Physicians of Urological Associates of Bridgeport

Female IncontinenceIncontinence in Women

Millions of women experience involuntary loss of urine called urinary incontinence (UI). Some women may leak a few drops of urine while running or coughing. Others may feel a strong, sudden urge to urinate just before losing a large amount of urine. Many women experience both symptoms. UI can be slightly bothersome or totally debilitating. For some women, the risk of public embarrassment keeps them from enjoying many activities with their family and friends. Sometimes women need to use pads or diapers, which can be expensive and bothersome. Urine loss can also occur during sexual activity and may cause tremendous emotional distress.

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Women experience UI twice as often as men. Pregnancy and childbirth, menopause, and the structure of the female urinary tract account for this difference. But both women and men can become incontinent from neurologic injury, birth defects, stroke, multiple sclerosis, and physical problems associated with aging.

Older women experience UI more often than younger women. But incontinence is not inevitable with age. UI is a medical problem. Your doctor or nurse can help you find a solution. No single treatment works for everyone, but many women can find improvement without surgery.

Incontinence occurs because of problems with muscles and nerves that help to hold or release urine. The body stores urine—water and wastes removed by the kidneys—in the bladder, a balloon-like organ. The bladder connects to the urethra, the tube through which urine leaves the body.

During urination, muscles in the wall of the bladder contract, forcing urine out of the bladder and into the urethra. At the same time, sphincter muscles surrounding the urethra relax, letting urine pass out of the body. Incontinence will occur if your bladder muscles suddenly contract or the sphincter muscles are not strong enough to hold back urine. Urine may escape with less pressure than usual if the muscles are damaged, causing a change in the position of the bladder. Obesity, which is associated with increased abdominal pressure, can worsen incontinence. Fortunately, weight loss can reduce its severity.


What are the types of incontinence?

Stress Incontinence

If exercising, coughing, laughing, sneezing, or other movements that put pressure on the bladder cause you to leak urine, you may have stress incontinence. Physical changes resulting from pregnancy, childbirth, and menopause often lead to stress incontinence. This type of incontinence is common in women and, in many cases, can be treated.

Childbirth and other events can injure the scaffolding that helps support the urethra and the bladder in women. Pelvic floor muscles, the vagina, and ligaments support these structures. If these structures weaken, your urethra can fall downward, pushing slightly out of the bottom of the pelvis toward the vagina. This prevents muscles that ordinarily force the urethra shut from squeezing as tightly as they should. As a result, urine can leak during moments of physical activity. Stress incontinence also occurs if the squeezing muscles are weakened.

The incidence of stress incontinence increases following menopause. Stress incontinence can also worsen during the week before your menstrual period. At that time, lowered estrogen levels might lead to lower muscular pressure around the urethra, increasing chances of leakage.

Urge Incontinence

If you lose urine after suddenly feeling the need or urge to urinate before you get to the toilet and are able to “release”, you may have urge incontinence. A common cause of urge incontinence is inappropriate bladder contractions.

Urge incontinence can mean that your bladder inappropriately empties during sleep, after drinking a small amount of water, or when you touch water or hear it running (as washing dishes or hearing a shower). Certain medications such as diuretics can worsen this condition. Fluids such as caffeine and alcohol also worsen urinary problems. Some medical conditions, such as hyperthyroidism and uncontrolled diabetes, can also lead to or worsen urge incontinence.

Involuntary actions of bladder muscles can occur because of damage to the nerves of the bladder, to the nervous system (spinal cord and brain), or to the muscles themselves. Childbirth and pregnancy is a common pelvic trauma for women. Some women have also had extensive pelvic surgery. Multiple sclerosis, Parkinson's disease, Alzheimer's disease, stroke, and injury that occurs during surgery all can harm bladder nerves or muscles.

Overactive Bladder

Overactive bladder occurs when abnormal nerves send signals to the bladder at the wrong time, causing its muscles to squeeze without warning. Voiding up to seven times a day is normal for many women, but women with overactive bladder may find that they must urinate far more frequently.

Specifically, the symptoms of overactive bladder include

  • urinary frequency—bothersome urination eight or more times a day or two or more times at night
  • urinary urgency—the sudden, strong need to urinate immediately
  • urge incontinence—leakage or gushing of urine that follows a sudden, strong urge
  • nocturia—awaking at night to urinate

Functional Incontinence

People with medical problems that interfere with thinking, moving, or communicating may have trouble reaching a toilet. A person with Alzheimer’s disease, for example, may not think well enough to plan a timely trip to a restroom. A person in a wheelchair may have a hard time getting to a toilet in time. Functional incontinence is the result of these physical and medical conditions. Conditions such as arthritis often develop with age and account for some of the incontinence of elderly women in nursing homes.

Overflow Incontinence

Overflow incontinence happens when the bladder doesn’t empty properly, causing it to spill over. Your doctor can check for this problem. Weak bladder muscles or a blocked urethra can cause this type of incontinence. Sometimes severe pelvic organ prolapse can kink a urethra. Nerve damage from diabetes or other diseases can lead to weak bladder muscles; tumors and urinary stones can block the urethra. Overflow incontinence is less common in women.

Other Types of Incontinence

Stress and urge incontinence often occur together in women. Combinations of incontinence and this combination in particular are referred to as mixed incontinence. Many women don't have pure stress or urge incontinence, and studies show that mixed incontinence is the most common type of urine loss in women.

Transient incontinence is a temporary version of incontinence. Medications, urinary tract infections, mental impairment, and restricted mobility can all trigger transient incontinence. Severe constipation can cause transient incontinence when the impacted stool pushes against the urinary tract and obstructs outflow. A cold can trigger incontinence, which resolves once the coughing spells cease.

The Types of Urinary Incontinence

  • Stress Leakage of usually small amounts of urine during physical movement (coughing, sneezing, exercising, lifting).
  • Urge Leakage of variable amounts of urine at unplanned times, associated with a strong sense of urgency.
  • Overactive Bladder includes urinary frequency and urgency, with or without urge incontinence.
  • Functional untimely urination because of physical disability, external obstacles, or problems in thinking or communicating that prevent a person from reaching a toilet.
  • Overflow incontinence involves an unexpected leakage of small amounts of urine because of a full bladder that isn’t emptying appropriately.
  • Mixed incontinence is the combination of stress and urge incontinence together.
  • Transient leakage occurs temporarily because of a situation that will pass (infection, taking a new medication, coughing with colds).

How is incontinence evaluated?

The first step toward relief is to see a doctor who has experience treating incontinence to learn what type or types you have. A urologist specializes in the urinary tract, and some urologists further specialize in the female urinary tract. Gynecologists and obstetricians specialize in the female reproductive tract and childbirth, and some OB/GYNs further specialize in pelvic floor dysfunction. A urogynecologist is a specialist who is an OB/GYN or urologist who has completed further training on urinary and associated pelvic problems in women. Family practitioners and internists see patients for all kinds of common health conditions. Any of these doctors may be able to help you. In addition, some nurses and other health care providers often provide rehabilitation services and teach behavioral therapies such as fluid management and pelvic floor strengthening.

To diagnose the problem, your doctor will first ask about symptoms and medical history. Your pattern of voiding and urine leakage may suggest the type of incontinence you have. Thus, many specialists begin with having you fill out a bladder diary over several days. These diaries can reveal obvious factors that can help define the problem—including straining and discomfort, fluid intake, use of medications, recent surgery, and illness. Often you can begin treatment at the first medical visit.

Your doctor may instruct you to keep a diary for a day or more—sometimes up to a week—to record when you void. This is referred to as a “Bladder Diary” or “Voiding Diary”. 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. You can also use the bladder diary to record your fluid intake, episodes of urine leakage, and estimated amounts of leakage.

If your diary and medical history do not lead to a diagnosis, or you have a complex surgical history, your doctor may recommend special testing called Urodynamics. This is office testing that looks at how your bladder and urethra function. It is not surgery, and does not require anesthesia. It can yield helpful information that may not be clear from your symptoms or Bladder Diary.

Your doctor will physically examine you for signs of medical conditions contributing to incontinence, such as prolapse, diverticulums, or other growths. Weakness of the pelvic floor leading to incontinence may cause a condition called pelvic organ prolapse, where the vaginal walls and the organs they support begin to protrude out of your body. This condition is important to diagnose at the time of an evaluation.

Your doctor may measure your bladder capacity. The doctor may also measure the residual urine for evidence of poorly functioning bladder muscles. To do this, you will urinate into a measuring pan, after which the nurse or doctor will measure any urine remaining in the bladder. Your doctor may also recommend other tests:

  • Bladder stress test—You cough vigorously as the doctor watches for loss of urine from the urinary opening.
  • Urinalysis and urine culture—Laboratory technicians test your urine for evidence of infection, urinary stones, or other contributing causes.
  • Ultrasound—This test uses sound waves to create an image of the kidneys, ureters, bladder, and urethra.
  • Cystoscopy—The doctor inserts a thin tube with a tiny camera in the urethra to see inside the urethra and bladder.
  • Urodynamics—Bladder function testing that involves various techniques that measure pressure in the bladder and the flow of urine.

How is incontinence treated?

Behavioral Remedies: Dietary Changes, Bladder Retraining and Kegel Exercises

By looking at your Bladder Diary, your doctor may see a pattern and suggest making it a point to use the bathroom at regular timed intervals, a habit called ‘timed voiding’. As you gain control, you can extend the time between scheduled trips to the bathroom. Behavioral treatment also includes Kegel exercises to strengthen the muscles that help hold in urine. Dietary changes that can help incontinence include limiting excessive fluid intake, decreasing caffeine and alcohol consumption, and weight loss.

How do you do Kegel exercises?

The first step is to find the right muscles. One way to find them is to imagine that you are sitting on a marble and want to pick up the marble with your vagina. Imagine sucking or drawing the marble into your vagina.

Try not to squeeze other muscles at the same time. Be especially careful not to tighten your stomach, legs, or buttocks. Squeezing the wrong muscles can put more pressure on your bladder control muscles. Just squeeze the pelvic muscles. Don’t hold your breath. Most importantly, do not practice while urinating or this can lead to problems emptying your bladder.

Repeat often, but don’t overdo it. At first, find a quiet spot to practice—your bathroom or bedroom—so you can concentrate. Pull in the pelvic muscles and hold for a count of three. Then relax for a count of three. Work up to three sets of 10 repeats. Start doing your pelvic muscle exercises lying down. This is the easiest position to do them in because the muscles do not need to work against gravity. When your muscles get stronger, do your exercises sitting or standing. Working against gravity is like adding more weight.

Be patient. Don’t give up. It takes just 5 minutes a day. You may not feel your bladder control improve for 3 to 6 weeks. Still, most people do notice an improvement after a few weeks.

Some people with nerve damage cannot tell whether they are doing Kegel exercises correctly. If you are not sure, ask your doctor or nurse to examine you while you try to do them. If it turns out that you are not squeezing the right muscles, you may still be able to learn proper Kegel exercises by doing special training with biofeedback, electrical stimulation, or both.

Medicines for Overactive Bladder

If you have an overactive bladder, your doctor may prescribe a medicine to block the nerve signals that cause frequent urination and urgency.

Several medicines from a class of drugs called anticholinergics can help relax bladder muscles and prevent bladder spasms. Their most common side effect is dry mouth, although larger doses may cause blurred vision, constipation, a faster heartbeat, and flushing. Other side effects include drowsiness, confusion, or memory loss. If you have glaucoma, ask your ophthalmologist if these drugs are safe for you. If so, there is a new medication called mirabegron that is not an anticholinergic that may be a good option for you.

Some medicines can affect the nerves and muscles of the urinary tract in different ways. Pills to treat swelling (edema) or high blood pressure may increase your urine output and contribute to bladder control problems. Talk with your doctor; you may find that taking an alternative to a medicine you already take or changing the timing of your medicine may solve the problem without adding another prescription.

Scientists are studying other drugs and injections that have not yet received U.S. Food and Drug Administration (FDA) approval for incontinence to see if they are effective treatments for people who were unsuccessful with behavioral therapy or pills.

Biofeedback

Biofeedback uses measuring devices to help you become aware of your body’s functioning. By using electronic devices or diaries to track when your bladder and urethral muscles contract, you can gain better control over these muscles. Biofeedback can supplement pelvic muscle exercises and electrical stimulation to help stress and urge incontinence.

Sacral Neuromodulation

For urge incontinence not responding to behavioral treatments or drugs, stimulation of nerves to the bladder leaving the spine can be effective in some patients. Sacral neuromodulation is the name of this therapy. The FDA has approved a device called InterStim for this purpose. It is a surgically implanted device that talks to your bladder nerves, similar to an implanted cardiac pacemaker for the heart. It is a two-step process, in which the doctor applies an external stimulator to determine if neuromodulation works for you. If you experience a 50 percent reduction in symptoms, your doctor will surgically implant the device. Although neuromodulation can be extremely effective, it is not for everyone. The therapy is expensive, involving surgery with possible surgical revisions and replacement.

Botox bladder injections

Another treatment option for urge incontinence not responding to behavioral treatments or drugs is Botox bladder injections. This involves injections of the medication Botox into your bladder via cystoscopy (a thin tube with a tiny camera at the end to see inside the bladder). Since Botox is eventually consumed by the body, sometimes this treatment is repeated after several months, depending on your symptom resolution.

Pessaries for Stress Incontinence

One of the reasons for stress incontinence may be weak pelvic muscles, the muscles that hold the urethra and bladder in place to hold urine inside. A pessary is a stiff non-disposable device that a doctor or nurse inserts into the vagina, where it presses against the wall of the vagina and supports the nearby urethra. The pressure helps reposition the urethra, leading to less stress leakage. If you use a pessary, you should see your doctor regularly.

Injections for Stress Incontinence

A variety of bulking agents, such as collagen and carbon spheres, are available for injection near the urinary sphincter. The doctor injects the bulking agent into tissues around the bladder neck and urethra to make the tissues thicker and close the bladder opening to reduce stress incontinence. After using local anesthesia or sedation, a doctor can inject the material over a few minutes. Over time, the body may slowly eliminate certain bulking agents, so you may need repeat injections depending on your symptom resolution. Your doctor will discuss which bulking agent may be best for you.

Surgery for Stress Incontinence

In some women, the urethra and bladder can shift out of its normal position, especially following childbirth. Surgeons have developed different techniques for supporting the urethra and bladder back to its normal position. The 2 main types of surgery are retropubic suspensions and slings.
Retropubic suspension uses surgical threads called sutures to support the bladder neck (where the urethra and bladder meet). The most common retropubic suspension procedure is called the Burch procedure. In this operation, the surgeon makes an incision in the abdomen a few inches below the navel and then secures the threads to strong pelvic ligaments to support the urethral sphincter. This procedure can be done at the time of an abdominal procedure such as a hysterectomy.

Sling procedures are performed through a vaginal incision. The traditional sling procedure uses a strip of your own tissue called fascia to cradle the bladder neck. Sometimes cadaveric fascia is used, if your own fascia is not optimal. The surgeon attaches both ends of the sling to the pubic bone or ties them in front of the abdomen just above the pubic bone.

Modern slings use a man-made material called mesh. All slings essentially support the urethra or bladder neck. Midurethral slings are newer procedures that you can have on an outpatient basis. These procedures use synthetic mesh that the surgeon places midway under the urethra. The two main types of midurethral slings are retropubic slings such as the transvaginal tapes (TVT), and transobturator slings (TOT). The surgeon makes small incisions behind the pubic bone or in the groin folds, respectively, as well as a small incision in the vagina. The surgeon uses specially designed needles to position a mesh tape under the urethra. The surgeon pulls the ends of the tape through the pubic or groin incisions and adjusts them to provide the right amount of support to the urethra. There are also single-incision slings, involving only a vaginal incision, but there are limited studies supporting their use since they are newer.

Recent women’s health studies performed with the Urinary Incontinence Treatment Network (UITN) compared the suspension and sling procedures and found that, 2 years after surgery, overall 86 percent of women with a sling and 78 percent of women with a suspension said they were satisfied with their results. Women who are interested in joining a study for urinary incontinence can go to www.ClinicalTrials.gov for a list of current studies recruiting patients.

If you also have pelvic prolapse, your surgeon may recommend an anti-incontinence procedure along with a prolapse repair and possibly a hysterectomy. Urodynamics is often used for women planning prolapse surgery who suffer from incontinence as well.

Talk with your doctor to explore if surgery will help your condition and, if so, what type of surgery is best for you. The procedure you choose may depend on your own preferences and your surgeon’s experience. Ask what you should expect after the procedure. You may also wish to talk with someone who has recently had the procedure.

Catheterization

If you are incontinent because your bladder never empties completely—overflow incontinence—or your bladder cannot empty because of poor muscle tone, past surgery, or spinal cord injury, you might use a catheter to empty your bladder. A catheter is a tube that you can learn to insert through the urethra into the bladder to drain urine. You may use a catheter once in a while or on a constant basis, in which case the tube connects to a bag that you can attach to your leg. If you use an indwelling (long-term) catheter, you should watch for possible urinary tract infections.

Other Helpful Hints

Many women manage urinary incontinence with pads that catch slight leakage during activities such as exercising. Emptying your bladder before exercise or activity known to cause leakage may also help. Also, many people find they can reduce incontinence by restricting certain “trigger” liquids, such as coffee, tea, and alcohol.

Finally, many women are afraid to mention this problem. They have urinary incontinence that may improve with treatment, but remain silent sufferers and resort to wearing absorbent undergarments or diapers. This practice is unfortunate, because diapering can lead to diminished self-esteem, as well as skin irritation and sores. If you are relying on diapers to manage your incontinence, you and your family should discuss with your doctor the possible effectiveness of treatment.

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