A Common but Treatable Condition
Michael Guralnick, MD
Medical College of Wisconsin Urologist
Millions of Americans experience incontinence at some point in their lives, and up to 80 percent of those affected are women. Yet, many women fail to seek treatment due to embarrassment or the belief that incontinence is inevitable. Michael Guralnick, MD, describes the different types of female incontinence and the treatment options available that can help women manage the condition and resume a normal life.
Q. What is female incontinence?
Incontinence is the involuntary loss of control of urine, usually resulting in leakage or wetting accidents. The common types that generally affect women can be broken down into two categories. Stress incontinence is the loss of urine associated with anything that causes a woman to tense up her stomach muscles – coughing, sneezing, lifting, bending, exercise – things like that. It's the most common type of incontinence found in younger women and is typically related to trauma of the pelvic floor muscle structure from injury, surgery, radiation, but most commonly, childbirth.
Vaginal prolapse is also related to childbirth and often goes hand-in-hand with stress incontinence. When the tissues of the pelvic floor that provide a support structure for internal organs, such as the bladder or uterus, become overstretched or weakened, these organs can prolapse or bulge into the vagina and stress incontinence may result.
Another type of leakage is called urge incontinence and is associated with a strong desire to urinate with little warning or time to reach a bathroom. It is usually due to what is called an overactive bladder. The bladder itself is deciding to go at any opportune moment. It typically occurs in middle age and beyond, but it can occur at a younger age as well. The causes for urge incontinence are less clear. Aging itself may not be the cause but it definitely is a risk factor just because urge incontinence is so common in elderly patients. Anything that can irritate the bladder – infection, bladder stones, bladder tumor – can potentially cause urge incontinence. There is also a potential for a neurologic cause, and in some cases the bladder dysfunction is the first sign of conditions such as multiple sclerosis or spinal cord problems. A neurologic cause is less common, but something we always need to keep in mind.
Some women actually suffer stress incontinence and urge incontinence, which makes it more difficult to manage. Mixed incontinence is most often seen in middle age to older women.
Q. How are these types of female incontinence diagnosed and treated?
We can usually determine the type of incontinence a patient is experiencing through questioning and a physical exam. I also always have patients keep a bladder diary for a 48-hour period in which they measure and record how much they urinate and any wetting episodes they experience. If needed, we will also resort to urodynamic testing. In this invasive but highly sophisticated test, catheters are placed into the bladder to study function and determine any troubles holding or emptying urine.
Something that helps both types of incontinence are Kegel pelvic floor exercises to strengthen the muscles involved in urination. Websites or a woman's healthcare professional can more fully explain how to do the exercises. Whether they suffer from incontinence or not, all women should start doing Kegel exercises in their teenage years and continue them throughout their life.
We also counsel patients to watch the amount of fluids they drink. This is where the bladder diary really comes in handy. Sometimes when patients say they go to the bathroom often, it's because they're simply taking in more fluids than they need. Caffeine in coffee can aggravate an overactive bladder. We also educate patients about bladder function and control – sometimes patients come to the realization that their bladders are functioning within a normal range. These behavioral therapies can be quite successful if the incontinence is caught at an early stage and patients follow the therapies.
If these methods fail to work, other treatments are available. Surgery is typically what comes next for patients with problematic stress incontinence and a variety of options exist. A minimally invasive procedure involves injecting a substance, usually collagen, into the urethra to bulk up the tissues and create a better seal. A more aggressive type of surgery is referred to as a sling operation and adds a layer of support underneath the urethra. These procedures are highly successful and sometimes will not only improve stress incontinence, but also urge incontinence. However, they do not always come without a price, such as difficulty in urinating or even bringing on or worsening urge incontinence. Although these side effects are rare, surgery should be considered only after conservative measures fail. There is also a promising medication that should soon be available to treat stress incontinence.
Urge incontinence is most often treated with medications that calm the overactive bladder. Newer medications have fewer side affects and work well. A surgical option called an implantable neurostimulator – essentially a pacemaker for the bladder – is also available when medication or behavioral therapies don't work.
Q. Does Froedtert & Medical College of Wisconsin have special expertise in treating female incontinence?
As a regional referral center, we tend to see very complex patients, especially ones that are experiencing complications following surgery. For that reason, we have a high degree of experience in treating difficult cases. This knowledge also helps us better treat more straightforward cases. Additionally, our urodynamic diagnostic testing is the most sophisticated available. We routinely look at both the storage phase, (urine holding) as well as the emptying phase (urine voiding). Many hospitals focus only on the urine holding. Our system also takes fluoroscopic x-rays so that we can correlate the function and dysfunction of the lower urinary tract with its anatomy.