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Urinary incontinence is defined as the involuntary loss of urine. You may leak urine, or you may not be able to “hold” your urine when you can’t get to a bathroom. When any part of the urinary system malfunctions, incontinence can result.

Who is affected by incontinence?

Urinary incontinence is reported to affect 13-25 million people in the United States. This is most likely a low estimation due to underreporting. Many patients do not seek treatment due to embarrassment, or a misperception that nothing can be done about it. Many women believe that incontinence is a normal part of the aging process. Fortunately, once identified, urinary incontinence can usually be successfully treated.

What causes incontinence?

Urinary incontinence can be caused by many factors. A few of the most common causes are:

  • Pregnancy and childbirth
  • Diabetes
  • Bladder or kidney infection
  • Menopausal drying/thinning of the urethra
  • Interstitial cystitis
  • Excess alcohol consumption
  • Excess caffeine consumption
  • Excess fluid consumption
  • Certain medications
  • Nervous system disorders that may effect the lower urinary tract
    • Spinal cord lesions
    • Multiple sclerosis
    • Parkinson’s
    • Stroke

What are the different types of incontinence?

Stress Incontinence

Stress incontinence occurs when the pelvic muscles have been damaged, or the sphincter muscle has weakened. This causes the bladder to leak during exercise, coughing, laughing, sneezing, or any other activity.

Urge Incontinence/Detrusor Instability/Overactive Bladder

Urge incontinence is the involuntary loss of urine associated with an abrupt, strong, and uncontrollable urge to void. This is caused by overactivity of the detrusor muscle, or it can be the result of damaged nerve pathways from the bladder to the brain. Bladder spasms can also be the result of conditioning. For example, many people are continent when they are out all day, but when they put the key in the front door, they have a sudden urge to void. This could be the result of many years of using the bathroom immediately upon arriving home.

Mixed Incontinence

The presence of stress and urge incontinence symptoms together.

Overflow Incontinence

Overflow incontinence refers to the leakage that occurs when the amount of urine produced exceeds the bladder’s holding capacity. This type of incontinence is common in women with a large cystocele. The urge to void is usually absent. When urinating, there may be intermittent flow, hesitancy, a weak stream, or dribbling.

How is incontinence diagnosed?

Urinary incontinence is diagnosed by a thorough clinical evaluation.

This may include:

  • Detailed medical and drug history
  • Pelvic exam
  • Voiding diary (recorded over 3-7 days)
  • Urinalysis and culture

How is urinary incontinence treated?

Treatment of urinary incontinence depends on the type of incontinence you have. The three major categories of treatment are behavioral modification, pharmacological therapy, and surgical treatment.

Cystometrogram (CMG)

What is a cystometrogram?

A cystometrogram or CMG is a test used to evaluate your bladder’s ability to store and release urine.

How to prepare?

Please arrive for your procedure on time. Do not empty your bladder for 1 hour prior to your appointment time. You may eat and drink as usual and remain active right up until the time of your cystometrogram.

What to expect?

Once you are settled in the room you will be asked to disrobe from the waist down. A physician or nurse will talk to you about any urinary problems you have experienced in the past. He or she will also take a brief medical history and discuss which medications you are currently taking.

You will then be asked to empty you bladder into a special commode. This commode can record the rate at which you empty your bladder, as well as the amount of urine you emptied at that particular time.

A catheter (a thin, long, flexible tube) is then inserted into the bladder and any urine remaining in the bladder is drained and measured (post-void residual). Then, a second catheter is placed into the rectum.

The catheter will be used to fill your bladder with a sterile saline solution. Meanwhile, the physician or nurse will ask you several questions about the sensations you are experiencing. Then you will be asked to perform certain activities, such as coughing, or pushing (“bearing down”), while your bladder is being filled.

Once you feel that your bladder is filled to capacity, you will be asked to empty it with the catheters in place. The computerized instrument will record the pressures generated by your bladder. The catheters will be removed after the computerized instrument collects sufficient pressure readings.

The test takes approximately 30 minutes to complete. You may resume your normal activities immediately.

How are the results interpreted?

Normal

The amount of urine left in the bladder after urinating, when the urge to urinate is felt, and when urine can no longer be held back are within normal ranges.

Abnormal

One or more of the following may be found:

  • More than a normal amount of fluid remains in the bladder after urinating. A large volume of urine remaining in the bladder suggests the flow of urine out of the bladder is partially blocked or the bladder muscle is not contracting properly to force all the urine out (overflow incontinence).
  • The bladder contains less fluid, or more fluid than is considered normal when the first urge to urinate is felt.
  • The person is unable to retain urine when the bladder contains less than the normal amount of fluid for most people.

Treating Incontinence: Behavioral Modification

Lifestyle Changes

  • Quit Smoking – Smoking can lead to a chronic cough that strains pelvic floor muscles. It may also damage the bladder and urethra.
  • Lose Weight – Excess weight puts extra pressure on the pelvic floor muscles.
  • Dietary Changes – Some foods may make you urinate more, so you should avoid them. These include caffeine and alcohol.

Timed Voiding

Timed voiding means urinating on a set schedule. This empties the bladder and helps avoid accidents. Visit the restroom at the scheduled time. Do not wait for the urge to urinate. Your physician may instruct you to urinate every 2-4 hours, while awake. If you have to, set an alarm to remind you. The goal of this therapy is simply to keep the patient dry.

Bladder Re-training

This involves timed voiding, but the length of time between the bathroom trips is gradually increased. This therapy trains the bladder to delay voiding for larger time intervals.

Pelvic Muscle Exercises (Kegels)

Kegel exercises help to strengthen the pelvic floor muscles. The success of pelvic muscle exercises depends on the patient’s ability to correctly identify the muscles for the exercise and her commitment to performing them daily.

Kegel Exercises

Kegel exercises are easy to learn and simple to do. If you do them right, no one can tell your doing them, so they can be done anywhere.

Isolating The Pelvic Floor Muscles

  • While urinating, try to stop the flow of urine. Start and stop as often as you can.
  • Tighten your muscles as if you were stopping your stream of urine, but do it when you are not urinating.
  • Tighten your rectum as if trying to not pass gas. Contract your anus, but don’t move your buttocks.

If you have isolated the right muscles, your leg, buttock or stomach muscles should not move.

How long should I hold them?

Try holding each contraction for 5 seconds. This will be difficult at first but it will get easier as the pelvic floor gets stronger.

How often should I do them?

Kegels should be done several times a day. The more you do, the stronger the muscles become. However, just like any exercise, the muscles can become fatigued if overworked.

When and Where can I do my Kegels?

Kegels can be done anywhere and anytime. After you have learned to isolate the correct muscle group, it is recommended that you do not continue to use them to stop the flow of urine. It is possible that this could eventually lead to a dysfunctional voiding pattern.

Treating Incontinence: Medication

Below are some types of medications that may help treat incontinence.

  • Antispasmodics: These medications may increase the amount of urine the bladder can hold. They also help the bladder muscle work more efficiently. Examples of this type of medication are Detrol, Enablex, Sanctura, Vesicare, Ditropan, etc…

Side effects of these medications include dry mouth, constipation, and blurred vision. Sucking on sugar free hard candy is recommended to help with dry mouth.

Mild Antidepressants

  • Estrogen: Hormone therapy may help to improve muscle tone in the bladder and urethra.
  • Antibiotics: This type of medication will be prescribed if infection is present.

Tips for Taking Incontinence Medication

  • Take your medication as prescribed by your doctor
  • Call your doctor if you have problems taking your medication or are experiencing side effects
  • Do not stop taking your medication until after you have been instructed to do so by your physician
  • Be patient. Many of these medications take a few weeks to work. Some adjustments may be needed to find the right medication and dosage for you.

Treating Incontinence: Surgery

There are many types of different surgical procedures that may be used to treat incontinence. The type of surgery recommended will depend on the type and cause of your incontinence.

Slings: Urethral slings are used to treat stress incontinence (SI). SI is usually caused by sagging of the urethra and/or bladder neck, or by problems with the sphincter (muscular outlet of the bladder). This involves placing a “sling” around the urethra to lift it into place and to exert pressure on the urethra to aid in holding the urine.

The advantages of sling surgery are:

  • Usually done in an outpatient setting (go home the same day)
  • Quick recovery time
  • Very little to no pain
  • Extremely effective in eliminating incontinence

What happens during surgery?

The operation is usually performed under local anesthesia and mild sedation, or with regional anesthesia.

  • You will have one small incision in your vagina and two in your groin or lower abdomen.
  • A special tape or mesh is looped under your urethra to provide lift and support.
  • At the end of the procedure, the surgeon looks inside your bladder to check for bladder injury.
  • The operation takes 15-30 minutes to perform.

What are the risks and possible complications?

  • Damage to the bladder, urethra, or nearby blood vessels
  • Bleeding
  • Infection
  • Blood clots
  • Mesh erosion or rejection of the sling material (the sling material may wear away the tissue of the urethra or vagina)
  • The stitches used to attach the sling may pull out
  • A small percentage of patients will have trouble urinating immediately following the procedure and may need a catheter until normal bladder emptying is established. This catheter is usually removed 3-7 days post-op.

What can I expect during recovery?

Most women return home within 24 hours of the procedure. You will be sent home once you are feeling well and are able to urinate. If you need pain relief, mild analgesics are usually enough.

It is important to rest after the operation and allow yourself to heal.

General recommendations are:

  • Restrict activity for first 2 weeks following procedure
  • Weeks 2-6, light activity only
  • Avoid heavy lifting for 6 weeksThis includes shopping bags, laundry baskets, and children.
  • No sexual activity for 6 weeks
  • No sports or strenuous exercise for 6 weeks
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