Incontinence

WHAT IS URINARY INCONTINENCE? 

Urinary incontinence (leakage) refers to the involuntary loss of urine from the bladder, which constitutes a social or hygienic problem for the individual. Bladder control problems affect about 17 million people in the United States. It can be a cause of anxiety, social embarrassment and may limit ones social and daily activities. Fortunately, most of these conditions can be treated. However the first step to curing this condition is acknowledging the problem and then deciding to see a physician who has been properly trained in treating this condition. 

CAUSES OF INCONTINENCE 

There are many causes of urinary incontinence. Some of these causes are related to temporary conditions. Once they are treated, the incontinence usually goes away. Temporary causes include: 

• Urinary tract infection
• Constipation 
• Certain medications 
• Increased dietary intake of caffeine, alcohol, artificial sweeteners and carbonated beverages 

Some other causes of incontinence are not temporary. There is, however, treatment available for many of these conditions. Other causes include: 

• Weakness of the muscles that hold the bladder in place 
• Weakness of the bladder and or the sphincter muscles 
• Overactive or underactive bladder muscles 
• Decreases in certain hormones, especially estrogen 
• Neurological disorders (ex: Multiple Sclerosis, Parkinson's Disease)  

TYPES OF INCONTINENCE

• Urge (overactive bladder) 
• Stress (activity related) 
• Overflow 
• Mixed 
• Fistula 

Urge Incontinence
(overactive bladder, detrusor instability, bladder spasms)

Urge incontinence occurs when someone cannot delay the bladder's message to empty. When this occurs, the person often experiences "the urge" and often the individual can not make it to the restroom on time. This is the most common type of incontinence and is usually readily treated with medication. Patients may experience: 

• Difficulty maintaining their urine on the way to the bathroom 
• Getting up frequently during the night to urinate 
• The need to go to the bathroom at least every two hours
• Feeling of a weak bladder or a small bladder

Stress Incontinence (activity leakage)

Stress incontinence is the loss of urine during coughing, sneezing, laughing or lifting something heavy. These activities cause an increase in "belly pressure", which forces the urine out of the bladder. Some patients will leak only a few drops while others may leak more than a cup. Stress incontinence occurs almost exclusively in women and is thought to be due to "pelvic (vaginal)
relaxation" from childbirth or aging. Excessive weight can be a contributing factor. Patients may experience: 

• Leakage of urine when coughing, sneezing, or laughing 
• Frequent trips to the bathroom in order to avoid accidents 
• Reluctance to exercise to avoid accidents 
• Sleeping through the night but leaking when getting out of bed in the morning 
• Leakage upon rising from a chair

Overflow Incontinence

Overflow incontinence occurs due to an inability to completely empty the bladder. There is a constant or frequent small amount of urine leakage. Essentially, the bladder becomes overfilled and the urine leaks out because the bladder can no longer maintain any more urine. A simple analogy would be like water seeping over the top of a dam because it has met its capacity. Patients may
experience: 

• Frequent night time urination 
• Taking a long time to urinate 
• Dribbling stream with little force 
• Urinating small amounts and not feeling completely empty afterward 

Mixed Incontinence

Many patients have a combination of incontinence types. Especially prevalent are patients with both stress and urge incontinence. These patients experience symptoms of: 

• Leakage with cough, sneeze and rise of abdomen pressure 
• Leakage which is sudden and with little warning 
• Frequent daytime urination 
• Urgency 
• Etc. ......please see above for other symptoms

Fistula Incontinence

A fistula is defined as an abnormal connection between two organs lined with some type of skin. It most commonly forms between the bladder or urethra and the vagina. Though uncommon in developed countries such as the United States it can occur after surgical trauma, pelvic cancer, pelvic radiation therapy and obstetric trauma. Patients may experience. 

• Continuous urine leakage 
• Leakage with cough, sneezing, or rise of abdominal pressure 
• Uncontrollable leakage 

CLINICAL EVALUATION

All patients should have a comprehensive history and physical examination, which emphasizes the
woman's urogenital tract. A focused physical examination assesses vaginal tissue and neighboring organ support. On a patients' first visit to Dr Miklos' office, some simple, relatively painless tests are conducted and may include the following:

Q-tip test - a moistened Q-tip or cotton swab is inserted into the urethra. The patient is asked to strain and the change in angle of the cotton swab is measured. The change in angle is proportional to the degree of bladder-neck descent on bearing down or Valsalva maneuver. Although this anatomical defect is associated with stress incontinence it is not diagnostic, and may occur in women with vaginal relaxation without incontinence. 

Uroflowmetry - The patient is asked to urinate over a urine catch, which sits on a scale. This test will measure rate of urination, length of urination and whether the urine stream is continuous or intermittent. This test helps determine whether the patient might have an obstruction and interfere with her urinating process. 

Bladder Scan - Upon completion of the uroflowmetry, an ultrasound is performed just above the pubic hairline. This is a quick, painless test that determines the quantity of urine in the bladder. This is helpful in determining if a person empties the bladder completely when urinating. 

Simple Cystometry - The patient is then catheterized and the bladder is filled with sterile water via the catheter. The physician can determine if the patient has normal capacity on this filling technique. The catheter is then removed and the physician then asks the patient to cough and strain to determine whether there is stress incontinence. 

Urinalysis - The urine obtained at the time of catheterization is tested for blood and bacterial infection. 

The physician may recommend other testing or more sophisticated urodynamics to provide for accurate diagnosis and treatment for particular types of incontinence. Advanced Urodynamic testing is usually performed if the patient is not responding to conservative therapy and/or is considering surgery. 

Advanced Urodynamic Testing

Advanced Urodynamic Testing is a series of tests and/or x-rays that give a detailed look at the function of the bladder, urethra and sphincters. This helps to diagnose any problems with storing urine or voiding. Urodynamic testing involves having a small catheter placed in the bladder (via the urethra), the vagina or the rectum. Most patients consider urodynamic testing painless. 

Complex Cystometrogram 
The bladder is filled with approximately 10-15 ounces of sterile water. Bladder pressures are recorded to determine whether the patient has spontaneous contractions (bladder spasms). After the filling phase the patient is asked to cough and any urine leakage is recorded. Simultaneous coughing and urine leakage is consistent with stress urinary incontinence. 

Voiding Pressure Study
The final portion of the study involves having the person urinate on a special commode with the catheters still in place. 

The entire test takes approximately 20-30 minutes. Other tests such as leak point pressure and urethral closure pressures are also performed during advanced urodynamic testing.

References:

Copyright ©2000, 2001 Dr. John R. Miklos
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