Urinary Incontinence


YOUR BODY'S DESIGN FOR URINARY CONTROL


If you live with a bladder control problem you are not alone. Over 30 million Americans, both men and women, suffer from the involuntary loss of urinary control. While there may be many different causes and degrees of severity, one thing is certain: bladder control problems are not normal in adults of any age. Most problems can be treated successfully at any age. More than ten billion dollars are spent each year on this condition and, of this, one billion is spent on adult diapers. Overactive bladder and urinary Incontinence can lead to embarrassment, prevent those affected from participating in life's activities as they would like, and leads to social isolation. The information below covers Overactive Bladder and Urinary Incontinence.


WHAT IS YOUR BLADDER AND HOW DOES IT WORK?


Three sets of muscles control urine. One set is the bladder muscle itself. The second set is sphincter muscles that open and close the urethra and the third set is the pelvic floor muscles. They support the uterus, rectum and the bladder. The bladder is the muscle that sits just under your pubic bone and is connected to the kidneys. The two tubes (ureters) bring urine made by the kidneys down to the bladder. The bladder has two main jobs:

  • To store urine. Every time you eat or drink, your body absorbs liquids. The kidneys filter out waste products from the blood and make urine.
  • To empty the urine out that it has stored or "to void".

When the bladder is trying to store urine its job is to relax. The bladder is helped out with its storage function by two muscles, the internal sphincter and the external sphincter. These sphincters are muscles too and their job is to squeeze down tight to prevent loss of urine during storage. Pelvic floor muscles under the bladder also help keep the urethra closed. Urine stays inside the bladder when the sphincter and the pelvic floor muscles are tight. When the bladder is trying to empty urine its job is to contract and the sphincters help out here too by relaxing, allowing urine to pass through. Bladder control means you urinate only when you intend. For good bladder control, all parts of your system must work together. The pelvic muscles must hold up the bladder and the urethra. The sphincter muscles must open and shut the urethra and the nerves must control the muscles of the bladder and the pelvic floor.

HOW DOES YOUR BLADDER KNOW WHAT TO DO?

The slight need to urinate is sensed when urine volume reaches about one half of the bladder's capacity. When your bladder is full, nerves in your bladder signal the brain that it is full and you get the urge to go to the bathroom. Your brain sends signals through nerves in your spinal cord that tell the large bladder muscle called the detrusor (layered smooth muscle that surround the bladder) when to relax and when to contract. Once stimulated, the detrusor contracts into a funnel shape ready to expel the urine. The brain also helps to co-ordinate the bladder, the sphincters and pelvic floor muscles so that they are working together to relax and to let the urine through. So, conditions that affect brain function and spinal cord function often affect a person's ability to control urination.

TYPES OF URINARY INCONTINENCE:

The key to accurate diagnosis of urinary incontinence is consideration of all possible causes during the initial assessment. Most cases of urinary incontinence fall under one of the following these major subtypes: stress incontinence, urge incontinence, mixed incontinence, overflow incontinence, or functional incontinence.

STRESS INCONTINENCE:
Stress incontinence is the involuntary loss of urine during an increase of intra-abdominal pressure produced from activities such as coughing, laughing, lifting or exercising. The ultimate reason for stress incontinence is that the urethra fails to seal completely. The underlying abnormality is typically urethral hypermobility caused by a failure of the normal anatomic supports of the urethral-bladder junction, or bladder neck. Normally, increased intra-abdominal pressure is transmitted evenly across the bladder body and neck, but when poor anatomic support allows the bladder neck to be displaced outside the abdominal cavity during such activities as coughing or laughing, a disproportionate rise in bladder pressure over urethral pressure results in urine loss. Loss of bladder neck support is often attributed to nerve, muscle and connective tissue injury occurring during vaginal delivery, however, childbirth is certainly not the only contributing factor.

The lack of normal intrinsic pressure within the urethra—known as intrinsic urethral sphincter deficiency—is another factor leading to stress incontinence. Advanced age, inadequate estrogen levels, previous vaginal surgery and certain neurologic lesions are associated with poor urethral sphincter function. The diagnosis is made by a combination of assessing the severity of leakage and conducting specialized tests such as urodynamics and cystourethroscopy.

URGE INCONTINENCE:
Involuntary loss of urine preceded by a strong urge to void, whether or not the bladder is full, is a symptom of the condition commonly referred to as “urge incontinence.” To expand the number and types of patients eligible for clinical trials, the U.S. Food and Drug Administration (FDA) adopted the term “overactive bladder” to describe a clinical syndrome that includes not only urge incontinence, but urgency, frequency, dysuria and nocturia as well. Other commonly used terms such as detrusor instability and detrusor hyperreflexia refer to involuntary detrusor contractions observed during urodynamic studies that are caused by neurologic condition.

Some cases of urge incontinence or OAB can be attributed to specific conditions, such as acute or chronic urinary tract infection, bladder cancer and bladder stones, but many cases result from an idiopathic inability to suppress detrusor contractions.

MIXED INCONTINENCE:
Women with genuine stress incontinence and overactive bladder or urge incontinence are said to have mixed incontinence. For these patients, it is helpful to identify the most bothersome symptom and treat accordingly.

OVERFLOW INCONTINENCE:
Overflow incontinence is urine loss associated with overdistension of the bladder. Patients can present with frequent or constant dribbling, overactive bladder or stress incontinence. Overdistension is typically caused by an underactive bladder (detrusor) muscle and/or outlet obstruction. The detrusor muscle may be underactive secondary to drug therapy (especially with psychotropic medications) or conditions such as diabetic neuropathy, low spinal cord injury, radical pelvic surgery and multiple sclerosis. Outlet obstruction in women is almost always a result of urethral occlusion from pelvic organ prolapse or previous anti-incontinence surgery.

FUNCTIONAL INCONTINENCE:
Men and women with urinary incontinence caused by chronic impairment of physical or cognitive function, or both, are said to have functional incontinence. These patients have overactive bladder relative to the ability or speed with which they can get to the toilet. Because many functionally impaired persons can also have other types of urinary incontinence that may respond to specific treatments, pure functional incontinence should be a diagnosis of exclusion.


CAUSES OF INCONTINENCE:

The most common types of urinary incontinence in women are stress urinary incontinence and urge urinary incontinence. Women with both problems have mixed urinary incontinence. Stress urinary incontinence is caused by loss of support of the urethra which is usually a consequence of damage to pelvic support structures as a result of childbirth. It is characterized by leaking of small amounts of urine with activities which increase abdominal pressure such as coughing, sneezing and lifting. Additionally, frequent exercise in high-impact activities can cause athletic stress incontinence to develop. Urge urinary incontinence is caused by uninhibited contractions of the detrusor muscle. It is characterized by leaking of urine in association with insufficient warning to get to the bathroom in time.



DIAGNOSIS OF INCONTINENCE:

A careful history taking is essential especially in the pattern of voiding and urine leakage as it suggests the type of incontinence faced. Important points to note include number of pregnancies and labor history, chronic straining or heavy lifting, medications taken, pelvic or spine surgery, and any muscular or neurological disease states.

The physical examination will focus on looking for signs of medical conditions causing incontinence, such as abnormalities of the pelvic anatomy, pathology of the bladder lining or urethra, constipation, or neurologic changes.

A test often performed is the measurement of bladder capacity and residual urine for evidence of poorly functioning bladder muscles.

Patients are often asked to keep a diary for a day or more, up to a week, to record the pattern of voiding, noting times and the amounts of urine produced.

Research projects that assess the efficacy of anti-incontinence therapies often quantify the extent of urinary incontinence. The methods include the pad test, measuring leakage volume; using a voiding diary, counting the number of incontinence episodes (leakage episodes) per day; and assessing of the strength of pelvic floor muscles, measuring the maximum vaginal squeeze pressure.

  • Urodynamic testing.  A pressure monitor measures and records the pressure within your bladder. This test helps measure your bladder strength, urethral sealing pressure, and urine flow pattern. It also gives a measurement of bladder capacity and residual urine for evidence of poorly functioning bladder muscles. Urodynamic evaluation is an important tool for distinguishing the type of incontinence you have.
  • Stress Test. The patient relaxes, then coughs vigorously. Any urine loss is noted.
  • Urinalysis. Urine is tested for infection, urinary stones, or other contributing causes.
  • Ultrasound. Sound waves are used to visualize the kidneys, ureters, bladder and urethra.
  • Cystoscopy. Your doctor inserts a thin tube with a tiny lens into your urethra. Your doctor can check for, and possibly remove, abnormalities in your urinary tract.
  • Cystogram. Your doctor inserts a catheter into your urethra and bladder and injects a special dye. As you urinate and expel this fluid, X-ray images of your bladder help reveal problems with your urinary tract.
  • Renal, bladder and pelvic ultrasound. All levels of the urinary tract are checked for abnormalities.



MECHANISM OF INCONTINENCE:

Continence and micturition involve a balance between urethral closure and detrusor muscle activity. Urethral pressure normally exceeds bladder pressure, resulting in urine remaining in the bladder. The proximal urethra and bladder are both within the pelvis. Intraabdominal pressure increases (from coughing, sneezing or lifting) are transmitted to both urethra and bladder equally, leaving the pressure differential unchanged, resulting in continence. Normal voiding is the result of changes in both of these pressure factors: urethral pressure falls and bladder pressure rises.

The body stores urine — water and wastes removed by the kidneys — in the urinary bladder, a balloon-like organ. The bladder connects to the urethra, the tube through which urine leaves the body.

During urination, detrusor muscles in the wall of the bladder contract, forcing urine out of the bladder and into the urethra. At the same time, sphincter muscles surrounding the urethra relax, letting urine pass out of the body. Incontinence will occur if the bladder muscles suddenly contract (detrusor muscle) or muscles surrounding the urethra suddenly relax (sphincter muscles).


TREATMENTS FOR INCONTINENCE:

Treatment for urinary incontinence depends on the type of incontinence, its severity and the underlying cause. A combination of treatments may be needed. Your doctor is likely to suggest the least invasive treatments first and move on to other options only if these techniques fail.

Behavioral techniques:

  • Bladder training, to delay urination after you get the urge to go. You may start by trying to hold off for 10 minutes every time you feel an urge to urinate. The goal is to lengthen the time between trips to the toilet until you're urinating only every two to four hours.
  • Double voiding, to help you learn to empty your bladder more completely to avoid overflow incontinence. Double voiding means urinating, then waiting a few minutes and trying again.
  • Scheduled toilet trips, to urinate every two to four hours rather than waiting for the need to go.
  • Fluid and diet management, to regain control of your bladder. You may need to cut back on or avoid alcohol, caffeine or acidic foods. Reducing liquid consumption, losing weight or increasing physical activity also can ease the problem.


PELVIC FLOOR MUSCLE EXERCISES:

Your doctor may recommend that you do these exercises frequently to strengthen the muscles that help control urination. Also known as Kegel exercises, these techniques are especially effective for stress incontinence but may also help give better control with urge incontinence.

To do pelvic floor muscle exercises, imagine that you're trying to stop your urine flow. Then:

  • Tighten (contract) the muscles you would use to stop urinating and hold for five seconds, and then relax for five seconds. (If this is too difficult, start by holding for two seconds and relaxing for three seconds.)
  • Work up to holding the contractions for 10 seconds at a time.
  • Aim for at least three sets of 10 repetitions each day.

To help you identify and contract the right muscles, your doctor may suggest you work with a physical therapist or try biofeedback techniques.

Electrical Stimulation or Biofeedback:

Electrodes are temporarily inserted into your rectum or vagina to stimulate and strengthen pelvic floor muscles. Gentle electrical stimulation can be effective for stress incontinence and urge incontinence, but you may need multiple treatments over several months.


MEDICATIONS COMMMONLY USED TO TREAT INCONTINENCE:

  • Anticholinergics. These medications can calm an overactive bladder and may be helpful for urge incontinence. Examples include oxybutynin (Ditropan XL), tolterodine (Detrol), darifenacin (Enablex), fesoterodine (Toviaz), solifenacin (Vesicare) and trospium (Sanctura).
  • Mirabegron (Myrbetriq). Used to treat urge incontinence, this medication relaxes the bladder muscle and can increase the amount of urine your bladder can hold. It may also increase the amount you are able to urinate at one time, helping to empty your bladder more completely.
  • Alpha blockers. In men with urge or overflow incontinence, these medications relax bladder neck muscles and muscle fibers in the prostate and make it easier to empty the bladder. Examples include tamsulosin (Flomax), alfuzosin (Uroxatral), silodosin (Rapaflo), terazosin (Hytrin) and doxazosin (Cardura).
  • Topical estrogen. Applying low-dose, topical estrogen in the form of a vaginal cream, ring or patch may help tone and rejuvenate tissues in the urethra and vaginal areas. This may reduce some of the symptoms of incontinence.


INTERVENTIONAL THERAPIES THAT ARE SUCCESSFUL IN TREATING INCONTINENCE:

  • Bulking material injections. A synthetic material is injected into tissue surrounding the urethra. The bulking material helps keep the urethra closed and reduce urine leakage. This procedure is generally much less effective than more-invasive treatments such as surgery for stress incontinence and usually needs to be repeated regularly.
  • Botulinum toxin type A (Botox). Injections of Botox into the bladder muscle may benefit people who have an overactive bladder. Botox is generally prescribed to people only if other first line medications haven't been successful.
  • Neuromodulation: Urgent PC or Interstim Therapy. A needle placed at the TIbial Nerve near the ankle or a device resembling a pacemaker is implanted under your skin to deliver painless electrical pulses to the sacral nerves involved in bladder control. Stimulating the sacral nerves can control urge incontinence if other therapies haven't worked.


SURGICAL INTERVENTION FOR INCONTINENCE:

If other treatments aren't working, several surgical procedures can treat the problems that cause urinary incontinence:

  • Sling procedures. A thin strip of an inert synthetic tape is used to create a pelvic sling around your urethra and the area of thickened muscle where the bladder connects to the urethra. The Monarc Sling is designed to provide support that has been lost with tissue stretching and weakness of the pelvic floor and helps keep the urethra closed, especially when you cough or sneeze. This procedure is used to primarily treat stress incontinence.

  • Prolapse surgery. In women with mixed incontinence and pelvic organ prolapse, surgery may include a combination of a sling procedure and prolapse surgery.