Urinary Incontinence and Voiding Dysfunction
The function of the bladder is to store urine that is produced in the kidneys and transported to the bladder via the ureters (tubes leading from the kidneys to the bladder). The bladder should store urine effortlessly and painlessly until a socially appropriate situation arises for its evacuation. Voiding (urinating) should be voluntary, painless, and result in the near-complete emptying of the bladder. Urinary incontinence is defined as the involuntary loss of urine that is objectively demonstrable. There are various reasons why a woman develops urinary incontinence. It is important to determine the mechanism responsible for leakage since treatment strategies will vary accordingly. Difficulty in emptying the bladder is termed voiding dysfunction and has various causes and manifestations.
Incontinence affects an estimated 13 million Americans. The prevalence increases with age and varies widely among various studies from 2% to 27% depending upon the population studied and the definitions given for incontinence as well as the method of data collection. An increasing number of vaginal deliveries seems to correlate with the presence of incontinence.
TYPES OF URINARY INCONTINENCE
The most common type of incontinence in women is stress incontinence, which is defined as involuntary loss of urine that occurs coincident with increased intra-abdominal pressures. These can occur during coughing, sneezing, laughing, exercising, or even while getting up from a seated position.
Urge incontinence is the involuntary leakage of urine coincident with a strong urge to urinate. This is often accompanied by urinary frequency (going more than eight times during the day), urgency (“when I gotta go, I gotta go!!!”), and nocturia (awakening frequently at night to urinate). This condition has been recently termed overactive bladder. Mixed incontinence refers to having features of both conditions of stress and urge incontinence.
Overflow incontinence is less common in women, and is associated with incomplete emptying of the bladder and maintaining excessive urine in the bladder (a high residual volume) even after voiding. Such voiding dysfunction can be the result of neurological disease, medications, acute inflammatory conditions of the tube leading out from the bladder (urethra) and/or genital structures (vulva), obstruction from surgery, prolapse (inversion) of the bladder, or a variety of other pelvic, endocrinologic, or psychogenic conditions. In addition to overflow incontinence, other consequences may occur such as frequent urinary tract infections, symptoms of overactive bladder, and in rare instances damage to the kidneys.
Other rare conditions that result in urinary incontinence include fistulas, which are abnormal communications between the urinary tract and other organs. The most common urinary fistula is one between the bladder and vagina, termed a vesicovaginal fistula, which leads to constant leakage of urine from the vagina. In the United States, this occurs most commonly following hysterectomy, whereas in the Third World, the most common reason is childbirth. Other causes of incontinence are congenital due to abnormal development of the urinary tract, and remain very rare.
Keeping in mind the definition of incontinence (“… loss of urine that is objectively demonstrable”), a primary goal of medical evaluation is to demonstrate the leakage experienced. This may require multiple attempts of coughing or other maneuvers in an attempt to replicate in the office, what occurs in daily life. An equally important goal of initial evaluation is ensuring that there is no reversible cause of incontinence, which if found, should be addressed. Reversible causes of incontinence include disorders of consciousness/alertness (delirium), urinary tract infection, disorders of the vaginal walls (vaginal atrophy), medications, psychological, endocrine (hormonal) disorders, restricted mobility making it difficult to get to the bathroom on time, and severe constipation with stool buildup (impaction). A pelvic exam is needed to look for any pelvic organ invasion (prolapse), signs of atrophy (lack of the effects of estrogen on the vagina), and other gynecologic abnormalities that may affect the urinary tract system. The exam should also include a targeted neurological evaluation focusing on the lower spinal nerves in the area of the lower pelvis (sacrum).
When evaluating abnormal bladder function, evaluation of the “postvoid residual volume” is very important, that is, urine still in the bladder after voiding has taken place. This can be done by specialized visualization techniques (ultrasound) or catheterization (using a
small tube) of the bladder. Urine is obtained for urinal-ysis and culture to rule out urinary tract infection and the presence of microscopic amounts of blood in the urine. After the first visit, many centers require the patient to keep a bladder diary for several days in which she measures and records all urine volumes of each void for the period of time the diary is being kept.
More specialized testing called urodynamics (measuring how well the bladder functions) may be necessary to increase diagnostic accuracy. Some practitioners prefer urodynamic studies on all patients who are being considered for surgery to improve counseling regarding the risks and benefits and to help determine the type of surgery that would be most appropriate for the particular situation. Urodynamics usually involves pressure measurement of the bladder via a bladder catheter (small tube) and simultaneous intra-abdominal pressure measurement by a catheter in the rectum or vagina. The bladder is filled, and attempts are made to elicit urinary incontinence that mimics the symptoms at home at different bladder volumes. Further tests are done to evaluate how well the tubes leading out from the bladder function (urethral competence), and usually the patient is asked to void with the catheters in place to ascertain the bladder’s function during the voiding process. In many cases additional information is obtained by specialized measurements of nerve conduction by the urethral muscle (electromyographic [EMG] recordings) during the entire study, which usually lasts 30-60 minutes overall.
Initial therapy of urinary tract infections, vaginal atrophy, and/or constipation is instituted, and improvement monitored; if incontinence persists despite adequate therapy, further diagnostic and therapeutic options are explored. The bladder diary is useful in ruling out excessive fluid intake, which should be addressed before instituting specific therapy. Most women will maintain adequate hydration with drinking 50-60 ounces of fluid a day. Dietary restriction of substances considered to be bladder irritants, most notably alcohol and caffeine, is instituted. Early intervention with adequately performed and persistently done Kegel exercises may cure mild cases of incontinence and improve many others. Kegel exercises are specialized and easy-to-learn exercises which strengthen the pelvic muscles. Biofeedback and electrical stimulation may be used to increase the effectiveness of Kegel exercises alone for stress or urge incontinence as well as mixed incontinence.
Specific therapy regarding urge incontinence (over-active bladder) includes bladder retraining, which is designed to gradually increase the bladder’s ability to hold urine for increasingly longer periods of time. Biofeedback and electrical stimulation are commonly used methods for the treatment of urge incontinence, and tend to be more effective when done while on medication. Medications used to treat urge incontinence and the overactive bladder work by calming the bladder muscle and reducing its contractility. These include various preparations such as the medications toltero-dine, oxybutynin, hyoscyamine, propantheline, and imipramine. The most common side effects include dry mouth and constipation.
In patients who continue to have severe symptoms of urgency, frequency, and/or urge incontinence, and for whom all other options have failed, implantation of a medical devise (sacral neuromodulation) may offer significant benefit. This involves surgically implanting an electrode in the pelvis (sacral region) and connecting it to a small external generator. If it is found during the testing phase that the therapy is effective, an implantable programmable battery is placed (similar to the battery used for cardiac pacemakers). Other, more aggressive surgery is possible, but is rarely used nowadays.
Specific therapy for stress incontinence beyond Kegel exercises and biofeedback may include nonsur-gical as well as surgical modalities. For mild degrees of stress incontinence that occurs during specific and well-defined circumstances (such as playing tennis), it may be helpful to take the medication pseudoephedrine just prior to the activity. Another option is using a relatively small anti-incontinence device inserted into the vagina (pessary), which works by supporting the urethra during times of increased intra-abdominal pressure.
Many surgeries have been proposed for the treatment of stress incontinence. Some of these surgeries can be done abdominally (conventional surgery) or laparoscopically (using a small tube inserted into the abdomen), although laparoscopic procedures have been shown to have inferior long-term success rates. Injection of bulking agents into the tube leading out from the bladder (urethra) is also a simple procedure that has some success in treating certain patients with stress incontinence. Various sling procedures have been described where a strap of material, either fascia (covering of muscle) from the patient, from a donor, other
biological tissue, or artificially produced, is placed under the urethra to provide a new supportive platform for restoring continence. The ends of the strap must be attached to appropriate tissue to create the support needed. The various sling procedures differ not only in the source of the sling material, but also in the way it is suspended. All surgeries carry risks along with the potential benefits they provide. Unique risks of surgeries for stress incontinence include possible difficulty in bladder emptying, development of overactive bladder symptoms, and erosion of permanent materials used for the repair through the vagina, and rarely through surrounding structures.
For patients with mild mixed incontinence, the medication imipramine is especially useful. Biofeed-back and electrical stimulation has also shown benefit. Another strategy is treating the worst component first with type-specific approaches, and then tackling the other component if needed.
Overflow incontinence and voiding dysfunction with incomplete bladder emptying is first addressed by having the women with incontinence use a procedure called clean intermittent catheterization (CIC). This involves the patient catheterizing herself with a special short rigid catheter, usually several times a day. The technique does not need to be done under sterile conditions, rather under clean conditions. The procedure is relatively easy to learn and quick to do at home or in a public restroom. Most patients do very well with this; however, some will continue to have problems with recurrent urinary tract infections or other difficulties. If the cause of the dysfunctional voiding is not due to blockage of the tube leading out from the bladder obstruction, as may occur from prolapse or following surgery for stress incontinence, these patients may be candidates for sacral neuromodulation (see earlier explanation of this procedure), which is effective in restoring normal voiding. Diagnostic procedures that evaluate the functional capability of the bladder (uro-dynamic studies) are important in the diagnosis of voiding dysfunction to guide therapy.
- Adam, R. A., & Preston, M. R. (2002). Urinary incontinence: Diagnosis and treatment. Women Health, Gynecology Edition, 2(4), 218-229.
- Agency for Healthcare Policy and Research. (1992). Urinary incontinence in adults [Publication 93-0552]. Rockville, MD: United States Department of Health and Human Services.
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