Urinary Incontinence in Women (cont.)
How is incontinence treated?
Behavioral remedies: bladder retraining and
Kegel exercises
By looking at your bladder diary, the doctor may see a pattern
and suggest making it a point to use the bathroom at regular timed intervals, a
habit called timed voiding. As you gain control, you can extend the time between
scheduled trips to the bathroom. Behavioral treatment also includes Kegel
exercises to strengthen the muscles that help hold in urine.
How do you do Kegel exercises?
The first step is to find the right muscles.
One way to find them is to imagine that you are sitting on a marble and want to
pick up the marble with your vagina. Imagine sucking or drawing the marble into
your vagina.
Try not to squeeze other muscles at the same time. Be careful not to tighten
your stomach, legs, or buttocks. Squeezing the wrong muscles can put more
pressure on your bladder control muscles. Just squeeze the pelvic muscles. Don't
hold your breath. Do not practice while urinating.
Repeat, but don't overdo it. At first, find a quiet spot to practice -- your
bathroom or bedroom -- so you can concentrate. Pull in the pelvic muscles and hold
for a count of three. Then relax for a count of three. Work up to three sets of
10 repeats. Start doing your pelvic muscle exercises lying down. This is the
easiest position to do them in because the muscles do not need to work against
gravity. When your muscles get stronger, do your exercises sitting or standing.
Working against gravity is like adding more weight.
Be patient. Don't give up. It takes just 5 minutes a day. You may not feel
your bladder control improve for 3 to 6 weeks. Still, most people do notice an
improvement after a few weeks.
Some people with nerve damage cannot tell whether they are doing Kegel
exercises correctly. If you are not sure, ask your doctor or nurse to examine
you while you try to do them. If it turns out that you are not squeezing the
right muscles, you may still be able to learn proper Kegel exercises by doing
special training with biofeedback, electrical stimulation, or both.
 |
| Figure 3. Front view of bladder. Weak pelvic muscles allow urine leakage
(left). Strong pelvic muscles keep the urethra closed (right). |
Medicines for
overactive bladder
If you have an overactive bladder, your doctor may prescribe
a medicine to block the nerve signals that cause frequent urination and urgency.
Several medicines from a class of drugs called anticholinergics can help
relax bladder muscles and prevent bladder spasms. Their most common side effect
is dry mouth, although larger doses may cause blurred vision, constipation, a
faster heartbeat, and flushing. Other side effects include drowsiness,
confusion, or memory loss. If you have glaucoma, ask your ophthalmologist if
these drugs are safe for you.
Some medicines can affect the nerves and muscles of the urinary tract in
different ways. Pills to treat swelling (edema) or high blood pressure may
increase your urine output and contribute to bladder control problems. Talk with
your doctor; you may find that taking an alternative to a medicine you already
take may solve the problem without adding another prescription.
Scientists are studying other drugs and injections that have not yet received
U.S. Food and Drug Administration (FDA) approval for incontinence to see if they
are effective treatments for people who were unsuccessful with behavioral
therapy or pills.
Biofeedback
Biofeedback uses measuring devices to help you become aware of
your body's functioning. By using electronic devices or diaries to track when
your bladder and urethral muscles contract, you can gain control over these
muscles. Biofeedback can supplement pelvic muscle exercises and electrical
stimulation to relieve stress and urge incontinence.
Neuromodulation
For urge incontinence not responding to behavioral treatments
or drugs, stimulation of nerves to the bladder leaving the spine can be
effective in some patients. Neuromodulation is the name of this therapy. The FDA
has approved a device called InterStim for this purpose. Your doctor will need
to test to determine if this device would be helpful to you. The doctor applies
an external stimulator to determine if neuromodulation works in you. If you have
a 50 percent reduction in symptoms, a surgeon will implant the device. Although
neuromodulation can be effective, it is not for everyone. The therapy is
expensive, involving surgery with possible surgical revisions and replacement.
Vaginal devices for stress incontinence
One of the reasons for stress
incontinence may be weak pelvic muscles, the muscles that hold the bladder in
place and hold urine inside. A pessary is a stiff ring that a doctor or nurse
inserts into the vagina, where it presses against the wall of the vagina and the
nearby urethra. The pressure helps reposition the urethra, leading to less
stress leakage. If you use a pessary, you should watch for possible vaginal and
urinary tract infections and see your doctor regularly.
Injections for stress incontinence
A variety of bulking agents, such as
collagen and carbon spheres, are available for injection near the urinary
sphincter. The doctor injects the bulking agent into tissues around the bladder
neck and urethra to make the tissues thicker and close the bladder opening to
reduce stress incontinence. After using local anesthesia or sedation, a doctor
can inject the material in about half an hour. Over time, the body may slowly
eliminate certain bulking agents, so you will need repeat injections. Before you
receive an injection, a doctor may perform a skin test to determine whether you
could have an allergic reaction to the material. Scientists are testing newer
agents, including your own muscle cells, to see if they are effective in
treating stress incontinence. Your doctor will discuss which bulking agent may
be best for you.
Surgery for stress incontinence
In some women, the bladder can move out of
its normal position, especially following childbirth. Surgeons have developed
different techniques for supporting the bladder back to its normal position. The
three main types of surgery are retropubic suspension and two types of sling
procedures.
Retropubic suspension uses surgical threads called sutures to support the
bladder neck. The most common retropubic suspension procedure is called the
Burch procedure. In this operation, the surgeon makes an incision in the abdomen
a few inches below the navel and then secures the threads to strong ligaments
within the pelvis to support the urethral sphincter. This common procedure is
often done at the time of an abdominal procedure such as a hysterectomy.
Sling procedures are performed through a vaginal incision. The traditional
sling procedure uses a strip of your own tissue called fascia to cradle the
bladder neck. Some slings may consist of natural tissue or man-made material.
The surgeon attaches both ends of the sling to the pubic bone or ties them in
front of the abdomen just above the pubic bone.
Midurethral slings are newer procedures that you can have on an outpatient
basis. These procedures use synthetic mesh materials that the surgeon places
midway along the urethra. The two general types of midurethral slings are
retropubic slings, such as the transvaginal tapes (TVT), and transobturator
slings (TOT). The surgeon makes small incisions behind the pubic bone or just by
the sides of the vaginal opening as well as a small incision in the vagina. The
surgeon uses specially designed needles to position a synthetic tape under the
urethra. The surgeon pulls the ends of the tape through the incisions and
adjusts them to provide the right amount of support to the urethra.
If you have pelvic prolapse, your surgeon may recommend an anti-incontinence
procedure with a prolapse repair and possibly a hysterectomy.
 |
| Figure 4. Side view. Supporting sutures in place following retropubic or
transvaginal suspension (left). Sling in place, secured to the pubic bone
(center). The ends of the transobturator tape supporting the urethra are pulled
through incisions in the groin to achieve the right amount of support (right).
The tape ends are removed when the incisions are closed. |
Recent women's health
studies performed with the Urinary Incontinence Treatment Network (UITN)
compared the suspension and sling procedures and found that, 2 years after
surgery, about two-thirds of women with a sling and about half of women with a
suspension were cured of stress incontinence. Women with a sling, however, had
more urinary tract infections, voiding problems, and urge incontinence than
women with a suspension. Overall, 86 percent of women with a sling and 78
percent of women with a suspension said they were satisfied with their results.
For more information, please visit www.uitn.net. Women who are interested in
joining a study for urinary incontinence can go to www.ClinicalTrials.gov for a
list of current studies recruiting patients.
Talk with your doctor about whether surgery will help your condition and what
type of surgery is best for you. The procedure you choose may depend on your own
preferences or on your surgeon's experience. Ask what you should expect after
the procedure. You may also wish to talk with someone who has recently had the
procedure. Surgeons have described more than 200 procedures for stress
incontinence, so no single surgery stands out as best.
Catheterization
If you are incontinent because your bladder never empties
completely -- overflow incontinence -- or your bladder cannot empty because of poor
muscle tone, past surgery, or spinal cord injury, you might use a catheter to
empty your bladder. A catheter is a tube that you can learn to insert through
the urethra into the bladder to drain urine. You may use a catheter once in a
while or on a constant basis, in which case the tube connects to a bag that you
can attach to your leg. If you use an indwelling -- long-term -- catheter, you should
watch for possible urinary tract infections.
Other helpful hints
Many women manage urinary incontinence with menstrual
pads that catch slight leakage during activities such as exercising. Also, many
people find they can reduce incontinence by restricting certain liquids, such as
coffee, tea, and alcohol.
Finally, many women are afraid to mention their problem. They may have
urinary incontinence that can improve with treatment but remain silent sufferers
and resort to wearing absorbent undergarments, or diapers. This practice is
unfortunate, because diapering can lead to diminished self-esteem, as well as
skin irritation and sores. If you are relying on diapers to manage your
incontinence, you and your family should discuss with your doctor the possible
effectiveness of treatments such as timed voiding and pelvic muscle exercises.
Next: Points to remember about urinary incontinence »
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