- Medications
- Medications can effectively control many types of
incontinence. Some drugs work by stopping excessive contractions of the bladder, whereas
others are muscle relaxants that permit more complete bladder emptying during urination.
In addition, some drugs prevent leakage by directly tightening the bladder neck and
urethral muscles. Many of the drugs are anticholinergic: that is, drugs that block the
passage of impulses through the low back nerves. Hormonal medications, such as estrogen,
may improve bladder control by helping the urinary muscles to function normally. And
antibiotics may eliminate short-term incontinence by treating an underlying urinary tract
infection.
All medications have the potential to produce harmful side
effects, especially if they are used for long periods in susceptible individuals. Of the
medications prescribed for urinary incontinence, hormonal preparations and alpha-blockers
cause the most concern. In particular, hormone replacement therapy with estrogen has been
associated with increased risks for cancers of the breast and endometrium (lining of the
uterus). Therefore, before taking any medication, ask your physician about the long-term
risks and benefits of anti-incontinence drugs.
Below is a list of common medications prescribed to treat
various types of urinary incontinence.
Anticholinergic
Medications
- Propantheline
bromide (Pro-Banthine)
- Oxybutynin
chloride (Ditropan)
- Hyoscyamine
sulfate (Levbid; Cytospaz)
- Tricyclic Antidepressants (TCAs)
Propantheline bromide
(Pro-Banthine) - Although bladder spasm is not an FDA-approved indication for
this drug, propantheline has been widely prescribed over the years for the treatment of urge incontinence (typical dosage:
7.5-30 to be taken without food 3 to 5 times/day). It is a classic anticholinergic
medication that stops muscle contractions in the normal bladder. Some of the unwanted side
effects of propantheline include dry mouth, visual blurring, nausea, constipation,
tachycardia (fast heartbeat), drowsiness and confusion. Propantheline is specifically
contraindicated (improper) for patients with obstructive urinary tract disorders and for
those with narrow-angle glaucoma (eye disease characterized by high pressure within the
eye).
Oxybutynin chloride(Ditropan)
- Oxybutynin is an anticholinergic drug medication that also directly relaxes
bladder smooth muscle. It is prescribed for neurogenic bladder patients, and patients who
have symptoms of bladder instability with voiding: that is, patients with urge incontinence, frequency, urinary leakage, or
painful urination. The typical dosage is 2.5-5.0 mg to be taken orally 3 to 4 times/day).
Oxybutynin's notable side effects are dry mouth, dry skin, visual blurring, nausea and
constipation.
Ditropan® XL Extended-release tablets contain oxybutynin
chloride. Ditropan® XL is a once-a-day medication for overactive bladder. One tablet
releases medication into your system continuously for relief that lasts up to 24 hours
with one dose. In many patients, once-a-day Ditropan® XL has been shown to help
effectively treat urgency, frequency, and wetting accidents. Some patients use far fewer
pads. Some patients experienced relief after taking Ditropan® XL after 1 week. In a
clinical study with Ditropan® XL, patients experienced a 90% reduction (from 16 to 2) in
the number of wetting accidents per week versus patients taking a sugar pill who
experienced a 51% reduction (from 21 to 11). The typical dosage is 5-15 mg to be taken
orally 1 time/day. In clinical studies, the most common side effect was dry mouth.
However, only 1% of patients discontinued therapy for this reason. Other common side
effects included constipation, drowsiness, diarrhea, blurred vision, dry eyes, dizziness,
and runny nose. Only 7% of patients in clinical studies discontinued therapy due to side
effects.
Hyoscyamine sulfate
(Levbid; Cytospaz) - Hyoscyamine sulfate, like oxybutynin chloride, is an
anticholinergic and antispasmotic drug. It is prescribed for the treatment of urge incontinence. Hyoscyamine sulfate
is specifically contraindicated (improper) for patients with obstructive urinary tract
disorders (for example, bladder neck obstruction due to an enlarged prostate) and for
those with glaucoma or ulcerative colitis (severe inflammation of the large intestine). -
The usual dosage of hyoscyamine sulfate is one to two 0.375 mg tablets every 12 hours.
Tricyclic
Antidepressants (TCAs) - Tricyclic antidepressants -- such as imipramine
pamoate (Tofranil-PM) -- are often prescribed as part of incontinence treatment programs,
but they are not FDA-approved for incontinence. Tricyclic antidepressants have
anticholergenic effects. Many experts believe that tricyclic antidepressants are
beneficial because they decrease nighttime incontinence and are useful for the management
of urge incontinence. The usual
oral dose of imipramine is 10-25 mg, 1 to 3 times/day, for a total daily dose of 25-100
mg).
Other tricyclic antidepressants that potentially may be
useful for incontinence are: doxepin hydrochloride (Sinequan), desipramine hydrochloride
(Norpramin), and nortryptyline hydrochloride (Pamelor).
Alpha-1
Adrenergic Blocking Agents (Alpha Blockers)
Benign
prostatic hyperplasia -- noncancerous enlargement of the prostate -- can encroach upon
the urinary tract, leading to overflow or urge incontinence. Alpha-1 adrenergic
receptor blocking agents --known as alpha-1 blockers or alpha blockers -- are used to
treat BPH, because they reduce the tone of striated and smooth muscle, thereby decreasing
urethral resistance and relieving symptoms of obstruction. Alpha blockers should not be
used in people who are hypersensitive (have an exaggerated reaction) to such medication or
who experience postural hypotension (extremely low blood pressure when standing up or
standing still).
Doxazosin mesylate (Cardura)
- Doxazosin mesylate is a drug that acts by blocking the alpha-1 adrenergic r
receptor
sites within the body. Doxazosin is prescribed for the treatment of urinary outflow
obstruction in BPH and for hypertension. The typical dose is 1-8 mg, taken once daily.
Terazosin hydrochloride
(Hytrin) - Terazosin hydrochloride also blocks the alpha-1 adrenergic receptor sites
in the body. Like doxazosin, terazosin is prescribed for the treatment of urinary outflow
obstruction in BPH, as well as for hypertension. The typical dose is 1-10 mg, taken once
daily.
Tamsulosin hydrochloride
(Flomax) - Tamsulosin hydrochloride blocks only the alpha-1a adrenergic receptors in the prostate. Tamsulosin is
used to treat the signs and symptoms of BPH; however, because of its prostate-specificity,
tamsulosin is not a recommended treatment for hypertension. The usual oral dose of
tamsulosin is 0.4-0.8 mg, once daily.
- Alpha Adrenergic Agonists
- Alpha adrenergic agonists are drugs which stimulate sites in the nervous system
that respond to the chemical norepinephrine. Therefore, patients suffering from forms of
incontinence requiring increased muscle tone and urethral resistance -- for example, stress incontinence
-- may benefit from the use of alpha-adrenergic agonists.
Phenylpropanolamine
hydrochloride - Phenylpropanolamine hydrochloride is found in many
prescription and nonprescription cough/cold preparations and antihistamines (anti-allergy
drugs). A typical dosage for bladder control is 25-75 mg in sustained- released form,
twice a day. Phenylpropanolamine, like all other alpha adrenergic agonists, should not be
used by individuals with obstructive forms of incontinence; it should be used with caution
by individuals with hypertension (high blood pressure), hyperthyroidism (overactive
thyroid gland), arrhythmia (irregular heartbeat), and angina (heart pain caused by
decreased oxygen supply to the heart muscle).
Pseudoephedrine
Hydrochloride - Pseudoephedrine Hydrochloride is found in many prescription
and nonprescription cough/cold preparations and antihistamines. A typical dosage for
bladder control is 15-30 mg, three times a day.
Other Alpha
Adrenergic Agonists - Other Alpha Adrenergic Agonists include ephedrine
and epinephrine and norepinephrine. Since the actions of these drugs are so widespread
within the body, they are not specifically indicated for incontinence and should be
prescribed with caution. The significant side effects of these drugs are hypertension,
tachycardia (fast heartbeat) and arrhythmia (irregular heartbeat).
Tolterodine Tartrate
(Detrol) - Tolterodine tartrate is a new drug that is classified as a muscarinic
receptor antagonist: that is, it blocks nerve receptors that respond to the chemical
muscarine. Both bladder contraction and salivation (formation of saliva) are controlled by
muscarinic receptors. By blocking muscarinic nerve receptors, tolterodine tartrate can
reduce symptoms of urinary frequency or urgency, and it is able to treat bladder
over activity and urge incontinence.
The typical dose of tolterodine tartrate is 1-2 mg, twice a
day. Tolterodine tartrate should not be used in people who are hypersensitive (have an
exaggerated reaction) to the drug or who have urinary retention, gastric (stomach)
retention, or uncontrolled narrow-angle glaucoma (eye disease characterized by high
pressure within the eye).
Hormonal
Replacement/Estrogen Therapy - Estrogen therapy helps to maintain and restore
the health of urethral tissues in women who have undergone menopause (the end of monthly
menstrual periods). In particular, estrogen appears to reduce stress incontinence and
heighten bladder outlet resistance by increasing blood flow, tone and nerve response in
the urethral muscle. Yet the exact mechanism of estrogen is still unknown.
Studies suggest that estrogen replacement therapy, by oral or
vaginal administration, may benefit patients with stress incontinence or mixed
incontinence. To prevent an abnormal build-up of the endometrium (lining of the uterus),
estrogen replacement should be given with the pregnancy hormone progesterone (Premphase).
Medications such as Introl and Suctimpro should only be used
if the patient's uterus is present --that is, only if the patient has not had a
hysterectomy (operation to remove the uterus).
Various doses of estrogen and progesterone are available.
Oral conjugated estrogen usually is given at doses of 0.3-1.25mg per day, and vaginal
estrogen is given at 0.5-2.0g per day.
In addition, estradiol --the most potent naturally-occurring
estrogen in humans --is available as a skin-patch (Alora, Climara, Fempatch, Vivelle,
Estraderm) and as a vaginal ring (Estring). All of the sepreparations release estrogen
slowly.
Estrogen therapy is not recommended for patients with
diagnosed or suspected cancer of the breast, cervixoruterus, or for patients with
undiagnosed vaginal bleeding or blood clotting disorders such as thrombophlebitis
(inflammation and clotting of the veins) or thromboembolism (blood clot |plugging2 of a
blood vessel).
Combined
Estrogen/Alpha-Adrenergic Agonist Therapy - Since estrogen therapy appears to
heighten the response of nerve receptors in the urethra (that is, the alpha-adrenergic
receptors, which increase the tone of striated and smooth muscle), it is believed that a
combination of estrogen and alpha-adrenergic agonists (drugs specific for the
alpha-adrenergic receptors) may be beneficial in women who have undergone menopause and
who lose bladder control because of insufficiency (malfunction) of the urinary sphincter
muscles.
A common estrogen/alpha-adrenergic agonist combination is
phenylpropanolamine (PPA, 25-100 mg twice a day) plus intravaginal or oral conjugated
estrogen (1.25 mg/day orally or 2 g/day vaginally). Phenylpropanolamine is found in many
over-the-counter cough/cold preparations, such as Tavist-D, Comtrex, Dimetapp, Triaminic,
and Robitussin-CF.
Electrical
Stimulation
Electrical stimulation of the sacral autonomic and somatic
nerves has been used with varying degrees of success to treat stress and urge urinary
incontinence as well as urgency and frequency syndromes. Most of the studies documenting
use of the technology have been uncontrolled. Stimulation with electric current causes
initial contraction of the bladder that is followed by a prolonged relaxation and gradual
fatigue of the contractile response. In addition, stimulation results in reflex inhibition
that may "calm" the detrusor and improve storage; however, the ultimate role of
this treatment modality is not yet known.
Surgical Treatments
Physicians generally recommend surgery
to alleviate incontinence only after other treatment options have been exercised. A number
of procedures are available, and many surgical options have high success rates. Yet
surgical procedures should be considered only after confirmation of the diagnosis and its
severity, an appraisal of surgical risk, and an estimation of the impact of surgery on the
individual's quality of life.
Urethrolysis - Urethrolysis
is an anti-incontinence operation that involves the cutting of obstructive adhesions
(fibrous tissue bands) that fix the urethra to the pubic bone. Urethral obstruction is a
well-recognized complication of surgical procedures for disorders such as stress incontinence. The symptoms of
post surgical urethral obstruction include urinary retention, incomplete bladder emptying,
irritation or pain when urinating, decreased force of the urine stream, hesitancy, and
recurrent urinary tract infections.
Urethrolysis that is performed via an incision through the
vagina (female reproductive canal) is known as transvaginal urethrolysis. Transvaginal
urethrolysis is associated with fewer complications than other methods of urethrolysis,
and it permits the correction of coexisting vaginal abnormalities. Transvaginal
urethrolysis is the most effective procedure to mend urethral obstruction after surgical
repair of stress incontinence.
Open Abdominal Surgery
- Sometimes incontinence surgery takes place via an incision through the abdomen.
Two standard suspension procedures that require abdominal incisions are the Marshall
Marchetti Krantz procedure and the Burch procedure.
The Marshall Marchetti Krantz (MMK) procedure is still
offered in many medical centers throughout the United States, but it is no longer a
favored technique. This is because the sutures (stitches) in the procedure are placed
around the urethra, creating the potential for obstruction; in addition, the surgical
entryway limits the physician's ability to correct cystocele (herniation of the bladder
into the vagina). During the MMK procedure, the bladder neck and urethra are separated
from the back surface of the pubic bone. Sutures are placed on either side of the urethra
and bladder neck, which are then elevated to a higher position. The free ends of the
sutures are anchored to the surrounding cartilage and pubic bone.
The Burch procedure, also known as Burch colposuspension
(vaginal suspension), often is performed when the abdomen is already open for another
purpose, such as abdominal hysterectomy (removal of the uterus). During the suspension
procedure, the sutures are placed laterally (sideways), which avoids urethral obstruction
and allows the physician to repair any small cystoceles that may be present. The bladder
neck and urethra are separated from the back surface of the pubic bone. The bladder neck
then is elevated by means of lateral sutures that pass through the vagina and Cooper's
(pubic) ligaments. The vaginal wall and ligaments are brought together without tension,
and the sutures are tied.
Needle Suspension - Needle
suspension procedures are simpler than abdominal suspension procedures and are less
invasive (because they require smaller/fewer incisions and punctures). A surgeon named
Pereyra first described transvaginal (through the vagina) needle suspension in 1959. Since
that time, numerous surgical adaptations have been developed, each named after its creator
(Stamey, Raz, Gittes, etc.); however, the principles of needle suspension remain the same.
In essence, sutures are placed blindly through the pubic skin
or via vaginal incision into the anchoring tissues on each side of the bladder neck. The
bladder neck then is supported by the sutures, which are threaded on a needle and tied to
the fascia (fibrous tissue) or the pubic bone. Operative times and recovery periods are
shorter for needle suspension versus other suspension techniques. Some healthcare
facilities even conduct needle suspensions as outpatient procedures.
The Stamey technique can be performed both vaginally or
through a small incision above the pubic bone. A nylon suture is used to suspend the
urethra on each side. Cystoscopy is employed to ensure that the urethra and bladder are
not injured during the procedure. (Note: When endoscopy -- visual examination of the
bladder by means of a tiny, telescope-like device connected to a video camera -- is used
to examine the organs of the abdominal cavity, the procedure is called laparoscopy.)
The Raz procedure often is chosen for patients who are
incontinent due to urethral and bladder neck hypermobility (dropping down) and who have
minimal or no cystocele (herniation of the bladder into the vagina). An inverted U-shaped
incision is made at the base of the anterior (front) vaginal wall, and adhesions (fibrous
tissue bands) around the bladder neck and urethra are released. A needle is passed through
the surgical incision, and the suspending sutures are pulled up, lifting the front of the
vagina and urethra. The Raz procedure is very similar to the Stamey procedure, but the
sutures are not placed near the urethra; instead, they are placed in the front of the
vaginal wall.
The Gittes procedure is a transvaginal technique that does
not require an incision. Instead, a small puncture is made above the pubic fat pad. A
suture is then transferred by a needle through the rectus (muscle of the pubic crest) and
down toward the vaginal wall, where it is looped and drawn back and out through the
puncture. A second pass is made through the same incision (1 or 2 cm beside the first
pass) to create a strong support for the suspension. The process is repeated through
another puncture hole, which is made 1.5 to 2.0 cm away from the first site. Both
suspending sutures are tied down within their respective puncture sites.
Bone anchors are new additions to the techniques for needle
suspension of the bladder neck. When needle suspension was first developed, surgeons
questioned the amount of tension that was suitable for the suspension
sutures. They wanted
to avoid the complications of bladder outlet obstruction and suture breakdown that could
because by too much tension or sutures pulling out of the anchoring tissue.
Recent innovations, such as the vesica® bladder suspension
kit and Intac/Infast kits, employ bone anchoring devices to improve the needle suspension
procedures.
With vesica®, a disposable suture carrier creates a large
Z-stitch that is used move pubic fascia beside the bladder neck and urethra. Next, the
suspension sutures are fixed to an anchor that is inserted into the pubic bone and they
are tied without tension by means of a removable spacer. Bone anchoring is not a very
painful procedure and can be performed on an outpatient basis.
Patients with severe stress incontinence and intrinsic sphincter deficiency (Type III SUI or
weakening of the urethra muscle) may not be helped by simple suspension procedures. Yet
such individuals are good candidates for the pubovaginal sling procedure, which can create
the urethral compression necessary to achieve bladder control.
This technique involves the creation of an autologous sling
-- that is, a sling made out of a strip of tissue from the patient's own abdominal fascia
(fibrous tissue). Occasionally, surgeons use a synthetic (artificial, man-made) sling for
this procedure, although urethral erosion (breakdown) appears to be more common when
synthetic slings are used.
During the pubovaginal sling procedure, a strip of fascia is
obtained via an incision above the pubic bone. This strip of fascia becomes the sling.
Another incision is made in the front of the vaginal wall, through which the surgeon can
grasp the sling and adjust its tension around the bladder neck. The sling itself has
sutures attached to it. The sling is secured in place when the two sutures are loosely
tied to each other above the incision in the pubic fascia, providing a hammock for the
bladder neck to rest on.
The pubovaginal sling procedure generally results in high
success rates, with bladder control lasting more than 10 years. Some of the complications
of pubovaginal sling procedures are: accidental bladder injury, wound infections and
prolonged urinary retention.
Sling Procedures - Patients
with severe stress incontinence and Intrinsic Sphincer Deficiency (Type III SUI or
weakening of the urethra muscle) may not be helped by simple suspension procedures. Yet
such individuals are good candidates for a sling procedure, which can create the urethral
compression necessary to achieve bladder control.
There are two techniques available for sling procedures:
a) The percutaneous approach which requires a small abdominal
incision to be made.
b) The transvaginal approach where the procedure is performed
vaginally and no incision is required.
Percutaneous Slings
- The pubovaginal sling involves the creation of an autologous sling -- that is,
a sling made out of a strip of tissue from the patient's own abdominal fascia (fibrous
tissue). Occasionally, surgeons use a synthetic (artificial) sling for this procedure,
although urethral erosion (breakdown) appears to be more common when synthetic slings are
used.
During the pubovaginal sling procedure, a strip of fascia is
obtained via an incision above the pubic bone. This strip of fascia becomes the sling.
Another incision is made in the front of the vaginal wall, through which the surgeon can
grasp the sling and adjust its tension around the bladder neck. The sling itself has
sutures attached to it.
The sling is secured in place when the two sutures are
loosely tied to each other above the incision in the pubic fascia, providing a hammock for
the bladder neck to rest on.
The pubovaginal sling procedure generally results in high
success rates, with bladder control lasting more than 10 years. Some of the possible
complications of pubovaginal sling procedures are accidental bladder injury, wound
infections and prolonged urinary retention.
The Vesica® sling procedure, a
minimally invasive (reduced operative risk and a shorter recovery phase) surgery, involves
the placement of a sling to support the bladder neck, urethra and sphincter.
Through the opening created by the incision's), your surgeon
will place two small anchors into the pubic bone in order to provide stable fixation for
the bladder neck. He/she will then take one end of the suture and guide it through the
tissue on one side of the bladder neck then the other side.
Depending on your diagnosis your physician may elect to use a
sling made of either a biocompatible synthetic material or of your own tissue. This sling
(like a hammock) is secured to the anchor placed in the bone and serves as additional
support for the urethra, bladder neck and sphincter.
To help with the healing process, a catheter may be placed
into your bladder. The catheter will be connected to a drainage bag, which will collect
your urine.
Routine physical activity may be restricted for a short time
after the procedure and strenuous activity for 8-12 weeks. Your doctor or nurse will
provide you with specific guidelines.
Transvaginal Slings
(Precision Tack) - Precision Tack™ Transvaginal Anchor System is a device
that allows your physician to perform a minimally invasive procedure to restore urinary
function by returning your anatomy to its original position.
The transvaginal approach means no abdominal incision is
made, therefore eliminating any visible scars on the body surface. With Precision Tack two
tiny anchors are placed in the back side of the pubic bone to provide long-term support of
the bladder neck and urethra.
To begin with, your physician will make a small incision in
the vaginal area. This incision is necessary in order to create an area for a sling to be
inserted. The size and shape of the incision will be determined by your physician, based
on whether there is a need for additional repairs. Once the incision is made your
physician will place two small tacks in the pubic bone, one on each side. These tacks
provide a stable fixation for the bladder neck.
After the tacks are in place, your physician will insert a
sling into the vagina. A sling is a small piece of material that attaches to the tacks
with sutures. The sling will remain in the body providing support, like a hammock, holding
the anatomy in its original position.
With the tacks and sling in place, the vaginal incision is
closed. The Transvaginal Sling procedure is complete and normal urinary function should be
restored.
To help with the healing process, a catheter may be placed in
your bladder. It will be connected to a drainage bag, which will collect your urine. The
catheter will be removed within a short time. After the procedure is complete, specialized
nurses will monitor you. You will probably be discharged within 24 hours.
Routine physical activity may be restricted after the
procedure. Strenuous activity may be restricted for 8 ‚ 12 weeks and physical
activity for 6 ‚ 8 weeks. Your doctor or nurse will provide you with specific
guidelines.
Injectables -
Other alternatives to invasive, stress incontinence surgery include injectable agents that
increase the bulk around the urethra. These agents compress the urethra near the bladder
outlet and can greatly improve the function of the urethral sphincter muscle. Injectable
materials include collagen (a naturally occurring protein found in skin, bone and
connective tissues), polytetrafluoro-ethylene (PTFE, a synthetic compound known as Teflon,
Polyte for Urethrin) and fat.
In women, injectable agents are a good choice if the patient
is older, is not a good candidate for surgery, and has persistent intrinsic sphincter
deficiency without urethral hypermobility (distinguished by leak point pressures less than
90 cm of water). In men, injectable agents may be beneficial for patients with intrinsic
sphincter deficiency that has lasted longer than one year.
The Contigen Bard implant is a new collagen-based form of
injection therapy for leakage caused by stress incontinence. Contigen uses a highly
purified form of collagen made from cowhide; therefore, all potential Contigen recipients
should receive a skin test 28 days before scheduled injection to determine whether or not
they are allergic to bovine collagen.
The Contigen implant is injected around the top of the
urethra using prefilled syringes. The procedure generally is conducted on an outpatient
basis with a local anesthetic (painkiller). Most patients need one to three Contigen
treatments (up to 28 cc) to achieve bladder control.
Polytetrafluoroethylene (PTFE, a synthetic compound known as
Teflon, Polytef or Urethrin), in the form of a micro polymer paste, can be injected into
the upper urethra. The PTFE particles spur the growth off ibroblasts (fiber-making
cells),
which help to fix the PTFE in the urethral tissue and assist in urethral closure. PTFE is
not approved in the United States for treatment of incontinence, because questions remain
regarding the potential for PTFE particles to migrate to other regions of the body, such
as the lungs, brain and lymph nodes.
Fat injections also have been used to treat intrinsic
sphincter deficiency. Autologous fat (fat from the patient's own body) is gathered by
liposuction from the abdominal wall and is then injected around the urethra. Like collagen
and PTFE injection, fat injection is a simple technique that can take place under local
anesthesia. The results of this procedure appear favorable and cost-effective, although
long-term findings are lacking.
Bladder Augmentation
- Individuals who suffer from a low-capacity bladder -- for example, a bladder
that is small, hyperactive or nonresilient -- may benefit from surgery that increases the
fluid-holding potential of the bladder. Surgery that increases bladder capacity, otherwise
known as bladder augmentation or augmentation cystoplasty, is conducted using either the
bladder itself (autoaugmentation) or bowel (intestine) segments. Such surgery is not
recommended for patients who are unable to perform self-catheterization (self-placement of
a urinary tube) or who have kidney disorders, bowel disease or urethral disease.
Autoaugmentation is a novel method of bladder augmentation.
It increases the capacity of the bladder without using bowel or stomach segments, which
may result in complications after other augmentation procedures. During autoaugmentation,
the detrusor (the smooth muscle in the wall of the bladder that contracts and expels
urine) is cut out of the dome of the bladder, leaving the mucosa (mucous membrane tissue)
intact. This procedure creates a bladder with reduced muscle squeezing ability and
improved function; however, long-term findings in some subjects suggest that contraction
of the mucosa eventually can occur.
Bowel augmentation makes use of segments from the ileum (the
last part of the small intestine), cecum (the first part of the large intestine) or
ileocecum (junction between the small and large intestines) to increase the capacity of
the bladder. In all bowel augmentation procedures, the bowel segments are changed in shape
from a cylinder to a sphere to produce a flexible, low-pressure vessel. The bladder is
opened at the dome and is cut at right angles on each side to create a clam-like shape.
The open bowel segment then is joined to the "clammed" bladder with sutures.
Bowel augmentation is associated with post-operative
complications, such as leakage of urine, continued incontinence, and kidney problems.
Long-term risk factors include the development of bladder stones, increased risk of
bladder cancer and increased risk of incontinence during and after pregnancy.
Artificial Sphincter
 - Sometimes complicated cases of
incontinence require implantation of a device known as an artificial urinary sphincter.
People who might benefit from this treatment include those who are incontinent after
surgery for prostate cancer
or stress incontinence, trauma victims and people with congenital (present at birth)
defects in the urinary system.
The artificial sphincter has three components, including a
pump, balloon reservoir, and a cuff that encircles the urethra and prevents urine from
leaking out. The cuff is connected to the pump, which is surgically implanted in the
scrotum (in men) or labia (in women). The pump can be activated (usually by squeezing or
pressing a button) to deflate the cuff and permit the bladder to empty. After a brief
interval, the cuff refills itself and the urethra is again pressed closed.
Because the artificial sphincter is an implant, it is subject
to the risks common to implants, such as infection, erosion (breaking down of tissue) and
mechanical malfunction. Yet with appropriate presurgical evaluation, operative techniques
and postoperative follow-up, many problems can be avoided and incontinent patients can
experience an improved quality of life with this device.
Sacral Nerve
Stimulation-InterStim - InterStim® Continence Control Therapy is a
reversible treatment alternative for people with urinary urge incontinence who have found
behavioral and pharmacological treatments ineffective or not well tolerated. InterStim®
Continence Control Therapy uses a small stimulation system, about the size of a pacemaker
that is surgically placed under the skin in the lower abdomen and lower back. The therapy
uses mild electric pulses to stimulate a sacral nerve in the lower spine. This nerve
influences the bladder and surrounding muscles that control urinary function.
Clinical studies have shown that nearly half of all urge
incontinent patients using the therapy are completely dry and many others have had their
symptoms reduced significantly. The exceptional success rate of InterStim® Therapy is
linked to the test stimulation procedure. This unique feature allows patients and their
physicians determine the effect of InterStim® Therapy prior to consideration of a
surgical implant procedure.
Done on an outpatient basis, this cost effective and
informative test stimulation procedure:
- locates and identifies the integrity of the sacral nerves
- demonstrates the effect of sacral nerve stimulation on patient
symptoms
- allows the patient to experience the sensation of stimulation
- helps the clinician and patient make an informed choice about
InterStimTherapy as a long-term therapy option.
During the test stimulation procedure patients are asked to
keep a voiding diary to record voiding patterns with the stimulation. The voiding diary is
then compared to diaries from before the test stimulation procedure and after the test
stimulation procedure to determine the effect of the treatment on their symptoms.
The test stimulation allows the clinician to evaluate the
therapy as an option for the patient without significant cost or delay. It also provides
patients with realistic expectations about the results of InterStim Therapy. Usually
within three to five days both the patient and clinician can determine if InterStim®
Therapy is a viable treatment option.
After successful evaluation of the test stimulation, the
InterStim® System may be implanted for long-term therapy. The procedure is performed
under general anesthesia, and the InterStim® System can generally be activated on the
first day after surgery.
Potential side effects of the InterStim® Continence Control
Therapy include: pain at the implant sites, lead migration, infection, change in bowel
function, and undesirable stimulation or sensations.
Alternative
Treatment Devices - In addition to standard methods such as biofeedback, drug
therapy and surgery, a number of treatment devices are available to help patients achieve
bladder control.
Interstim is a new therapy which may be effective in treating
urge incontinence in some patients. It consists of a device, about the size of a
pacemaker, that is implanted into the sacral nerves of the lower spine, where it delivers
electrical impulses that help regulate bladder function.
In this way, Interstim reduces the likelihood and severity of
accidental urination or leakage. The surgery required for implantation is minimal, and the
device can be adjusted to meet the bladder control needs of each patient.
Prosthetic occluding devices can be used to block the flow of
urine by squeezing the urethra shut. For men, such mechanical devices include penile
clamps (for example, the Cunningham clamp) and compression rings. The penile clamp is a
V-shaped casing with a foam cushion that fits over and under the penis. When closed, the
penile clamp should stop the flow of urine without causing discomfort. Compression devices
are adjustable rings that surround the penis and, when inflated with air, pinch off the
urine flow. Occluding devices usually are reserved for temporary use by individuals with
stress incontinence. These devices must be removed at regular 2- to 3-hour intervals to
empty the bladder. Therefore, they should be used only by mentally competent individuals
who are able to adjust them by hand and who are able to remember the bladder-emptying
schedule. Improper use of penile clamps and compression devices can result in penile and
urethral erosion, penile edema (swelling), pain and obstruction.
Vaginal pessaries -- ring, cube or doughnut-shaped devices
made of rubber or silicone -- are inserted into the vagina to support the bladder neck in
female patients with stress incontinence. Vaginal pessaries are available in different
sizes, and they are generally put in place by a gynecologist. The major side effects of
pessary use are wearing away of the vaginal skin and vaginal infection. Therefore, people
who use pessaries need frequent examinations to ensure vaginal health. Erosion problems
usually can be managed by removal of the pessary until the skin heals, and vaginal
infections are treatable by douching and/or antibiotic therapy. Pessaries may be an
alternative form of treatment for frail elderly women who cannot undergo other forms of
incontinence therapy.
Introl is a pessary-like vaginal
prosthesis that also works to support the bladder neck. A woman can insert and remove the
device, which should not be worn continuously for more than 24hours without proper
cleaning. The manufacturer recommends removing the prosthesis at night before going to
bed.
A number of additional treatment devices recently have become
available for women. The first device--the Reliance urinary control insert--also is known
as a urethral plug. The Reliance insert is a single-use, balloon-tipped tube that is about
one-fifth the size of a tampon. The insert can be placed in the urethra by means of a
special applicator. When in place, the small balloon (which extends into the bladder) can
be inflated with air to prevent leakage. If the wearer wishes to urinate, she just pulls a
string to deflate the balloon and then removes the insert. Unfortunately, fairly high
infection rates are seen with this device, because it is placed directly into the urethra.
The manufacturer reports that urinary tract infections are most common during the first
month of use and decrease as women become more familiar with its proper use.
Noninvasive/External
Devices - Several noninvasive, or external, devices are among the newer
promising treatments for stress incontinence.
The Miniguard Patch and Impress (Uromed) are single-use foam
pads that are slightly larger than a postage stamp. One surface of the patch is covered
with a gel-like glue that adheres to the region around the opening of the urethra. The
patch fits between the labial folds and provides opposing pressure on the urethra to
prevent leakage. When the wearer wants to urinate, she simply removes the patch and
applies a new one afterward. The patch is less bulky than cumbersome pads and provides a
neater alternative for leakage.
FemAssist and Bard Cap Sure Continence Shields are external
devices that function like foam pads, but can be reused used for about one week before being
replaced. Both are small, circular, silicone rubber devices that are positioned over the
flat area surrounding the urethra. Using suction, they support and reinforce the muscle
that naturally control urine output and help prevent accidental urine loss in women who
suffer from stress incontinence. An ointment is used to create a mild vacuum seal that
holds the device in place. When a woman wants to urinate, she removes the device, which
can then be cleaned and reapplied. Because they are used externally, FemAssit and CapSure
have lower rates of associated infection than internal devices, though some woman report
discomfort or mild irritation when using these products.
- Non-Surgical
- Fortunately, there are numerous forms of treatment for urinary
incontinence. Before treatment of urinary incontinence can begin, the type of urinary
incontinence must be diagnosed.
There are three main general strategies for treating urinary
incontinence:
Behavioral Techniques - Your
physician and healthcare team can teach you techniques to control your own bladder and
muscles of urination. These behavioral methods usually are very simple and effective for
specific types of urinary incontinence. The most commonly used behavioral methods are
pelvic floor exercise, biofeedback and bladder training.
Below is a list of common behavioral techniques. Click on the
title of an entry to find out more.
Kegels - Exercises to strengthen the pelvic floor muscles were
originally described by Kegel in 1948. Such exercises, which are now
known as Kegel exercises, can be used to regain bladder control, especially if the levator
ani (pelvic floor muscle) and/or sphincter muscles have been weakened by childbirth or
other factors.
To identify these muscles, you can perform a contraction
(muscle squeeze) to stop the flow of urine in midstream. If the urine flow stops, you've
located the correct muscles. The next step is to repeat the exercise frequently throughout
the day. Programs of 10 Kegels (for 30 seconds each) every hour, or twice-daily Kegels (4
seconds each for 5 minutes) have proven effective. The benefits of Kegel exercises are not
immediate, so you should continue the program for at least 8 to 12 weeks before expecting
to experience any results. After you identify the muscles, Kegels should not be performed
during voiding, since urine could be retained.
In women, weighted vaginal cones sometimes are used to help
patients find the proper muscles to squeeze during Kegel exercise. When the cone is held
in place, the exercise is being performed correctly. Weighted cones should be worn for 15
minutes twice daily while walking or standing.
Kegel exercises improve the urethral support and closure
mechanisms, particularly during activities such as coughing or bending. Therefore, Kegel
exercises are notably helpful for stress incontinence due to the effects of pregnancy in
women or prostatectomy (prostate surgery) in men.
Biofeedback/Electrical
Stimulation - Biofeedback is practiced to help people gain awareness and
control of their urinary tract muscles. The principle of biofeedback is simple: a variety
of instruments are used to record small electrical signals that are given off when
specific muscles are squeezed during contraction. These contraction- related signals are
instantly converted into audio and/or visual signs that patients can recognize and learn
from, in order to control muscular activity. With biofeeback, weak muscles can be better
activated on demand, overly tense muscles can be relaxed, and overall muscle activity can
be coordinated.
Biofeedback usually is performed in conjunction with Kegel
exercises, since it helps to reinforce correct Kegel techniques. Biofeedback lets patients
visualize and identify the pelvic floor and/or abdominal muscles that are appropriate for
their exercise programs.
Neuromuscular electrical stimulation (NMES) also is employed
to "reeducate" and strengthen weak urinary muscles. In NMES, electrical
stimulation of the pudendal nerve causes contraction of the pelvic floor and periurethral
(urethra-encircling) muscles. A probe is inserted into either the vagina (female
reproductive canal) or anus (outside opening of the large intestine), and NMES is applied
at an intensity that is below the threshold of pain. Most NMES devices are biphasic: that
is, they produce a current that stimulates contraction, followed by a rest period of 5 to
10 seconds. Patients are instructed to join in with the NMES-stimulated contraction. Such
assisted exercise eventually strengthens the pelvic floor muscles and improves bladder
control. Electrical stimulation can be used to reduce both stress incontinence and urge incontinence. NMES treatment programs usually
last 20 to 30 minutes. NMES devices are available for both home and hospital use.
Neocontrol Pelvic Floor Therapy System - The Neocontrol Pelvic Floor
Therapy System is a pulsating magnetic chair designed by Neotonus, Inc. The Neocontrol system
was recently approved by the Food and Drug Administration for the treatment of stress,
urge, and mixed urinary incontinence due to pelvic floor weakness in women. The most
common causes of pelvic floor weakness are childbirth, surgery, injury, or hormonal
changes during menopause. With the Neocontrol system, patients relax fully clothed for
20-30 minutes twice a week in a chair that has magnetic technology embedded in the seat.
Pulsating magnetic fields induce muscle contractions in the pelvic floor to build
strength. Neocontrol treatment is painless. The treatment course takes about eight weeks
or more. The technology produces highly focused pulsing magnetic fields. Patients sit in a
chair for treatment which allows the therapeutic fields to be easily aimed at the muscles
of the pelvic floor that control continence. These muscles contract and relax with each
magnetic pulse, exercising them just as you would exercise any other muscle in our body,
except your brain is not directing the contraction. "One way to think of NEOCONTROL
is as an automatic Kegel exercise
machine." Fifty percent of clinical trial participants report being "completely
dry" after eight weeks of therapy. More than 3/4 of clinical trial participants
reported significant improvement in their continence.
Bladder
Training/Timed Voiding - In timed voiding, the patient fills out a chart that
notes all episodes of urination and leaking. The physician then analyzes the chart and
highlights the patient's pattern of urination. Using this timetable, the patient can plan
to empty his or her bladder before experiencing accidental leakage. In bladder training,
methods of biofeedback and muscle conditioning are used to alter the bladder's schedule
for storing and passing urine. The patient is taught to resist the sensation of urgency
(the strong desire to pass urine), to postpone urination and to urinate according to a
timetable. Bladder training and timed voiding are useful techniques for urge and overflow
incontinence.
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