Help for Women with Urinary Incontinence

Understanding Incontinence

Incontinence not caused by illness or injury typically falls into three categories: stress, urge and mixed. Determining which type you have is the first step in determining the right treatment.

• Stress urinary incontinence involves the involuntary or accidental loss of urine during activities that increase internal abdominal pressure, such as coughing, sneezing, laughing, exercise or lifting. Stress urinary incontinence is usually related to weakened pelvic floor muscles, the muscular hammock that sits between the pubic bone and the tail bone and functions to support the pelvic organs (bladder, uterus, rectum), as well as increase sexual pleasure and stabilize the body’s core. In younger women, the main cause of stress urinary incontinence is vaginal childbirth. Certain surgeries and anatomic abnormalities can also play a part, as well as normal deterioration of the muscles as women age. Approximately 60 to 70 percent of women of all ages have stress urinary incontinence.
• Urge incontinence is a sudden, strong feeling of needing to urinate caused by overactive and uncontrolled contractions of the bladder. This urge is often accompanied by the involuntary leaking of urine, ranging from a small amount to the complete emptying of the bladder. A number of situations can serve as triggers: the sound of running water; actions such as putting the key in the door or walking by a bathroom; or consumption of certain foods and beverages such caffeinated drinks or citrus juices. The prevalence of urge incontinence increases with age and the loss of estrogen, affecting approximately 15 percent of women in their 50s, and increasing to about 50 percent of women in their 70s and 80s, according to Dr. Krishnan.
• If you have symptoms of both stress and urge urinary incontinence, you have mixed urinary incontinence.

Preventing Incontinence

Although there is no magic formula to prevent incontinence – especially since the causes range from genetics to natural aging to childbirth – there are a few things you can do to reduce your chances of developing the problem, or to limit symptoms.

• Pelvic exercises – A large study of Japanese women has shown that younger women who do pelvic floor exercises (Kegel exercises) after vaginal childbirth (and continuing) have more success preventing stress incontinence, Dr. Krishnan says. Older women may also benefit from pelvic exercises, since they strengthen and retrain the nerves and muscles of the pelvic floor that control the bladder.
  
  The American Urogynecologic Society recommends 4 to 8 sets of 10 Kegel squeezes spread throughout the day.
  
  “The key is to do these correctly and to continue the exercises. Studies show that 60 percent of women do not do their Kegel exercises correctly. Women who visit a pelvic floor physical therapist to learn correct technique do much better,” Dr. Krishnan says. Ask your doctor to refer you to someone with the right expertise.
• Hormone therapy – For women entering menopause, vaginal estrogen treatments applied locally with an applicator through a vaginal pill or cream can relieve symptoms of urge urinary incontinence.
• Healthy living – Some lifestyle changes can also help your bladder and bowel to work more effectively. First, eat a fiber-rich diet to prevent constipation, which can weaken and stretch pelvic floor muscles, nerves and tissues. Keep weight in check through exercise and a healthy diet, since extra weight increases both risk and severity of incontinence. And don’t smoke, since smoking – and especially related coughing – adds to your risk.

You can also avoid caffeine and reduce liquid intake strategically to reduce the episodes of urgency.

Getting the Right Diagnosis

If you’re experiencing urinary incontinence, don’t hesitate to visit your doctor and explain your symptoms. Many types of doctors can diagnose urinary incontinence, including a primary care physician, OB/GYN or urologist. Urogynecologists have special training and expertise in women’s incontinence issues.

Your doctor will take a detailed medical history and conduct a physical exam. This includes a detailed pelvic exam to assess the organs and muscles. Your doctor will also look for signs of underlying medical conditions that may be causing incontinence and perform any necessary diagnostic tests. You may be asked to keep a bladder diary to keep track of when you urinate and when you experience leakage. After the doctor has examined all the data, he or she will make a diagnosis and discuss potential treatments.

Choosing the Best Treatment

Treatment options have expanded rapidly over the last few years, making solutions much more feasible for women of all ages. These include:

For both stress and urge incontinence:

• Physical therapy – Considered an effective and non-invasive treatment, physical therapy that includes techniques such as pelvic floor muscle exercise (Kegels), bladder retraining and biofeedback can reduce or eliminate both stress and urge urinary incontinence in most women. You’ll want to find a physical therapist specially trained in the area of incontinence; ask your doctor for a referral. The physical therapist will create a treatment plan designed to meet your needs.

For urge incontinence:

• Medications – A number of drugs have proven successful in addressing urge incontinence by blocking signals that cause the bladder to contract too frequently or by helping the bladder to relax. Unfortunately, most of these have side effects including drowsiness, constipation and dry eyes. “We now have a newer medication, called Myrbetriq® or Mirabegron, that has fewer side effects. But it’s not covered by all insurances,” Dr. Krishnan says. Talk to your doctor to determine which drug will work for you.
• Botox – The same medication long used by plastic surgeons can be used to treat urge incontinence. In a 10-minute procedure, a specially-trained doctor will inject Botox into the back wall of the bladder. The Botox relaxes the bladder and decreases sensitivity to nerve fibers, which helps the bladder to contract more normally.  Dr. Krishnan says a small percentage of patients have difficulty emptying their bladder for a short time after surgery, but this resolves on its own. “Most patients do really well,” she says. “But you do have to return to your doctor every three to six months to repeat the procedure.”
• Percutaneous tibial nerve stimulation – Similar to acupuncture, this therapy for urge incontinence uses a small, needle electrode inserted near the ankle to send impulses to the nerves of the pelvis that control bladder function. “This therapy has been shown to be equal to medication in treating urge incontinence without the side effects,” Dr. Krishnan says. “But it does involve a time commitment: 12 weeks of therapy each week for 30 minutes, and then once a month to maintain results. The good news is, Medicare does cover it and many urology and urogynecology departments now offer it.”
• Sacral neuromodulation – This therapy involves implanting a system that sends electrical pulses directly to the third sacral nerve root to help improve bladder control in people with urge incontinence. If you and your doctor agree to this approach, the doctor will first test the effectiveness by implanting through the back a lead, which is attached to an external monitor. You can determine after seven to 10 days whether the therapy works, after which a long-term device will be implanted. “Women with severe urge incontinence who don’t respond to medicines are good candidates for this treatment. Sacral neuromodulation also has the advantage of addressing fecal incontinence, which is a problem for about a third of women who have urinary urge incontinence,” Dr. Krishnan says.

For stress urinary incontinence:

• Vaginal devices – Some devices, inserted vaginally, can help improve stress urinary incontinence without the risks of surgery. A pessary is a silicone ring inserted into the vagina by your doctor, similar to a vaginal contraceptive diaphragm. The pessary helps support the urethra to prevent leakage. It can remain in place long-term but needs monitoring by the doctor to avoid problems with vaginal abrasions.
  
  Another device, called Impressa®, can be inserted by a woman like a tampon to lift and give support to the urethra. It can reduce or prevent urine leaks for up to eight hours.

• Urethral bulking – This procedure for stress incontinence involves an injection of material around the urethra to help thicken its walls. It can be done in the doctor’s office or an ambulatory surgery center using local anesthesia. The procedure may need to be repeated every two to three years as the body absorbs the material. “Only 40 percent of women are dry after this procedure, but 70 to 80 percent are improved,” Dr. Krishnan says. “It’s a good option for women who can’t undergo a more invasive surgery. I think my oldest patient was 95 years old.”
• Surgery – Thanks to improved methods and higher success rates, surgical intervention is now a viable option for stress urinary incontinence. The most popular surgical method, called the mid-urethral synthetic sling, involves using a thin strip of surgical mesh to lift and support the urethra, preventing the leakage of urine. This surgery can be performed in less than an hour through a small incision in the vaginal area, rather than the abdomen. This helps reduce pain and recovery time. “Eighty to eighty-five percent of women are still dry 10 years after this procedure,” Dr. Krishnan says.

Although most women choose to try less invasive methods first, Dr. Krishnan says the advance of less invasive surgical approaches means even older women with stress incontinence  or those who have had prior surgeries may want to give surgery another look.

For all women, dealing with urinary incontinence no longer need be a humiliating or hopeless endeavor. Learn more about urinary incontinence and evidence-based treatment options at the American Urogynecologic Society site “Voices for PFD” or talk to your doctor about treatment options available to you.