Urinary Incontinence

Urgency urinary incontinence refers to urinary incontinence occurring with a sudden desire to urinate and loss of urine before reaching the bathroom. The incontinence episode is often triggered when hearing or feeling water, such as when washing hands, social situations, such as opening the door upon arriving home, or even commonly performed daily habits, such as standing from a seated position. The loss of urine is usually a larger amount and a woman usually has no way of stopping it. Due to the uncontrolled urge to void (urinate), patients often void more often than normal (more than 8 voids in 24 hours) and wake up more than once at night to void. This type of incontinence is often caused by bladder spasms. Some patients may only have urgency and not necessarily have leakage of urine when the compelling desire to urinate is noted; however, frequency and discomfort caused by this condition impacts their life negatively. This urgency is a component of overactive bladder syndrome.

What to expect

If you have urgency incontinence symptoms, your evaluation will begin with a comprehensive history and exam to assess pelvic floor support and strength, gross neuromuscular function, urinalysis and screening for voiding dysfunction. You may be asked to complete a voiding diary. Occasionally, urodynamic studies and/ or cystoscopy are also needed.

Pelvic floor rehabilitation

Many patients notice that their incontinence symptoms started when their pelvic floor muscle strength began to weaken. Improvement and regaining continence is commonly seen when patients begin doing their "kegel exercises" at home. Additional improvements can be achieved with the rehabilitation approach when a specialist in pelvic floor physical therapy assesses the patient and assists in personalizing the exercise routine to meet the patient's specific needs. Sometimes biofeedback is also introduced by the therapist to assist the patient in isolating and strengthening the weakened pelvic floor muscles. Pelvic floor physical therapy can benefit both urinary urgency incontinence, but also stress urinary incontinence.

Medical treatment – overactive bladder medications

Oral/transdermal medications for overactive bladder remain a first line treatment with the primary difference between drugs being the differing side effects. Most drugs show their efficacy after one month. Occasionally, a drug will be less efficacious over time and dose modification or switching from one medication to another can improve results. The sympathomimetics are the newer products on the market with good control of the overactive bladder symptoms. If the overactive bladder medications do not adequately treat incontinence, or patients experience side effects from the drug, other options include sacral neuromodulation and Botox bladder injections.

Surgical treatments

• Sacral neuromodulation for overactive bladder management
  When overactive bladder medication does not adequately manage incontinence symptoms, sacral neuromodulation is another option. We test the nerve that controls the bladder initially and if your symptoms and leakage improves by at least 50%, then we can proceed with the actual placement of the pacemaker. This is an FDA suggested treatment for overactive bladder that has not responded well to oral treatments. Through a very short outpatient procedure that only involves mild sedation, a bladder pacemaker and wire lead are placed. Once activated, the pacemaker re-educates the nerve that controls bladder activity. The bladder pacemaker is placed under the skin in a concealed area through an incision often smaller than an inch in size above the buttock where no one can see it. The pacemaker battery requires replacement only every 5-7 years. You can adjust the pacemaker using a remote control so that it matches your needs and comfort level. Like other pacemakers such as for the heart, this equipment is not MRI compatible yet, although newer models are to be released that will be MRI compatible. This treatment option may not be appropriate for you however if you have a spinal cord lesion or have to have frequent MRIs on a regular basis.
• Botulinum toxin for overactive bladder management (BOTOX®)
  When overactive bladder medication does not adequately manage incontinence symptoms, injection of Botox into the bladder is another option. Botox is a chemical that inhibits the activity of the muscle. When injected into a specific location of the bladder in small measured doses, the result is often resolution of urinary urgency incontinence. This FDA approved procedure is commonly performed on an outpatient basis. The results last 6-9 months and may require repetition. There is less than 10% incidence of urinary retention reported with Botox use in the bladder. Learning self-catheterization may be necessary for transient retention.

The Women's Health Urogynecology and Female Pelvic Medicine fellowship-trained physicians are highly experienced with managing overactive bladder and develop a care plan just for you.

Stress urinary incontinence refers to loss of urine during a physical "stress" or activity where a force causes an increase in intra-abdominal pressure. Common examples include laughing, coughing, sneezing or jumping. Often patients will be limited in their ability to engage in exercise and sport activities due to their incontinence. This type of incontinence is caused by anatomic changes in the support of the urethra and bladder, and often is associated with weakness of pelvic floor muscles supporting the bladder.

What to expect

If you have stress urinary incontinence symptoms, your evaluation will begin with a comprehensive history and exam to assess pelvic floor support and strength, gross neuromuscular function, urinalysis and screening for voiding dysfunction. You may be asked to complete a voiding diary. Occasionally, urodynamic studies and/ or cystoscopy are also needed.

Pelvic Floor Rehabilitation

Many patients notice that their incontinence symptoms began when their pelvic floor muscle strength begins to weaken. In stress urinary incontinence, a loss of support and weakening of the urethra contributes to changes in the ability of the urethra to hold urine. Improvement in regaining continence is commonly seen when patients begin doing their "Kegel exercises" at home. Additional improvements can be achieved with this approach when a specialist in pelvic floor physical therapy assesses the patient and assists in personalizing an exercise routine to meet the patient's specific needs. Sometimes biofeedback is also introduced by the therapist to assist the patient in isolating and strengthening the weakened pelvic floor muscles. Pelvic floor PT can benefit both stress urinary incontinence and urge urgency incontinence.

Pessary

A pessary is a device, usually made of silicone that is placed in the vagina to maintain support whether for incontinence or prolapse. Patients often elect to use a pessary if they want to avoid surgery, or have plans for childbearing before they will be able to undergo definitive surgical therapy. There are several pessaries that are designed to provide support under the urethra and can be an effective therapy for stress incontinence. Also, some patients who are only bothered by their stress incontinence when they run or exercise prefer to use these pessaries specifically during their workout activity.

Surgery

Your physician may suggest a sling procedure to support the urethra. Slings are considered to be the gold standard surgical therapy for stress incontinence. Slings are often made of mesh. Your physician will only suggest a sling that is FDA monitored. Sling placement is a procedure that takes less than an hour, can be done on an outpatient basis, and is cosmetic (with only two very small cuts within the pubic hair below the bikini line, each measuring less than a quarter of an inch).

Urethral bulking

Is a treatment for incontinence but often used for patient who cannot tolerate anesthesia well since this is a treatment performed in the office.

The Women's Health Urogynecology and Female Pelvic Medicine fellowship-trained surgeons are highly experienced and trained so as to help you manage your stress urinary incontinence and provide you with expert medical and surgical management.

Mixed urinary incontinence refers to conditions where both urgency urinary incontinence and stress urinary incontinence may be present and impacting a patient’s life concurrently. Treatment often requires management of both, keeping in mind that each is treated differently.

It is important that the proper evaluation be made to determine the type of incontinence. Each type is treated differently. Some require only medical treatment, whereas other types require surgical management. Incontinence often has multiple etiologies. To achieve a successful outcome, each of the underlying causes must be identified and addressed in the treatment plan.