PATIENT CONDITION
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Urinary Incontinence Urinary incontinence has recently gained considerable attention in the United States. It is estimated that over 12 million Americans have urinary incontinence. Incontinence affects all ages, both sexes, and people of every social and economic level. It is also estimated that 15 to 30 percent of people over the age of 60 who live at home have incontinence. Women are twice as likely as men to have this condition. In addition, at least half of the 1.5 million Americans who reside in nursing homes are incontinent.
The exact number of people with incontinence is not known, but the total number of people affected may be far greater than current estimates. The estimated cost of diagnosis and treatment of this group is 15 billion dollars per year. Though these numbers are staggering, about half of incontinent patients do not alert their physician or family members of their problem. Unfortunately, most of these individuals assume nothing can be done for incontinence or feel that leakage is a normal part of aging. For millions of Americans, incontinence is not just a medical problem. It is a problem that also affects their emotional, psychological, and social well-being. Many people are afraid to participate in normal daily activities that might take them too far from a toilet. So it is particularly important to note that the great majority of incontinence causes can be treated successfully. Pelvic Anatomy
With normal bladder control you urinate only when you need or want to. Good bladder control means that all parts of the system must work in sync:
Urinary control relies on the finely coordinated activities of the smooth muscle tissue of the urethra and bladder, skeletal muscle, voluntary inhibition, and the autonomic nervous system.  (The prostate gland, which surrounds the upper urethra in men, is not shown in these illustrations.) Urinary incontinence can result from anatomic, physiologic, or pathologic (disease) factors. Congenital and acquired disorders of muscle innervation (e.g., ALS, spina bifida, multiple sclerosis) eventually cause inadequate urinary storage or control. Cause of acute or temporary incontinence:
There are 4 types of urinary incontinence. A brief explanation of each follows. 1. Stress incontinence Stress incontinence is the most common type of leakage encountered. Stress incontinence is the loss of urine that occurs with any maneuver that increases intra-abdominal pressure, such as
2. Urge incontinence Leakage that occurs when there is a sudden uncontrollable need to urinate is called urge incontinence. With urge incontinence, the bladder contracts and squeezes out urine involuntarily. Sometimes a large amount of urine is released.
Overflow incontinence occurs when the bladder is inefficiently emptied, leaving large amounts of urine in the bladder. As the volume increases, the resistance provided by the bladder, neck and urethra may be overcome, and urine loss may occur. This type of incontinence is a constant dripping of urine. It's caused by an overfilled bladder. This pattern is common in diabetics, male patients with enlarged prostates, urethral structures and in some patients with spinal cord injuries. In some cases this may be caused by medications taken for other conditions. 4. Functional incontinence This type occurs when you have normal urine control but have trouble getting to the bathroom in time. Functional incontinence is common in disabled or demented patients and is the most common type of incontinence in the nursing home setting. Patients with functional incontinence have normal orderly bladder activity but are unable to respond to this signal, due to immobility or impaired mental functioning. As a consequence, they become incontinent unless they are prompted to void or asked void on a schedule. Diagnosis Incontinence is never normal. If you have a problem with urine leakage, you should see a medical professional. The first step toward relief is to see a doctor who is well acquainted with incontinence to learn the type you have. A urologist specializes in the urinary tract and treats urinary incontinence of all types. Create a urination diary (appendix A). Take notes every day on your urination patterns. This diary should note the times you urinate and the amounts of urine you produce. To measure your urine, you can use a special pan that fits over the toilet rim. This will help your health care provider in diagnosing your problem:
Words used to described bladder control problems include the following:
Your doctor will physically examine you for signs of medical conditions causing incontinence, such as tumors that block the urinary tract, stool impaction, and poor reflexes or sensations, which may be evidence of a nerve-related cause. 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 sometimes necessary to assess the sphincter tone and possible fecal backup. Your doctor will measure your bladder capacity and residual urine for evidence of poorly functioning bladder muscles. To do this, you will drink plenty of fluids and urinate into a measuring pan, after which the doctor will measure any urine remaining in the bladder. Your doctor may also recommend
Treatment options are multiple and based on the type of incontinence:
Behavioral modifications are one of the first line treatment options for all incontinence and are the least invasive. These include:
 Estrogens Conjugated estrogens, either oral or vaginal, increase the tone of urethral muscle by up-regulating the alpha-adrenergic receptors in the surrounding area, and they enhance alpha-adrenergic contractile response to strengthen the pelvic muscles, which is important in urethral support (ie, prevents urethral hypermobility). Mucosal turgor of periurethral tissue from proper nourishment enhances urethral mucosal coaptation. The result is an improved mucosal seal effect, which is important in urethral function (ie, prevents intrinsic sphincter deficiency). Estrogen supplementation appears to be the most effective in postmenopausal women with mild-to-moderate incontinence. Both urge and stress incontinence may benefit from estrogen fortification. Anticholinergic drugs (Anticholinergic means to oppose or counteract the activity of certain nerve fibers that cause the bladder to contract.). This is often a first-line therapy for women with urge incontinence. These agents are effective in treating urge incontinence because they inhibit involuntary bladder contractions. Useful in treating urinary incontinence associated with urinary frequency, urgency, and nocturnal enuresis. All anticholinergic drugs have a similar performance profile and toxicity. Potential adverse effects of all anticholinergic agents include blurred vision, dry mouth, heart palpitations, drowsiness, and facial flushing. When anticholinergic drugs are used in excess, the bladder may go into acute urinary retention.
Tricyclic antidepressants Historically, these drugs were used to treat major depression; however, they have an additional use, treatment of bladder dysfunction. They facilitate urine storage by decreasing bladder contractility and increasing outlet resistance. This class of drugs includes imipramine hydrochloride (Tofranil) and amitriptyline hydrochloride (Elavil). However, it is extremely effective in decreasing symptoms of urinary frequency in women with pelvic floor muscle dysfunction and helps break the cycle of pelvic floor muscle spasms. Alpha-adrenergic drugs (Alpha-adrenergic drugs mimic actions of the sympathetic nervous system, which controls various involuntary body functions.) -- The bladder neck contains a high concentration of receptors that are sensitive to alpha-agonists. Alpha-agonists increase bladder outlet resistance by contracting the bladder neck. This class of drugs unclude midodrine (Pro-Amatine) and pseudoephedrine hydrochloride (Sudafed) Surgery Several operations for incontinence exist to treat specific anatomical problems. The decision to use surgery must always be based on an accurate diagnosis and realistic expectations for the surgery. In men, an operation may be required to relieve the blockage caused by an enlarged prostate. In women, an operation may be required to restore the support of the pelvic floor muscles or to reconstruct or compress the sphincter. Stress incontinence is the most common type of incontinence that is treated with surgery. Injection therapy Injecting material to increase the bulk around the urethra can improve the function of the urethral sphincter and compresses the urethra near the bladder outlet. Injectable agents can help women who are not candidates for surgery and have persistent intrinsic sphincter deficiency (very weak urethral sphincter) without urethral hypermobility. Injectable agents also may help men with intrinsic sphincter deficiency that has lasted longer than 1 year. Injectable materials include collagen (naturally occurring protein found in skin, bone, and connective tissue), fat from the patient's body (autologous fat), and polytetrafluoroethylene (PTFE) and Durasphere™ (synthetic compounds). Collagen Collagen is a natural substance that breaks down and is excreted over time. The Contigen® Bard® collagen implant uses a purified form of collagen derived from cowhide. Potential recipients have a skin test 28 days prior to treatment to determine whether or not they are sensitive to the material. Sensitivity is indicated by inflammation at the injection site. A prefilled syringe is used to inject the collagen around the urethra. Some physicians conduct a series of treatments over a few weeks or months. Others instruct patients to return for additional treatment when leakage occurs. Results vary from patient to patient and from physician to physician. Some patients achieve continence for 12 to 18 months and others require more frequent treatment. Some remain dry for 3 to 5 years. Durasphere™ Durasphere is a water-based gel that contains tiny, carbon-coated beads. Unlike PTFE, this material is not absorbed by the body. The procedure is usually performed under local anesthesia, although some patients may require general anesthesia. A cystoscope is inserted into the urethra, allowing the physician to see the bladder neck area. The gel is injected through a hollow needle into the numbed areas of tissue around the bladder neck. This increases the bulk around the urethral sphincter, allowing it to close enough to help prevent urine from leaking. After treatment, 9 out of 10 women experience improved continence. Treatment options for urinary incontinence depend on the type of incontinence as outlined below. Surgical Therapies Marshall Marchetti Krantz (MMK) This procedure requires an abdominal incision. The bladder neck and urethra are separated from the back surface of the pubic bone. Sutures are placed on either side of the urethra and bladder neck, which are elevated to a higher position. The free ends of the stitches are anchored to surrounding cartilage and pubic bone. MMK is no longer a favored technique because there is potential for the development of obstructive adhesions and the incision limits the physician's ability to correct herniation of the bladder into the vagina. Burch Colposuspension This vaginal suspension procedure often is performed when the abdomen is open for another purpose, such as abdominal hysterectomy. The bladder neck and urethra are separated from the back surface of the pubic bone. The bladder neck then is elevated by lateral (sideways) sutures that pass through the vagina and pubic ligaments. (Lateral sutures prevent urethral obstruction and allow the repair of small cystoceles, or hernias.) The vaginal wall and ligament are brought together, and the sutures are tied. Needle Suspension Several needle suspension procedures have been developed, each named after its creator (e.g., Stamey, Raz, Gittes); however, the basic technique is the same. Essentially, sutures are placed through the pubic skin or a vaginal incision into the anchoring tissues on each side of the bladder neck and tied to the fibrous tissue or pubic bone. Sling Procedures 
Patients with severe stress incontinence and intrinsic sphincter deficiency may be candidates for a sling procedure. The sling procedure takes a different approach to preventing incontinence. This procedure places support material directly under the urethra and attaches it up to the connective tissue (fascia) of the abdominal muscles. There are many variations of this operation and some doctors prefer to attach the supporting material to the ligaments near the pubic bone. The supporting material rests under the urethra like a firm hammock. When a cough or sneeze pushes the urethra down, it's forced against the sling, and the urethra is closed off. The goal of this treatment is to create sufficient urethral compression to achieve bladder control.
There are two techniques:
The pubovaginal sling is made of a strip of tissue from the patient's abdominal fascia (fibrous tissue).An incision is made above the pubic bone, and a strip of abdominal fascia (the sling) is removed. Another incision is made in the vaginal wall, through which the sling is grasped and adjusted around the bladder neck. The sling is secured by two sutures loosely tied to each other above the pubic bone incision, providing a hammock to support the bladder neck. After this procedure, patients generally regain bladder control for more than 10 years. Possible complications include accidental bladder injury, infection, and prolonged urinary retention, which may require chronic intermittent self-catheterization. Synthetic slings: Gynecare TVT™ Gynecare TVT™ (tension-free vaginal tape) is a synthetic mesh tape that prevents urine leakage during sudden movement (e.g., laughing, coughing, sneezing) and while exercising by reinforcing the ligaments and tissues that support the urethra. This minimally invasive procedure is used to correct stress incontinence and combined stress and urge incontinence in women. The tape is placed beneath the middle of the urethra in an outpatient surgical procedure that takes 30 to 50 minutes to perform. The procedure is performed under local, regional, or general anesthesia and does not require a urinary catheter. If local or regional anesthesia is used, adjustments can be made during the procedure to ensure that adequate support is provided. Cystoscopy is performed to make sure there has been no injury to the bladder during the procedure. Gynecare TVT does not require anchors or sutures and produces minimal scarring. Recovery from the procedure takes 3 to 4 weeks. Heavy lifting and sexual intercourse should be avoided for 4 to 6 weeks. Normal daily activity can resume within 1 to 2 weeks. Complications are rare and include bleeding; blood vessel, bladder, and bowel injury; and urinary retention. If painful urination (dysuria), bleeding, or other concerns arise, the patient should contact her physician immediately. Transobturator Tape Newer procedures such as the Monarc™ subfascial hammock and transobturator tape (TOT) also can be used to correct stress incontinence and combined stress and urge incontinence in women. These techniques may result in fewer complications (e.g., blood vessel, bladder, and bowel injury) than other transvaginal procedures. Artificial Sphincter An artificial urethral sphincter may help patients who are incontinent after surgery for prostate cancer or stress incontinence, trauma victims, and patients with birth defects in the urinary tract. The device has three components: a pump, a balloon reservoir, and a cuff that encircles and closes the urethra. All three components are filled with fluid (e.g., saline). The cuff is connected to the pump, which is surgically implanted in the scrotum (in men) or the labia (in women). The pump is activated by squeezing or pressing a button. The fluid in the cuff empties into the reservoir, the urethra opens, and the bladder empties. Fluid from the reservoir returns to the cuff, which again closes the urethra. Possible complications include infection, tissue breakdown, and mechanical failure. Sacral Nerve Stimulation 
InterStim® therapy is a reversible treatment for people with urge incontinence caused by overactive bladder who do not respond to behavioral treatments or medication. InterStim is an implanted neurostimulation system that sends mild electrical pulses to the sacral nerve, the nerve near the tailbone that influences bladder control muscles. Stimulation of this nerve may relieve the symptoms related to urge incontinence.
A device can be placed under your skin to deliver mild electrical pulses to the nerves that control bladder function. Prior to implantation, the effectiveness of the therapy is tested on an outpatient basis with an external InterStim device. For a period of 3 to 5 days, the patient records voiding patterns that occur with stimulation. The record is compared to recorded voiding patterns without stimulation. The comparison demonstrates whether the device effectively reduces symptoms. If the test is successful, the patient may choose to have the device implanted. The procedure requires general anesthesia. A lead (a special wire with electrical contacts) is placed near the sacral nerve and is passed under the skin to a neurostimulator, which is about the size of a stopwatch. The neurostimulator is placed under the skin in the upper buttock. Adjustments can be made at the doctor's office with a programming device that sends a radio signal through the skin to the neurostimulator. Another programming device is given to the patient to further adjust the level of stimulation, if necessary. The system can be turned off at any time. Possible adverse effects include the following:
In extreme cases, when incontinence is severe and other treatments have failed, the bladder may be made larger through an operation known as augmentation cystoplasty, in which a part of the diseased bladder is replaced with a section taken from the patient's bowel. This operation may improve the ability to store urine but may make the bladder more difficult to empty so that regular catheterization is needed. Possible adverse effects include the following:
 TVT (Tension-free Vaginal Tape) What is Tension-free Vaginal Tape? Tension-free Vaginal Tape (TVT), is a minimally invasive surgical procedure used to surgically treat some women with stress urinary incontinence. The procedure can be performed under local or minimal anesthesia and takes only about 30-60minutes to complete. The recovery period following the procedure is short, and patients experience few complications and minimal scarring after surgery. TVT is a doctor-applied ribbon-like strip that stops urine leakage by supporting your urethra. You can go back to your routine in just a day or two. It's also clinically proven: 98% of women who participated in a study begun seven years ago are still dry, or experience significantly less leakage (Source: Nilsson et. al., 7 Year Follow-up on the Tension-free Vaginal Tape (TVT) Procedure; International Urology, IUGA Abstract #116 (89): October 2003). The TVT stops urine leakage the way your body was designed to - by supporting your urethra. Normally, the urethra is supported by the pelvic floor muscle to maintain a tight seal and prevent involuntary urine loss. In women with SUI, the weakened pelvic floor muscle and connective tissue can't support the urethra in its normal position. To correct this, your doctor will insert a ribbon-like strip of mesh under the urethra to provide support whenever you stress this area (such as during coughing, sneezing, or walking). This allows the urethra to remain appropriately closed, preventing involuntary urine loss. The unique elastic properties of the TVT prevent the mesh from affecting normal voiding (Source: H.P. Dietz et. al., Mechanical properties of urogynecologic implant materials. International Urogynecology Journal. 0937-3462). The ribbon-like mesh is made from a permanent material that will be incorporated by your body. The TVT mesh will be placed in one of two different methods (shown below), based on your doctor's assessment: 1. The mesh is placed under the urethra and exits the abdomen just above the pubic bone.  2. The mesh is placed under the urethra and exits near the creases of the thighs  The anatomy in these photos is shown with the woman in the gynecological exam position. The procedure is short - it usually takes just 30-45 minutes. The TVT procedure can be performed under local, regional or general anesthesia. After your anesthesia takes effect, your surgeon will insert the mesh tape through a small incision in the vagina. Then your surgeon will "weave" the tape beneath the urethra and pull the tape up through two tiny punctures in the skin's surface just above the pubic bone or near the creases of the thighs. Your surgeon may evaluate whether the tape is providing adequate support by asking you to cough. So, even before you leave the operating room, the surgeon can determine if the procedure is likely to be successful. Usually, a catheter is not needed after the procedure (unlike some other stress incontinence procedures). At the end of the procedure, your surgeon will "snip" the tape, just under the skin's surface, and close the two small incisions. Unlike other procedures, no sutures or anchors are necessary, except for small absorbable sutures to close the small vaginal incision. What does recovery involve? You may be able to go home as early as a few hours after your procedure and return to a relatively normal schedule of activities the next day. You may be sore and may need ibuprofen (e.g., Motrin®) or pain medicine for a few days. Your doctor will advise you to avoid heavy lifting and intercourse for two to six weeks. What are the risks and complications? All surgical procedures present risks. Although rare, complications associated with the treatment include injury to blood vessels, difficulty urinating, and bladder and bowel injury. Rarely, the tape may be slightly "tight" or "loose". If it is too tight, it may be more difficult to urinate or empty the bladder. If it is too loose there may still be some residual leakage. Fortunately these problems are uncommon. For More Information American Foundation for Urologic Disease 1000 Corporate Boulevard, Suite 410 Linthicum, MD 21090 Phone: 1-800-828-7866 or (410) 689-3990 Email: admin@afud.org Internet: www.afud.org National Association for Continence P.O. Box 1019 Charleston, SC 29402-1019 Phone: 1-800-BLADDER (252-3337) or (843) 377-0900 Email: memberservices@nafc.org Internet: www.nafc.org The Simon Foundation for Continence P.O. Box 835 Wilmette, IL 60091 Phone: 1-800-23-SIMON (237-4666) or (847) 864-3913 Email: simoninfo@simonfoundation.org Internet: www.simonfoundation.org Society of Urologic Nurses and Associates East Holly Avenue, Box 56 Pitman, NJ 08071-0056 Phone: 1-888-TAP-SUNA (827-7862) or (856) 256-2335 Internet: www.suna.org |
