Originally submitted by Dr. Jay Motola on November 22, 2014
Not all urinary incontinence is equal. Many patients can have stress incontinence, which is the involuntary loss of urine that occurs when the intra-abdominal pressure exceeds the ability of the urinary sphincter to maintain the pressure that is transmitted. It is seen with coughing, sneezing, laughing or many other activities resulting in an increased pressure. Urge incontinence occurs when an urge to go to the bathroom suddenly occurs and you are unable to control it, resulting in an inability to get to the bathroom in time and wetting yourself. Mixed incontinence is a combination of stress and urge incontinence.
Simple stress incontinence is easily correctable in most female patients with a simple outpatient procedure known as a sling. Providing that there isn’t a significant amount of descent of the bladder into the vaginal canal (a cystocele), the procedures are very straightforward and are associated with very high success rates. If a cystocele is present, the problem is correctable, but is more complicated. Slings are available for men, too, however success rates are not as good. Male stress incontinence most usually occurs as a result of prior treatment for prostate cancer.
Prior to surgical correction of the problem, there are several nonsurgical options that may be beneficial for patients. The American College of Physicians has published guidelines for females that identify some of these options. Pelvic floor muscle exercises, known as kegels, are somewhat effective for helping to overcome this problem. Many patients who perform these exercises do not do them well, therefore making them ineffective. These exercises are very simple to perform and involve a tightening of the muscles that support the floor of the bladder. Kegel exercises do not help with urge incontinence.
Bladder training is another nonsurgical option, especially for those with urge incontinence. This involves patients controlling their trips to the bathroom by utilizing a timed voiding pattern. When the urge to void occurs, the patient is asked to suppress the urge for a fixed period of time; as training progresses, that interval is lengthened. Another means of doing this is to go to the bathroom only in strict two- or three-hour intervals. Although this is theoretically effective, in clinical practice, many who suffer from incontinence remain so despite these exercises. Biofeedback can be added to the therapy with kegels and bladder training, however efficacy is demonstrated only when patients have stress of mixed urinary incontinence.
The Urgent PC System (also referred to as Percutaneous tibial nerve stimulation, PTNS) is another option for patients who suffer from urge incontinence as a result of overactive bladder. This form of neuromodulation involves the placement of a very small needle electrode near the ankle, and a low voltage electrical stimulus is passed up the leg to the pelvic nerves that control the bladder. This technique is fairly effective in these patients. Interstim is another form of neuromodulation, but it involves a minor surgical procedure that involves the placement of electrodes, attached to a battery pack, into the base of the spine. The stimulation of the sacral nerves leads to an improvement in symptoms.
Medical therapy is recommended for urge incontinence, however patients with stress incontinence do not benefit from the use of medications. There are two major categories of medications: anti-cholinergics and beta-3 blockers. Each of these medications has a different mechanism of action, but they both result in improved symptoms of urge incontinence. Side effects of these medications tend to be worse with anti-cholinergic agents, and include dry mouth, constipation, blurring of vision and possible confusion in the elderly.
In addition to the above recommendations, controlling fluid intake is always helpful when one suffers from urinary incontinence. Do not drink large volumes if you know that accessing a bathroom may be difficult. Patients with both forms of incontinence can benefit from weight loss, as well.
These non-medical approaches to controlling urinary incontinence may be helpful for many patients. However, many may not benefit and for those patients, surgical intervention can be considered. An evaluation with a urologist is one of the most important steps to regaining continence.