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Incontinence Treatment
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Incontinence Treatment
August 02, 2011 | Menopause [1], Infertility [2], Incontinence [3], Integrative Medicine [4],
Laparoscopy [5], ObGyn Compensation Survey [6], ObGyn Nurses [7], Urogynecology [8]
By John Miklos, MD [9] and Neeraj Kohli, MD [10]
This is the exercise which, when done faithfully and correctly, can help decrease the urgency a
patient may have and help with both urge incontinence and stress incontinence. The pelvic floor
muscle is like a hammock that stretches from the pubic bone in the front to the tailbone in the back.
TABLE OF CONTENTS
Treatments for Stress Incontinence
Conservative Therapy
Pelvic Floor Exercises
Urinary Meatal Occlusion Devices
Collagen Injections
Urinary Incontinence Surgery
Anterior Repair and Kelly plication
Pubovaginal Sling Procedures
Burch Urethropexy Procedures
Treatments for Urge Incontinence
Treatments for Overflow Incontinence
Conservative Therapy
Pelvic Floor Exercises (Kegel exercises)
This is the exercise which, when done faithfully and correctly, can help decrease the urgency a
patient may have and help with both urge incontinence and stress incontinence. The pelvic floor
muscle is like a hammock that stretches from the pubic bone in the front to the tailbone in the back.
This set of muscles supports the organs of the pelvic region, which include the bladder, large
intestines and uterus. Since this muscle is often not exercised, it is generally weak to begin with,
which contributes to urinary symptoms. Childbirth will weaken this muscle more because during
vaginal delivery, the child's head and body push under the pelvic floor muscle and stretches it
extensively which causes temporary additional damage/weakening. Learning to do these exercises
can help with incontinence, however to perform these exercises effectively the patient must first
identify the correct muscles.
Two methods of identifying the correct muscles:
1. While urinating stop the flow of urine by tightening the pelvic floor muscles. Do not perform
these exercises while urinating, since this can lead to difficulty in voiding. Stopping and
starting the stream as a person voids is a popular misnomer and should not be done. Patients
may elect to try to stop the stream once or twice to check for contraction of the correct
muscle.
2. Place a finger in the vaginal opening and attempt to squeeze the finger. Upon squeezing, the
patient should feel a tightening around her finger. She has identified the correct muscles that
are to be exercised.
One key point is that patients do not want to use other muscles, such as the abdomen, legs or
buttocks. It is important to isolate the muscles only to further increase their strength. If you are
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moving these muscles or holding your breath, you are probably trying too hard!
Concentrate just on the pelvic floor muscles and do the best you can. This contraction will get easier
with practice. One exercise program is described below:
Attempt to contract and hold the muscle squeeze for 10 seconds
Relax for a period of 10 seconds
Perform 10-15 contractions and relaxation
Perform this regimen 3-4 times a day
It may take awhile to work up to a 10 second hold. In the beginning, you will probably not be able to
hold for more than five or six seconds and that is all right. Between each contraction, relax for 10
seconds. This allows the muscle to rest adequately to be able to perform well for the next
contraction. If you do not relax the muscle well enough, the muscles will tire quickly. By faithfully
doing your Kegel exercises, you should see an improvement in your symptoms starting in four to six
weeks.
Vaginal Cones - are miniature weights which are placed into the vagina and help pelvic floor exercises.
Urethral Opening Occlusion Devices
There are several new non-surgical products on the market for female stress
urinary incontinence. Brand names are listed:
CapSure® and FemAssist®. - This type of device creates enough suction to keep the walls
of the urethra together during stressful activities where someone might otherwise leak. The
patient places a small amount of Vaseline-like material on the suction cup and places it in the
area of the urethral opening, which is just above the vaginal opening. The placement does
not have to be exact and once the device is in place the labia fold over it and the device
cannot be seen or felt. When the patient needs to urinate, the suction cup is easily pulled off.
The device is washed with soap and water and dried and is re-usable.
Reliance® - is an inter-urethral insert. This product requires the patient to insert a small
catheter/plug into the urethra (tube that the urine travels through from the bladder to the
toilet). These devices are comfortable to wear and when the patient needs to urinate, she
pulls on a string, much like a tampon, to remove the device. When finished urinating, a new
device is replaced in the urethra. There is a higher rate of urinary tract infections with this
product versus the ones listed in the prior paragraph.
Tampons - can also be used for stress incontinence activity based leakage. Placing a
tampon in the vagina acts as a support or buttress for the urethra and bladder. Supporting
this area can reduce urine leakage with coughing, sneezing, bearing down (Valsalva
maneuver) or exercising.
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Comparing Sizes - Q Tip, tampon and Reliance® urethral insert.
Collagen Injections
Collagen is a naturally occurring protein found in humans and animals. When it is injected into the
tissue around the urethra, it adds bulk and helps it close tightly to prevent urine leakage, especially
urine leakage associated with activity (Stress Urinary Incontinence). Most patients will leak much
less or not leak at all after collagen therapy. Some patients will need to have one or more injections
done at a later date because the body will absorb some of the collagen material. The length of time
between injections varies with each patient. Some need to be re-injected after a few months and
some after a few years.
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Collagen Injection - Used for bulking up and tightening the urethra. This is a minimally invasive technique of treating stress urinary incontinence.
Urinary Incontinence Surgery
More than 150 operations have been described in literature for the treatment of Stress Urinary
Incontinence. Unfortunately many of these operations, which are commonly performed throughout
the world, have very poor surgical cure rates. A common misnomer of surgical cure is the surgeon is
performing a bladder tack operation. Actually the goal for most of these surgeries is to stop urinary
leakage and this is accomplished by supporting the urethra. The urethra is the tube that allows urine
to be expelled from the body. In an attempt to support the urethra, actually the vagina under and
beside the urethra is the area which the operation takes place. The two most successful operations
described and researched in the literature are: Pubovaginal Sling procedure and the Burch
urethropexy (colposuspension) procedure. These two operations are commonly called the SLING and
the BURCH procedures. Though some doctors may argue which is the better of the procedures, there
are too many variables for this question to ever be answered scientifically. By narrowing the choice
to these two operations the patient is getting one of the most successful operations described in the
literature. Interestingly, the most common operation still performed in the United States is the
anterior repair and/or Kelly plication.
For surgical treatment information, click here.
Anterior Repair and/or Kelly Plication
Anterior repair (colporrhaphy) has been used to treat stress incontinence in conjunction with a
bladder and urethra drop (cystourethrocele) for years. Although this operation is commonly used for
both incontinence and anterior vaginal wall relaxation, it is probably not the operation of choice for
most patients. It is a minimally invasive operation that is done through an incision in the anterior
vaginal wall but only has a cure rate of 20-30 % for stress urinary incontinence. The poor cure rate
associated with the anterior repair is quite discouraging and often forces a patient to have a second
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surgery. Most urogynecologists or urologists would not recommend this operation, as their procedure
of choice, for cure of stress urinary incontinence. Many surgeons who perform both sling and Burch
procedures will choose the most appropriate operation based upon the individual patient's needs
and urodynamic testing results.
Pubovaginal Sling Procedure
A sling procedure is done to create support where the urethra connects to the bladder (a.k.a. bladder
neck). A sling is especially effective for the woman who has the diagnosis of Intrinsic Sphincter
Deficiency (ISD) where the sphincter muscle is ineffective at holding urine in the bladder during
certain "stressful" activities such as coughing, sneezing or exercising. There are many different types
of "sling" operations described in the literature. The slings differ in the type of material, sutures, and
points of anchoring. The decision on the type of sling utilized is surgeon dependent. The sling is
placed under the bladder neck and is secured to a point of attachment (bone, abdominal wall, and
ligament) through a vaginal incision. Therefore, when the woman coughs or sneezes, the bladder
does not have as much motion now that the "backboard" is in place and so she will not experience
any leakage. This procedure is done in the operating room under anesthesia and the patient goes
home either the same day or the following day. The most recent efficacy statistics for patients
undergoing pubovaginal sling procedures is upwards of approximately 85% for patients who have
had the surgery 10 years ago. A sling procedure is considered "curative" for the female patient.
Tension-Free Vaginal Tape (TVT) Sling
Dr. Miklos has been trained to perform a number of different types of sling operations utilizing
various types of material, sutures and points of anchoring. Currently he chooses to offer his patients
an extremely minimally invasive sling operation known as the TVT or tension free vaginal tape sling
he learned in Stockholm, Sweden in 1998. This type of sling has been performed in Europe for more
than 6 years with great success. Dr Miklos was the first surgeon in the Southeastern United States to
perform the operation and serves as a preceptor to teach this operation to Urologists,
Urogynecologists and Gynecologists throughout the world. In June 2000, Dr Miklos traveled to Russia
to introduce the TVT sling operation to his colleagues at the University of Moscow. Dr. Miklos chooses
the TVT sling for his patients because the operation is/has:
Minimally invasive (two incisions of 1/3 inch on the pubic hairline)
Minimal pain (40% of patients will not need a pain reliever after 24 hours)
Proven cure rate of 86%
Same day or next day discharge for 98% of patients
Performed under local anesthesia and IV sedation
Operative time 20-30 minutes
Minimal postoperative need for catheterization
Minimal complications
For surgical treatment information, click here.
Burch Urethropexy
First described in 1961, by John Burch this procedure has stood the test of time and is currently
considered one of the two most curative operations for the treatment of Stress Urinary Incontinence.
It is used for both primary and recurrent stress incontinence and has a cure rate of 80-90%, 5-15
years following surgery. This procedure can be performed through a larger abdominal wall incision
(i.e. Laparotomy) or through small abdominal incisions using cameras and TV screens (i.e.
Laparoscopy). Despite the surgical approach, or size of incision, the operative technique for urinary
incontinence should remain the same. In an attempt to support and stabilize the urethra, sutures are
placed in the vaginal wall beside the urethra and anchored to the Coopers ligament of the pubic
bone. Routinely, two sutures are placed on each side of the urethra, one at the mid-level of the
urethra and one at the level of the urethra bladder junction (i.e. bladder neck).
Laparoscopic Burch Urethropexy
Dr. Miklos prefers to use a laparoscopic approach to Burch urethral stabilization. Since 1993, he has
performed more than 500 of these operations with minimal complications or blood transfusion. He
prefers this method for his patients because it is/has:
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Minimally invasive
Minimal pain
Cure rates 80-95%
23 hour hospital stay
Operative time 30-40 minutes
Reduced postsurgical catheterization
Minimal complications
Allows for repair of other vaginal wall relaxation (cystocele, enterocele, uterine, vault
prolapse)
Allows direct access for paravaginal (cystocele) repair---more than 90% of patients with
Stress Urinary Incontinence have these defects that should be repaired thereby eliminating a
second surgery.
For surgical treatment information, click here.
Treatments for Urge Incontinence
Dietary M1odification
Medication
Timed Voiding
Bladder Retraining
Urge Suppression
Pelvic Floor Stimulation
Sacral Nerve Stimulation
Dietary Modification
Certain foods and beverages have been shown to contribute to urgency, frequency or urge
incontinence. Caffeine and alcohol are big offenders! Many people are unaware of how much
caffeine they ingest in a single day. They often just remember the one or two cups of coffee that
they drink in the morning, forgetting the cola drink with lunch and the cup of tea in the afternoon.
Foods, beverages and products which should be avoided:
Tea
Coffee
Alcohol
Chocolate
Nicotine
Women with mild or intermittent symptoms may require only reassurance and simple measures such
as decreased fluid intake and avoidance of the above irritants. The majority of patients will require
further treatment.
Medication
Many patients with urge incontinence often can be treated effectively using medication and bladder
re-training. There are a number of available to treat urge incontinence. Some of the more common
anti-cholinergic or anti-spasm medications are:
Ditropan
Ditropan XL (slow releasing - one tablet per day)
Detrol
Tofranil
Levsin
Propantheline
Contraindications or reasons why the above medications should not be taken include:
Acute (narrow) angle glaucoma---untreated
Gastric retention
Severe constipation
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Allergies to this type of medicine
Estrogen is also considered a helpful in the treatment of urinary incontinence. It works by increasing
the blood supply to the vagina and urethra making the urethra more substantial and watertight.
Timed Voiding
This involves urinating on a set schedule during the day regardless of the need or urge to void. For
example, a patient would urinate every two hours during the waking hours. This is an attempt to
pre-empt the urge incontinence episodes before they occur. However, there is no goal at increasing
the interval between voids. This form of behavioral therapy is useful in older adults or other
individuals for whom bladder retraining is not an option.
Bladder Retraining
Many people with urgency, frequency and urge incontinence can be helped through the use of
bladder re-training. Bladder re-training involves urinating on a set schedule during the day. The
patient goes to the bathroom by the clock only, not the urge to void. For example, if the patient
normally goes to the bathroom every hour or less during the day, they would start this technique by
voiding every hour. After one week one should increase the time interval between voids by 30
minutes so one is now voiding every 1 hour and 30 minutes. After one week the interval is increased
by another 30 minutes. This exercise is continued until the interval between voids is 3-4 hours. The
patient may void at anytime during sleeping hours. This retraining program encourages the bladder
to retain more urine without bladder urgency or spasms.
Urge suppression
Patients get the urge to urinate as the bladder signals the brain by sending a message through the .
This is just a message about the filling status of the bladder; it is not a direct order to urinate.
Believe it or not, a patient can and in fact, should wait, to void. The worst possible time to try to get
to the bathroom "in time" is when one really has to go. A lot of people will leak especially the closer
that they get to the bathroom. In an attempt to suppress the urge, patients should contract their
pelvic floor muscles (i.e. Kegel exercise). Tightening and relaxing the pelvic floor muscle in rapid
succession will help until the urge subsides. This will help to kick in a natural reflex that quiets down
the bladder.
Pelvic Floor Stimulation (Electrical Stimulation)
This technique involves stimulation of the pelvic floor musculature using vaginal or rectal plug
electrodes. Stimulation of nerve fibers leads to inhibition of bladder contractions. Physicians, Nurse
Practitioners, or Physical Therapists that specialize in pelvic floor dysfunction often deliver this type
of treatment.
Electrical Stimulation - Innova electrical stimulation unit (Empi, Minneapolis, MN)
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Electrical Stimulation Application - This illustration shows the electrode in place, within the vagina. The stimulator will pass a mild current of electricity through the electrode which stimulates the pelvic floor muscles to contract. This is a passive way of performing pelvic floor exercises.
Sacral Nerve Stimulation
Sacral Nerve Stimulation (SNS) is a relatively new surgical procedure to treat urge incontinence that
is not responsive to other treatments and therapies. SNS is a two-phase treatment therapy. By
stimulating the sacral nerve, the signals that regulate the bladder are better in control and able to
allow decreased urgency and more urine to be held in the bladder. This procedure involves having a
testing procedure done first to determine the effectiveness of the treatment.
The testing portion entails placing a small wire into the lower back to the area of the sacral nerve.
Once in place, the wire is taped to the person's back and connected to a small portable stimulator
unit that is about the size of a pager. The person then keeps a log of their urinary symptoms and
voiding episodes to determine if the treatment is effective. After discussion with the physician, the
decision to implant the device is agreed upon.
The surgical procedure for implant of the Interstim® SNS therapy takes about two to four hours.
There are two or three incisions: One in the lower back, the other one or two incisions is where the
implantable pulse generator (IPG) is placed. The patient stays overnight in the hospital and the
device is programmed one week later in the office. The patients use a hand held programmer to
increase or decrease the level of stimulation. The stimulation feels like a pulsing or tingling in the
rectum or vagina. This procedure is totally reversible if the patient chooses to have it removed.
SANS UNIT - Percutaneous Ankle Nerve Stimulator
The FDA has recently approved a new minimally invasive method of peripheral nerve stimulation,
which affects bladder control. The device works via a needle placed near the ankle about three
fingerbreadths above the inside anklebone. The needle ties in with the tibial nerve, which ascends to
the sacral (tailbone) nerve complex. The percutaneous Stoller Afferent Nerve Stimulation System
(perQ SANS UNIT) is low-frequency electrical stimulation that is applied for 30 minutes once a week
for approximately 12 weeks. After this initial trial of therapy, the patient's therapy is tritated from
every week to every other or every third week, depending on the patient response.
Clinical trials have suggested success rates as high as 80%. Success was defined by study design as
at least a 25% reduction from baseline in daytime or nighttime frequency. Side effects from the
treatment were classified as transient and resulting from insertion of the very fine needle. No serious
adverse results have been reported.
Click image below to enlarge.
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SANS Unit - An acupuncture needle is placed in the nerve behind the ankle and is stimulated to modulate nerve impulse going to the bladder from the sacral nerves.
Download a SANS Procedure brochure by clicking here.
Treatments for Overflow Incontinence Overflow
Overflow incontinence in men commonly occurs due to benign prostate hypertrophy (enlarged
prostate). This condition causes obstruction to the urethra and inhibits complete emptying of the
bladder. Women do not have a prostate but can have overflow incontinence because of:
Poor bladder contractility
Bladder neck obstruction due to uterine/vaginal prolapse
Bladder neck obstruction due to strictures (rare)
Bladder neck obstruction due to previous anti-incontinence surgery
Clean Intermittent Catheterization
For certain patients, the bladder has limited or no ability to contract to empty. These patients include
those who may have as well as other diagnoses. Since the bladder muscle has weakened too much,
it is important to empty the urine to prevent either infection or kidney damage as well as decrease
the irritative voiding symptoms of frequency and urgency or urge incontinence. These patients learn
to catheterize themselves on a schedule usually two to four times a day. They use a small, clear,
flexible catheter that is much softer than catheters used in the hospital setting. The procedure is
done with clean, not sterile, technique and is best learned by sense of touch and not by use of
mirrors.
Vaginal Prolapse Treatment - Improving Bladder Neck Obstruction
Severe uterine and vaginal relaxation can cause a kinking of the urethra at the bladder neck. These
patients will not be treated effectively by urethral dilation. The kinking of the urethra and bladder
neck must be removed. This can be accomplished by using non-surgical management (i.e. pessary)
or by surgical correction of the vaginal prolapse. The surgery procedure chosen is dependent upon:
Area specific for the prolapse
Desire to maintain fertility (maintain uterus)
Desire to maintain sexual function
Patients age
Patients overall general health
References:
Copyright ©2000, 2001 Dr. John R. Miklos
All text and images in this article are property of Dr. John R. Miklos and may not be reproduced in
any way without permission.
www.miklosandmoore.com
Source URL: http://www.obgyn.net/menopause/incontinence-treatment
Links:
[1] http://www.obgyn.net/menopause
[2] http://www.obgyn.net/infertility
[3] http://www.obgyn.net/incontinence
[4] http://www.obgyn.net/integrative-medicine
[5] http://www.obgyn.net/laparoscopy
[6] http://www.obgyn.net/obgyn-compensation-survey
[7] http://www.obgyn.net/obgyn-nurses
[8] http://www.obgyn.net/urogynecology
[9] http://www.obgyn.net/authors/john-miklos-md
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[10] http://www.obgyn.net/authors/neeraj-kohli-md
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