Urinary incontinence is the involuntary loss of urine to the degree that it causes a problem. It affects millions of many millions of Americans, and occurs predominately in women. The risk increases with age, but causes significant problems in many young and active patients. A number of factors have been identified, including:
– Immobility
– Decreased mental status
– Certain medications, such as diuretics
– Smoking
– Low fluid intake
– High Impact physical activities
– Diabetes
– Stroke and other neurological disease
– Decreased estrogen levels
– Pelvic muscle weakness
– Pelvic support defects
– Pregnancy, childbirth and episiotomy
– Poor bladder habits
Effective management includes full assessment by careful history, physical examination, urine testing, bladder function testing, discussion of reversible causes, treatment options and an individualized care plan. Please see our website for more information and health links at our home page at www.sworcare.com
Types of Incontinence
Stress Incontinence – signs and symptoms include the loss of small to medium amounts of urine during coughing, sneezing, laughing, or other physical activities. The most common form of incontinence in patients with pelvic support problems is called Genuine Stress Incontinence (GUI)
When patients experience continuous leaking at rest or with minimal exertion, this suggests Intrinsic Urethral Deficiency. (ISD)
Urge Incontinence – signs and symptoms include the loss of urine with an abrupt and strong desire to urinate; usually loss of urine on the way to the bathroom. This type of incontinence is called Detrusor Dysenertia or Detrusor Instability (DI)
When patients experience an involuntary loss of urine without symptoms, this suggests Involuntary Sphincter Relaxation (ISR)
When patients experience elevated post-void residual (inadequate emptying), this suggests Detrusor hyperactivity with impaired bladder contractility (DHIC)
Mixed Incontinence (MUI) – combinations of stress and urge incontinence
Overflow Incontinence (Overflow )- problems caused by factors such as poor bladder muscle function, certain drugs, neurological conditions (stroke, diabetes, etc), severe pelvic prolapse and other blockage issues
Functional Incontinence (FI) – bladder leakage due to physical impairments or disabilities
Reflex Incontinence (Reflex) – neurological dysfunction due to problems such as inflammation, radiation changes, radical surgery and spinal cord damage
Your Workup for Incontinence may include:
– The degree of symptoms, determining mild moderate or severe incontinence
– A bladder health survey
– Medical and Drug History
– Urinalysis or dipstick urine
– Bladder event Diary
– Pelvic Examination, cough test, q-tip test
– General and mental health evaluation
– Resting and Active Pelvic tone measurements
– Urodynamics testing
– Pelvic Vaginal Ultrasound
Once the testing and examination are completed, the Overall Assessment will be determined and a treatment plan recommended
What is Urodynamics Testing?
Preparation for the testing includes arriving to the office at your appointment time with a full bladder but DO NOT DRINK ANYTHING FOR 30 MINUTES PRIOR TO YOUR SCHEDULED APPOINTMENT TIME. Please avoid any bladder irritants, such as caffeine beverages. If you have any symptoms of a urinary tract infection, such as urgency, burning or dark cloudy urine, please advise the staff. You know your body better than we do so try to plan your fluids accordingly. The testing will take approximately an hour to complete, and will involve emptying, filling and holding a full bladder momentarily. We will also attempt to recreate the same types of events that cause problems with your bladder control. We encourage your feedback during the testing to get the most information possible.
The first test is a Uroflow study. In a private testing room, you will urinate in a special commode and measurements will be taken by the computer. These measurements give Dr. Swor information regarding the amount of urine output, amount of time, and whether or not there was hesitancy or stopping and starting of urination.
You will then be asked to move to the examination table. A small catheter will be placed into the bladder which will measure the residual amount of urine (if any) left in the bladder. Another catheter will be placed in the vagina to measure pelvic pressures during the rest of the testing.
The bladder will then slowly be filled while the computer records pressures, volumes and events, such as coughing, straining and leaking. The results tell us important information about how the bladder functions properly or improperly. This allows us to determine the type of problem you have and how we might help you improve your control and voiding ability.
At any time before, during or after testing, you should tell us about any significant discomfort or problem you are having. Following the tests, we will give you an antibiotic pill and specific instructions to help you. After the tests are reviewed by Dr. Swor, a treatment plan will be provided at a followup visit. This plan may include exercises, home therapy, medication, biofeedback, electronic therapy, minimally invasive surgery or a referral to a urologist if we feel additional testing or more significant surgery is required.
The Treatment Plan may include:
– dietary and nutritional and behavioral modification
– Antibiotics for infection
– Short term Estrogen therapy such as Estring, vagifem inserts, estrace cream, pills or patches
– a non-hormonal, natural hormone “boost”
– medication advice (such as being careful with the use of diuretics)
– bladder health advice (avoiding irritants such as caffeine)
– bladder training
– Kegel exercise or home resistance exercise (using a pelvic toner device)
– biofeedback and electronic stimulation bladder therapy
– pessary or vaginal device placement
– medications for urge incontinence such Detrol LA, Ditropan XL, Elavil/ Nortriptyline 25-100mg
– medication for stress incontinence such phenylpropanolamine 25-100 BID, Sudafed 15-30 TID
General Treatment Guidelines
Urge Incontinence (DI, DHIC, ISR) – training, therapy, medication such as Detrol LA, Ditropan XL, Elavil or Nortriptyline 25-100 mg/ day medication Side effects can include- dry mouth, visual, constipation
GSI – Exercises, therapy, medication, hormonal treatment, pessary, surgery such as minimally invasive SurX procedure, or Laparoscopic Burch procedure medication such as Phenylpropanolamine 25-100 mg bid, Sudafed or ephedrine 15-30 mg tid medication Side effects can include- anxiety, insomnia, sweating, arrhythmia, HTN
Mixed – Exercise, therapy, hormonal, device, trial medication
ISD – Urologic surgery (sling or bulking procedures)
Obstructive overflow – Obstruction relief with pessary or surgery
Non-obstructive overflow – further workup, may require catheter therapy
Reflex, Neurological and Unresponsive to therapy further evaluation and general medical treatment
Bladder training
Scheduled Voiding/ Habit Training – timed scheduled voiding every 3-4 hours while awake or individualized to the patient’s needs
Prompted Voiding – as above, but prompted by someone other than the patient
Urge Control – reteaching the bladder to overcome initial urges to void the bladder contracts at certain “fill” levels giving the sensation of needing to void- by “holding” through the early urge sensations, the bladder “learns” to become fuller before a real need to empty occurs – this training can be more effective by adding the use of Kegel exercises, home resistance therapy with the pelvic toner or office electronic therapy
Techniques for urge control involve:
1. noting an initial urge
2. stopping current activity
3. rapidly contracting and relaxing the pelvic floor muscles
4. deep breathing and biofeedback techniques
5. walking to the restroom in a controlled manner once the urge has gone away
6. This program relies on the fact that the pelvic floor muscles can inhibit the bladder.
Home therapy
* Up to 80% of patients who regularly practice home behavioral training and exercises will see improvement in their bladder control. The results may take several months, but some improvement should be noticed within a few weeks. Even better success has been seen with the use of resistance exercising using the pelvic toner device or the office electronic pelvic toning and biofeedback. Our philosophy is the team approach, starting simple and having realistic expectations.
* Home therapy is safe, easy to learn, and has no known ill-effects. These therapies have also been seen to improve general pelvic support and sexual response.
Pelvic Muscle Rehabilitation
The pelvic floor muscles and pelvic support are assessed by exam and, if insufficient, can be strengthened and improved with various techniques. Strong pelvic support and pelvic floor muscles are important in general well being, bladder control and sexual function. Many women are unable to isolate and contract their pelvic floor muscles and so have no defense mechanisms when stress or urgency incontinence occurs. Your pelvic floor muscle function is assessed during your examination.
Kegel Exercises
The pelvic floor muscles are the muscles you use to stop urine flow during voiding, and you can identify them by practicing stopping the flow during voiding. Dr. Kegel described an exercise program for these specific muscles many years ago that is commonly practiced by patients today. This is done by “drawing in” or “drawing up” the muscles in the region of the bladder, vagina and rectum. The muscles of the abdomen, thighs and hips should remain relaxed. Many patients mistakenly contract their buttock and/or abdominal muscles.
Try to contract the muscles with a little more strength each day. Do not strain too hard or continue the exercise so long that it causes fatigue or aching of the muscles. If continuous exercise causes fatigue, it is better to exercise one or two minutes and rest several minutes.
The effort to exercise weakened vaginal muscles may be difficult and tiresome the first day, or in some cases, the first five or six days. With moderate efforts and continued practice and exercise, a gradual increase in the strength of the muscles will be noted.
Pelvic floor contractions are entirely private and can be performed at any time and in any place or position. Some ideas for good Kegel times are:
– At red traffic lights.
– During commercials or while watching TV.
– Anytime you have to wait (especially standing).
– After coughing, sneezing, laughing, lifting, climbing stairs, straining
– Before arising in the morning or after retiring at night.
– During each of three meals.
– Each time you go to the bathroom (Average 6 times a day).
Quality is more important than quantity. Slowly contract the muscles as you would in making a hard fist, not just closing your fingers but clenching to bring in every muscle fiber. About 5 in a series, holding each contraction for about 5 seconds–then rest a while. Always end with an uplifting contraction.
Resistance Pelvic Toner Device
Once regular Kegel exercises are mastered, or when an accelerated program is desirable, we suggest using a device to assist in developing stronger pelvic floor muscles. We recommend the clinically-evaluated Pelvic Toner that can be purchased very reasonably and used with confidence. Ask our staff for information.
Sometimes a patient is unable or unwilling to try home therapy, or it has been unsuccessful or if an even more accelerated program is desired. In this case, we suggest biofeedback and electronic pelvic toning therapy in the privacy of our office, with a nurse therapist acting as evaluator and trainer. This therapy is done with the use of state-of-the-art technology recently imported from Europe. See the next section for more information.
Office Pelvic Floor Evaluation and Rehabilitation
Swor Women’s Care now offers state-of-the-art technology for those who want or need biofeedback techniques and electronic pelvic floor therapy.
If during your evaluation, the pelvic floor muscles are found to be extremely weak or that you have difficulty identifying the muscles or contracting them with Kegels, then this therapy is ideal. Our nursing staff will act as your “personal trainer”. We will measure the strength of the pelvic floor at rest and while contracting. We may use visual aids called “biofeedback” techniques. These are techniques that help you locate and isolate the pelvic floor muscles for maximal benefit. Then electronic pelvic floor stimulation and strengthening will be done during 30 minute sessions for 5 of 7 days.
Biofeedback – Electronic or mechanical instruments are applied and information is displayed about neuromuscular and/or bladder activity in regard to pelvic muscle exercises. This is effective in enabling and motivating patients to learn voluntary muscle control by direct observation of the biofeedback.
Electronic stimulation – Application of electrical current through the placement of a vaginal probe which is effective in improving muscle contractility and efficiency.
This will be done in addition to home therapy techniques and may help in more severe cases to avoid the need for pessaries and/or surgery. Further sessions may be recommended based on response and needs of the individual patient.
Minimally Invasive Surgery
At Swor Women’s Care, we offer several techniques for treating pelvic floor and incontinence problems, depending on the nature and severity of the abnormality. Dr. Swor has over 15 years of surgical experience in treating these problems, and is currently trained in some of the newest proven techniques. A chosen procedure may be done vaginally or laparoscopically in an outpatient/same day arrangement with a short anticipated recovery phase and low complication rate. Long term improvement is anticipated in 85% of our surgically treated patients. The latest technique for healthy patients with mild to moderate stress incontinence is the SurX procedure. Small incisions are made vaginally or laparoscopically and radiosurgical frequency is used to treat the bladder neck to tighten and strenghten it. For more information on this new technology, see www.surx.com