Urinary incontinence, the uncontrolled release of urine is not a disease but a biophysical problem that stems from one or more disorders in the urinary tract. It is a common problem among older adults. Because the incontinence may result from one or more of several problems, treatments vary and are tailored to the specific clinical circumstances and needs of the patient.
Urinary incontinence (UI) is a general term describing circumstances in which there is an involuntary release of urine. The problem is divided into two broad categories, each of which is further divided into subcategories. The two broad categories are acute UI and chronic UI. Acute UI is brief period of incontinence associated with a disease such as a urinary tract infection, bladder stones, or as a side effect of some medications. It is sometimes called transient incontinence. Chronic or long-term incontinence is often related to changes in the patients urinary anatomy, musculature or the nerves controlling those muscles. Chronic incontinence is categorized according to the circumstances of voiding. These categories are:
Stress incontinence: loss of urine during contractions of the abdomen caused by sneezing, laughing, coughing, exercising and other such actions. It is often caused by movement of the bladder neck lower into the pelvis.
Overactive Bladder : the urge to urinate is sudden and extreme, and urine is often expelled before a bathroom is reached. This occurs even when there is a minimal amount of urine in the bladder.
The problem is twice as common in women as in men and far more common in older women than younger. It is estimated that 10% of American women under the age of 65 have UI compared to 35% of those older than 65. This is compared to 1.5% of men under 65 and perhaps 22% of those older than 65. The rates are much higher in women in care facilities and nursing homes. Between 30% to 50% of these individuals may have some form of incontinence.
The presentation of the problem is sufficient for a general diagnosis of UI. The challenge is identifying the origins of the problem. Diagnosis begins with a careful medical history that leads to a description of the character of the problem. The pattern and nature of the leakage will help determine the type of incontinence. A physical examination that includes reflex testing and palpation of areas around the urinary tract will offer additional information suggesting the cause of the incontinence.
Bladder scanning in the office setting represents a simple, painless, noninvasive way to visualize the bladder contents. Your doctor can assess emptying ability with this test, similar to an ultrasound.
Urine and blood samples may be taken to be analyzed for evidence of infection, kidney stone or metabolic imbalances. A urodynamic study may be conducted in which bladder pressure and flow rates are determined. Ultrasound is a technology which bounces sound waves off interior structures. The resultant echoes are translated to images of the kidneys, bladder, ureters, urethra and adjacent structures. Cystoscopy involves inserting a thin hollow tube into the urethra and advancing it into the bladder. Miniature lights and lenses at the tip of the tube allow the walls of the urethra and interior of the bladder to be examined.
Creating a urination diary is a simple and informative task. The patient is given a pan that fits across a toilet seat. The date, time and quantity of urine expressed are recorded for several days to a week.
Not all of these tests are utilized in every patient. Testing stops as soon as the origin of the incontinence is reliably determined.
Acute urinary incontinence associated with infections, kidney stones or medication side effects often resolves when the primary problem is successfully treated.
As noted, chronic incontinence can originate from a variety of circumstances. The nature and mix of therapeutic measures are tailored to the individual patient.
A simple exercise routine involving Kegel exercises can strengthen pelvic floor and sphincter muscles to reduce or eliminate leakage.
Electrical stimulation can also strengthen muscles in cases of stress and urge incontinence. This therapeutic approach, also called transcutaneous electrical nerve stimulaton (TENS), temporarily places small electrodes on the surface of the skin adjacent to targeted muscles or inside vagina or rectum. Minute pulses of electricity stimulate pulses of muscle contraction and strengthens them. Another form of electrical therapy involves placing a small sacral nerve stimulator (a sort of pacemaker about the size of a stopwatch), beneath the skin with wires leading to the sacral nerve in the lower back. Pulses from the stimulator offset hyperactive nerve activity around the bladder. The sensation has been described as a slight pulling in the pelvic area.
Biofeedback involves what might be called electronic training wheels. Electronic sensing devices are placed to record nerve impulses and muscle contractions. These offer the patient more information concerning voiding impulses than she would normally be aware of. By monitoring these impulses and learning to control them, additional control over urination can be gained.
There are a number of medications that can reduce leakage. Some of these drugs inhibit an overactive bladder’s activities by stabilizing muscle contractions and others have the opposite effect of relaxing muscles to permit more complete bladder emptying. Hormone replacement therapies, usually involving estrogen, may help restore normal bladder function.
Several devices and procedures help reposition and stabilize the bladder and urethra. A pessary is a semi-rigid ring placed in the vagina to reposition the urethra and reduce stress incontinence leakage. Bulking substances such as collagen (fat) or specially formulated artificial substances may be injected to provide support and bulk around the urethra. These substances compress the urethra near the bladder outlet to reduce the effects of stress incontinence. The substances are not permanent and the procedure may need to be repeated at annually or more frequent intervals.
Several other surgical procedures have been shown to have high success rates. Stress incontinence often results from the bladder losing support and gradually dropping toward the vagina. The bladder can be returned to a more normal position with sutures that stabilize it by attaching it to nearby structures such as muscle, stable tissue or bone. Another procedure that provides bladder support involves placing a pubo-vaginal sling, a sort of hammock, beneath the bladder. The sling is sutured to adjacent structures. Excellent results with the pubo-vaginal sling have been achieved in women with stress urinary incontinence.
An artificial sphincter is a novel device that mimics the musculature of the sphincter. It is a surgically implanted ring that encircles the urethra. It can be manually inflated to close around the urethra and prevent urine leakage. Sphincter implantation is not a common procedure but one that can be successfully employed in carefully selected patients.
Indwelling catheterization is a procedure employed in women whose bladder fails to empty completely as a result of loss of muscle tone, prior surgery, or spinal cord injury. The catheter (thin tube) is inserted in the urethra and allowed to drain into a bag attached to the leg.
This range of therapies briefly described here should suggest to the reader a single therapy is seldom employed to treat the UI. Instead combinations of these therapies are tailored to meet the condition and needs of the patient after extensive consultation, usually with several specialists in the varying aspects of UI therapy.