Incontinence is certainly a common problem that we see in urology. It tends to be somewhat more common as patients age, but certainly it cuts across all age groups and sexes. The good news is that incontinence is generally a very treatable problem. However, it is important to have a good and complete evaluation prior to treatment.

Urinary incontinence is a common problem. Patients should not feel embarrassed or apprehensive about talking to their physicians about this condition. The majority of patients can be successfully treated using either conservative or surgical therapy. Incontinence should not be considered in an inevitable part of getting older. The best source of information for the patient with incontinence is their family physician. They will be able to either diagnose and treat the problems themselves or make an appropriate referral.

I am a 43-year-old female; 3 full term pregnancies. I have urinary leakage. I wear a pad everyday. Do I need surgery, or is there something else available?

The first thing that you should have is an evaluation to see what type of incontinence you have. Generally speaking, incontinence falls into several categories. One can have overflow incontinence whereby the bladder fills, doesn't empty, and reaches its capacity and then the patient leaks urine more or less on a continuous basis. Another type of incontinence is stress incontinence. This is usually associated with activity, lifting, coughing, running. And then there is urge incontinence, which is caused by a bladder contraction that occurs when the patient is not trying to empty their bladder. Typically, patients will complain that they feel the need to empty their bladder but begin leaking before they can reach a bathroom. The treatments for these different types of incontinence generally fall into two categories: Conservative management with either medications, devices such as a pessary and sometimes biofeedback, and more invasive forms of therapy such as surgery. The type of incontinence, which is diagnosed during the evaluation, will dictate which type of treatment is appropriate.

Is incontinence a problem seen mostly in the elderly?

Incontinence is certainly more common as patients age, but incontinence can be seen in children, adolescence and adults, both male and female.

Is incontinence a problem seen in diabetes?

Incontinence can certainly been seen in the diabetic patient. Diabetics tend to have decreased bladder emptying and are somewhat prone to having overflow incontinence, but may also have stress or urge incontinence and therefore need a complete evaluation prior to treatment.

Does pregnancy leave a lasting problem with urinary incontinence?

Certainly not all pregnant patients have incontinence following delivery. But pregnancy can certainly predispose to urinary incontinence especially in the case of a vaginal delivery.

How do you decide if you really have a problem? I certainly have some "laxness" after several childbirths, but my doctor hasn't indicated there is a problem.

Do you have incontinence or some dropping down of the bladder?

Can incontinence come & go? Some weeks I have no problems.

Yes, incontinence can come and go depending on its cause. For instance, some patients will complain of stress incontinence only when they have a severe cold with coughing or during periods of excessive activity. Patients with urge incontinence frequently report increased leakage during cold weather and sometimes related to dietary factors such as excessive fluid intake, particularly with products containing caffeine such as coffee.

Do you know of any home remedies for this problem?

No, I do not know of any home exercises for this problem except the Kegel exercises, but you need to be taught how to do them properly.

Do you have any advice about the embarrassing nature of this problem?

If this troubles you, you should visit your physician and undergo an evaluation and seek therapy.

What causes incontinence, is it lifestyle, or biological?

It is primarily biological in most cases. However, it can be made worse by lifestyle such as someone with urge incontinence that drinks excessive amounts of fluids.

What is the most effective treatment for incontinence in older women? My mother is 77 and has had this problem for some time. She has had some relief with pills but still experiences problems.

The evaluation for an older woman should be similar to that for a woman of any age. Once the cause of the incontinence is identified, then your mother should have a discussions with her physician regarding the risk and benefits of the various therapeutic options which are available.

What are some newer treatments that we can look to for help with incontinence?

Neuromodulation or electrical stimulation of the nerves to the bladder is a newer treatment which holds some promise especially for those patients with urge incontinence which does not respond to more conservative forms of management. There are also injectable agents, which may be useful in some forms of stress incontinence. These injectables are placed around the urethra to help it coat.

What is overflow incontinence, and how does it occur and get treated?

Overflow incontinence occurs because the bladder does not empty properly. It can occur for a variety of reasons including problems with the nerves, which innervate the bladder, or long standing obstruction of the bladder among others. It can be treated in a variety of ways depending on its severity which include frequent voiding or voiding by the clock, double voiding, intermittent catherization and indwelling catheter; in some cases, neuromodulation or by diverting the urine from the bladder completely.

How are incontinence cases diagnosed?

Taking a history and performing a physical examination diagnose patients with urinary incontinence. Usually a urinalysis is performed and depending on the findings of the history and physical, further testing with either x-ray studies or an urodynamics study may be appropriate. Get a full evaluation prior to any treatment because the treatments are different because of the etiology or cause of the incontinence.

Any new techniques for control of urinary incontinence following radical prostatectomy?

Following radical prostatectomy patients may be incontinent because of weakness in the valve mechanism or problems associated with the bladder such as decreased capacity. The treatments for incontinence will obviously depend on which of these is the primary cause. Generally, the treatments for sphincteric weakness include pelvic floor exercises, injections of a bulking agent, or an artificial urinary sphincter.

How can recurring bladder infections impact on incontinence?

Recurrent bladder infections can in and of themselves cause enough bladder irritation to cause incontinence. They will also make any underlying condition which causes incontinence worse.

I have a problem not making it to the bathroom without drizzling so to speak. Is this incontinence, or what do you think it might be?

Any leakage of urine would be considered to be incontinence.

What is the normal amount of time between voiding?

The normal amount of time between voiding will depend on a number of factors but primarily fluid intake. Normally, with average fluid intake, approximately 8 voids per day are considered to be within the normal range.

What are main causes of urinary incontinence?

In men, prostate surgery is probably the most common reason we see patients for urinary incontinence. In women, pregnancy and vaginal delivery is probably the most common cause of urinary incontinence.

How does incontinence relate to age?

Incontinence should not be considered to be a normal condition of aging. Elderly patients should be evaluated in essentially the same way that patients of any age should be evaluated.

Can urinary incontinence be caused by decreased (improper) nerve function of the sacral nerve supply and if so can a chiropractor help by restoring the proper nerve function through the adjustment and restoring the normal parasympathetic response to this organ (bladder)?

Incontinence can be caused by problems with the sacral nerves.

What is the surgery where the bladder is shifted? Is it successful?

It is certainly one option, but it is not the only option. I think it is important to have a complete evaluation before one options for any therapy.

What percentage of incontinence is male and which is female?

I think it is safe to say that incontinence is more common in women.

What are common meds for incontinence?

Probably the most common medications used for the treatment of incontinence fall into the general category of anticholinergics or drugs designed to "relax" the bladder.

What is the difference between 'urge’ incontinence and 'stress' incontinence?

Stress incontinence is also known as activity related incontinence. It typically occurs when the patient is lifting, coughing, straining, or otherwise engaging in some form of physical activity. The bladder contracting when the patient doesn't want it to and is typically described by patients as "I feel I have to go to the bathroom, but I can't make it in time" urge incontinence.

Should a general care physician or specialist treat incontinence? What type of specialist if not a general care physician?

Incontinence may be successfully treated by a variety of physicians including general practice or family practice physicians, urologists, or gynecologists depending on the cause of complexity of the particular case.

If a person has an indwelling catheter in place long term because of incontinence, is irrigation indicated and if so, with what?

Generally, a long term indwelling catheter is only used as one of the last options for the treatment of incontinence. Irrigation is sometimes helpful in keeping the catheter functional and potentially decreasing the incidence of catheter associated infections. A number of irrigation solutions are available and the treating physician is the best one to decide what might be best for a particular patient.

I frequently have strong urges to go to the bathroom that soon pass. What can this be attributed to? Has happened to other males in my family and I'm 63.

Frequent strong urges to go to the bathroom in a 63 year old male can commonly be due to enlargement of the prostate. An evaluation by a physician would certainly be advisable.

Am I correct in saying that my first line of action to prevent incontinence is not to cut back on fluids, but specifically fluids with caffeine?

Well, it depends on how much fluid the patient is taking in. Cutting back too much on fluid can be detrimental. But assuming the patient is getting an adequate amount of fluids, it might be worthwhile to try limiting caffeine to see if this helps the incontinence.

Can a female patient be diagnosis with an ectopic ureter?

Yes.

What about Ditropan XL?

DitropanXL is an extended release anticholinergic medication. Your physician is the best one to decide if you are a candidate for this.

What are Kegel exercises and whom do they benefit?

Kegel exercises are also known as pelvic floor muscle strengthening exercises and are designed to strengthen the muscles that support the pelvic floor and maintain continence. Kegel exercises will benefit patients with stress or urge incontinence and are very worthwhile treatments as they have virtually no side effects and a relatively high degree of success.

Please instruct on PROPER way to do KEGEL exercises?

The best way to instruct a patient on how to do proper Kegel exercises is in the office while doing a physical exam to be sure they are using the proper muscles.

How can fistulas (urinary) cause involuntary urine loss?

Fistulas are abnormal connections from the urinary tract usually into the vagina in the case of female or into the skin in the case of males. They cause incontinence because they bypass the normal sphincter mechanism.

About 1 out of 3 women has incontinence. The important thing to remember is that there are many therapies available. I would urge you to consult your health care provider if you have incontinence that is problematic for you.

Could you please comment on the utility of Kegel exercises in helping incontinence?

Kegel exercises are very effective in helping incontinence. The most important thing about these exercises is that they are done correctly and that they are done for long enough. Kegel exercises are for strengthening pelvic muscles just like push-ups for legs and arm muscles. It takes about two to three months for muscles to get strong enough to see a difference. It is important to have patience to do them correctly. It is helpful sometimes to ask your health care provider to check your technique because about one out of three women do the exercises wrong without instruction.

Any tips on how best to practice this exercise?

People often say that these exercises can be done any place. While that is true, they can be quite difficult to do at the beginning when you are learning. At the beginning, I suggest that you just do the exercises by themselves. Start lying down so that you can feel the muscles. Place one hand on your belly to make sure you are not straining. Then, squeeze the muscles you would squeeze if you were trying to stop your flow of urine. Try to hold this squeeze for 4 counts and relax for 4 counts. Work your way up to doing this for five minutes. While it is okay to try to stop your flow of urine in the bathroom, it is not a good idea to do the exercises always while you are urinating because this ends up causing problems with normal urination. Once the muscles are strong enough, then you need to start using them in your daily life. By that, I mean squeeze the muscles before you sense a cough, before you lift something heavy, or as you are on your way to the bathroom.

What are the different types of incontinence?

There are main 2 main types of incontinence and others that are less common. One main type is stress incontinence, which is where you lose urine with physical stresses like coughing, sneezing, jumping or lifting. The other main type is urge incontinence. This has several synonyms including overactive bladder, unstable bladder, and detrusor instability. This type of incontinence occurs when you get a sudden urge to urinate and just can't hold it. Women often notice this as they are heading towards the bathroom and they are putting the key in the door, or when they are opening their automatic garage door on the way home.

How do you know if you have a problem?

Incontinence is a condition in which whether or not its a problem is almost completely defined by the person experiencing it. For example, I have some patients who are incontinent every day and do not consider it a problem for them. Others lose urine once a month and are devastated.

I have an irritable bladder. What can I do to help relieve these symptoms without taking medications?

By irritable bladder, I am assuming that you mean urgency, frequency, or bladder pain. It is important to make sure that there are no medical problems causing this. Some things that people find helpful include cutting down on caffeine, carbonated beverages, alcohol, or acidic foods. Another important thing is to stay well hydrated. Often times having very concentrated urine makes people have more urgency. For example, if somebody has urge incontinence and tries to cut down on fluids to cut down on leakage, they may actually end up with more urgency. Some people also have urgency because they have spastic pelvic floor muscles. This condition can be diagnosed by a health care provider and treated.

Can being overweight cause it?

Most of the studies that are trying to find out risk factors for incontinence do show a link between overweight and incontinence. It is not clear why this is but might be related to the increased abdominal pressure that happens from being overweight. Having said that, at this time there is only one good study which has carefully looked at the effect of losing weight on resolution of incontinence. In that study, the researchers followed a group of very overweight women (in the range of 300 pounds) before and after surgical treatment of obesity. They did see a decrease in leakage of urine after the women lost over 100 pounds. This is not the situation most women find themselves in, so we don't have any information about women who are just slightly overweight. There are some ongoing studies right now that are looking at that so we will know more in a couple of years.

Is it likely that after giving birth you will experience incontinence? If so, why?

A lot of women do experience incontinence either while they are pregnant or right after giving birth. The reasons range from hormonal changes to damage of the nerve supply to the pelvis to actual damage to muscles and ligaments. It is quite common for women to have some incontinence for the first 6 to 8 weeks. Most women gradually improve and regain the bulk of their nerve functions by 6 months postpartum.

What is detrusor instability?

As we talked about a couple of minutes ago, detrusor instability is another word for overactive bladder. Both of these names apply to someone who suddenly loses urine with a strong sense of urgency. The only difference is that a physician might not call something detrusor instability unless she had direct evidence from bladder testing to support that diagnosis.

Are there lifestyle causes of bladder control problems and can they be avoided?

Lifestyle causes are an area that we know the least about. There are no rigorous studies that assess lifestyle changes. I can tell you what health care providers often tell patients or what patients tell us. For example, many people find that cutting down on caffeine and carbonated beverages are helpful. The relationship between smoking and incontinence is unclear, and there are conflicting studies about that. Health care providers may tell women to lose weight but as we talked about earlier, we don't have much information about what you can expect if you do lose weight. Many women do find that urge incontinence occurs if they are very stressed. So, like many areas of health, stress reduction is important.

With what kind of incontinence is Detrusor Dysinergia most closely associated? How is it discovered, and any specific treatments for it?

Detrusor dysinergia is an uncommon type of urinary incontinence that we haven't mentioned. In this particular condition, when a woman is trying to urinate, the bladder contracts which it is supposed to do, but at the same time, the urethra muscle also contracts when it is suppose to relax. Most commonly, we see this condition in women who have some type of spinal cord problem. However, the diagnosis is not always clear. The diagnosis is made during bladder testing and sometimes what appears to be urethral muscle contraction is actually an inability of the patient to relax while voiding.

Do more men or women experience incontinence?

More women experience incontinence, particular at younger ages. The ratio is in the range of 5 to 1.

Is nighttime incontinence for a 19-year-old female treatable? And how?

Generally nighttime incontinence is treatable. We need to know whether somebody has always had nighttime incontinence or whether somebody has been dry at night for the last 15 years and now having nighttime incontinence. For some women, it takes a long time for the axis between the brain and the bladder to fully mature. I have had several patients who continue to have nighttime incontinence at 19 who were dry by age 21. The treatments that physicians often use include restricting fluids in the evening, setting an alarm clock in the middle of the night to get up and urinate, medications and pads. For some young women, this problem seems to be hormonally related and sometimes medications such as birth control pills can help where there is a cyclical pattern to the problem.

Does the stress reduction help a person with MS reduce incontinence problems?

It is unlikely that stress reduction would be the main thing to help a person with MS since their incontinence problem is largely neurologic. In conjunction with other therapies, it might prove helpful.

What is the normal amount of time between voiding? I have never been normal so I do not know how long to try to wait?

The typical number of voids for women ranges from 6 to 9 per day. Obviously, the more someone drinks, the more often she will void. Most women tend to void somewhat more frequently as they get older.

How can collagen injections help with incontinence?

Collagen injections are a specific kind of treatment for a type of stress incontinence in which the sphincter muscle around the urethra isn't working as well. The advantage of collagen injections is that it can be done in the office. The disadvantage is that the body reabsorbs collagen and so the effect only lasts for a year or so.

When is PVR testing useful?

PVR stands for post-void residual measurements. This is a measure of how much urine is left in the bladder after you have emptied your bladder in the bathroom. Checking this is an important part of an evaluation for incontinence. It is usually normal but when it is not, it will lead your health care provider down a completely different path of evaluation and treatment. It usually increases slightly with age but in general is less than 50 cc's.

How can recurring bladder infections impact on incontinence?

Bladder infections usually worsen incontinence. When a woman is having a bladder infection, one of her symptoms might be incontinence at that time. Usually, the incontinence gets better once the bladder infection is treated. A more difficult clinical situation comes up in older women, about 1 out of 5 women over the age of 65 have some bacteria in her urine from time to time. The question then comes up as to whether this is causing her incontinence. Generally, if the incontinence does not get better after treating the bacteria in the urine (which is otherwise asymptomatic), we conclude that the two are not related.

Is there a way too use gene theory to rejuvenate the nerves near the bladder to control the urge?

At this time, no. But this is an exciting potential area for the future.

Is increased PVR seen in all types of incontinence?

Increased PVR is unusual in women with stress incontinence. Sometimes though women with stress incontinence also have a significantly dropped bladder. When the bladder is dropped a lot, it can kink off the urethra making it more difficult to completely empty. Some women with a dropped bladder find it helpful to push the front wall of the vagina up (that's the wall next to the bladder) when they are urinating.

Regarding the surgery where the bladder is shifted up, what is the success rate?

This sounds like an easy question, but it is actually not. There are several different types of surgeries for stress incontinence. Generally, they all shift the bladder up in some way, shape or form. It is hard to interpret the literature about this area because often timeÕs women are not studied longer than about six months after the surgery. Obviously most women like to be dry for longer than that. What I can say in big generalities is that the success rate of the surgery in terms of curing the stress incontinence is in the range of 80 percent if we look 2 to 5 years after the surgery. It appears that the success rate then declines somewhat with time such that by 10 years, approximately 60 percent are still dry. Unfortunately there are some women who are cured of the stress incontinence but, because of the surgery, develop other problems such as urge incontinence, vaginal prolapse, or painful intercourse. Therefore, if we ask the question how many women are dry and do not have any side effects from the surgery, the success rate is in the range of 50 to 60 percent.

Do you treat all elders with asymptomatic bacteruria and incontinence?

Most women with asymptomatic bacteuria don't need treatment in general unless they have a weakened immune system. To try to answer the question of whether for that particular woman the bacteria are causing the symptom of incontinence, I do prescribe one course of antibiotics and ask the woman to play detective to see whether the incontinence improves while she is on the antibiotics. Usually, it does not and, at that point; I make no effort to try to get rid of the bacteria in healthy women.

What are some of the treatments for urge incontinence?

There are several treatments for urge incontinence, which again is also known as overactive bladder. People are most familiar with medications used to treat this condition. Indeed, medications can be quite effective helping nearly 3/4 of women with the problem. Other treatment options include the Kegel exercises we talked about earlier, bladder training, electrical stimulation therapy to the nerves going to the bladder and biofeedback. While some women do very well with medication, others find that the side effects of dry mouth make it hard to tolerate. Therefore, it is, in a sense, a trial and error process for any given person. For women who have incapacitating urge incontinence, there are surgical procedures. These are completely different types of surgeries than those commonly done for stress incontinence. The surgeries for urge incontinence are more of a "big deal" and are usually reserved for a last resort.

How common is interstitial cystitis as cause of incontinence, and what is the latest therapy for it?

Generally interstitial cystitis is not associated with incontinence; certainly a woman could have two diagnoses.