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Minimally Invasive Management of Urinary Incontinence

Urinary incontinence is a very common problem affecting as many as 13 million people in the United States. Many of these people suffer in silence unnecessarily, since incontinence can be managed or treated. The following information should help you discuss this condition with your urologist and what treatments are available to you.

What happens under normal conditions?

Coordinated activity between the urinary tract and the brain controls urinary function. The bladder stores urine because the smooth muscle of the bladder ( detrusor muscle ) relaxes and the bladder neck and urethral sphincter mechanism are closed. The urethral sphincter is a circular muscle that wraps around the urethra . During urination, the bladder neck opens, the sphincter relaxes and the bladder muscle contracts. Incontinence occurs if closure of the bladder neck is inadequate ( stress incontinence ) or the bladder muscle is overactive and contracts involuntarily (urge incontinence).

What is urinary incontinence?

Urinary incontinence is the involuntary loss of urine and is not necessarily a part of aging. It is a common condition experienced by men and women of all ages. 

What are the different types of urinary incontinence?

Stress urinary incontinence: Stress incontinence is leakage that occurs when there is an increase in abdominal pressure caused by physical activities like coughing, laughing, sneezing, lifting, straining, getting out of a chair or bending over. The major risk factor for stress incontinence is damage to pelvic muscles that may occur during pregnancy and childbirth. 

Urge urinary incontinence: Also referred to as "overactive bladder," this type of incontinence is usually accompanied by a sudden, strong urge to urinate and an inability to get to the toilet fast enough. Frequently, some patients with urge incontinence may leak urine with no warning. Risk factors for urge incontinence include aging, obstruction of urine flow, inconsistent emptying of the bladder and a diet high in bladder irritants (such as coffee, tea, colas, chocolate and acidic fruit juices).

Mixed urinary incontinence: Mixed incontinence is a combination of urge and stress incontinence.

Overflow urinary incontinence: Overflow incontinence occurs when the bladder does not empty properly and the amount of urine produced exceeds the capacity of the bladder. It is characterized by frequent urination and dribbling. Poor bladder emptying occurs if there is an obstruction to flow or if the bladder muscle cannot contract effectively.

What is minimally invasive management of urinary incontinence?

Some of the causes of incontinence are temporary and easily reversible. Reversible causes include urinary tract infection , vaginal infection or irritation, medication, constipation and restricted mobility. However, in some cases, further medical intervention is necessary. Minimally invasive treatment options are those treatments that do not involve surgery and should be the first line of treatment for patients. However, they may also be used in conjunction with surgical therapy.

Fluid management: This option consists of instructing a patient to increase or reduce their fluid intake. Incontinent patients may need to reduce the amount of caffeine or other dietary irritants (such as acidic fruit juices, colas, coffee and tea), while at the same time increase water intake to produce an adequate amount of non-irritating, non-concentrated urine. A recommended water intake is six to eight glasses per day.

Bladder training: A diary is the starting point for bladder training. Patients are instructed to record fluid intake, urination times and when their urinary accidents occur. The diary allows the patient to see how often they actually urinate and when incontinence occurs. The diary is also used to set time intervals for urination. Patients who urinate infrequently are instructed to do "timed urination" where they urinate by the clock every one to two hours during waking hours. By achieving regular bladder emptying they should have fewer incontinent episodes. Timed urination may be effective in patients with both urge and stress incontinence.

Bladder retraining: Bladder retraining is used for patients with urinary frequency. The goal of retraining is to increase the amount of urine that the patient can hold within their bladder. Patients are instructed to keep a diary to determine their urination interval. Patients are then instructed to gradually increase their urination interval by 15 to 30 minutes per week. The goal is to have patients urinating every two to four hours while awake with less urgency and less incontinence.

Pelvic floor exercises: Also known as Kegel exercises, this type of minimally invasive treatment focuses on strengthening the external sphincter muscle and the pelvic muscles . Patients who are able to contract and relax their pelvic floor muscles can improve their strength by doing the exercises regularly. Other patients require help from a health-care professional to learn how to contract those muscles. Biofeedback and electrical stimulation can be used to aid patients in doing pelvic floor exercises. During electrical stimulation, a small amount of stimulation from a sensor placed in the vagina or rectum is delivered to the muscles of the pelvic floor. Like any exercise program, the patient must continue to do the exercises to maintain the benefit. Patients with stress incontinence benefit from pelvic floor exercises by increasing resistance at the urethra and by increasing the strength of the voluntary pelvic floor muscles. Patients can also be taught to compensate by contracting the pelvic muscles with certain activities like coughing.

Pelvic floor muscle exercises are effective for urge incontinence, since a contraction of the pelvic floor can interrupt a contraction of the bladder smooth muscle and stop or delay an accident.

Medicinal treatment: Stress incontinence may be treated with drugs that tighten the bladder neck, such as pseudoephedrine or imipramine. Just as pseudoephedrine causes constriction of the blood vessels in the nose, it also causes the muscles at the bladder neck to contract.  Because of its effect on the smooth muscle in blood vessels, it should not be used in patients with a history of hypertension . Imipramine is a tricyclic antidepressant. In addition to causing the bladder muscle to relax, it also causes the smooth muscles at the bladder neck to contract. Urge incontinence is also treated with drugs that have anticholinergic properties. Anticholinergics allow for relaxation of the bladder smooth muscle. A commonly used anticholinergic is oxybutynin chloride. This drug works well to treat urge incontinence but has side effects including dry mouth, confusion, constipation, blurred vision and an inability to urinate. New drugs or new formulations of older drugs have been developed in an effort to reduce side effects. Oxybutynin is now formulated in a slow-release tablet taken once daily. The slow release of this new drug allows for a steady level of the drug and fewer side effects. Tolterodine tartrate is another new anticholinergic that is different than the older ones in that it has less effect on the salivary glands and therefore causes less dry mouth. It is also available in a slow-release, one-a-day form. Postmenopausal women with incontinence may benefit from hormone treatment. Normally the bladder neck and the urethra are closed at rest. With loss of estrogen , the tissues become weakened or dried and normal closure is lost. Hormone replacement improves the health of these tissues and allows for closure to be regained through increased tone and improved blood supply.

What can be expected from minimally invasive treatment for urinary incontinence?

Minimally invasive therapies can lead to improvement in incontinence but not necessarily a cure. Improvement generally does not occur overnight. Patients need time to adapt to behavioral changes. Results with pelvic floor exercises may take three to six months. Some patients may notice an immediate effect with medical therapy, whereas in others an effect may not be seen for approximately four weeks. Incontinence may also recur after treatment. Continuing behavioral techniques or continuing or resuming pharmacologic treatment as well as practicing preventive strategies may prevent such recurrence. Incontinence may also be prevented by good toileting habits including regular urination, pelvic floor exercises, avoidance of constipation , avoidance of bladder irritants and adequate water intake. 

Frequently asked questions:

What should I do if I suffer from incontinence?

Talk to your health-care provider. Incontinence can sometimes be treated by a primary care physician or it may be necessary for you to see a urologist who specializes in treating incontinence. You can help your doctor by bringing a list of your medications to your appointment. Prior to the appointment, you might want to record for two to four days the amount and type of liquids that you consume, the number of times you urinate and the number of accidents you have.

What can I do about my incontinence prior to being seen by a health-care provider?

You can urinate every two to three hours during the day, drink six to eight glasses of water, avoid bladder irritants (e.g., coffee, tea, colas, chocolate and acidic fluid juices), avoid constipation and do pelvic floor exercises. 

What foods or drinks are irritating to the bladder?

Caffeine is a common bladder irritant but there are other substances that can also cause bladder irritation. Not all incontinent patients are bothered by certain foods or drinks. The only way to know if diet is a factor is to eliminate possible irritants and see if continence is improved. Some of the most common bladder irritants are: alcohol, carbonated beverages (with and without caffeine), coffee or tea (with and without caffeine), chocolate, citrus fruits, tomatoes and acidic fruit juices.

How do I know if I am doing pelvic floor exercises properly?

When you do pelvic floor exercises only the pelvic floor should move. The pelvic floor muscles are tightened as if you wanted to stop urinating midstream or stop the passage of gas. The abdominal, buttock or leg muscles should not be tightened. By doing the exercises in front of a mirror or by placing a hand on the abdominal or buttock muscles you will be able to tell if you are contracting any of the wrong muscles. If the exercises are done properly, they can be done anywhere. There are written instructions available from support groups or from your health-care provider.

Could any of my medications be causing my incontinence?

Certain types of medications can cause or exacerbate incontinence. These medications include diuretics, sedatives, narcotics, antidepressants, antihistamines, calcium channel-blockers and alpha-blockers.

Will my incontinence get worse as I continue to get older?

Your urinary incontinence will not necessarily get worse, but it also will not improve without treatment.

I have a small amount of incontinence very infrequently that doesn't bother me. Is this abnormal and do I need to be treated?

Any leakage of urine is abnormal. You should consider treatment if your incontinence prevents you from doing the activities that you want to do. Although adult absorbency products may prevent embarrassing accidents, there are other treatment options currently available that can eliminate your need to wear such protection.



Reviewed January 2011

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Incontinence: Minimally Invasive Management Glossary
  • abdominal: in the abdomen, the cavity of this part of the body containing the stomach, intestines and bladder.

  • alpha-blockers: Also known as alpha-adrenergic blockers. Drugs used to treat high blood pressure and other conditions like an enlarged prostate.

  • anticholinergic: Blocking impulses from the part of the nervous system that controls heartbeat, blood pressure and other responses to stress. A drug that interferes with the effects of acetylcholine. These drugs assist with bladder storage by increasing bladder contractions and are used to treat urge incontinence.

  • antidepressants: Medications used to treat depression and other related conditions.

  • antihistamine: Drug that blocks cell receptors for histamine, either to prevent allergic effects like sneezing and itching or to reduce the rate of certain secretions in the stomach.

  • behavioral techniques: Methods of changing a person's symptoms or behavior for the treatment of abnormal urination patterns. Includes modifying bladder habits by methods such as bladder training or timed urination.

  • bladder: The bladder is a thick muscular balloon-shaped pouch in which urine is stored before being discharged through the urethra.

  • bladder neck: Area of thickened muscle fiber where the bladder joins the urethra. Acting on signals from the brain, bladder neck muscles can either tighten to hold urine in the bladder or relax to allow urine out and into the urethra. These muscles also tighten during ejaculation to prevent backflow of semen into the bladder.

  • bladder training: A behavioral technique that teaches the patient to urinate on a regular schedule and to empty the bladder completely.

  • calcium: A mineral that the body needs for strong bones and teeth. Calcium may form stones in the kidney.

  • cholinergic: Fibers in the parasympathetic nervous system that release a chemical called acetylcholine.

  • constipation: A condition in which a person has difficulty eliminating solid waste from the body and the feces are hard and dry.

  • constriction: The process of becoming narrower.

  • continence: The ability to control the timing of urination or a bowel movement.

  • contract: To shrink or become smaller.

  • detrusor muscle: Contracting muscle in the bladder that helps to expel urine.

  • diuretic: A drug that increases the amount of water in the urine, removing excess water from the body.

  • electrical stimulation: A treatment that is an application of an electric current or impulse to the pelvic floor muscles and bladder to cause a muscle contraction. This treatment is used in people who have nerve damage to the bladder or pelvis.

  • estrogen: Female hormone produced by the ovaries.

  • frequency: The need to urinate more often than is normal.

  • gas: Material that results from: swallowed air, air produced from certain foods or that is created when bacteria in the colon break down waste material. Gas that is released from the rectum is called flatulence.

  • gene: The basic unit capable of transmitting characteristics from one generation to the next.

  • gland: A mass of cells or an organ that removes substances from the bloodstream and excretes them or secretes them back into the blood with a specific physiological purpose.

  • histamine: A hormone transmitter involved in local immune response regulating stomach acid production and in allergic reactions.

  • hormone: A natural chemical produced in one part of the body and released into the blood to trigger or regulate particular functions of the body. Antidiuretic hormone tells the kidneys to slow down urine production.

  • hypertension: High blood pressure, which can be caused either by too much fluid in the blood vessels or by the narrowing of blood vessels.

  • incontinence: Loss of bladder or bowel control; the accidental loss of urine or feces.

  • infection: A condition resulting from the presence of bacteria or other microorganisms.

  • invasive: Having or showing a tendency to spread from the point of origin to adjacent tissue, as some cancers do. Involving cutting or puncturing the skin or inserting instruments into the body.

  • invasive: Not just on the surface; with regard to bladder cancer, a tumor that has grown into the bladder wall.

  • ions: Electrically charged atoms.

  • liver: A large, vital organ that secretes bile, stores and filters blood, and takes part in many metabolic functions, for example, the conversion of sugars into glycogen. The liver is reddish-brown, multilobed, and in humans is located in the upper right part of the abdominal cavity.

  • menopausal: Time in a woman's life when menstruation diminishes and stops.

  • obstruction: something that obstructs, blocks, or closes up with an obstacle

  • overactive bladder: A condition in which the patient experiences two or all three of the following conditions: urinary urgency, urge incontinence or urinary frequency--defined for this condition as urination more than seven times a day or more than twice at night.

  • pelvic: Relating to, involving or located in or near the pelvis.

  • pelvic floor muscles: The hammock or sling of muscles in the pelvic floor that normally assists in maintaining continence by supporting the pelvic organs (bladder, uterus and rectum).

  • pelvic muscles: Muscles around the rectum.

  • pharmacologic: Reaction to drugs.

  • pregnancy: The condition of being pregnant.

  • rectum: The lower part of the large intestine, ending in the anal opening.

  • sphincter: A round muscle that opens and closes to let fluid or other matter pass into or out of an organ. Sphincter muscles keep the bladder closed until it is time to urinate.

  • sphincter muscle: Circular muscle that helps keep urine from leaking by closing tightly like a rubber band around the opening of the bladder.

  • stent: With regard to treating ureteral stones, a tube inserted through the urethra and bladder and into the ureter. Stents are used to aid treatment in various ways, such as preventing stone fragments from blocking the flow of urine.

  • stress incontinence: Also referred to as stress urinary incontinence. The most common type of incontinence that involves the leakage of urine caused by actions--such as coughing, laughing, sneezing, running or lifting--that put pressure on the bladder from inside the body. Can result from either a fallen bladder or weak sphincter muscles.

  • tissue: Group of cells in an organism that are similar in form and function.

  • tricyclic: Having a molecular structure containing three rings.

  • urethra: A tube that carries urine from the bladder to the outside of the body. In males, the urethra serves as the channel through which semen is ejaculated and it extends from the bladder to the tip of the penis. In females, the urethra is much shorter than in males.

  • urethral: Relating to the urethra, the tube tha carries urine from the bladder to outside the body.

  • urethral sphincter: Muscle fibers around the outside of the urethra that tighten to close off the flow of urine or relax to open the urethra to allow the passage of urine.

  • urge: Strong desire to urinate.

  • urgency: Strong desire to urinate.

  • urinary: Relating to urine.

  • urinary frequency: Urination eight or more times a day.

  • urinary incontinence: Inability to control urination.

  • urinary incontinence: Involuntary loss of urine associated with a sudden strong urge to urinate.

  • urinary tract: The system that takes wastes from the blood and carries them out of the body in the form of urine. Passageway from the kidneys to the ureters, bladder and urethra.

  • urinary tract infection: Also referred to as UTI. An illness caused by harmful bacteria, viruses or yeast growing in the urinary tract.

  • urinate: To release urine from the bladder to the outside. Also referred to as void.

  • urination: The passing of urine.

  • urine: Liquid waste product filtered from the blood by the kidneys, stored in the bladder and expelled from the body through the urethra by the act of urinating (voiding). About 96 percent of which is water and the rest waste products.

  • urologist: A doctor who specializes in diseases of the male and female urinary systems and the male reproductive system. Click here to learn more about urologists. (Download the free Acrobat reader.)

  • urology: Branch of medicine concerned with the urinary tract in males and females and with the genital tract and reproductive system of males.

  • vagina: The tube in a woman's body that runs beside the urethra and connects the uterus (womb)to the outside of the body. Sometimes called the birth canal. Sexual intercourse, the outflow of blood during menstruation and the birth of a baby all take place through the vagina.

  • vas: Also referred to as vas deferens. The cordlike structure that carries sperm from the testicle to the urethra.

  • void: To urinate, empty the bladder.

Incontinence: Minimally Invasive Management Anatomical Drawings

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