Urinary Incontinence

I leak and everyone I know leaks too… is this normal?

Written by Kurian Thott, MD When it comes to leakage of urine it is by and large one of the more hidden and least discussed health care issues afflicting women today. By the most recent estimates about 30-40 million women in North America experience involuntary loss of urine at some point in their life, this number is only expected to rise substantially in the next 10 years as the baby boomer generation becomes older. In the past doctors were reluctant to engage women in the conversation of leakage because for many it was either too hard to treat or not enough experienced providers in the community to refer them too. Added to this most women when asked did not claim it to be a major issue, as they assumed that since their mom and aunt and sister are going through this it must be one of those crosses women are asked to bear. Advances in science and specialized tests have allowed physicians to understand the disease and now have minimally invasive techniques available to help diagnose and treat women with these issues. The drug companies have done a great job marketing one aspect of incontinence that women may experience. “I gotta go, gotta go…” commercials have been a hit, and many physicians ill equipped to understand the nature of incontinence would write a prescription and send the patient out the door. If they stopped leaking or got a little better, success! However if they didn’t, then they would refer them to a gynecologist or urologist, who may or may not be able to treat them effectively.

The 3 main types of urinary incontinence are urge incontinence, stress incontinence and mixed incontinence.

Urge Incontinence Urge incontinence can be defined as detrusor instability or a dysfunction of the muscles of the bladder that may be due to neuronal dysregulation, bladder irritants or infections. Urge incontinence is what the commercials from the drug companies are aimed at. Urge to go to the bathroom multiple times a day and before you get there you may leak. This can also occur at night where you wake up and find yourself a little wet. Typically this is treated with bladder retraining, biofeedback and Kegel’s exercises and in my practice I will typically wait till after 6-8 weeks of pelvic rehabilitation before starting someone on any medication. Stress Incontinence Stress incontinence can be defined as the involuntary loss of urine with laughing, sneezing, coughing, running, jumping etc. Any type of stress that leads to leakage is stress incontinence. This type of disorder has been amenable to pelvic rehabilitation but also in many cases requires surgery. Sometimes depending on the situation I will perform the surgery first and then have the patient go through pelvic rehabilitation, or vice versa, this will depend on their results after urodynamics testing. Mixed Incontinence Mixed incontinence, as the name implies, is a combination of the two mentioned above and as many can discern may require treatment that incorporates the two treatment modalities mentioned. But once again all this to be properly diagnosed need urodynamics testing to confirm what type of incontinence and to what degree the patient is afflicted will ultimately decide the method of treatment.

So What Is Urodynamics Testing?

To simplify the concept of urodynamics testing, imagine that if a cardiologist needs an EKG to diagnose a heart problem, a gynecologist or urologist needs urodynamics to diagnose a bladder problem. It is a series of measurements that takes bladder pressures, abdominal pressures, bladder wall pressures, and urethral pressures to determine where the problem area is. No one should undergo surgery without having completed urodynamics first. I mentioned bladder irritants before, and these are substances that eventually make their way through our bodies via our kidneys into our bladders. These substances can irritate the lining of the bladder causing detrusor or bladder muscle irritably and urge incontinence. Some of the common culprits are below:
  • Caffeine
  • Alcohol
  • Acidic fruits and fruit juices from oranges, grapefruits, lemons and limes
  • Spicy foods
  • Tomato-based products
  • Carbonated drinks
  • Artificial sweeteners
If you feel that you may be suffering from some form of incontinence seeing your Gynecologist will help determine the best treatment for you. The physicians at the Women’s Health and Surgery Center perform urodynamics in office and have extensive experience in the diagnosis and treatment of urinary incontinence.

Urethroscopy

Urethroscopy is an office procedure that is done with minimal discomfort to the patient. It is used to evaluate the urethra for abnormalities that could be contributing to incontinence. It is also useful in women that have painful urination, or recurrent bladder infections. The opening to the urethra is prepped with a gel that has a numbing effect. After the urethra is numb, a small scope is inserted into the urethra. The doctor is able to see the lining of the urethra and check the condition of the tissues. Careful evaluation is done for any evidence of infection, or infected glands. Also small out-pouches call “diverticula” can be found. These can be responsible for recurrent symptoms of bladder infection (burning and frequency). With the scope in place, a patient with stress incontinence will be asked to cough or “bear down”. The neck of the bladder can frequently be seen to open up during this activity. This helps to confirm the diagnosis of stress incontinence. Also the doctor can make sure that the tissue is healthy and that if surgery is done–it should be successful. Most patients have minimal discomfort with this procedure and can go home immediately afterward. A mild antibiotic may be given for a few days after to prevent infection. Urethroscopy is only useful to evaluate conditions in the urethra. If a bladder problem is suspected, then a more aggressive, but similar technique is used call “cystoscopy”. If cystoscopy is felt to be indicated, then many times a urologist will be consulted for this.

Biofeedback Pelvic Floor Therapy

Biofeedback training is a relatively new treatment for urinary incontinence, however the roots can be traced back to 1940. Dr. Arnold Kegel designed an exercise program to help strengthen the pelvic floor to treat urinary incontinence and pelvic floor problems like cystocele and rectocele. These exercises became known as “kegels.” Unfortunately, many women do not do them correctly, or do not understand how to do them at all. Recent studies have shown that if done correctly, pelvic floor exercises are effective for the treatment of mild to moderate urinary incontinence and other conditions related to pelvic floor weakness.