Urinary Incontinence- the

BasicsPresented by:

Rhonda Walsh, MD

February 26, 2015

About Me

• Urology Residency at University of Texas-

San Antonio

• Fellowship in Female Urology/Voiding

Dysfunction at NYP-Columbia

• Operate at St. Barnabas, Overlook,

Morristown

• Also treat pelvic pain, prolapse, UTIs,

kidney stones, bladder and kidney cancer

What is incontinence?

• Incontinence is defined as “the inability

to restrain natural discharges or

evacuations of urine or feces”

• For our purposes, it refers to the

involuntary leakage of urine

Female Bladder

What does the bladder do?

• The function of the bladder is to store

urine

• In theory, the bladder should hold urine,

without leakage, until you say it is time

to empty

• This process can fail either because of

the urethra not holding urine in, or the

bladder squeezing to get urine out

Female Pelvis

Different types of incontinence

• Stress

• Urge

• Mixed

• Overflow

• Associated symptoms like frequency,

urgency, nocturia

Stress Incontinence

• Leakage of urine with increases in

abdominal pressure

• Often described as happening when

coughing or sneezing, or bending to lift

an object

• Caused by a lack of urethral support

• Often seen in women after childbearing

years- extended labor can damage the

perineal nerve worsening incontinence

in those prone to it

Urge Incontinence

• Leakage of urine when there is an urge to go to

the bathroom and one does not get there in

time

• Thought to be caused by overactive bladder

(OAB)- the bladder muscle squeezing without

permission

• Possible to have urgency without incontinence-

OAB wet vs. OAB dry

• OAB is a symptom complex that can include

urgency, frequency, incontinence, and nocturia

Other types

• Mixed incontinence- stress and urge

together

• Overflow incontinence- Leakage of

urine because bladder is full and cannot

be emptied

• Constant urine leakage following pelvic

surgery or childbirth can be due to a

fistula

How common is incontinence?

• The prevalence of incontinence in

studies ranges from 11% to 72%,

depending on the definition used

• A more accurate assessment may be

21% of women over 70 having at least

weekly incontinence

• Stress is most common (49%), followed

by mixed (29%) and urge (22%)

Risk factors

• Exercise

• Childbirth

• Obesity

• Aging

• Back injuries and neurologic problems

can contribute to bladder dysfunction

Other causes of incontinence

• Urinary tract infections sometimes cause

incontinence

• Very rarely, bladder cancer will cause the

bladder to be overactive

• It is important to see your doctor about

incontinence as it may be a sign of

another problem (sudden)

• Some medications (lithium, SSRIs)

• Diabetes can cause urgency and

frequency

Nocturia

• Defined as waking from sleep to void

• More common with age

• Caused by increased urine production

at night due to hormonal changes as

well as sleep apnea, cold

• Difficult to treat

Workup

• Making sure you empty your bladder

(ultrasound)

• Checking for urine infection

• Physical examination including pelvic exam to

make sure there are no abnormalities

• Voiding diary

• Possibly cystoscopy (looking in the bladder with

a camera)

• Urodynamic testing (looking at how the bladder

squeezes)

Physical Exam

Voiding diary

Cystoscopy

Urodynamics

How is incontinence treated?

• Behavior changes

• Exercises

• Medication (URGE)

• Surgery (STRESS)

Why is incontinence treated?

• “No one ever died from wetting their

pants”

• Caveat: sometimes increases injury and

infection in the elderly

• If incontinence is limiting your ability to

live your life, it should be treated

Treatment Algorithm

Leaking

Urge

Neuro-modulation

Medication Botox

Stress

Biofeedback Surgery

Overflow

Behavior Modification

Behavioral Changes

• Quitting smoking- less coughing!

• Losing weight

• Managing fluid intake- what goes in

must come out

• Managing constipation

• Managing stress and depression

Exercise Therapy

• In conjunction with behavioral

modification, can work for both types of

incontinence

• Special pelvic floor physical therapists

teach kegel exercises and do muscle

stimulation/biofeedback

Urge incontinence treatment

Urge incontinence

Medication Urodynamics

Neuro-modulation

Botox

Antimuscarinics

• Most common medications/least expensive

• Work on the bladder to relax it and reduce

involuntary contractions

• Reduce urgency episodes by 2-3/day and

incontinence episodes by 2/day

• Drawbacks are side effects of dry mouth

and constipation

• Used with caution in elderly due to

cognitive side effects

Mirabegron (Myrbetriq- Astellas)

• B3 agonist

• Works to increase bladder capacity

• Significantly reduces voids by 1.75/day

and incontinence episodes by 1.5/day

• NO constipation and dry mouth

• Most common side effect is elevation of

systolic blood pressure, but no more

than other bladder medications

Posterior Tibial Nerve Stimulation

• Treats frequency, urgency, and urge

incontinence

• Involves 12 weeks of 1-30 minute session a

week, then monthly maintenance

• Needle inserted into ankle stimulates the tibial

nerve

• Results are similar to medications- Decreases

incontinence episodes by 3 a day and urge

episodes by 5

PTNS (Uroplasty)

Interstim (Medtronic)

• A device placed for overactive bladder

that does not respond to medication

• Stimulates the pelvic nerves to reduce

overactivity

• Like a pacemaker for the bladder,

providing constant low-level stimulation

to override errant signals

Botulinum toxin

• Injected through a cystoscope into the

bladder wall

• Partially paralyzes the bladder

• Works for 3-6 months the first time, then

6-12 months with subsequent injections

• Decreases urge episodes by 3 and

incontinence episodes by 2/day

• Risk of urinary retention

Stress incontinence

Stress incontinence

Mid-urethral sling

Injectibles

Kegels

Pelvic floor muscle exercises• 10 slow-twitch contractions and 10 fast

5 times daily

• Learn to contract these muscles at

times of increased abdominal pressure

• Works for urge incontinence as well

• 70% improvement rate, but must keep

doing them

Mid-urethral Sling

• Multiple surgeries have been done over

the years for stress incontinence

• In the past, women had open abdominal

surgery to “lift the bladder”

• Now the most common is a sling put in

through the vagina

• Often will help with mixed incontinence

• Successful in 80-90% of women

Mid-urethral sling

TVT

TOT

Vaginal Mesh

• YES it is safe in properly selected

patients

• The FDA warning is for PROLAPSE

REPAIR, not for slings

Injectibles

• Macroplastique (Uroplasty) and

Coaptite (Boston Scientific)

• Injected into the bladder neck with a

cystoscope

• Not as successful as slings,

work 40% of the time after 2

injections

Summary

• Incontinence is a common problem

• Incontinence can be treated with

minimal side effects

• If your urine leakage is bothering you,

please get it treated

Thank you

• Questions???