Urinary Incontinence

The history will guide your physician in diagnosing your problem. Just as there are different causes of UI, there are also different types of UI.

The bladder acts as a reservoir to store urine. It has two functions, to store and to empty urine. Urinary incontinence is the result of failure of one of those functions.

Stress urinary incontinence (SUI)

It occurs when increases in abdominal pressure force open the bladder outlet (urethra) and urine spurts out. This usually happens when weak pelvic floor muscles fail to support the bladder and urethra during coughing, sneezing, lifting, or other strenuous activity.

Childbirth is most often the cause of poor pelvic floor muscle tone. A weakening in the urethral tube that drains the bladder may also cause SUI.

Women with SUI typically experience the loss of a few drops of urine during an accident.

Urge incontinence (OAB)

It is a condition in which the bladder is overactive and empties without one's permission. The bladder is supposed to store urine until there is a socially acceptable time and place to empty it. Then, and only then, the bladder muscle squeezes down to empty. People with urge incontinence may experience a sudden, strong urge to urinate, but fail to make it to the bathroom without leaking.

Bladder infections and lack of astrogen can cause urge incontinence.

Any condition that affects the nervous system such as spinal injuries, stroke or Parkinson's disease may also cause urge incontinence. Women with urge incontinence often urinate very frequently and lose moderate to large amounts of urine when they leak.

Mixed incontinence

It is especially common in older women and occurs when symptoms of both stress and urge types of incontinence are present. Symptoms of one type of incontinence may be more severe than the other. Treatment will depend on which symptom is more bothersome to the patient. Stress, urge, and mixed incontinence - each is a failure of the bladder to store urine.

Overflow incontinence

It is a failure of the bladder to empty completely. As the bladder becomes overfilled, frequent dribbling occurs to release pressure. Overflow incontinence may happen when pelvic organs drop and block the urethra or when certain medications cause the bladder to stop contracting. Swelling of pelvic tissues after childbirth or surgery, injured nerves, or a bladder that is habitually overstretched may also result in overflow incontinence.

Incontinence from surgery is a transient condition that follows such operations as hysterectomies, caesarean sections, lower intestinal surgery, or rectal surgery. This is not considered a diagnostic category. Incontinence can also occur due to other reversible factors, often outside of the urinary tract, such as restricted mobility.

Mobility aids can help remove barriers to self-toileting on a timely basis. Other factors such as arthritis may interfere with managing zippers, buttons, and articles of clothing - or moving quickly enough to reach the toilet.

Pelvic muscle exercises are an important part of the behavioural treatment techniques that help increase bladder control and decrease bladder leakage. These techniques require your conscious effort and consistent participation.

Pelvic muscle exercises, also called pelvic floor muscle or Kegel exercises - after Dr. Arnold Kegel, have been shown to improve mild to moderate urge and stress incontinence. When performed correctly, these exercises help strengthen the muscles that support your bladder. Through regular exercise you can build strength and endurance to help improve, regain, or maintain bladder and bowel control.

The muscles of the pelvic floor are located in the base of your pelvic between your public bone and tailbone.

These muscles have three main functions:

1. They help support the abdominal and pelvic contents from below.
2. They help control bowel and bladder function.
3. They are involved in sexual response. Like other muscles in the body, if they get weak they are no longer efficient at doing their job.

It can be difficult to find the pelvic floor muscles (PFM). They are the ones you use to hold back gas or stop a urine stream. Squeeze and lift the rectal area as if you were trying to hold back gas. For women, carry this movement forward to the vaginal area as well. Try to avoid tightening the buttocks or abdomen.

Another technique used only to help you identify the PFM is to attempt to stop or slow the flow of urine when you go to the bathroom.

Remember to relax and completely empty your bladder when you have finished this test. Do not do this start-and-stop test on a regular basis. It is not a helpful way to exercise the PFM and doing it too often can lead to infections.

There are two types of exercises you should perform to lessen the symptoms of incontinence.

The first exercise is a quick contraction.

The muscles are quickly tightened, lifted up, and than released. This works the muscles that quickly shut off the flow of urine (like a faucet) to help prevent accidents. You should rest for 10 seconds in between contractions.

The second exercise works on the holding ability of the muscles, building a strong dam to hold back urine. The muscles are slowly tightened, lifted up, and help to a count of five. At first, you will probably notice that the muscles do not want to stay contracted for 1-2 seconds.

You should progress slowly over a period of weeks to a goal of 10-second holds.

Now, you are ready to begin:

1. Remember, it is important to exercise only the muscles of your pelvic floor. Do not tense or contract the legs, buttocks, or belly.
2. You should contract the PFM as you blow out, or exhales, then continue to breathe normally as you do the exercises.
3. Remember to relax the body before and after the exercises.
4. In the beginning, it is best to do the exercises lying down so that there is little stress on the muscles. Bend your knees or elevate your legs on a pillow or stool so you are comfortable and your legs are relaxed.

Each of the exercises explained previously can be done with or without assistive devices. If you are using vaginal weights or wands, it is easier for some women to walk around while doing the contractions.

Most people try to perform too many exercises and sacrifice quality.

It is important to remember to stop and rest when you are no longer performing each contraction properly.

To improve muscle function you must challenge the muscles to work harder than normal by exercising them on a regular basis. Start with a set of 5 quick and 20 slow contractions, twice a day. You should progress at your own pace. The amount of time needed to show improvement varies from person to person. Increase the exercise periods as you notice improvement.

Remember, you must continue challenging your PFM for improvement. Your bladder and bowel control can begin to improve in three to four weeks. However, some people take three to six months to see improvement.

Pelvic muscle exercises require a life time commitment. Start your day with a set of pelvic muscle exercises. This is especially important if you have chosen to use vaginal weights or wands. It is easiest to use weights in the morning, as later in the day your muscles tend to become tired.

• Always tighten the PFM before you lift, cough, or sneeze to help hold back the flow of urine.
• Remember, learn to "squeeze before you sneeze".
• Tighten the PFM before you clear your throat blow your nose.
• Use pelvic muscle exercises to help suppress a strong urge to urinate until you can locate an appropriate place to empty your bladder.
• Pelvic muscle exercises should be incorporated into a regular exercise program.

Various devices and techniques have been developed to help you locate, exercise, and rehabilitate the correct muscles.

These include biofeedback training, electrical stimulation, and, for women, vaginal weights and cones.

Biofeedback can be done with a healthcare professional or with a home device. It helps locate the right muscles by sending a signal (biofeedback) when you perform the correct contraction.

Pelvic muscle exercises performed with biofeedback equipment have demonstrated to be highly effective because the machine helps isolate PFM activity and gives an immediate audio or visual indication of successful exercises.

These different training aids have also been known to add discipline to a kegel program - helping people stick with a routine.

Talk to your healthcare provider about these and other ways to assist your

Working With Your Healthcare Provider

Because these muscles are out of sight, they are frequently out of mind and difficult to isolate. If you have any questions or difficulties, be sure to discuss them with your healthcare provider. If you are considering Kegel exercises, it is wise to get proper instructions from a healthcare professional before you invest the time in the program.

In addition to the assistive techniques mentioned previously, bladder retraining, medications, and surgery are also used to treat incontinence.

Sometimes a combination of all or some of these therapies is most helpful in managing and improving your bladder health.

Always consult your doctor before trying anything recommended in this or any other publication that speaks to general health issues.

Most women with urinary incontinence can be significantly improved or even cured. Appropriate treatment depends on obtaining an accurate diagnosis. Everyone with incontinence deserves to be properly evaluated.

The evaluation may include the following:

• A complete medical history with a focus on the incontinence.
• A thorough physical exam that screens for neurological problems and provides a complete pelvic exam
• Post-void residual urine (a measure of the amount of urine left in bladder after urinating)
• Urinalysis to check for infection
• Bladder diary to keep track of frequency and volume urinated
• Urodynamic testing (bladder function tests)
• Cystoscopy - a test in which the doctor looks inside the bladder

Treatment options depend on the underlying diagnosis.

After a diagnosis has been made, the doctor should discuss the many ways to treat the different types of urinary incontinence. Most patients will respond to nonsurgical treatment.

Dietary modification with specific attention to fluid management (the amount of water and other beverages consumed) improves both stress and urges incontinence. Avoiding bladder irritants is a simple first approach to treating UI.

Bladder retraining helps to prevent urgent and frequent urination, both of which can lead to urge incontinence. Retraining gradually helps the patient increase the amount of time between urinations.

Topical estrogen is specifically helpful for women after menopause (change of life when hormone levels decrease). Estrogen restores blood circulation, nerve function, and improves the quality of the tissues that surround the bladder and urethra. Topical estrogens are used in cases of vaginal dryness and atrophy where bladder control problems exist. They are available as a vaginal cream or ring insert and should not be confused with hormone replacement therapy (HRT) because dosages are much lower.

Pelvic muscle exercises can be used to treat stress, urge, and mixed incontinence.

There are several techniques that make it easier to find and use the pelvic muscles correctly. Many women benefit from the use of biofeedback.

Biofeedback uses a mechanical or computerized instrument to measure the activity of the pelvic muscles and immediately show their function to the patient.

Vaginal weights (weighted cone-shaped vaginal inserts), electrical stimulation (a small electrical impulse which causes the muscles to contract) and magnetic therapy (magnetic pulse that causes muscles to contract and relax) may also be used to help the muscles work more efficiently.

Medications used to control urge incontinence help relax the bladder muscle and allow a larger amount of urine to be stored. They include:

• Tolteradine - DetrolTM, DetrolTM LA
• Hycosamine - Levsin
• Oxybutinin - Ditropan, Ditropan XL, OxytrolTM
• Imipramine

Medications that control SUI tighten the bladder opening or urethral sphincter muscle.

They include:

• Pseudoephedrine - Sudafed
• Imipramine - Tofranil

A pessary is a device usually shaped like a ring or cube that is placed in the vagina to help support a dropped bladder (cystocele), or dropped uterus (uterine prolepses, dropped vagina (enterocele), or dropped rectum (rectocele).

These are various forms of hernias.

The pessary provides support for these organs when the muscle support is torn or weakened.

Pessaries may worsen incontinence depending on the underlying problem. There are many bands, and some are designed specifically to reduce stress incontinence.

Internal urethral barriers or inserts are placed into a woman's urethra to prevent unintended urine leakage. As a woman advances this small, single-use, liquid and silicone insert, the soft sleeve slides into and conforms to the urethra, creating an effective seal at the bladder neck. The insert is removed for voiding and discarded. It is replaced by a fresh one if continued protection is desired. Urethral inserts can be associated with an increased risk of urinary tract infections.

Surgery may be indicated to treat stress incontinence when conservative therapy has not been successful.

For patients with severe SUI, surgery may be the first choice of treatment.

The patient's preference should always be a primary factor in making a treatment choice.

The goal of surgery for stress incontinence is to restore the urethra and bladder to their normal position in thee pelvis. Historically the most successful operations (Burch or MMK) were performed through an incision in the lower abdomen. Other operations require a small abdominal as well as a vaginal incision, such as Pereyra, Stamey, Raz,etc.

The most recent, proven procedures involve a vaginal approach and are therefore less invasive, with faster recovery.

Cystocele, or anterior repair, is a vaginal surgery that is no longer considered suitable for treating stress incontinence.

Laparoscopic bladder suspension surgeries usually require a shorter hospital say; however, long term results are not yet available.

A sling procedure is an operation that places a piece of fascia (muscle support tissue or synthetic material) underneath the urethra. This material acts as a hammock-like "sling" to support and compress the urethra, this preventing incontinence.

Injectibles around the urethra may help it close more effectively. Candidates for this treatment have severe stress incontinence with weakened urethral sphincters. Results show that several injections are usually necessary.

New technologies involving heat-related treatments are evolving.