Friday, December 19, 2014

Urinary Incontinence

Definition

Urinary incontinence is the inability to control urination.

Description

There are five types of urinary incontinence: stress incontinence, urge incontinence, overflow incontinence, mixed incontinence and functional or environmental incontinence.

Stress incontinence is the most common type of urinary incontinence and happens when a person leaks urine when they cough, sneeze, exercise or do anything that puts pressure on the bladder.

Urge incontinence occurs when the bladder muscles are too active. People with urge incontinence lose urine as soon as they feel a strong desire to go to the bathroom.

Overflow incontinence is the feeling of never completely emptying the bladder.

Mixed incontinence is the combination of stress and urge incontinence.

Functional or environmental incontinence occurs when people cannot get to the toilet or get a bedpan when they need it. The urinary system may work well, but physical or psychological disabilities prevent normal toilet usage.

Causes

Urinary incontinence can be caused by temporary problems, such as urinary tract infection, vaginal infection or irritation, constipation, obesity, smoking, frequent, high-impact aerobics or effects of medicine. Incontinence can also be caused by other permanent conditions, such as:

  • Aging (bladder holds less and urine stream may be weaker)
  • Weakness of muscles that hold the bladder in place
  • Weakness of bladder itself
  • Weakness of the urethral sphincter muscles
  • Weakness of the pelvic muscles due to pregnancy, followed by a long, difficult vaginal birth
  • Overactive bladder muscles
  • Blocked urethra (caused by prostate enlargement in men)
  • Hormone imbalance in women
  • Neurological disorders
  • Prolapsed uterus
  • Structural abnormalities in the urethra
  • Immobility
  • Diabetes
  • High calcium levels in the blood

Women are far more prone to the urinary incontinence problems than men for several reasons. For one thing, childbirth exerts a heavy toll on the bladder and the sphincter muscle that controls the urethra (the canal that carries urine from the bladder out of your body). Additionally, the loss of female hormones after menopause leads to a thinning and weakening of the urethral lining that is supposed to keep the bladder closed except during urination.

Diagnosis

The doctor will talk to you about your medical history as well as your urinary habits. A vaginal and rectal examination will also be performed. The vaginal exam can reveal anatomic causes, such as a dropped bladder (cystocele), a prolapsed uterus or structural abnormalities in the urethra. A rectal exam is necessary to assess the sphincter tone and possible fecal backup.

A battery of laboratory and diagnostic tests will also be performed. The laboratory tests include blood and urine samples. The diagnostic tests may include a cystoscopic examination, post-void residual (PVR) measurement, stress test and urodynamic testing.

The cystoscopic examination is a procedure in which a small tube with a telescope attached, is inserted into the bladder so the doctor can look for any abnormalities in the bladder and lower urinary tract. PVR measurement measures how much urine is left in the bladder after urinating by placing a small soft tube into the bladder. A stress test looks for urine loss when stress is put on the bladder muscles. Urodynamic testing involves inserting a small tube into the bladder and examining the bladder and urethral sphincter function.

Treatment

Stress incontinence can be treated in one or more of the following ways:

1. Behavioral Techniques

Behavioral treatments include pelvic muscle rehabilitation, retraining the bladder, weight loss and dietary changes, such as alleviating caffeine-based and carbonated beverages, citrus foods and juices, chocolate, highly spicy foods and alcohol.

Pelvic muscle rehabilitation includes pelvic muscle exercises, biofeedback therapy, vaginal weight training and pelvic floor electrical stimulation. These techniques are recommended to strengthen the muscles around the vagina and urethra. Pelvic muscle exercises (commonly known as "Kegels") involve contracting the muscle of the urethra, vagina and rectum for a period of time and then relaxing them. For women who have trouble kegeling, biofeedback training can help. Several electrodes are placed on the women's abdomen and a probe is placed inside the vagina. A monitoring device displays the force of the muscle contraction so the woman can tell if she is contracting the correct muscles and how strongly she should be squeezing.

Vaginal weight training uses a weighted vaginal cone inserted by a woman into the vagina twice daily and worn for 15 minutes. To keep the cone from coming out, the woman tries to retain it by contracting the vaginal muscles. Pelvic floor electrical stimulation uses a battery-operated electrode that is placed in the vagina or rectum whereby electrical impulses are delivered. This impulse triggers muscle contractions that help strengthen the pelvic floor.

Bladder training. People are taught to "hold on" for increasing amounts of time and to void at regular, scheduled intervals. This technique teaches patients to resist the urge to void and gradually expands the intervals between voiding.

Weight loss. Losing extra pounds, especially in the abdomen, can relieve pressure on the bladder and pelvic floor muscles.

2. Medication

Stress incontinence can also be treated with medications that increase the contractility of the sphincters at the bladder neck. The most effective medications are ephedrine, pseudoephedrine, phenylpropranolamine hydrochloride and imipramide.

If a woman is past menopause and incontinence is due to the thinning or drying of urethral walls, a vaginal estrogen cream is recommended.

Collagen implants are also an option that some physicians use to treat stress incontinence. This treatment involves inserting a viewing instrument (called a cystoscope) into the urethra. A needle is then passed through the cystoscope where small amounts of collagen are injected into the lining of the urethra. These injections add bulk to the tissues of the urethra, closing the gap that allowed leakage.

3. Surgery

Surgery can be 90 percent successful in women with severe stress incontinence. The vaginal sling operation creates a hammock under the urethra to give support. More complicated surgical procedures include implantation of an artificial sphincter (a cuff which can be inflated to squeeze the urethra, impeding urine flow) or laparoscopic bladder neck suspension. In this procedure, three incisions are made in the abdomen and sutures are used to reposition the bladder neck.

Urge incontinence can be treated in one or more of the following ways:

1. Behavioral techniques

Bladder training. People are taught to "hold on" for increasing amounts of time and to void at regular, scheduled intervals. This technique teaches patients to resist the urge to void and gradually expands the intervals between voiding.

2. Medication

Urge incontinence may be treated by various types of drugs that work different ways to increase bladder capacity. The most effective ones are propantheline, oxybutynin, hyosyamine sulfate, imipramine hydrochoride, flavoxate hydrochloride and dicyclomine hydrochloride. A new medication, tolterodine (Detrol), has become popular for treating this condition.

3. Surgery

Laparoscopic bladder neck suspension is one surgical alternative to treating urge incontinence. In this procedure, three incisions are made in the abdomen and sutures are used to reposition the bladder neck. Another surgical procedure called Percutaneous Bladder-neck Stabilization (PBNS) is also recommended. In this procedure a tiny incision is made at the pubic hairline and screws and sutures are used to stabilize the bladder neck.

Overflow incontinence may be treated with medications, such as pazosin, terazosin or doxazosin.

Mixed incontinence: See the Stress and Urge Incontinence treatment sections for treatment methods.

Functional or Environmental incontinence incontinence can be addressed by providing absorbent undergarments and accessible bedpans or toilets. Toileting assistance, such as routine/scheduled toileting, habit training and prompted voiding may also help the problem.

Questions

What type of incontinence is it?

What is causing it?

What are treatment options?

Will medication help?

Is bladder surgery necessary?

How can the bladder be strengthened?