Incontinence Management Article

Incontinence management will be determined based on the type of incontinence. The type of incontinence can be diagnosed by symptoms, a physical exam and as needed testing with urodynamics to determine how the bladder and urethra function or a cystoscopy, which I like to call a “pap smear “ for the bladder.

Once the type of incontinence has been determined then a treatment plan is recommended.

1) Stress incontinence is losing urine with physical stress, not psychological stress.

  • Management includes doing Kegel exercises initially. Since only 30% of women know how to do these exercises correctly sometimes a “personal trainer” for your pelvic floor is needed. This is pelvic floor physical therapy (PFT). PFT not only involves a vaginal pressure sensor to help you identify the correct muscles but electronic stimulation to automatically contract the correct muscles to help make them stronger. Usually 1 hour a week for 6 weeks.
  • In Europe, a medication is used to help stress incontinence called duloxetine.
  • A hammock or sling can be placed underneath the urethra. This is considered the gold standard for stress incontinence treatment and is minimally invasive via a small vaginal incision.
  • Some urethral sphincters have no strength and are more functionally like a lead pipe. For those a sling or a urethral bulking agent can help.
  • The urethral bulking agent can be done in the office.

2) Urge incontinence is losing urine with the sensation that you have to go the the bathroom.

  1. Diet review
  2. Bladder diary of  fluid intake
  3. Physical therapy for the pelvic floor helps people 60% of the time so that further medical or surgical treatment is not needed.
  4. Medications: multiple oral medications available
  5. Botox for the bladder can be done in the office
  6. Neuromodulation is treatment that involves sending electronic signals to the target nerves, muscles or organs that need to function better.
  7. Peripheral Neuromodulation is called Tibial Nerve Stimulation.

Please see section on TNS. Uroplasty.

More targeted Neuromodulation is called Sacral Nerve Stimulation- Interstim. See notes on Interstim and Medtronic.

3) Mixed: is a combination of both of the above and management is tailored based on the worse symptoms or which symptom bothers you more.

4) Overflow incontinence – this is a bladder that isn’t working because the muscles or nerves have been damaged. Sacral Neuromodulation with Interstim is FDA approved for this condition.

5) Neurogenic bladder- this results from bladder nerve damage as a result of trauma, accident, congenital reasons or medical conditions like multiple sclerosis or diabetes.  Sacral Neuromodulation with Interstim is FDA approved for this condition.

6) Fecal incontinence: loss of gas, staining, small liquid stool, pellets or large stool loss are included in fecal incontinence. Once a gastroenterology specialist has ruled out a systemic bowel problem and the incontinence is limited to a problem with the anal sphincter, treatments include:

  1. Diet
  2. Fiber
  3. Biofeedback, physical therapy
  4. Anal sphincter bulking agent , apainless office procedure called Solesta. See Solesta tab.
  5. Sacral neuromodulation with Interstim- FDA approved for fecal incontinence
  6. Anal sphincter surgery