Clinical Specialties : Female Pelvic Health

Female Urinary Incontinence

Female Urinary Incontinence (Voiding Dysfunction and Reconstruction)

What is Female Urinary Incontinence?

Urinary Incontinence (UI) is the uncontrolled leakage of urine from the bladder (failure to store). It is difficult to estimate the prevalence of UI because patients often feel embarrassed to report the condition to their physicians or consider urinary incontinence a “normal” result of the aging process.. It is known that UI afflicts an estimated 13 million adults in the United States, 85 percent of whom are women.

Since 30 percent of women will experience UI at some point in their lifetime, it is considered more prevalent than other chronic diseases such as asthma, coronary artery disease, or peptic ulcer disease. Although usually not life-threatening, UI has far-reaching medical and social implications.

Why does it occur?

Urinary control relies on the finely coordinated activities of the smooth muscle tissue of the urethra and bladder, skeletal muscle, voluntary inhibition, and the autonomic nervous system.

Urinary incontinence can result from anatomic, physiologic, or pathologic (disease) factors. Congenital and acquired disorders of muscle innervation (e.g., ALS, spina bifida, multiple sclerosis) eventually cause inadequate urinary storage or control.

Acute and temporary incontinence are commonly caused by the following:
• Childbirth
• Limited mobility
• Medication side effect
• Urinary tract infection

Chronic incontinence is commonly caused by these factors:
• Birth defects
• Bladder muscle weakness
• Blocked urethra (due to benign prostate hyperplasia, tumor, etc.)
• Brain or spinal cord injury
• Nerve disorders
• Pelvic floor muscle weakness

What types of Urinary Incontinence are there and how can I find out which one I have?

There are four types of UI: stress urinary incontinence; urge urinary incontinence; mixed urinary incontinence; and overflow urinary incontinence. A careful history, voiding diary, physical examination and, in some cases, a specialized test of the bladder (urodynamics) help to lead an experienced clinician to the correct diagnosis. The following patients illustrate the differences in diagnosis and management of UI.

Patient A, a 55-year-old accountant, wears three pads each day and leaks urine when she plays tennis, jogs or laughs. She has stress urinary incontinence (SUI), leakage with physical activity. Here the word “stress” refers to physical stress or exertion, not “emotional stress”. In many instances of SUI, the pelvic floor, which supports the bladder, bladder neck and urethra, becomes weak due to pregnancy, childbirth, hormonal changes, aging, and/or prior pelvic surgery. This may lead to excessive movement of the urethra, i.e. hypermobility, with physical “stress maneuvers”. Another cause of SUI is a weakened urethral sphincter, known as intrinsic sphincteric deficiency (ISD), in which the urethral sphincter becomes incapable of sealing the flow of urine during physical exercise.

Many experts believe that women with SUI and concomitant ISD should undergo either a sling-type procedure or an injection of bulking agents (collagen, carbon particles (Durasphere), Teflon, fat, silicon) around the bladder neck and proximal urethra. Patients with concomitant ISD and significant urethral hypermobility may respond less favorably to bulking agents and are best treated with sling procedures.
Three categories of surgical techniques used to treat SUI are: retropubic suspensions; transvaginal bladder neck suspensions; and sling procedures to create hammock-like support of the urethra using synthetic material or abdominal fascia, thigh fascia or similar tissue derived from carefully processed cadaveric tissue. One of the most novel and exciting procedures is the use of Tension Free Vaginal Tape (TVT) to treat SUI. The technique is similar to other suburethral “sling” devices. A supportive hammock of Prolene (a synthetic mesh) is placed below and under the mid portion of the urethra in a “tension-free” manner. The TVT mesh is placed vaginally using minimal tissue dissection. Commonly, the procedure is performed under local anesthesia so that the “cough test” can be performed to ensure proper tension on the Prolene tape. Patients resume full activity, except for sexual intercourse, the day following this less than one-hour outpatient procedure. Patient A underwent TVT and is now enjoying the freedom of being pad-free and dry. Historically, non-surgical treatments such as medications, biofeedback, Kegel exercises, and electrical stimulation have not usually been curative for the treatment of stress urinary incontinence because anatomical defects need to be addressed by surgery. Nevertheless, Dr. Gousse is currently investigating a new oral medication for the treatment of SUI .

Patient B, a 65-year-old retired schoolteacher, wears 4 pads a day because she often experiences a sudden strong urge to urinate along with an uncontrollable rush of urine. She suffers fromurge urinary incontinence. The cause may be an overactive bladder that “contracts without permission”. Patient B admits to being a heavy coffee drinker but has a normal physical exam with no identifiable neurologic condition. A special bladder test, urodynamics, reveals that her bladder involuntarily contracts while it is being filled.

Patient B was asked to restrict her coffee intake, strengthen her pelvic muscles by performing 100 Kegel exercises a day, void every 2 to 3 hours around the clock, and begin taking an oral medication (anticholinergic) to relax her bladder muscle. Four weeks later she no longer needed to use a pad for protection because she was dry as long as she complied with the recommendations.
In select patients with urge urinary incontinence and/or severe urinary frequency who do not respond to the above treatment, the urologist may offer Interstim Neuromodulation, a tiny implantable device with an electrode placed around the third sacral nerve, which was approved by the FDA in 1997. A minimally invasive procedure performed under local anesthesia (First Stage) can determine whether the Interstim will be successful. University of Miami School of Medicine was the first institution in South Florida to offer neuromodulation to bladder control patients, and has maintained the most active program in the region.

Patient C, a 78-year-old widowed mother, wears 5 pads a day and is embarrassed to play Bingo with her friends. Patient C leaks when she coughs and experiences frequent sudden urges to urinate followed by gross urinary leakage. She is suffering from mixed urinary incontinence. This condition is best managed by urologists who have expertise in the sub-specialty of voiding dysfunction. A comprehensive voiding diary, careful physical examination, urodynamics, cystourethroscopy, and urine cytology should be performed. Patient C was managed in a similar manner to Patient B and remained dry 27 out of 30 days. She leaked urine only when her bladder was very full and, therefore, by voiding every 3 hours around the clock, her incontinence disappeared. She has required no surgery.

Patient D, a 76-year old mother, has been an insulin dependent diabetic for 20 years. She leaks urine day and night, wears diapers and was placed in a nursing home facility primarily because of UI. She experienced no significant improvement on an anticholinergic but had 4 urinary tract infections in one year. The nursing home obtained a post-void residual, revealing a gross abnormality of 10 ounces of urine in the bladder after voiding (Less than 2 ounces being normal). This patient was diagnosed with overflow urinary incontinence and referred to Dr. Gousse for evaluation. Urodynamics revealed that her bladder could be filled to full capacity (500 ml or more) without sensation and that her bladder muscle was unable to contract (flaccid bladder). Patient D was started on self-intermittent catherization every 6 hours to drain the bladder. Self-intermittent catheterization allows a patient to insert a tiny plastic tube (catheter) in the urethra at regular time intervals in order to remove urine from the bladder. She is now dry and was discharged from the nursing home.

These cases illustrate that proper diagnosis and management are essential to a satisfactory outcome and that surgery is not the only solution for women with bladder control problems.

What types of treatments exist?

Treatment options for urinary incontinence depend on the type of incontinence as outlined below. Stress incontinence is urine loss during physical activity that increases abdominal pressure (e.g., coughing, sneezing, and laughing). Treatment options include:
• Injectables
• Nonsurgical treatments
• Medications
• Surgical treatments

Urge incontinence is urine loss with urgent need to void and involuntary bladder contraction (also called detrusor instability). Treatment options include:
• Nonsurgical treatments
• Medications
• Surgical treatments

Overflow incontinence is constant dribbling of urine; bladder never completely empties. Treatment options include:
• Medications
• Intermittent Self-Catheterization

Female Pelvic Floor Reconstruction

What is Pelvic Floor Reconstruction?

Pelvic floor reconstructive surgery consists of several procedures for correcting a condition called “pelvic organ prolapse.”

When the muscles of the pelvic floor are damaged or become weak – often due to childbirth – they are sometimes unable to support the weight of some or all of the pelvic and abdominal organs. If this occurs, one or more of the organs may drop (prolapse) below their normal positions, causing symptoms including discomfort, pain, pressure and urinary incontinence.

The goal of pelvic floor reconstruction is to restore the normal structure and function of the female pelvic organs.

About 35 percent of women will develop some form of pelvic organ prolapse. The condition can often be treated with nonsurgical therapies, but it sometimes requires pelvic floor reconstructive surgery. The expertise and skill of the physician is extremely important in these procedures.

What is the pelvic floor?

The pelvic floor consists of the muscles, ligaments, connective tissue and nerves that support and control the rectum, uterus, vagina, and bladder. This “floor” can be damaged by childbirth, repeated heavy lifting, chronic disease or surgery.

What are some symptoms associated with pelvic floor damage?

Incontinence – Loss of bladder or bowel control and leakage of urine or feces.

Prolapse – Descent of pelvic organs including dropped uterus, bladder, vagina or rectum. About 35 percent of women will develop some form of pelvic organ prolapse.

Emptying Disorders – Difficulty urinating or moving bowels.

Pelvic Pain – Discomfort, burning or other uncomfortable pelvic symptoms, including bladder or urethral pain.

Overactive Bladder – Frequent need to urinate, uncomfortable bladder pressure, urge incontinence and difficulty holding a full bladder.

Stress Urinary Incontinence

What is stress urinary incontinence (SUI)?

Stress urinary incontinence is a condition that affects approximately 1 in 3 women. It involves the involuntary loss of urine that is associated with activity or physical movement of the body. It often occurs when you cough, laugh, sneeze, exercise or upon standing.

Why do people develop stress urinary incontinence?

At the top of the list of risk factors for developing stress urinary incontinence is being of the female gender. We also see that stress incontinence is more common as age increases. Other risk factors that may cause stress incontinence include: obesity, smoking and diabetes mellitus. Pregnancy and childbirth are major risk factors due to the stretching and damage of the pelvic floor that supports the bladder. Pelvic surgery also has the potential to weaken the pelvic floor and cause potential nerve injury leading to stress incontinence.

What are the treatment options for stress urinary incontinence?

Treatment options for stress incontinence range from conservative physical therapy exercises to minor surgical procedures. Pelvic floor exercises (aka Kegels) are designed to strengthen the supporting muscles of your bladder and urethra in hopes of providing increased support for these structures and prevent leaking during activity. For information on how to perform these please visit this website: http://www.urologyhealth.org/urology/index.cfm?article=119. Along with Kegel exercises, simple lifestyle changes such as weight loss and smoking cessation have been shown to improve stress urinary incontinence.

When Kegel exercises do not work we still have other treatment options, which include urethral bulking agents and the urethral sling. Urethral bulking agents consist of injection a small amount of material within the urethra to help bring together the urethral tissue and prevent urine leakage during activity. While bulking agents are less effective than slings, they have the advantage of being performed without any incisions and have almost an immediate recovery.

Sling surgery is performed as an outpatient and does require a small incision in the vagina. A piece of biologic or synthetic material is placed under the urethra to supply additional support. Although is does require general anesthesia, patient are discharge home the same day with very little recovery time.

At the University of Miami Center for Pelvic Health and Reconstruction, we frequently take a multidisciplinary approach with the patient in mind to treat stress urinary incontinence. We often involve the aide of physical therapist to help patient strengthen the pelvic floor and avoid surgical procedures. When surgical procedures are involved, our fellowship trained physicians Dr. Christopher Gomez and Yvonne Koch employ to most advanced and minimally invasive techniques to help correct your incontinence.