. Many women are under the mistaken impression that no treatment is available. Others seek the advice of a doctor, only to be shrugged-off, dismissed or given ineffective medications.

Some women have undergone ... old-fashioned or outmoded surgeries, ... prone to failure ... [such as] the so-called "bladder tack surgery", "bladder neck suspension surgery", "Raz", "Stamey", "Pereyra", "Kelly Plication."

Some women have undergone attempted surgical correction of the problem in earlier years. However, in many cases these women underwent old-fashioned or outmoded surgeries which were prone to failure. These outdated surgeries include such procedures as the so-called "bladder tack surgery", "bladder neck suspension surgery", "Raz", "Stamey", "Pereyra", "Kelly Plication."

Incontinence is very common and it becomes more common and in many cases more severe with aging. However, incontinence certainly is not inevitable part of life. That is, unwanted urinary leakage is not at all a natural part of aging! Besides, any age is "too young" to have such a annoying and frustrating problem, especially when effective treatment is so readily available.

In order to effectively treat incontinence, it must be categorized according to cause. This requires a very thorough history and physical examination by a qualified urologist. Sometimes a voiding diary is needed. A voiding diary is simply a patients personal written record of her symptoms, activities, fluid intake and urine output over a set period of time. The diary can be very valuable tool. In fact, a number of our patients have had their incontinence problems completely reversed without medicine or surgery, simply based on the findings discovered on the voiding diary!

"The urology evaluation allows separation of incontinence problems into several broad categories -- each treated differently."

Diagnostic studies may be as simple as the voiding diary or they may include additional tests such as urodynamics (bladder pressure tests). The urology evaluation allows separation of incontinence problems into several broad categories -- each treated differently. The more common forms of incontinence include: anatomical stress urinary incontinence (SUI), urge urinary incontinence (UUI) and intrinsic sphincter deficiency (ISD).

However, less common forms of urinary incontinence should not be overlooked. One of these less common forms of incontinence involves the development of an abnormal connection between the urinary tract and the vagina, known as a fistula. This complicated and very special problem which may be very difficult to detect. Detection of a urinary fistula requires detailed x-rays and testing followed by surgical correction.

A somewhat more common cause of urinary incontinence is neurological disease. The type of urinary incontinence thus produced is known as neurogenic bladder dysfunction. Neurological causes of urinary incontinence include herniated disk disease, multiple sclerosis, stroke, Parkinson's disease and spinal cord or brain tumors.

Rarely, urinary incontinence is a symptom of a serious medical problem [such as, herniated disk disease, multiple sclerosis, stroke, Parkinson's disease and spinal cord or brain tumors].

Rarely, urinary incontinence is a symptom of a serious medical problem. Careful urological examination is also needed to exclude the possibility of these and even more serious medical problems which effect not only the bladder but the body as a whole. A urologist specializing in urinary incontinence evaluation and treatment is the most qualified medical professional for the accurate characterization and treatment of all forms of urinary incontinence.

Today, most cases of ... stress urinary incontinence [SUI] are completely reversible.

Of the more straightforward forms of incontinence, anatomical stress urinary incontinence (SUI) is perhaps the most common type. SUI is found in women of all ages but it is the most common form of incontinence in younger women. SUI results from weakness of the muscles and supportive ligaments of the pelvic floor. The muscle weakness allows the bladder and other pelvic organs to push down on the walls of the vagina creating prolapse of these organs into the vagina. Many patients refer to this as a "fallen bladder". The urine leakage occurs primarily with straining, coughing, sneezing, walking, standing up or most any activity that increases the pressure on the organs within the abdomen and pelvis. Sometimes incontinence even occurs during intercourse. Today, most cases of isolated stress urinary incontinence are completely reversible.

Intrinsic sphincter deficiency (ISD) produces urine leakage ... [with] the very slightest provocative cough or movement.

Intrinsic sphincter deficiency (ISD) produces urine leakage similar to stress incontinence. In fact, ISD is considered to be a variant of stress incontinence. It is more commonly found in older ladies and in women who have undergone prior pelvic surgery or who have a deficiency of estrogen. The urine leakage occurs under the same circumstances as stress incontinence, but ISD is not generally associated with any prolapse or movement of the bladder or pelvic organs. That is, ISD is not usually associated with weakness of the muscles and supportive ligaments of the pelvic floor. Rather, it is caused by fibrosis, drying or scarring of the urethra. Unlike stress incontinence however, the very slightest provocative cough or movement may produce wetness. Kegal exercises are often ineffective. Estrogen supplementation and a simple office procedure known as collagen injection often effectively control this form of incontinence. However, repeated collagen injections are necessary to maintain dryness, otherwise, formal surgical repair is generally needed.

Urge type urinary incontinence (UUI) is very common in women, resulting from bladder contractions which occur unpredictably. The unpredictable bladder contractions result in the involuntary sudden loss of urine associated with the sudden strong desire to urinate. A slight urge is often noticed after which a strong uncontrollable urge to urinate occurs, commonly on the way to the bathroom. This urgent need to urinate may also occur with stress incontinence. That is, UUI and stress incontinence commonly occur together in women. This scenario is simply called mixed urinary incontinence. Surgical correction of the stress urinary incontinence also corrects the urge incontinence in many cases.

While most cases of UUI are rather benign, sudden bladder contractions are commonly the first sign of neurogenic bladder disease, a serious medical condition described above. For this reason and others, a urologist specializing in urinary incontinence evaluation and treatment is needed for the accurate characterization and treatment of UUI . Sometimes, biofeedback training is required.

Both medical and surgical treatments for female incontinence have markedly improved over the last ten years. Novel treatments are now in routine use such that successful treatment or cure is possible for the vast majority of women. The treatments for various types of female urinary incontinence include: exercises (specific to the muscles which controlled urine flow), behavioral techniques, biofeedback techniques (often used in conjunction with exercises), electrical stimulation, neuromodulation, pelvic support devices, urethral occlusion devices, medications (which relax the bladder to allow it to hold greater volumes of urine without squeezing uncontrollably), vaginal procedures, abdominal/pelvic surgery and laparoscopic surgery (surgery done with telescope like instruments inserted through tiny incisions on the skin). A brief description of some of these treatments follows.

"Ditropan XL and Detrol LA ... are very safe and effective."

Newly FDA approved medications are now widely used for the management of urge type urinary incontinence (UUI). Brand names include Ditropan XL (oxybutynin) and Detrol L.A. (tolterodine). The generic form of Ditropan, oxybutynin, is a medication which has been used for many years. However, be side effects of oxybutynin are prohibitive and many patients choose not to take the generic oxybutynin because of its side effects.

The new Ditropan XL formulation however, has reduced the negative effects of of the older generic form of the medication, while maintaining the positive effects of oxybutynin. Detrol L.A. has also been proven effective, with limited side effects. While the older medications had to be taken two or three times per day, the present preparations only have to be taken once a day. Patients with uncontrolled narrow angle glaucoma should not use these medications and patients with gastroesophageal reflux should use these medications with caution. When these medications are prescribed and used properly, they are very safe and very effective. As usual, there are other relative contraindications to the use of these medications as included in the prescribing brochures.

"...new...Oxytrol...transdermal skin patch...only needs to be changed twice per week...(and) may have fewer side effects."

Recently, a new delivery system for oxybutynin (otherwise commonly known by the brand name of Ditropan) was formulated by Watson pharmaceuticals. The new formulation called Oxytrol is used as a transdermal "skin" patch. The patch has an adhesive surface which sticks easily to the skin. The patches only need to be changed twice per week. In addition to the easy semiweekly dosing schedule, the Oxytrol patch may have fewer side effects than the oral medications discussed above.

"At the Urology Center, a very experienced female nurse trained in ... anti-incontinence techniques works one-on-one with all patients. The results can be remarkable!"

Pelvic floor exercises are commonly known as Kegel exercises. When properly and regularly performed, the these exercises have been proven to reduce the number of episodes of urinary incontinence. At the Urology Center, we routinely use Kegel exercises in nearly every patient. However, the results of Kegel exercise therapy greatly depend on the understanding and motivation of the individual patient, and to some degree, the skill of the medical professional involved in communicating proper exercise technique to the patient. At the Urology Center, a very experienced female nurse trained in explaining the use of these and other anti-incontinence techniques works one-on-one with all patients. The results can be remarkable!

Unfortunately, despite all efforts, some women are unable to perform Kegel exercises, making additional treatment necessary. In some cases, even though the patient appropriately performs the exercises on a regular basis, the incontinence does not respond. Women with severe stress urinary incontinence rarely respond significantly to Kegel exercises. That is, we commonly prescribe a trial of Kegel exercises for patients with stress incontinence, but the exercises commonly do not work.

"If the appropriate combination of treatments are not used, the incontinence problem will certainly continue."

In women with urge incontinence, the Kegel exercises absolutely must be combined with dietary modification and other behavioral techniques. This is the shortfall of treatments recommended by many doctors, even urologists, who do not specialize in the treatment of this problem. If the appropriate combination of treatments are not used, the incontinence problem will certainly continue. For those patients failing combined treatments for urge incontinence, biofeedback training is very useful.

Biofeedback training entails the use of various instruments which promote awareness on the part of the patient concerning the location, strength and vitality of the pelvic floor muscles which control urinating. This treatment is commonly performed in the urologist's office. Small patch electrodes are attached to the skin overlying the muscles in question. Alternatively, a small vaginal probe may be used. Either method allows a machine to detect the response of the pelvic floor muscles to attempts by the patient to perform Kegel exercises, as well as attempts to relax the pelvic floor. The machine produces a video screen image which graphically informs the patient how well she is doing.

"In many cases, urge type urinary incontinence (UUI) resolves entirely with biofeedback training."

The combination of the use of the machine and the coaching by the female Urology Center nurse results in improvement of the urinary incontinence in almost every case. In many cases, urge type urinary incontinence (UUI) resolves entirely with biofeedback training. Once again however, Kegel exercises and other behavioral techniques must be continued indefinitely, even after the biofeedback training has been completed.

One of the most innovative and relatively noninvasive treatments for incontinence is endoscopic collagen injection. The same collagen used in cosmetic/plastic surgical procedures is used for incontinence. This procedure is most commonly used for women with problems of the urethra due to intrinsic sphincter deficiency (ISD). The urethra is the natural tube through which urine passes out of the body. The procedure involves only cystoscopy under local anesthetic with injection of collagen into the lining of the urethra. This produces bulking of the tissues around the urethra, resulting in improved coaptation of the walls of the urethra.

"Collagen injection is often performed in the doctor's office."

Collagen injection is often performed in the doctor's office. In properly selected patients collagen injection is highly effective in producing immediate dryness. Unfortunately, even though collagen injection is relatively simple to administer, relatively painless and often effective, the results are not generally long-lasting and repeated procedures are usually necessary. More recently, another commercially available injectable carbon material has become available. While there are theoretical advantages with the use of this newer material, the results are not necessarily better than the results with collagen injection.

Without question, the greatest advancement in the treatment of stress urinary incontinence has been the ... "sling" procedure.

Without question, the greatest advancement in the treatment of stress urinary incontinence has been the development of pubovaginal sling surgery, or simply a "sling" procedure. Sling surgery involves placement of strong sling material beneath the urethra which is suspended from above, behind the pubic bone. The sling material functions somewhat like a hammock within which the urethra rests. The goal of the surgery is to support the urethra and bladder neck to produce support and closure of the urethra, preventing leakage of urine during physically stressful activities such as coughing, sneezing, lifting, straining, standing, walking and the like.

The sling procedure has been proven to be as effective, if not more effective, than any other form of treatment.

The sling procedure has been proven to be as effective, if not more effective, than any other form of treatment. While the first sling procedures were performed in the early 1900s, progressive improvements have been made. Even as late as the 1990s, the procedure was more invasive and more complex than is presently the case. In the 1990s most urologists did not perform sling surgery because of the popularity of other "easy to perform" surgeries which were subsequently shown to be inadequate to stop incontinence in many patients. As previously discussed, these outdated surgeries include such procedures as the so-called "bladder tack surgery", "bladder neck suspension surgery", "Raz", "Stamey", "Pereyra", "Kelly Plication" and others. Doctors were eager to perform the less involved (but ultimately inadequate) surgeries. Furthermore, since many surgeons were unfamiliar with how to perform the sling procedure, they were logically apprehensive about possibly causing complications. As time when on, these easy to perform procedures began to fail, especially in active women and in overweight women. Additionally, surgeons did not clearly understand under which circumstances a sling should be performed. That is, they did not know for which patients the procedure was best suited.

In the early 1980s and 1990s a urologist in Houston, Texas popularized sling surgery by defining the patient population in which it should be performed. He used bladder pressure (urodynamic) testing to demonstrate the effectiveness of this technique under certain well defined conditions. Other urologists modified the technique but until the late 1990s the sling procedure still required surgical incisions of both the vagina and the skin of the lower abdomen. Furthermore, the substance used for the sling material itself had to be harvested from the patient. This sometimes required additional skin incisions or a total of three surgical incisions.

In the late 1990s materials and equipment were developed which made the pubovaginal sling procedure less invasive, faster and much easier to perform. These developments popularized the sling procedure with physicians who were previously uncomfortable performing such involved surgery. Since then, the sling procedure has become widely available. Even much less experienced physicians now perform the procedure.

"Dr. Watson has been performing sling procedures throughout the 1990's and ... 2000's. ... Skin incisions are rarely if ever necessary."

Dr. Watson has been performing pubovaginal sling procedures throughout the 1990s and into the 2000s. He is familiar with nearly every technique, new or old. He was the first physician in the local area to perform these procedures and he continues to perform sling procedures on a regular basis with excellent results. Over about the last three years, the procedure has been performed on strictly an outpatient basis. The procedure is performed in the operating room at either a hospital or at an outpatient surgery center. Most patients opt to undergo a general anesthetic and they experience no pain during the procedure. Skin incisions (other than inside the vagina) are rarely if ever necessary. Only a small opening in the lining of the vagina is used. It is no longer necessary to harvest sling material from the patient, thus preventing the need to make extra incisions. Other non-synthetic sling materials are now readily available.

Before having the sling procedure, always ask your doctor to be certain what material he or she plans to use.

Despite the fact the some clinical studies have demonstrated short-term safety of the use of synthetic polypropylene (Prolene) mesh, many urologic surgeons are concerned that synthetic materials such as this should not be used as sling material for fear of significant complications. Although the urologic surgeons of the Urology Center do not routinely use Prolene mesh, patients should be aware that other urologists are regularly using this material during surgery. Before having the sling procedure, always ask your doctor to be certain what material he or she plans to use.

Postoperatively, patients are observed in the hospital for several hours after which the bladder catheter is removed and patients urinate. Approximately ninety percent of patients urinate successfully and are discharged home several hours after surgery. At such time patients are urinating but no longer accidentally leaking urine with coughing, sneezing or similar physically stressful moves. Stress urinary incontinence is almost always cured. Ninety-five percent of patients no longer have stress urinary incontinence. A small percentage of patients require use of a temporary catheter. A minority of patients do experience urge type incontinence which is generally alleviated by using medications such as Ditropan or Detrol along with behavioral techniques.

We are very proud to offer this highly effective but minimally invasive, contemporary [sling] procedure which has helped so many women with the chronic problem of unwanted urinary leakage.

The vast majority of patients undergoing the sling procedure are extremely happy to have undergone procedure to become dry. Most indicate that they experience little if any discomfort at any time after the procedure. Again, most patients are discharged to go home several hours after the procedure has been completed. Patients miss very little work or other activity because they recover so quickly. We are very proud to offer this highly effective but minimally invasive, contemporary procedure which has helped so many women with the chronic problem of unwanted urinary leakage.

Urinary incontinence can be a very complex medical problem with potentially serious causes. A urologist specializing in urinary incontinence ... is the most qualified medical professional for the accurate characterization and treatment of all forms of urinary incontinence.

Incontinence is abnormal at any age but it is not a natural part of aging. Noninvasive or minimally invasive treatments such as collagen injection and sling procedures are now routinely available and new FDA approved medications have been proven to be safe and effective. Surgical therapy has vastly improved with success rates higher than ever. Now more than ever, women with urinary incontinence have more options available and there is no reason that anyone should have to live with pads, diapers, odor and wetness. Urinary incontinence can be a very complex medical problem with potentially serious causes. A urologist specializing in urinary incontinence evaluation and treatment is the most qualified medical professional for the accurate characterization and treatment of all forms of urinary incontinence. No other physician specialty group has the comprehensive training required to safely evaluate incontinent patients, exclude potentially serious causes of incontinence and effectively treat this complex problem. Effective treatment is readily available at the Urology Center. We welcome your questions.

Patient references are available on request by contacting us at:

Nurse@theUrologyCenter.org

(985) 345-5500

(985) 626-9910

If after seeing our doctors, you would like to speak or meet with another patient who has had similar urology problems or surgery, the appropriate arrangements will be made at your request.