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For many people, their best-kept secret
isn’t their age or their income. It’s that
they are incontinent. The uncontrolled leakage of urine
or the need to void frequently can hamper an active
lifestyle or cause shame, but with the many medical
and surgical advances now available, it doesn’t
have to be that way.
“Unfortunately,
people are embarrassed about their incontinence, and
they don’t want to tell anyone—even their
doctor,” says Dr.
Neil Sherman, an assistant professor –division
of urology at New Jersey Medical School and director
of reconstructive and female urology at University Hospital.
“These patients might be unaware of their options,
which usually are a vast improvement over adult diapers
and can be as convenient as a same-day procedure.”
Incontinence is a common
condition that affects an estimated 13 million Americans:
most are female – between 10% and 30 % of women
ages 15 to 65—but up to 5% of men can be affected
as well. There are different kinds of incontinence,
such as stress incontinence, in which urine is released
upon coughing, sneezing or exercising. Another type
is urge incontinence, in which the person frequently
needs to urinate and can’t “hold it”
until she or he reaches the bathroom. It’s possible
for a person to suffer from both types of incontinence
at the same time. A person does not have to leak urine
in order for there to be a problem. Many people suffer
from “overactive bladder, or OAB, which is a variation
of urge incontinence.
Even under ideal circumstances,
the ability to urinate is a complex process that involves
the bladder, the urethra and the muscles of the pelvic
floor, as well as the brain and the spinal cord. The
bladder expands like a balloon to hold urine; sphincter
muscles keep the bladder closed until nerve signals
indicate that the bladder is full and needs to be emptied.
The brain then allows the bladder to contract and the
sphincter muscles to relax, and urine travels out of
the body via the urethra. When there’s a problem
involving even one part, the entire urination process
can be affected.
The reasons a person becomes incontinent
are wide ranging and include neurological conditions
such as stroke; certain medications; and urinary tract
infection. For women, childbirth can strain the pelvic
floor muscles, and later in life, menopause can cause
a thinning or drying of the vaginal tissue Incontinence
in men is frequently associated with an enlarged prostate
gland or can be a complication following surgery for
prostate cancer.
Finding Answers
The multiple causes of
incontinence drive home the importance of a thorough
medical history and physical exam. The patient might
also be asked to keep a “diary” to document
how often she or he has something to drink and how frequently
and under what conditions the incontinence, or urinary
frequency, occurs. “This information gives the
urologist valuable insight that can lead to the appropriate
treatment for incontinence,” says Dr. Sherman.
Next, the urologist may
order some tests. Among the simplest tests is a urine
sample, which can detect whether a person has a urinary
tract infection. Other tests are more involved. To examine
the inner lining of the urinary tract anatomy, the doctor
uses a cystoscope—a thin instrument that is inserted,
usually with the patient under local anesthesia, through
the urethra and then to the bladder. The procedure,
a cystoscopy, is generally well-tolerated and lasts
just a couple of minutes. Another test, called urodynamics,
evaluates how a person’s bladder and pelvic muscles
respond when the bladder is filled and then emptied.
Doing Away With Stress
Stress incontinence is
most common among women who have had vaginal births,or
have gone through menopause. Other factors include obesity,
chronic cough and constipation. “All of these
events can weaken or place continued strain on the muscles
at the base of the pelvis, or the pelvic floor,”
says Dr. Sherman. “The treatment goal is to either
strengthen the weakened muscles or otherwise support
them.”
As any woman who has
ever given birth probably knows, Kegel exercises—a
series of movements that contract and relax the pelvic
floor—are an often-recommended way to strengthen
the weakened muscles and thus, improve continence. “Kegel
exercises can be extremely beneficial—if they
are done correctly and the patient actually does them,”
say Dr. Sherman. “We can teach the patient to
identify the proper muscles and even use biofeedback
as a teaching tool. However, when Kegels aren’t
done properly or on a regular basis, they won’t
help.”
For patients with more
significant stress incontinence or when non-surgical
treatments are not helpful, a “sling” that
provides support to the urethra can be placed through
minimally invasive techniques. Both women and men can
benefit from sling placement, which can be made from
a variety of materials, each with its own benefits.
“The sling reinforces the weakened pelvic and
urethral muscles and provides support, much like a hammock,”
says Dr. Sherman. “It is often a first-line treatment
for patients with severe stress incontinence. Cure rates
for slings range between 80 percent to 90 percent, and
the long-term data for slings is excellent.”
Patients who are frail physically or
those with mild stress incontinence probably are not
good candidates for a sling, but there are options for
them, too. Urethral bulking agents, such as collagen,
can be injected around the urethra to help prevent urinary
leakage.
At the moment, says Dr. Sherman, there
are no medicines that have proven successful in the
treatment of stress incontinence. “However, there
is a drug for mild stress incontinence that should be
available very soon,” he notes.
Reducing the Urge
Almost everyone’s
been in the situation where they “really need
to go,” but for people with overactive bladder
or urge incontinence, that need can wreak havoc on their
personal and professional lives. It’s not uncommon
for a person with urge incontinence to leak more than
a quart of urine a day. “Some patients with these
conditions have memorized the location of every bathroom
in their workplace—not because they want to, but
because they have to,” says Dr. Sherman. “The
first thing they look for in a new place is the bathroom.”
Unlike with stress incontinence, medicine
can have an important role in helping people with urge
incontinence and overactive bladder. These drugs work
by inhibiting the involuntary contractions that create
the sensation to void.. “The medicines decrease
the number of times a person needs to void and increase
the amount of urine output each time, making a real
improvement in quality of life,” says Dr. Sherman.
Incidentally, says the urologist, the advertising for
some of these medicines has helped take the “shame”
out of these conditions. “As people realize through
these ads that many others have an overactive bladder
and that it can be helped, there’s less stigma
attached to seeing a doctor about the problem.”
Kegel exercises usually are recommended along with the
medication.
Medications for overactive
bladder and urge incontinence are not without their
drawbacks. Dry mouth, dry eyes, headache and constipation
are among the side effects that occur in some patients.
However, says Dr. Sherman, these side effects generally
are associated with the older drugs used in the treatment
of urge incontinence; newer medicines are often better
tolerated.
There’s also a new therapy for
urge incontinence that Dr. Sherman describes as a “bladder
pacemaker.” Neuromodulation uses electrical current
to stimulate the nerves controlling the pelvic floor
muscles and the bladder. Candidates for neuromodulation
go through a “trial period” in which the
leads and an external battery pack are worn for a week.
If the device proves helpful, a small battery pack is
implanted in the fatty tissue of the buttock using minimally
invasive techniques.
Another new therapy for severe overactive
bladder and urge incontinence is the injection of botulinum
toxin, or Botox. “Botox has been used in many
parts of the body, and it appears that the bladder may
be another place where it has benefits,” says
Dr. Sherman. Although trials are in early stages, the
medication shows promise for appropriately selected
patients.
For patients with severe urge incontinence
who do not respond well to medicine or are not candidates
for neuromodulation or Botox, it is possible to enlarge
the bladder through augmentation cystoplasty. With this
operation, the surgeon takes a patch of the patient’s
intestine and uses it to make the bladder bigger. “There
are so many other options that augmentation cystoplasty
is rarely performed anymore,” says Dr. Sherman.
“It is the procedure of last resort.”
A Word for Men
Incontinence occurs more
frequently in women than in men, making it a “woman’s
problem” in some people’s minds. This makes
it even more difficult for some men to talk to their
doctor. However, men are not immune from the problem.
The prostate gland is usually the source of the incontinence,
and often, the incontinence occurs after prostatectomy—the
surgical removal of the prostate gland. The prostate
gland lies in front of the bladder and surrounds the
urethra. Inadvertent damage to the sphincter muscle
or neighboring nerves and blood vessels can cause urine
leakage or a frequent need to urinate. The good news
for men is that most prostatectomies today are performed
using either robotic instrumentation or with nerve-sparing
techniques, which appears to decrease the risk of incontinence.
In those men who do have incontinence
following removal of the prostate gland, many times
the incontinence is temporary. But there are options
for when the problem persists beyond a few weeks. In
addition to the male version of the sling, Kegel exercises
and medicine, some incontinent men can benefit from
having an operation to implant an artificial urinary
sphincter. “This same-day surgery can dramatically
improve the man’s quality of life,” says
Dr. Sherman.
There are many ways
that incontinence can be treated. It’s not necessary
to be inconvenienced or embarrassed by incontinence
anymore. For more information about treatment options
for incontinence or to contact Dr. Sherman, call the
Division of Urology at New Jersey Medical School at
(973) 972-4488.
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