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.
- Diet review
- Bladder diary of fluid intake
- Physical therapy for the pelvic floor helps people 60% of the time so that further medical or surgical treatment is not needed.
- Medications: multiple oral medications available
- Botox for the bladder can be done in the office
- Neuromodulation is treatment that involves sending electronic signals to the target nerves, muscles or organs that need to function better.
- 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:
- Biofeedback, physical therapy
- Anal sphincter bulking agent , apainless office procedure called Solesta. See Solesta tab.
- Sacral neuromodulation with Interstim- FDA approved for fecal incontinence
- Anal sphincter surgery