Condition Urinary Incontinence
Urinary incontinence is defined as involuntary leakage of urine.
There are four major types of incontinence:
- Urge Incontinence, also known as overactive bladder, is caused by uninhibited bladder contractions called detrusor overactivity (DO). Symptoms may include urgency, frequency, multiple trips to the bathroom at night, and involuntary leakage of urine accompanied by sudden desire to pass urine, which is difficult to deter. Leakage may range from drops to a soaking.
- Stress Urinary Incontinence (SUI) is leakage of urine on effort or exertion, or on sneezing or coughing. SUI affects up to 35 percent of women and is the most common cause of incontinence in younger women.
- Mixed Incontinence is the combination of urge and stress incontinence.
- Incomplete emptying (overflow incontinence) is dribbling and/or continuous leakage associated with incomplete bladder emptying. Overflow incontinence and urinary retention (inability to pass urine) may be due to underactivity of the bladder muscle (detrusor) and occurs in about five to 10 percent of older patients. There are many potential causes of incomplete emptying: obstruction or blockage of the urethra, spinal cord injury, peripheral neuropathy, smooth muscle damage, and other conditions.
WHAT IS THE CAUSE OF STRESS URINARY INCONTINENCE (SUI)?
The vaginal wall and overlying connective tissue provides the urethra with a stable supportive base upon which to rest (hammock theory). During exertion, sneezing, and coughing, the urethra is compressed against the supportive base to prevent the leakage of urine. Pregnancy/childbirth, aging, and repetitive stress on the pelvic floor (heavy lifting, chronic cough, obesity) as well as genetic factors can lead to weakening of the urethral support structures. When the urethra loses its support and is not compressed during exertion, leakage of urine occurs. This is called urethral hypermobility and is the most common cause of SUI. Neurologic dysfunction, which affects the tone of the pelvic muscles and urethral sphincter, can also lead to SUI.
- Multiple trips to the bathroom at night
- Involuntary leakage of urine accompanied by sudden desire to pass urine, which is difficult to deter
- Leakage may range from drops to a soaking
- Leakage of urine on effort or exertion, or upon sneezing or coughing
- Dribbling and/or continuous leakage associated with incomplete bladder emptying
HOW IS URINARY INCONTINENCE DIAGNOSED?
Diagnosis is based on history and physical examination. The important components of history include the onset and course of incontinence, leakage frequency, volume, timing, and associated symptoms. It is also important to identify precipitants such as caffeinated beverages, alcohol, physical activity, coughing, and laughing. Status of medical conditions such as diabetes control and current medications are also important. A pelvic exam can identify a pelvic or urethral mass or a large cystocele (bladder prolapse) that can cause urinary retention and overflow incontinence. A limited neurologic examination of the pelvic area can be performed to identify deficits, especially in patients with known neurologic disease or in patients with sudden onset of incontinence. Urinalysis should be completed to rule out urinary infection as potential cause of incontinence. Urodynamic testing is not always necessary but can be helpful, especially in women with complicated stress urinary incontinence (SUI) or when symptoms are not consistent with physical examination findings.
WHAT IS URODYNAMIC TESTING?
Urodynamics is a test performed in the office and takes approximately 20 minutes to perform. This test provides information on bladder sensation, capacity, the presence of detrusor overactivity (overactive bladder), contractility, bladder emptying, and the integrity of the urethral sphincter. The main disadvantages of urodynamic testing are that it is expensive and may cause the patient discomfort. The patient is asked to come into the office with a full bladder. She is then asked to empty her bladder into a special container, which monitors bladder emptying and looks for any evidence of obstruction or interrupted flow. Using sterile techniques a thin catheter is placed into the bladder to measure the post-void residual. The post-void residual measures how much urine is left in the bladder after voiding. With the catheter in the bladder and another catheter in the vagina, the bladder is filled with fluid and the patient is asked to indicate various stages of bladder fullness. When the bladder is full, the patient is asked to cough to look for involuntary leakage of urine. With the catheter in place, the presence of overactive bladder can be identified. To measure the integrity of the urethral sphincter, the catheter is slowly moved through the urethra.
In a recent survey, only 45 percent of women with incontinence sought treatment for their symptoms. This leaves women with unresolved physical, functional, and psychological morbidity, as well as diminished quality of life. The treatment will depend on the type of incontinence and the underlying cause.
WHAT ARE THE NON-SURGICAL TREATMENT OPTIONS FOR STRESS URINARY INCONTINENCE?
Conservative therapy for SUI includes pelvic muscle exercises (Kegels) with or without the use of incontinence pessaries. No studies have directly compared surgical versus non-surgical approaches. However, surgical treatments have been found to have a higher success rate, compared to conservative therapy (40 percent versus 70 to 80 percent).
WHAT ARE THE SURGICAL TREATMENT OPTIONS FOR STRESS URINARY INCONTINENCE?
The surgical treatment for SUI should be delayed until child-bearing has been completed. The most common treatment for SUI is mid-urethral sling via vaginal approach, which creates a “hammock” underneath the urethra for support. Since the introduction of mid-urethral slings in the 1990s, these procedures have become the procedure of choice and have shorter operative durations and lower risk of post-operative complications compared to other older methods. The two most common types of mid-urethral slings are TOT (transobturator tape) and TVT (tension-free vaginal tape). Both of these are made out of synthetic mesh material and are inserted via a vaginal approach. The non-synthetic mesh option exists, however, is rarely used due to high failure rates and low long-term effectiveness.
HOW EFFECTIVE IS THE TOT AND TVT?
The success rate of mid-urethral sling has been shown to be between 70 and 80 percent. Long-term effectiveness is about 85 percent at the 10-year mark.
WHAT ARE THE POTENTIAL COMPLICATIONS OF THE TOT AND TVT?
The risks of the mid-urethral slings in general include injury to bladder or urethra, worsening of urge incontinence, and urinary retention. The risk of bladder injury is five percent for TVT and less than two percent for TOT. Injury to the urethra is rare in both procedures and is less than one percent. The risks associated with synthetic mesh include infection, erosion, rejection, and pain. Mesh erosion is easily treated and usually does not cause long-term problems. Mesh rejection is a very rare reaction to the synthetic material and may require removal of the mesh.
WHAT IS THE FDA WARNING REGARDING THE USE OF TRANSVAGINAL MESH?
The FDA has issued several documents about the use of reconstructive materials for female pelvic floor surgery. The conclusions to date have been that transvaginal placement of these materials are of uncertain efficacy and are associated with safety risks. In contrast, use of synthetic mesh for sacral colpopexy (for apical prolapse repair) or for full-length retropubic or transobturator midurethral slings (for incontinence treatment) was considered safe and effective.
WHAT IS THE TREATMENT FOR URGE INCONTINENCE?
Urge incontinence is caused by an “overactive” bladder muscle. This condition is treated with medications that inhibit (suppress) bladder contractions. The most common side effects of these medications include dry mouth, dry eyes, and constipation. In older women, these medications may cause mental confusion and should be used with caution.
WHY CIGC® FOR MY URINARY INCONTINENCE PROCEDURE?
If you require a mid-urethral sling to treat your urinary incontinence, you should seek a surgeon who specializes in laparoscopic vaginal procedures. At CIGC, our doctors are minimally invasive GYN specialists – not generalists.
WHY NOT MY OB/GYN?
Surgeons can only improve and master their work by consistently performing a high volume of surgeries, and CIGC gets that volume. Many patients have a strong relationship with their OB/GYN and are wary of having a mid-urethral sling procedure for urinary incontinence performed elsewhere. It is important to understand that while your OB/GYN is a great place to get regular GYN check-ups, he or she may not have the skills to perform a delicate gynecological surgery.
GYN surgery is the only medicine we practice. We have made a commitment to surgery for urinary incontinence and other gynecological conditions. We are board-certified, and fellowship-trained in minimally invasive technology. We aim to treat your urinary incontinence through the most minimally invasive avenues possible, reducing the number of incisions, the amount of time spent in the hospital, and the potential for complications.
Know your options.
CIGC surgeons see cases of urinary incontinence on a daily basis, and we are familiar with the condition in all its severities. We are well-informed about your treatment options, and we will make sure that you are too. We can offer you conservative therapy options such as pelvic muscle exercises or surgical treatments such as a mid-urethral sling made of transobturator tape or tension-free vaginal tape. In any case, we will make sure you are well-informed about each potential treatment and can make the decision that makes the most sense for you.
Hear it from our customers.
Our patients share their success stories so you can hear it from them, not us, as to why our urinary incontinence surgeons are superior.
We know that our customers are selective when choosing their surgeons, and we think extensive research is important. When you are exploring your urinary incontinence treatment options, get to know our surgical specialists and see why they are the best in the industry.
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