Incontinence Treatment

TABLE OF CONTENTS

Treatments for Stress Incontinence
          Conservative Therapy
                    Pelvic Floor Exercises
                    Urinary Meatal Occlusion Devices
                    Collagen Injections

          Urinary Incontinence Surgery
                    Anterior Repair and Kelly plication
                    Pubovaginal Sling Procedures
                    Burch Urethropexy ProceduresTreatments for Urge IncontinenceTreatments for Overflow Incontinence Conservative Therapy Pelvic Floor Exercises (Kegel exercises)

This is the exercise which, when done faithfully and correctly, can help decrease the urgency a patient may have and help with both urge incontinence and stress incontinence. The pelvic floor muscle is like a hammock that stretches from the pubic bone in the front to the tailbone in the back. This set of muscles supports the organs of the pelvic region, which include the bladder, large intestines and uterus. Since this muscle is often not exercised, it is generally weak to begin with, which contributes to urinary symptoms. Childbirth will weaken this muscle more because during vaginal delivery, the child's head and body push under the pelvic floor muscle and stretches it extensively which causes temporary additional damage/weakening. Learning to do these exercises can help with incontinence, however to perform these exercises effectively the patient must first identify the correct muscles. 

Two methods of identifying the correct muscles: 

• While urinating stop the flow of urine by tightening the pelvic floor muscles. Do not  perform these exercises while urinating, since this can lead to difficulty in voiding. Stopping and starting the stream as a person voids is a popular misnomer and should not be done. Patients may elect to try to stop the stream once or twice to check for contraction of the correct muscle. 
• Place a finger in the vaginal opening and attempt to squeeze the finger. Upon squeezing, the patient should feel a tightening around her finger. She has identified the correct muscles that are to be exercised. 

One key point is that patients do not want to use other muscles, such as the abdomen, legs or buttocks. It is important to isolate the muscles only to further increase their strength. If you are moving these muscles or holding your breath, you are probably trying too hard! 

Concentrate just on the pelvic floor muscles and do the best you can. This contraction will get easier with practice. One exercise program is described below: 

• Attempt to contract and hold the muscle squeeze for 10 seconds 
• Relax for a period of 10 seconds 
• Perform 10-15 contractions and relaxation
• Perform this regimen 3-4 times a day

It may take awhile to work up to a 10 second hold. In the beginning, you will probably not be able to hold for more than five or six seconds and that is all right. Between each contraction, relax for 10 seconds. This allows the muscle to rest adequately to be able to perform well for the next contraction. If you do not relax the muscle well enough, the muscles will tire quickly. By faithfully doing your Kegel exercises, you should see an improvement in your symptoms starting in four to six weeks. 

Vaginal Cones - are miniature weights which are placed into the vagina and help pelvic floor exercises. 


Urethral Opening Occlusion Devices

There are several new non-surgical products on the market for female stress
urinary incontinence. Brand names are listed: 

• CapSure® and FemAssist®. - This type of device creates enough suction to keep the walls of the urethra together during stressful activities where someone might otherwise leak. The patient places a small amount of Vaseline-like material on the suction cup and places it in the area of the urethral opening, which is just above the vaginal opening. The placement does not have to be exact and once the device is in place the labia fold over it and the device cannot be seen or felt. When the patient needs to urinate, the suction cup is easily pulled off. The device is washed with soap and water and dried and is re-usable. 
• Reliance® - is an inter-urethral insert. This product requires the patient to insert a small catheter/plug into the urethra (tube that the urine travels through from the bladder to the toilet). These devices are comfortable to wear and when the patient needs to urinate, she pulls on a string, much like a tampon, to remove the device. When finished urinating, a new device is replaced in the urethra. There is a higher rate of urinary tract infections with this product versus the ones listed in the prior paragraph. 
• Tampons - can also be used for stress incontinence activity based leakage. Placing a tampon in the vagina acts as a support or buttress for the urethra and bladder. Supporting this area can reduce urine leakage with coughing, sneezing, bearing down (Valsalva maneuver) or exercising.

Comparing Sizes - Q Tip, tampon and Reliance® urethral insert.


Collagen Injections

Collagen is a naturally occurring protein found in humans and animals. When it is injected into the tissue around the urethra, it adds bulk and helps it close tightly to prevent urine leakage, especially urine leakage associated with activity (Stress Urinary Incontinence). Most patients will leak much less or not leak at all after collagen therapy. Some patients will need to have one or more injections done at a later date because the body will absorb some of the collagen material. The length of time between injections varies with each patient. Some need to be re-injected after a few months and some after a few years. 

Collagen Injection - Used for bulking up and tightening the urethra. This is a minimally invasive technique of treating stress urinary incontinence.

Urinary Incontinence Surgery

More than 150 operations have been described in medical literature for the treatment of Stress Urinary Incontinence. Unfortunately many of these operations, which are commonly performed throughout the world, have very poor surgical cure rates. A common misnomer of surgical cure is the surgeon is performing a bladder tack operation. Actually the goal for most of these surgeries is to stop urinary leakage and this is accomplished by supporting the urethra. The urethra is the tube that allows urine to be expelled from the body. In an attempt to support the urethra, actually the vagina under and beside the urethra is the area which the operation takes place. The two most successful operations described and researched in the literature are: Pubovaginal Sling procedure and the Burch urethropexy (colposuspension) procedure. These two operations are commonly called the SLING and the BURCH procedures. Though some doctors may argue which is the better of the procedures, there are too many variables for this question to ever be answered scientifically. By narrowing the choice to these two operations the patient is getting one of the most successful operations described in the literature. Interestingly, the most common operation still performed in the United States is the anterior repair and/or Kelly plication. 

For surgical treatment information, click here. 

Anterior Repair and/or Kelly Plication

Anterior repair (colporrhaphy) has been used to treat stress incontinence in conjunction with a bladder and urethra drop (cystourethrocele) for years. Although this operation is commonly used for both incontinence and anterior vaginal wall relaxation, it is probably not the operation of choice for most patients. It is a minimally invasive operation that is done through an incision in the anterior vaginal wall but only has a cure rate of 20-30 % for stress urinary incontinence. The poor cure rate associated with the anterior repair is quite discouraging and often forces a patient to have a second surgery. Most urogynecologists or urologists would not recommend this operation, as their procedure of choice, for cure of stress urinary incontinence. Many surgeons who perform both sling and Burch procedures will choose the most appropriate operation based upon the individual patient's needs and urodynamic testing results. 

Pubovaginal Sling Procedure

A sling procedure is done to create support where the urethra connects to the bladder (a.k.a. bladder neck). A sling is especially effective for the woman who has the diagnosis of Intrinsic Sphincter Deficiency (ISD) where the sphincter muscle is ineffective at holding urine in the bladder during certain "stressful" activities such as coughing, sneezing or exercising. There are many different types of "sling" operations described in the literature. The slings differ in the type of material, sutures, and points of anchoring. The decision on the type of sling utilized is surgeon dependent. The sling is placed under the bladder neck and is secured to a point of attachment (bone, abdominal wall, and ligament) through a vaginal incision. Therefore, when the woman coughs or sneezes, the bladder does not have as much motion now that the "backboard" is in place and so she will not experience any leakage. This procedure is done in the operating room under anesthesia and the patient goes home either the same day or the following day. The most recent efficacy statistics for patients undergoing pubovaginal sling procedures is upwards of approximately 85% for patients who have had the surgery 10 years ago. A sling procedure is considered "curative" for the female patient. 

Tension-Free Vaginal Tape (TVT) Sling

Dr. Miklos has been trained to perform a number of different types of sling operations utilizing various types of material, sutures and points of anchoring. Currently he chooses to offer his patients an extremely minimally invasive sling operation known as the TVT or tension free vaginal tape sling he learned in Stockholm, Sweden in 1998. This type of sling has been performed in Europe for more than 6 years with great success. Dr Miklos was the first surgeon in the Southeastern United States to perform the operation and serves as a preceptor to teach this operation to Urologists, Urogynecologists and Gynecologists throughout the world. In June 2000, Dr Miklos traveled to Russia to introduce the TVT sling operation to his colleagues at the University of Moscow. Dr. Miklos chooses the TVT sling for his patients because the operation is/has: 

• Minimally invasive (two incisions of 1/3 inch on the pubic hairline) 
• Minimal pain (40% of patients will not need a pain reliever after 24 hours) 
• Proven cure rate of 86% 
• Same day or next day discharge for 98% of patients 
• Performed under local anesthesia and IV sedation 
• Operative time 20-30 minutes 
• Minimal postoperative need for catheterization 
• Minimal complications  

For surgical treatment information, click here. 

Burch Urethropexy 

First described in 1961, by John Burch this procedure has stood the test of time and is currently considered one of the two most curative operations for the treatment of Stress Urinary Incontinence. It is used for both primary and recurrent stress incontinence and has a cure rate of 80-90%, 5-15 years following surgery. This procedure can be performed through a larger abdominal wall incision (i.e. Laparotomy) or through small abdominal incisions using cameras and TV screens (i.e. Laparoscopy). Despite the surgical approach, or size of incision, the operative technique for urinary incontinence should remain the same. In an attempt to support and stabilize the urethra, sutures are placed in the vaginal wall beside the urethra and anchored to the Coopers ligament of the pubic bone. Routinely, two sutures are placed on each side of the urethra, one at the mid-level of the urethra and one at the level of the urethra bladder junction (i.e. bladder neck). 

Laparoscopic Burch Urethropexy

Dr. Miklos prefers to use a laparoscopic approach to Burch urethral stabilization. Since 1993, he has performed more than 500 of these operations with minimal complications or blood transfusion. He prefers this method for his patients because it is/has: 

• Minimally invasive 
• Minimal pain 
• Cure rates 80-95% 
• 23 hour hospital stay 
• Operative time 30-40 minutes 
• Reduced postsurgical catheterization 
• Minimal complications 
• Allows for repair of other vaginal wall relaxation (cystocele, enterocele, uterine, vault prolapse) 
• Allows direct access for paravaginal (cystocele) repair---more than 90% of patients with Stress Urinary Incontinence have these defects that should be repaired thereby eliminating a second surgery.

For surgical treatment information, click here. 

Treatments for Urge Incontinence

• Dietary M1odification
• Medication
• Timed Voiding
• Bladder Retraining 
• Urge Suppression 
• Pelvic Floor Stimulation 
• Sacral Nerve Stimulation 

Dietary Modification

Certain foods and beverages have been shown to contribute to urgency, frequency or urge incontinence. Caffeine and alcohol are big offenders! Many people are unaware of how much caffeine they ingest in a single day. They often just remember the one or two cups of coffee that they drink in the morning, forgetting the cola drink with lunch and the cup of tea in the afternoon. Foods, beverages and products which should be avoided: 

• Tea 
• Coffee 
• Alcohol 
• Chocolate 
• Nicotine

Women with mild or intermittent symptoms may require only reassurance and simple measures such as decreased fluid intake and avoidance of the above irritants. The majority of patients will require further treatment. 

Medication

Many patients with urge incontinence often can be treated effectively using medication and bladder re-training. There are a number of medications available to treat urge incontinence. Some of the more common anti-cholinergic or anti-spasm medications are: 

• Ditropan 
• Ditropan XL (slow releasing - one tablet per day) 
• Detrol 
• Tofranil 
• Levsin 
• Propantheline

Contraindications or reasons why the above medications should not be taken include: 

• Acute (narrow) angle glaucoma---untreated 
• Gastric retention 
• Severe constipation 
• Allergies to this type of medicine

Estrogen is also considered a helpful medication in the treatment of urinary incontinence. It works by increasing the blood supply to the vagina and urethra making the urethra more substantial and watertight. 

Timed Voiding

This involves urinating on a set schedule during the day regardless of the need or urge to void. For example, a patient would urinate every two hours during the waking hours. This is an attempt to pre-empt the urge incontinence episodes before they occur. However, there is no goal at increasing the interval between voids. This form of behavioral therapy is useful in older adults or other individuals for whom bladder retraining is not an option. 

Bladder Retraining

Many people with urgency, frequency and urge incontinence can be helped through the use of bladder re-training. Bladder re-training involves urinating on a set schedule during the day. The patient goes to the bathroom by the clock only, not the urge to void. For example, if the patient normally goes to the bathroom every hour or less during the day, they would start this technique by voiding every hour. After one week one should increase the time interval between voids by 30 minutes so one is now voiding every 1 hour and 30 minutes. After one week the interval is increased by another 30 minutes. This exercise is continued until the interval between voids is 3-4 hours. The patient may void at anytime during sleeping hours. This retraining program encourages the bladder to retain more urine without bladder urgency or spasms. 

Urge suppression

Patients get the urge to urinate as the bladder signals the brain by sending a message through the spinal cord. This is just a message about the filling status of the bladder; it is not a direct order to urinate. Believe it or not, a patient can and in fact, should wait, to void. The worst possible time to try to get to the bathroom "in time" is when one really has to go. A lot of people will leak especially the closer that they get to the bathroom. In an attempt to suppress the urge, patients should contract their pelvic floor muscles (i.e. Kegel exercise). Tightening and relaxing the pelvic floor muscle in rapid succession will help until the urge subsides. This will help to kick in a natural reflex that quiets down the bladder. 

Pelvic Floor Stimulation (Electrical Stimulation)

This technique involves stimulation of the pelvic floor musculature using vaginal or rectal plug electrodes. Stimulation of nerve fibers leads to inhibition of bladder contractions. Physicians, Nurse Practitioners, or Physical Therapists that specialize in pelvic floor dysfunction often deliver this type of treatment. 

Electrical Stimulation - Innova electrical stimulation unit (Empi, Minneapolis, MN) 


Electrical Stimulation Application - This illustration shows the electrode in place, within the vagina. The stimulator will pass a mild current of electricity through the electrode which stimulates the pelvic floor muscles to contract. This is a passive way of performing pelvic floor exercises.

Sacral Nerve Stimulation

Sacral Nerve Stimulation (SNS) is a relatively new surgical procedure to treat urge incontinence that is not responsive to other treatments and therapies. SNS is a two-phase treatment therapy. By stimulating the sacral nerve, the signals that regulate the bladder are better in control and able to allow decreased urgency and more urine to be held in the bladder. This procedure involves having a testing procedure done first to determine the effectiveness of the treatment. 

The testing portion entails placing a small wire into the lower back to the area of the sacral nerve. Once in place, the wire is taped to the person's back and connected to a small portable stimulator unit that is about the size of a pager. The person then keeps a log of their urinary symptoms and voiding episodes to determine if the treatment is effective. After discussion with the physician, the decision to implant the device is agreed upon. 

The surgical procedure for implant of the Interstim® SNS therapy takes about two to four hours. There are two or three incisions: One in the lower back, the other one or two incisions is where the implantable pulse generator (IPG) is placed. The patient stays overnight in the hospital and the device is programmed one week later in the office. The patients use a hand held programmer to increase or decrease the level of stimulation. The stimulation feels like a pulsing or tingling in the rectum or vagina. This procedure is totally reversible if the patient chooses to have it removed. 


SANS UNIT - Percutaneous Ankle Nerve Stimulator

The FDA has recently approved a new minimally invasive method of peripheral nerve stimulation, which affects bladder control. The device works via a needle placed near the ankle about three fingerbreadths above the inside anklebone. The needle ties in with the tibial nerve, which ascends to the sacral (tailbone) nerve complex. The percutaneous Stoller Afferent Nerve Stimulation System (perQ SANS UNIT) is low-frequency electrical stimulation that is applied for 30 minutes once a week for approximately 12 weeks. After this initial trial of therapy, the patient's therapy is tritated from every week to every other or every third week, depending on the patient response. 

Clinical trials have suggested success rates as high as 80%. Success was defined by study design as at least a 25% reduction from baseline in daytime or nighttime frequency. Side effects from the treatment were classified as transient and resulting from insertion of the very fine needle. No serious adverse results have been reported. 

Click image below to enlarge.

SANS Unit - An acupuncture needle is placed in the nerve behind the ankle and is stimulated to modulate nerve impulse going to the bladder from the sacral nerves. 

Download a SANS Procedure brochure by clicking here. 

Treatments for Overflow Incontinence Overflow

Overflow incontinence in men commonly occurs due to benign prostate hypertrophy (enlarged prostate). This condition causes obstruction to the urethra and inhibits complete emptying of the bladder. Women do not have a prostate but can have overflow incontinence because of: 

• Poor bladder contractility 
• Bladder neck obstruction due to uterine/vaginal prolapse 
• Bladder neck obstruction due to strictures (rare) 
• Bladder neck obstruction due to previous anti-incontinence surgery

Clean Intermittent Catheterization

For certain patients, the bladder has limited or no ability to contract to empty. These patients include those who may have neurological diseases as well as other diagnoses. Since the bladder muscle has weakened too much, it is important to empty the urine to prevent either infection or kidney damage as well as decrease the irritative voiding symptoms of frequency and urgency or urge incontinence. These patients learn to catheterize themselves on a schedule usually two to four times a day. They use a small, clear, flexible catheter that is much softer than catheters used in the hospital setting. The procedure is done with clean, not sterile, technique and is best learned by sense of touch and not by use of mirrors. 

Vaginal Prolapse Treatment - Improving Bladder Neck Obstruction

Severe uterine and vaginal relaxation can cause a kinking of the urethra at the bladder neck. These patients will not be treated effectively by urethral dilation. The kinking of the urethra and bladder neck must be removed. This can be accomplished by using non-surgical management (i.e. pessary) or by surgical correction of the vaginal prolapse. The surgery procedure chosen is dependent upon: 

• Area specific for the prolapse 
• Desire to maintain fertility (maintain uterus) 
• Desire to maintain sexual function 
• Patients age 
• Patients overall general health

References:

Copyright ©2000, 2001 Dr. John R. Miklos
All text and images in this article are property of Dr. John R. Miklos and may not be reproduced in any way without permission.
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