Urinary Incontinence and Prolapse
in Women
In a 1996 study, the number of Americans experiencing urinary incontinence as estimated to be 13 million. This number is actually thought to underestimate the true incidence of this problem, as many individuals suffer in silence. Women are twice as likely than men to have issues relating to urinary incontinence during their lifetime. The problem is not only attributable to differences in anatomy but also to hormonal issues as well as issues relating to childbirth. Some studies have noted a prevalence rate of up to 35% of women over the age of 18 having some form of continence problem.
Classification
Stress Incontinence: Stress incontinence occurs with activities, which result in abdominal straining. Whether this is lifting, or laughing, or even a change in position, the end result is that the pressure with in the bladder rises. If this exceeds the pressure at the opening of the bladder and urethra, the individual will leak. The incidence of stress incontinence rises with age, and parity, and seems to be more likely to occur in women who have delivered their children vaginally. Having large babies, or prolonged labor also may contribute. With age, and hormonal changes, the vaginal tissues lose the ability to support the bladder base and the urethra. During labor and delivery, there also may be damage to nerves running along the pelvic sidewall. All of these issues are thought to be contributing factors.
Urge Incontinence: When the overwhelming need to urinate results in the loss of urine prior to reaching the bathroom, the condition is known as urge incontinence. The causes are many, and include infection, as well as disorders of the central nervous system, including stroke, multiple sclerosis, spinal chord injury, and Parkinson's disease. In a condition known as the "overactive bladder" the urgency and urge incontinence may mimic that of a neurological condition, without the neurological pathology. Other common causes may include constipation, medications (diuretics), alcohol and caffeine use. Treatment of pelvic tumors with radiation therapy may also contribute to this condition.
Mixed Incontinence: When both urge and stress incontinence occur together, the condition is known as mixed incontinence.
Overflow Incontinence: This condition is usually caused by the inability to empty the bladder resulting in near constant leaking and frequency. This is more common in men, occurring with severe prostate obstruction. In women, this condition may be seen in cases of longstanding diabetes.
Total Incontinence: When there is a complete inability to control the urinary leakage, the condition is known as total incontinence. This is a very rare condition, and is usually the result of severe sphincter damage that can occur with radical pelvic surgery for cancer, or as a result of radiation therapy. Less commonly, total incontinence can occur as a result of multiple, failed surgeries for the treatment of incontinence.
Functional Incontinence: When another condition makes it impossible for an individual to make it to the bathroom on time, incontinence may result. An individual may be bed ridden, or have a severe problem with ambulation due to arthritis or other orthopedic condition. Likewise, if there are cognitive deficits, an individual may have problems in recognizing that they need to go to the bathroom.
Diagnosis
The physician will make a diagnosis based primarily on the history, as related by the patient or the caregiver. A physical exam is also completed during which the bladder will be palpated, and the genitals examined. In women the vaginal exam is occasionally done with the patient standing, with one foot up on a stool, which may allow for the identification of uterine, and or pelvic floor prolapse, which can be masked if the examination is done in the supine position. The patient will be asked to strain or bear down during the exam, to help mimic the effect of stress on the vaginal vault and bladder. In most cases, a post void residual urine volume will be determined, by either ultrasound, or rarely catheterization.
Laboratory testing will include a urine analysis, as well as a culture. It may also include testing for bladder cancer.
At the end of the visit, the patient will often be asked to keep a voiding diary. In these cases, we will ask that you keep note of the time and type of fluids ingested, as well as the volume. You will be asked to record the time of each void, the volume, and whether or not there was any leakage, or urgency involved. Once this information is in hand, the decision will be made to go on to testing that may include x-rays (cystogram), cystoscopy or urodynamics.
Treatment
Medication: Urge incontinence is the most common type of incontinence to be treated with medication. Depending on the condition, medications known as antimuscarinics may be recommended. These drugs include commonly advertised mediations including Detrol LA™, Vesicare™, Enablex™, Ditropan XL™, Oxytrol™, and Sanctura™. Other drugs, including tricyclic antidepressants (imipramine) have also found a use in the treatment of urge incontinence. Research using novel agents such as Botulinum Toxin (Botox™) has resulted in the potential for this becoming a mainstream treatment for certain conditions causing urge incontinence. Attempts at developing medications to treat stress incontinence have been largely unsuccessful. Clearly, if a condition such as diabetes is though to be the etiology of the incontinence, the treatment is specific to the condition. In some instances vaginal estrogen cream or suppositories have also been used as an adjunct to the other treatments.
Behavioral: In many instances, pelvic floor training can be used as a primary treatment, and most certainly as an adjunct to any of the other treatments for incontinence. Often a visit to a physical therapist will help to identify and to strengthen the weak areas in the pelvic floor. The therapist may utilize biofeedback, as well as electrical stimulation.
The use of Kegel exercises may also be recommended. The Kegel exercises can be done at any time and place, and involve exercising the muscles that make up the pelvic floor. These are the same muscles used to prevent one from passing gas as well as to stop the flow of urine. Various routines exist. Almost all recommend squeezing the muscle for 3 seconds, followed by 3 seconds of relaxation. If this is repeated 30 times, 3 or 4 times per day, one may see significant changes in the ability to prevent stress incontinence. On occasion vaginal cones may be useful as an adjunct to Kegel exercises.
Timed voiding (every 2 or 3 hours) as well as wise fluid management will help tremendously with individuals who have functional incontinence.
Pessary: In women with stress incontinence, especially if there is associated anterior wall prolapse (cystocele), a pessary may be useful when surgery is not possible, or desired. Pessaries are plastic rings that can be placed into the vagina in order to support the structures that in turn support the bladder and urethra. These devices must be taken out, and cleaned on a regular basis, in order to prevent erosion and or infection.
Bulking Agents: In some instances, bulking agents such as collagen can be injected just under the urethral lining, to increase the bulk around the bladder neck. These agents can be injected under light sedation, or even local anesthesia. The results may not be as durable, as with some of the other surgical procedures yet to be discussed. In cases where surgery is not possible or desired, the result may be acceptable.
Surgery: The surgery to treat stress incontinence can be done through an abdominal incision, or via very small vaginal incisions. Often the decision to use one route or another is dependent on other surgical procedures done at the same time, for other conditions.
The procedures done through the abdomen have been referred to as "bladder lifts" and include a procedure known as the Burch repair. Although this is a very "old" surgical procedure, the results have proven durable. It is done most commonly at the time of an abdominal hysterectomy or other abdominal procedure, or when the vaginal anatomy is such that access for the newer sling procedures is impossible.
Transvaginal slings are not new. The use of mesh, and the change in location for the placement of some of the slings has changed over the years, resulting in surgeries that are simpler, and often done without the need to leave a catheter. These procedures are usually done as an outpatient. When stress incontinence is the problem, and there is no other anatomical concern such as a cystocele (see prolapse section) a sub urethral hammock can be placed utilizing one of the commercially available systems such as the Monarc™ (American Medical Systems (AMS)). This sling is placed via a trans obturator approach, via a 1.5 cm incision in the vagina, and 2 smaller incisions in the crease between the labia and the inner thigh. Other sub urethral sling systems such as the Sparc™ (American Medical Systems (AMS)) are placed through the space between the bladder and the pubic bone. In instances where mesh may be contraindicated, these procedures can be done with natural products such as bovine, or cadaver grafts. Your physician will help you to decide which procedure is the correct one for you.
In very rare circumstances, an artificial urethral sphincter may be recommended. The AMS 800™ is used very frequently for the treatment of continence problems in men. It is a 3 piece prosthetic device that includes a small pump, placed in one of the labia. There is a large cuff that is placed around the neck of the bladder and a pressure reservoir that is situated in the pelvis. In order to void, the pump must be pushed 3 or 4 times, allowing the fluid to transfer from the cuff to the reservoir. Once voiding is complete, the system refills.
Interstim™ is an implantable neuromodulator that is manufactured by the Medtronic, Corporation. It is a unique approach to the treatment of urge incontinence that involves placement of electrodes in the 3rd sacral foramen, which in turn stimulate the nerves that supply the bladder. The end result may be a drop in the number of incontinent episodes of up to 50% or more. It is a reversible treatment, in that it can be implanted on a test basis, and removed if it is not successful. If successful, a battery powered intermittent pulse generator is implanted and may last between 6 and 10 years before needing a change.
Prolapse
Traditionally the anatomic description of the vagina has divided it into 2 compartments, referred to as anterior and posterior. The anterior vaginal wall is charged with the task of supporting the bladder and urethra. When a weakness in this portion of the vaginal wall occurs, the resulting anatomic defect is known as a cystocele. The posterior wall of the vagina keeps the rectum in "position". When this area becomes weakened the resulting defect is known as a rectocele. In a woman who has not had a hysterectomy, the uterus may descend as well. In instances where a hysterectomy was preformed in the past, the entire vaginal wall may prolapse.
The presenting symptoms may include complaints of a vaginal bulge, urinary urgency, frequency, incontinence, pain with intercourse and constipation, or fecal incontinence.
While the diagnostic work up from the urologic standpoint may not differ too much from that for incontinence, it may also include a referral to a colon and rectal specialist.
In the past, the treatment may have included "tuck procedures" that utilized a woman's own tissues to support the weakened areas. Taking a tip from our general surgeon colleagues, who largely abandoned these procedures in favor of using mesh, to repair inguinal and incisional hernias, urologists have begun to use mesh products as well.
The Perigee™ and Apogee™ systems are new and efficient ways for placing mesh via a minimally invasive approach for the correction of cystocele, and rectocele with or without vaginal prolapse. These procedures are done via a vaginal approach with only very small incisions outside of the vaginal vault. The end result is restoration of normal vaginal anatomy with potentially fewer complications and pain than an abdominal approach. An overnight stay in the hospital is suggested.
Our practice is able to offer the latest in medical and surgical treatments for all of these conditions. Your physician will be happy to explain the stepwise evaluation as well as treatment, including risk and complications.