Urology

December 14, 2007

Urinary Incontinence ("Weak Bladder," or "Fallen Bladder")

Differences in Incontinence Are Important For Treatment

At some point in evolution, man stood erect. Soon thereafter, he began complaining and whining about hemorrhoids.

Women, many thousands of years later, learned through social constraints to keep complaints of urinary incontinence to themselves. They play tennis but can't give their all for those important shots in fear of indiscretions. They pick up their children in awkward ways, funneling the exertion along unnatural lines to prevent some urine loss. They wonder if this is normal with aging. The answer is no.

In short, urinary incontinence came about when we got off of all fours and became bipeds, walking gracefully into the civilization that demanded poise and elegance in motion. The problem of gravity soon became evident in the human upright body. Besides the aforementioned hemorrhoids, varicose veins sludge their circulation ineffectively, trying to drain the extra distances against gravity that erectness created. Back pain became the legacy of standing up straight as vector forces ganged up on the pelvis instead of being distributed evenly along the entire torso. And hernias unknown to the species became exceedingly common.

With incontinence, the most troubling hernia process in women develops as a weakness of the vagina from child-bearing, child-birth, child-lifting--or garage-door-lifting, grocery-lifting, that tennis court smash for the winner, and all of the other exertions that women make several times every single day of their lives. True, it doesn't happen every time, yet even occasional soiling oneself is enough to cause severe anxiety and ruin any recreation or duty or employment.

In female anatomy, the back of the vagina holds in the abdominal organs; the roof of the vagina supports the bladder and more importantly the bladder sphincter; the floor of the vagina holds down the rectum. All of these supporting roles are made weaker by upright posture and some trauma to the support around the urinary sphincter; any sudden increase in abdominal pressure, either by exertions described above, or just by simply coughing, laughing, or sneezing, can cause the sudden laxness to pucker open the weakly supported sphincter that is supposed to be nestled tightly closed at the bladder neck. When the exertion causes the weakened area that contains the sphincter to descend, it can leak, and incontinence occurs. (Actually, it's a complex mechanism wherein the pressure against the closure of the sphincter becomes stronger than the pressure used to keep the sphincter closed.

Compounding the process is the uterus (womb), a weight that acts like a little anvil creating additional tugging. If the uterus is enlarged due to otherwise harmless fibroids or other reasons, the hinge effect is more pronounced, making stress incontinence more likely. And if there's prolapse ("fallen uterus"), it's very difficult to treat the urinary incontinence without hysterectomy added to a surgical bladder neck suspension. Of course a woman desiring more children can forego hysterectomy, but subsequent pregnancy may undo a surgical repair for the incontinence.

There are several considerations in treating urinary incontinence in women. First of all, a simple bladder infection must be ruled out, as this can cause almost any type of incontinence symptoms. If a proven infection is cured with antibiotics, then there's every likelihood that a recent incontinence problem will be cured as well. Secondly, hormones (estrogen in particular) play a significant role in beefing up the strength of the support around the bladder and sphincter by thickening the muscle and tissue. Often some estrogen cream or estrogen pills (or both) can cure or improve an incontinence problem. Thirdly and most importantly, it is necessary to determine just what type of incontinence a doctor is dealing with before deciding on surgery as the last resort.

For surgery, it must be assumed there is a mechanical weakness in the support around the bladder and sphincter due to some type of trauma--either pregnancy, delivery, or repeated straining. In these scenarios, urine is lost with some type of intra-abdominal heaving, causing the anatomy to shift suddenly such that normal structures fail in keeping urine from accidentally leaking. This is called true stress incontinence. It is a mechanical phenomenon, and if estrogen can't fix it, usually surgery is the only answer.

But another type of incontinence, called "urge" incontinence, is a different disorder altogether. A gynecologist or urologist must be careful to rule this out, because surgery can't fix this. In this type of incontinence there is an exaggerated urge to urinate with only small amounts of urine in the bladder. What's happening is that nerves in the bladder, the ones that sense when the bladder is full, become exquisitely sensitive to only small amounts of distention, and bladder spasms occur. A woman driving up the driveway, for instance, can't get out of the car and into the house fast enough trying to beat out the urge to urinate. Yet, at other times, a cough or sneeze finds her quite dry. With this type of urge incontinence, surgery to support the sphincter just won't work, and a patient who has surgery for it (with or without hysterectomy) may be disappointed with the persistence of her complaints. Unlike stress incontinence which is a mechanical defect, urge incontinence is a medical condition, and medications like Detrol are used to treat the overly sensitive nature of the nerves in the bladder that cause the bladder spasms felt as urgency.

Of course there are those with both stress and urge incontinence, yielding mixed results when surgery alone is used.

Incontinence is a complicated problem resulting in embarrassment, social crippling, lost wages, and sexual hesitation. It need not be. With the advances in vaginal, laparoscopic, and suspension surgery, stress incontinence can be easily treated. Urge incontinence responds to new medications. If standing erect has ushered in some unwelcome repercussions, we need not accept them as our penalty for improvement. Incontinence may be natural under complex conditions, but it's not normal. It should be evaluated and treated for a good quality of life.

 

Incontinence Can Be A Mixed Bag

 

Many women choose to see their gynecologists rather than urologists when urinary incontinence occurs. The reason for this is simply that gynecology is more of a primary care specialty than urology.  In other words, a woman sees her gynecologist anyway for routine check-ups in contrast to a urologist who is usually the specialist a patient is referred to.  Gynecologists can address many aspects of urology, but the urologist is the ultimate authority on problems with the urinary tract.

Certainly an acute problem like a kidney stone will have a woman seeing a urologist as a first step, but the most common urinary tract complaints seen by the gynecologist are bladder infections, which can cause incontinence, and incontinence as its own problem.

Infections are usually a simple matter of getting a culture to see just what the infecting bacterium is and applying the correct antibiotic that the bacteria are sensitive to.  Tub baths and sexual intercourse are frequently the cause, because the woman's urethra (tube connecting her bladder to the outside world) is just so short--it doesn't take much of a journey for rectal or skin bacteria to get into the normally sterile bladder.  Tub baths expose the opening of the urethra to floating bacteria, and the mechanical act of intercourse drives bacteria into the urethra.  (We often advise a patient to empty her bladder before intercourse and after intercourse, before intercourse to prevent the full bladder from being traumatized and after intercourse to swish out any bacteria that may have been driven in.)  An occasional infection can be addressed by any medical doctor, but repeated, frequent infections and sterile cystitis (no bacteria identified) need evaluation by someone who can do it the best--the urologist.

Incontinence can often be a mixed bag (no pun intended).  There are basically two types of incontinence: 1) Loss of urine when one laughs, coughs, or sneezes, and 2) Urgency to urinate suddenly, associated with bladder spasm--the "will-I-make-it-to-the-bathroom-in-time?" incontinence.

The first one is called stress incontinence and is due to a distortion of tissue support under the urinary sphincter.  With a sudden abdominal exertion (a Valsalva manouver), the tissue support pivots which puckers open the sphincter momentarily and urine can escape.  The other one, urge incontinence, is a neurological and muscular dysfunction--an overactive bladder--wherein the bladder has the urge to empty at significantly lower amounts of urine than usual.

Since stress incontinence is a mechanical failure of tissue support, it can be fixed mechanically with surgery if hormones don't improve the situation.  But urge incontinence won't benefit from surgery.  This is a medical problem requiring medicines to stabilize.  In the past there were medicines which helped, but compliance in taking them was poor due to intolerance to side effects.  Drugs that affected the nerves of the bladder affected the nerves elsewhere, too.  But now there is a newer such drug that seems to have successfully tweaked its effects on the bladder alone.  It is called Detrol, and it is the first new drug for this embarrassing problem in a long time.  There are still reported side-effects, but they are significantly reduced enough to allow a patient to treat her overactive bladder, which is a life-long commitment, over her entire long life.  The twice-a-day dosage is convenient, also, because many geriatric patients already have a long list of scheduled pills to take every day.

But it must be remembered that the overactive bladder of urge incontinence is not just a problem of the elderly.  Talk to any tennis player.  Years of lifting garage doors, hauling groceries, and the hundreds of minor abdominal exertions that go by unnoticed every day all take their toll and add to the nerve twangs and ruination of support that periodic childbirth has already created.  And at the receiving end of this is the female of a species that was never meant to walk upright.  (See above.)

For every victory of longevity we've won there's a new surprise waiting for us, but as long as our brains keep outsmarting the troubles of our longevity, we'll keep up.  Drugs like Detrol is one example of keeping up.

 

Urinary Incontinence: Losing control

 

As the average life expectancy of women in our society zooms into the 80's, urinary incontinence has become more and more prevalent, and more and more of a problem. Incontinence is defined as the immediate, involuntary loss of urine during activities involving increased abdominal straining.

This does not only mean during weightlifting or moving furniture. These women often leak urine even with coughing, laughing, or sneezing, not to mention when walking or exercising. Some even leak urine with no warning at all. This affliction is known as "genuine stress incontinence" and is the most common cause of leaking. Often the problem becomes so severe that these women rarely leave the house and shy away from any social situation for fear that a "crisis" might occur in public. But this need not be the case.

Let's first look at what can cause incontinence, and then we can examine how to treat this problem and return these women to society. First and foremost we must understand that incontinence is a symptom of other pathology that must be understood and corrected before the symptom can be cured. The most common cause of this problem is something called "pelvic relaxation." Over a period of years the female reproductive organs undergo a lot of strain, and this can result in a slow destruction of the support structures of these organs. As a result of this deterioration the bladder, uterus, and other organs that usually remain in the abdominal cavity "fall down" and are allowed to protrude to varying degrees out of the vagina. This produces pressure change, particularly in the bladder, which off-sets the usual balances and allows urine to leak during times of increased pressure when usually it would not.

Many different etiologies are responsible for the demise of the female pelvic support structures, the main culprit being childbirth. Large fetal heads, prolonged labors, and large lacerations can result in damage to ligaments that are responsible for holding the pelvic organs in place. In the "days of old" when a woman remained in labor "as long as it took" (sometimes days), the fetal head was allowed to apply extreme pressure to the bladder and surrounding tissues for very long periods of time resulting in decreased blood supply to those areas which caused damage. Maybe not immediately, but at some point down the line many of these women would experience the symptoms of pelvic relaxation, usually urinary incontinence. Today we have ways to control the time a woman remains in labor  to avoid such prolonged tissue strain, so as today's women of reproductive age get older we will probably see a smaller percentage of women with this problem; but the problem will still remain.

Incontinence need not only be in older women. Sometimes the damage can be so severe that the symptoms are prevalent in much younger women, with the problem even occasionally occurring in the early twenties. Childbirth is not the only cause of pelvic relaxation. Previous pelvic surgeries, like a hysterectomy, can cause the same problems. Menopause can also be a contributing factor. The support tissues of the female pelvis are under the direct influence of estrogen, and with its disappearance at menopause these fibers can become thin and lose their support capabilities. The end result is the same as above. Anything which increases intra-abdominal pressure dramatically and regularly can result in support tissue damage and cause prolapse and incontinence. Chronic coughing in smokers, obesity, tumors in the pelvis, ascites, increased physical exertion, heavy lifting, straining, and chronic constipation are only some examples. Radiation of the pelvis for cancer can cause the same problems.

Pelvic relaxation, although the most common, is not the only cause of incontinence. Instability of the muscle around the bladder can cause the same symptom, leaking of the bladder into the vagina, and some congenital problems can also cause this. Damage to the nerves controlling the bladder can cause bladder malfunction and lead to leaking also.  So now we understand that leaking is only a symptom of one of many problems in the female pelvis, and we must first diagnose the underlying problem before we fix the symptom.

As with any medical problem the first step in diagnosis is the history. Anything protruding from the vagina must be identified. (Often a woman's cervix or even entire uterus can be seen at the opening of the vagina with straining.) Low back pain, pain with sex, problems with bowel movements, rectal pain, problems with starting or stopping the urine stream, and large amounts of urine remaining in the bladder after urinating can help identify a specific problem. A diary should be kept detailing when leaking occurs, how often it occurs, how long an episode lasts. Special circumstances should be related, such as emotional strain (often incontinence can be transient at times of stress). A thorough medication record should be given since some medications (specifically some antidepressants and some high blood pressure medications) list incontinence as a possible side effect in their profiles. Frequency, or how many times a day, of voiding can point out problems with more than seven possibly being a problem. Nocturia, or having to get up at night, should be noted especially if one must arise to void more than one time during the night on a regular basis. All intake should also be recorded. After all, someone who drinks three gallons of water a day will urinate more than someone who drinks only two glasses. The only basic lab work necessary would be a urinalysis.  Sometimes a simple, chronic infection which is easily treated with a course of antibiotics may be present.

The next step in diagnosis is a thorough physical examination. First the lungs are examined for evidence of chronic upper respiratory infections which could cause a chronic cough (a cause of increased abdominal strain listed above). Next we examine the abdomen for any masses or increased fluid, another cause of increased pressure. The pelvic exam will probably provide the most helpful information. Overly relaxed muscles, organ protrusions through the vagina, or a thin vagina lacking in estrogen can all be identified by a speculum and manual exam of the vagina and pelvis. Nerve supply to the area will also be examined which might point out a possible problem with control of the bladder.

The hallmark of urinary incontinence, especially that which can be repaired or reversed, is that it can be reproduced on exam. This can be as simple as having a person "hold it" until they feel they must go and then having them cough or strain. The person may then be asked to void and then a catheter can be inserted into the bladder to see how much is left. More complicated machines can provide pressure readings which can be more specific and help diagnose more complicated problems. Once a diagnosis is obtained our sight turns to treatment, and a treatment must be tailored both to the specific problem causing this symptom and the individual's personal needs.

Urine leakage, although a social and hygienic problem, is not life threatening, so a person will not be offered treatment until it becomes a problem for them. A patient must be questioned in terms of desire for more children, desire to maintain their vagina, and desire to continue having a period (there are some women who feel this is essential). Specific diagnosis, severity of condition, as well as the patient's overall health must be considered before deciding if medical treatment is optimal or surgery is a better choice--and which surgery.

Conservative, non-surgical management may be appropriate in some cases. As stated before, the support tissues of the female pelvis are directly influenced by estrogen, and its replacement may strengthen the tissues and help them resume their support role. In the postmenopausal woman who is a candidate for estrogen replacement, therapy may deserve a course of this hormone.

Kegel Exercises and Other Treatments

A person with seemingly relaxed muscles may try exercises to strengthen their muscle tone. These are called Kegel exercises and can be performed anywhere from sitting in class, to watching a movie, to waiting in my office. Basically a woman should tighten the muscles of the pelvis floor (like trying to stop one's urine mid-stream) and hold for five seconds and release. This should be performed fifteen to twenty times per session three times a day. Electrical stimulation of these same pelvic muscles via electrodes in the vaginal floor has also been tried, but is poorly tolerated by the patient. Behavioral modification may work with some women, known as bladder training. With this method a woman is told to watch a clock and try to urinate at a specific interval, say every 4 hours, whether she feels the urge or not. Gradually the interval is increased. This works for the woman whose bladder has lost the ability to recognize the urge to urinate by teaching it once again to recognize this urge. After instituting any of these conservative measures a patient should be examined at regular intervals to assess results, and their symptom diary should be continued to assess concrete results.

Sometimes incontinence may be due to either muscle spasm or inactivity. Medications are available which target both of these circumstances, but some have a fair number of side effects. (See Detrol, above, which is seen as an improvement to lower such side effects.)

Many different surgical procedures are available to correct pelvic relaxation, the most common cause of incontinence, and as mentioned earlier must be tailored to the situation and to the person. All are designed to restore normal anatomy and either remove or return to their intended position all pelvic organs. A description of each is far beyond the scope of this article, but I or any gynecologist would be willing to explain which ones apply to each patient and what they involve. Always be aware that these are elective and are therefore your decision.

So we see that urinary incontinence, although a socially paralyzing problem, is not of itself life-threatening and is in the large majority of cases treatable. Causes vary, but most are due to excessive, prolonged, regular increases in intra-abdominal pressure. To prevent these, women should avoid nicotine (leading to a chronic cough), excessive weight gain, tight clothes, traumatic vaginal deliveries, constipation, or weightlifting. Once leaking becomes a part of your life, remember that it is often treatable as mentioned above and is most often something that you don't have to live with.

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