Incontinence

Overview

Incontinence is defined as the involuntary loss of urine. Incontinence affects both sexes and may be due to a number of different causes. Incontinence treatment can range from muscle-relaxing medications and exercises to surgery and implants.

Causes of female incontinence include a “fallen” bladder (stress incontinence), bladder instability (the frequency-urgency syndrome) and neurologic causes such as strokes or multiple sclerosis. Men may experience urinary incontinence for the preceding reasons but may also experience leakage following surgery of the prostate or after treatment for prostate cancer.

Identifying the cause of a patient’s incontinence is essential before any treatment options can be considered and begins with a detailed medical and surgical history. A thorough discussion of the factors which precipitate leakage is critical and the nature of these precipitating events will provide much insight into the cause of the incontinence. Physical examination with a detailed exam of the genitourinary system will identify many of the common causes of incontinence.

Evaluation

In some cases the cause of the patient’s leakage is not obvious from the history and physical examination, and in such cases an evaluation of bladder function with a urodynamic study is necessary. Urodynamics are performed on an outpatient basis in either the physician’s office or in a urodynamics lab. The study is performed by placing a small catheter in the bladder and filling the bladder with sterile water.

During this filling phase, the pressure in the bladder is measured to determine if the bladder capacity is normal. One can also determine whether or not there are any uninhibited contractions or spasms during this phase as evidenced by “spikes” in bladder pressure. Additional information regarding muscle and sphincter tone can be obtained by recording electrical activity in the muscles of the pelvic floor. More complex cases of incontinence may require the use of simultaneous fluoroscopy to make a diagnosis.

Incontinence Treatment

Once the cause has been determined, incontinence treatment recommendations can be made. Patients who leak because of bladder instability (bladder spasms) are started on medication to relax the overactive bladder muscle. Some forms of incontinence are treated with biofeedback or exercises to strengthen the pelvic floor muscles (Kegel exercises).

More severe cases of stress incontinence require surgical intervention to correct. A number of new surgical techniques have been developed, several of which can be done either through the vagina or through a laparoscope with a one- or two-day hospital stay.

Some cases of incontinence can be managed by injecting a material called collagen into the sphincter muscle under direct vision through a small scope called a cystoscope. This procedure can be performed on an outpatient basis.

More complicated cases of incontinence (in particular, men who are incontinent following treatment or surgery for prostate cancer) may require implantation of a device called an artificial urinary sphincter. This device consists of three components—one of which is a small cuff that encircles the urethra. This results in the passive compression of the urethra to prevent urine from leaking out. The cuff is connected to a small pump implanted in the scrotum or labia which can be compressed to deflate the cuff and allow the bladder to drain. After a short period of time the cuff passively refills and the urethra is again compressed.

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