Incontinence Management

A focus on bladder control issues – female urology
(A Common Occurrence in Women of All Ages)

What are Bladder Control Issues?

Up to 95% of women in their reproductive and postmenopausal years report experiencing an involuntary loss of urine. This does not mean that the overwhelming majority of these women have urinary incontinence. To qualify as having urinary incontinence, the involuntary loss of urine must have a negative impact on the quality of the individual’s life, particularly for hygienic and/or social standpoints. As such, the only person who can ultimately determine the presence of urinary incontinence is the woman herself. As with any medical condition, there are always new words to learn. It’s important to know how to talk about your symptoms so you can understand your condition and its treatment options. Here are some words that should be useful to you:

Stress Incontinence: Stress urinary incontinence is loss of urine that occurs at the same time as physical activities that increase abdominal pressure (such as sneezing, coughing, laughing, and exercising). These activities can increase the pressure within the bladder, which behaves like a balloon filled with liquid. The rise in pressure can push urine out through the urethra, (the tube you urinate out of) especially when the support to the urethra has been weakened.

Urge Incontinence: Often referred to as overactive bladder (OAB), this condition is characterized by a sudden, uncomfortable need to urinate with or without urine leakage. It is a common and distressing problem in both men and women and may have a profound impact on one’s quality of life. People with urge incontinence also tend to have increased urinary frequency, an increased need to rush to the bathroom frequently, or wake up more than once or twice at night to urinate.

Overflow Incontinence: Leakage or “spill-over” of urine when the quantity of urine exceeds the bladder’s capacity to hold it. This generally happens when there is some blockage or obstruction to the urethra or if the nerves to the bladder are damaged and the bladder doesn’t contract well. With overflow incontinence small amounts of urine may leak out frequently. This kind of leakage is less common among women, unless they have had bladder surgery, vaginal prolapse, or certain neurological conditions.

Mixed Incontinence: A patient with this type of urine loss has two or more causes that contribute to the urinary incontinence. For example, someone has the combination of stress incontinence (leaking with coughing, sneezing, exercise, etc.) and urge incontinence (leaking along with a need to get to the bathroom). Often, a woman may first experience one kind of leaking, and finds that the other begins to occur later.

How is Urinary Incontinence evaluated?

The first step is to talk to your physician. You want to speak with a female urologist who specializes in urogynecologic issues.Your doctor will perform an exam and look for signs of medical conditions which cause urinary incontinence. Keeping a bladder diary, which is a way to document your symptoms, will also help your doctor make the proper diagnosis. Based upon your doctor’s findings, other tests may be needed. These can include a bladder stress test, urinalysis, blood tests, ultrasound, or cystoscopy

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What Treatment Options are there?

The good news is that 80-90% of women who seek help will experience significant improvement. A wide array of treatment options, ranging from behavioral and diet changes all the way through surgical options exist, and are being used every day to help women improve their quality of life and lead more active lifestyles.

Depending upon the extent of symptoms, and a woman’s goals, there are multiple treatment options for bladder control problems.

  • Lifestyle Changes/ Behavioral Therapy: Often basic changes can make a big difference. This includes decreasing intake of known bladder irritants, timed voiding, pelvic floor strengthening and urge suppression.

  • Medications: The vast majority of medications used to treat incontinence are indicated for the treatment of urge incontinence/ OAB . They all are anticholinegics and have their effect on the muscarinic receptors in the bladder. Their effect is to decrease contractility of the bladder and limit urgency and frequency. There are some medicines, (tricyclic antidepressants, alpha agonists) which are sometimes used for the treatment of stress or mixed incontinence. However significant side effects limit their usefulness.

  • Pessary Use: Traditional pessaries have been modified to treat stress incontinence. There is a knob on one side of the pessary that applies some compression to the urethra during activities that are known to cause leakage. They may be used for the treatment of stress urinary incontinence and vaginal or uterine prolapse. They are a low risk treatment option when compared to surgery for symptomatic urinary incontinence. About half of the women who are successfully fitted with a pessary will continue to use it on a long-term basis.

  • Nerve Stimulation: Electrical stimulation of the sacral nerves has been shown to significantly improve symptoms of urgency, frequency and urge incontinence, as well as bladder emptying problems, in some people. This treatment is an alternative for patients with urge incontinence who have been refractory to other more conservative therapies.

  • Surgeries: Surgeries are indicated for the treatment of stress urinary incontinence. There has been progressive improvement in success rates while the procedures have become less and less invasive, often performed as an outpatient. Surgeries are not intended to treat urge incontinence and may at times worsen urgency symptoms.

  • Combination: Many times your female urology physician may recommend a combination of the treatments mentioned above

Lifestyle and behavioral changes
(Improving urinary urgency, frequency and urge incontinence)

Manage your Fluid Intake: There is no scientific evidence that states we need eight 8 oz. glasses (64 oz.) of fluid every day. Remember, what goes in must come out! Many women, unless you exercise heavily or work in hot conditions can drink less than 64 oz. per day. In 2004, the Institutes of Medicine reported that most people meet their daily hydration needs by letting their thirst be their guide. You must also remember that we get additional fluids from our diets in the form of soups, stews, fruits, etc. It has been shown that we get as much as 20% of our daily fluids from our diet. If you are used to drinking large amounts of fluids every day and you are bothered by how frequently you need to go to the bathroom, these suggestions may help you:

  • Don’t carry a water bottle or large container of fluid around with you
  • Use a smaller glass or cup
  • Take small sips of fluids instead of large gulp
  • If your mouth is dry, try sugar free gum or candy

Try spreading out fluids during the day instead of drinking large amounts at one time. This is especially important before leaving the house. If you get up to void more than 2 times per night, you should limit your drinking after dinner.

Avoid Fluids that can be Bladder Irritants: Some chemicals in our beverages can behave as diuretics and bladder irritants. If you are sensitive to these chemicals, they may cause you to make large amounts of urine or may aggravate bladder spasms resulting in a more frequent need to urinate. Some common bladder irritants include:

  • Caffeine – Try to stop or at least reduce your caffeinated beverages like coffee, tea, and cola to see if your bladder control improves. If you drink a lot of caffeine, you should taper down slowly to avoid a caffeine withdrawal headache.
  • Artificial Sweeteners – Beverages that contain artificial sweeteners like aspartame or saccharin can also be a bladder irritant. Diet Pepsi, Mountain Dew or Coke then would be especially problematic because of the artificial sweetener and the caffeine.
  • Citrus juices – Some people find that juices like orange or grapefruit juice can also irritate their bladder. Although there are no scientific studies to prove this, the best thing to do is to stop the suspected irritant for a week or two and see if it makes a difference.

Weight Loss: Being overweight puts extra pressure on your bladder. Weight loss will relieve some of that pressure and will help you regain your bladder control.

Void on a Schedule: Sometimes, the message that the bladder is full comes without warning and often too late. In these cases, women find that they lose urine on the way to the bathroom. There isn’t enough time between the message and their ability to get to the bathroom before they start to leak. Voiding on a schedule, also referred to as “Timed Voids” may help prevent these leaking episodes. It is exactly what it sounds like. You urinate on a schedule, sometimes even when you don’t feel like you have to so that you are not caught off guard. Completing a Bladder diary helps to determine when you usually leak and what is a reasonable period of time between trips to the bathroom.

Slowly, you can stretch the time between trip to the bathroom until you are voiding every 3 or 4 hours. Often times women find that keeping a bladder diary helps them be more consistent with their schedule. Your doctor or health care clinician can help you determine your best schedule if you are having a difficult time figuring it out.

Strengthen your Pelvic Floor Muscles with Kegel Exercise: Most bladder control problems are caused by weak pelvic muscles. These pelvic floor muscles attach to the bones of the pelvis in a way that creates a trampoline of support for the pelvic organs. These muscles help prevent urine leakage. Pregnancy, childbirth, increasing age all weaken the muscles of the pelvic floor. Exercising the pelvic floor muscles can strengthen the pelvic muscles and improve bladder control. Identifying the correct muscles to exercise is important. These are the same muscles you would use to hold back gas or to stop the flow of urine midstream. Your doctor or nurse can help make sure that you are contracting the right muscles. Once you have correctly identified the muscles, you contract and hold the squeeze for a few seconds and then completely relax the muscles before the next squeeze. For more detailed instruction on how to perform pelvic muscle exercises, visit www.mypelvichealth.org. Expect that it will take about 6 to 8 weeks of exercising before you notice that you have fewer leaks and more bladder control.

Urge Suppression Strategies – “Freeze and Squeeze”: If you have trouble reaching the bathroom before you start losing urine, we recommend trying this technique. When you get the urge to urinate:

  • Stop and stay still, sit down if you can
  • Squeeze your pelvic floor muscles quickly 3 to 5 times; repeat as needed
  • Relax the rest of your body and take a deep breath
  • Concentrate on suppressing the urge
  • Distract yourself to get your mind on something else
  • Wait until the urge subsides, then walk to the bathroom at a normal pace
  • Don’t ignore the message

Bladder Training: Once you have mastered the Urge Suppression technique, you can now train your bladder to increase the time between the initial urge and the time you actually void. Simply follow the Urge Suppression technique, but instead of walking calmly to the bathroom at your normal pace, you will wait a few minutes before voiding. At first you may only be able to postpone voiding by 1 minute, but keep trying to increase the interval between the initial urge and the time you actually void until you are only voiding every 3 to 4 hours. Like any new technique, this takes practice and time to master, so we recommend trying this at home initially until you become more successful.

More on pelvic floor muscle strengthening

(Improving urinary urgency, frequency and urge incontinence)

Helpful Instructions for doing Kegel exercises

Kegel exercises are frequently discussed in childbirth classes or written about in magazine articles. Unfortunately, because pelvic muscles are hidden from view, it is difficult to know if you are doing them correctly. Some tips that can help you find the right muscles include:

  • Try to stop your urinary stream. If you succeed then you have identified the right muscles to exercise. This is a learning tool. Do not stop your urine frequently as there is concern that this may create problems with bladder emptying.
  • Imagine you are going to pass gas, then, squeeze the muscles that would prevent that gas from escaping from your rectum. Exercising the muscles around the rectum will also strengthen those around the vagina and under the bladder.
  • Use a hand mirror to look at your vaginal opening and the perineum (the muscle wall between the vagina and rectum). You should see the perineum lift up when you contract your pelvic muscles.
  • While lying or sitting, place one finger inside your vagina. Squeeze as if you were trying to stop urine from coming out. You should feel your finger lifted and squeezed if you are correctly contracting your pelvic muscles.
  • Do not hold your breath while exercising.
  • Remember not to tighten your stomach and back muscles or squeeze your legs together. These should be relaxed as you isolate and contract just your pelvic muscles
  • You don’t have to do this alone! If you are just not sure that you are doing the exercises correctly ask your doctor or their nurse at a pelvic exam to check if your squeeze is working the right muscles.
  • GET A PERSONAL TRAINER FOR YOUR PELVIC FLOOR! Ask your doctor for a referral to a physical therapist with expertise in pelvic floor muscle rehabilitation. They are trained to evaluate your back and abdominal strength, your gait and your posture. These all effect how your pelvic muscles work.

Treatments Options: Female Urologist

URETHRAL BULKING

Stress urinary incontinence can be from having a stiff open urethra that acts like a lead pipe rather than a sphincter. While urethral hammocks are used for this condition, urethral bulking may also be used. Several biocompatible materials have evolved in the market. Durasphere from Coloplast and Macroplastique from Uroplasty are two of the non- dissolvable options available to bulk of the urethral sphincter and decrease the caliber of the lumen. This allows the mucosal walls to coapt and acts like a road block to passive loss of urine, as well as, leaking from slightly higher pressures.