Diagnosis, Treatment, and Prevention of Urinary Incontinence

More than 75 percent of women can experience significant improvement in their incontinence symptoms with appropriate diagnosis and treatment.

Diagnosis

It is critical that the correct diagnosis be made prior to instituting a treatment plan. Most often, the diagnosis can be made in the office and does not require complex or invasive testing. The diagnosis starts with a complete history and physical exam which can often determine the cause of urinary incontinence. Details regarding frequency and amount of urination as well as urinary leakage are reviewed. A past surgical and medical history as well as current medications may provide additional information. A voiding diary is used for the patient to record how much she drinks and voids, and to note specifics regarding leakage episodes.

The physical exam includes a detailed pelvic exam. The pelvic exam will often provide valuable information regarding the cause for urinary incontinence. A urine sample to rule out infection may be obtained.  Office based testing can help to further determine and characterize urinary incontinence. This testing can include urodynamics (a filling test of the bladder using a catheter to assess normal and abnormal bladder sensation and function), cystoscopy (a lighted scope inserted into the urethra to visualize the bladder and assess for anatomic abnormalities), and radiologic tests (X-ray, ultrasound, or CT scan to assess for kidney stones and other anatomic abnormalities).

Treatment

Treatment is customized for each patient based on their diagnosis, severity of condition, age, and ability to comply with treatment recommendations. Typically, treatment for overactive bladder is medical while treatment for stress incontinence is surgical. This may vary depending on the severity of the condition and the age of the patient as well as exam/test findings. Minimally invasive surgical techniques for patients with stress incontinence are generally performed as outpatient procedures. Patients receiving treatment for advanced prolapse may stay in the hospital overnight, if necessary.

Overactive bladder

Treatment of OAB is focused on reducing bladder spasms and increasing bladder capacity-thereby minimizing frequent urination and leakage. Typically, various treatments are recommended to achieve improvement in a short time.  Patients who are refractory may benefit from addition of other treatment modalities including neuromodulation.

• Reduction of the excess fluid intake and bladder irritants including caffeine and alcohol;
• Pelvic floor exercises or Kegels exercises – contraction of the pelvic floor;
• Bladder retraining – emptying the bladder at set intervals which increase weekly to allow the bladder to hold more urine over time;
• Anticholinergic medication – primary medication type used for OAB helps to prevent bladder spasms and increase bladder capacity (Detrol, Ditropan, Oxytrol, Vesicare, Enablex, Sanctura). Side effects include dry mouth, constipation, and dry eye;
• Pelvic floor physical therapy can help improve the muscles and nerves of the pelvis with techniques including biofeedback and electrical stimulation;
• Neuromodulation techniques are used in patients who do not respond to traditional noninvasive treatment options.

Stress Urinary Incontinence

Treatment of SUI is focused on improving bladder neck support and reducing urinary leakage. In cases of mild stress incontinence, pelvic floor exercises and physical therapy may result in significant improvement.  In cases of moderate to severe incontinence, surgery is often the best option. Over the last decade, surgery has evolved to become a very safe and effective outpatient procedure with success -rates greater than 90 percent and complication rates less than five percent.

• Pelvic floor exercises or Kegel exercises – involve contractions of the pelvic floor muscles. Pelvic floor physical therapy can help strengthen the of the pelvis;
• Pessaries have been designed to specifically treat stress incontinence and are used in those patients who are poor candidates for surgery or would like to pursue nonsurgical treatment options. Often patients are referred for physical therapy and additional instructions;
• Surgery – The most popular procedure currently performed involves suburethral sling. This outpatient, minimally invasive procedure is performed in the operating room with intravenous sedation and local anesthesia. During the procedure a small permanent mesh or tape is inserted underneath the urethra which acts as a hammock and prevents movement during activity.

Prevention

Given the increasing incidence of urinary incontinence in our aging population, greater attention is being paid to prevention. An easy preventive intervention would be learning proper technique of pelvic floor exercises or Kegels and performing them prior to the onset of urinary incontinence. Most patients currently perform Kegels incorrectly. All patients would benefit from confirmation of proper exercise technique by their physician or qualified pelvic floor physical therapist. Avoidance of chronic straining and maintaining a healthy weight also can reduce the risk of stress urinary incontinence.

In addition, patients with complaints of overactive bladder or urinary incontinence should be evaluated soon after the onset of the condition as patients with mild symptoms often have greater success with more conservative treatment options. Treatment of long-standing disease often involves more aggressive treatment with lower success rates.

The long-term effects of method of delivery, vaginal versus cesarean section, on urinary incontinence are currently controversial with conflicting data. It has been suggested that cesarean section protects the pelvic floor from long-term conditions including pelvic prolapse, urinary incontinence, and fecal incontinence but greater data needs to be analyzed prior to making clinical recommendations.