Tarek Khalife, M.D.
Obstetrics & Gynecology (OB-GYN), Women's Health
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Urine incontinence, or the involuntary leakage of urine, is a common symptom that affects 1 in 4 women. Prevalence of this problem increases with age, as up to 75 percent of women above age 65 report urine leakage. A woman’s physical, social and psychological well-being is adversely impacted. Quality of life at home and in the workplace may deteriorate.
Despite being a common problem, only 45 percent of women who experience weekly urine incontinence episodes discuss the problem with their providers. Some women may find it too embarrassing to discuss symptoms, while others may think it is normal for them to experience incontinence after childbirth or with aging.
Urine incontinence is not a singular issue; rather, it is caused by several factors. A myriad of factors often coexist, and increase the severity of symptoms and complexity of treatment.
The two most common types of urine incontinence are stress incontinence and urge incontinence. A combination of both also can occur and is called mixed incontinence.
Stress incontinence is involuntary urine leakage in relationship to physical activities, such as coughing, laughing, sneezing, jumping or even walking. The term "stress" is used to define this type of incontinence because the stress exerted on the bladder and bladder neck by increased abdominal pressure results in failure of the weakened continence mechanisms and causes urine leakage. Women with this type of incontinence tend to disengage from favorite sports or recreational activities and try to adapt to a less-active lifestyle.
TREATMENT OPTIONS FOR STRESS INCONTINENCE
Women with stress incontinence issues most often will first be referred to a physical therapist who specializes in women’s health. The therapist will coach on how to conduct Kegel exercises to strengthen pelvic floor muscles to work more effectively and efficiently. Should that strategy fail to improve symptoms after six months, the next step is to consider other treatment options.
Other nonsurgical treatments include an intravaginal pessary. A pessary is a silicone-based device that is fitted to the vagina and inserted by a provider in the clinic. Different types of pessaries are used for different pelvic floor problems, such as urine incontinence and uterovaginal prolapse, with different shapes and sizes to fulfill the function and maintain patient comfort. The knob present in incontinence ring pessaries exert external pressure on the urethra to overcome the stress pressure imposed by daily activities. The therapeutic effect is immediate and reversible upon removal of the device.
Surgical options are available when other therapies fail. The most commonly utilized surgical procedure with a high success rate is the midurethral sling. The sling procedure utilizes a synthetic mesh material that is positioned to replace the damaged fibromuscular sling support under the midsegment of the urethra and re-establishes the continence mechanism. The procedure carries an 85 to 95 percent success rate with mesh complications reported at 3 percent. The sling procedure is considered minor surgery. Patients often are discharged home the same day with minor limitations.
Even though stress incontinence is distressing, urge incontinence usually elicits higher distress scores to women who experience it. Urge incontinence is defined as the compelling sudden urge to void that cannot be delayed or postponed and results in urine leakage. This type of incontinence does impose more restrictions on a woman's lifestyle. Women tend to practice toilet mapping strategies, and limit outings and social activities because of the fear of social embarrassment.
This type of incontinence usually is caused by the inability of the bladder to allow pressure-free storage of urine under normal bladder capacity. The bladder tends to contract and increase pressure that results in the strong urge to void and often is associated with urine loss. Risk factors for this dysfunctional neuronal functionality usually are related to neuropathy, such as diabetes or multiple sclerosis, menopausal symptoms or some type of brain injury that alters the bladder inhibitory pathways.
TREATMENT OPTIONS FOR URGE INCONTINENCE
Treatments for this type of condition also should address the underlying cause, such as better diabetic control; weight loss; or altering the lifestyle with limitation of bladder irritants, such as caffeine and carbonated beverages.
Medications that relax bladder muscles are commonly used as first-line therapeutic options. The most commonly reported side effects include dry mouth, constipation and low blood pressure. Recently, bladder muscle Botox injections are being used in patients who have severe symptoms. Injections offer reasonable improvements in symptoms for six months with common side effects being related to urine retention or frequent urinary tract infections.
Sacral nerve root modulation — the surgical implantation of a device that helps modulate the neuronal circuitry to render the bladder more receptive to urine with decreased urgency symptoms — is a viable option for women with severe symptoms, especially those who do not respond to conventional first- and second-line treatments.
Although urine incontinence is common, it is not normal. Therefore, appropriate evaluation is necessary to determine the type and cause of this problem. Treatment options are available to help women optimize quality of life. Discussing the issue with a health care provider is the first and most important step to consider.