URINARY INCONTINENCE

Overview

An estimated 51 million women (17 million of them in the U.S. alone) cope with urinary incontinence. Some are unable to prevent leaking urine when they cough, sneeze or exercise. Others experience a strong urge to urinate but are unable to make it to the bathroom in time.

Urinary incontinence is the medical term used to describe the condition of not being able to control the flow of urine from your body. Incontinence usually occurs because the urethra cannot close tightly enough to hold urine in the bladder.

You may be surprised to learn how prevalent this rarely talked about condition actually is. Consider these statistics:

Between the ages of 18 and 44, approximately 24% of women experience incontinence.¹
For women over age 60, approximately 23% deal with incontinence, and the problem is more common in women than men.²

Fully half of nursing home residents have urinary incontinence.³

1. Palmer MH, Fitzgerald S, Berry SJ, Hart. Urinary incontinence in working women: an exploratory study. Women Health. 1999 v. 29(3)p. 67-82.
2. Hampel C, Wienhold D, Benken N, Eggersmann C, Thuroff JW. Definition of overactive bladder and epidemiology of urinary incontinence. Urology 1997 v. 50 (suppl. 6A) p. 4-14.
3. Overview: Urinary Incontinence in Adults, Clinical Practice Guideline Update. Agency for Health Care Policy and Research, Rockville, MD. March 1996. http://www.ahrq.gov/clinic/uiovervw.htm

Physiology

To learn more about urinary incontinence, it is important to understand how the bladder works normally.

In women, the sphincter muscle is located below the bladder, surrounding the urethra. When the sphincter muscle tightens, it holds urine in the bladder. When it relaxes, the bladder contracts and the urethra opens, allowing urine to flow outside the body.

The bladder and urethra must be well supported by the pelvic muscles and tissue to allow them to work properly.

Causes of urinary incontinence

Urinary incontinence usually is caused by weakened or damaged pelvic muscles and tissue that prevent the urethra from closing tight enough to hold urine in the bladder.

To determine the type and cause of urinary incontinence, doctors take a complete medical history and conduct a thorough physical examination. Specialists such as gynecologists, Urologists and urogynecologists may use a variety of testing methods to determine the cause and type of urinary incontinence.

Urinary incontinence in women can be caused by any single condition or a combination of conditions. To effectively diagnose and treat urinary incontinence, a doctor must determine the cause.

Pregnancy and Vaginal Childbirth: Weakened or damaged pelvic muscles and tissue can be the result of pregnancy and childbirth, causing the bladder and urethra to relax from their normal positions. The bladder and urethra must be well supported by the pelvic muscles and tissue to allow them to work properly.

Aging and Genetic Factors: Aging tends to worsen all forms of muscular injury. Changes in pelvic muscles can contribute to urinary incontinence.

Medical Conditions: Certain medical and neurological conditions, such as hysterectomies, spinal cord problems (e.g., spina bifida, spinal cord injury, malformation of the lower spine), multiple sclerosis, Parkinson's disease, stroke and diabetes can make incontinence worse.
Infections and medications—Urinary tract infections can cause temporary incontinence, and certain medications may increase the likelihood of temporary incontinence.

Obesity: While obesity does not cause incontinence, it does contribute to the condition due to the increased abdominal pressure. 

Smoking: While not a direct cause of incontinence, smoking may aggravate urinary incontinence.

Types of urinary incontinence

There are five basic types of urinary incontinence: stress urinary incontinence, urge incontinence, mixed incontinence, overflow incontinence, and functional incontinence. In many cases, individuals experience symptoms of more than one type of incontinence. Proper diagnosis of the type of urinary incontinence is an important factor in successful treatment.

Stress Incontinence: Occurs when you leak urine during a physical activity like lifting, exercising, sneezing and coughing. Stress urinary incontinence is typically a result of both hypermobility and intrinsic sphincter deficiency. Hypermobility is a result of significant shifting of the urethra and bladder neck from their normal positions and results in urine leakage during activities such as lifting, sneezing, coughing or exercising. Intrinsic Sphincter Deficiency (ISD) occurs when the urethral sphincter is unable to close tightly enough to hold urine in the bladder during exertion and typically results in continuous leakage.

Urge Incontinence: Is described as overactivity of the detrusor muscle surrounding the bladder. This overactivity causes your bladder to contract frequently and creates an overwhelming need to urinate—even if you just went. This condition often is called "overactive bladder" or "unstable bladder" and makes it difficult for you to hold your urine long enough to reach a toilet.

Mixed Incontinence: A combination of stress incontinence and urge incontinence, where you have symptoms of both conditions.

Overflow Incontinence: When your bladder never completely empties, causing
urine to leak.

Functional Incontinence: Factors outside the lower urinary tract, such as weaknesses in physical and/or cognitive function, cause this form of urinary incontinence.

Signs of incontinence

There are a number of signs of incontinence, depending on the type. You may be experiencing involuntary loss of urine during physical activity; a compelling need to urinate with inability to stop leakage long enough to reach a toilet; or continued leakage because the bladder is full beyond capacity. Ask yourself the following questions:

- Do you leak urine unexpectedly?

- Is the urine leakage:
      Mild (a few drops)
      Moderate (wet underwear)
      Severe (wet outerwear)

- Does the urine loss occur during coughing, sneezing, laughing, bending or lifting?

- Does the urine loss occur when you change from a sitting or lying position to a
standing position?

- Do you leak urine continuously?

- Is urine loss a problem to you?

- Has this urine loss caused you to change your lifestyle?

- If you have changed your lifestyle, how?
      I limit the fluids I drink
      I stay at home
      I limit my choice of clothing to dark colors

If you answered "Yes" to any of these questions, or if your answers are of concern to you, you are not alone. Over 51 million women worldwide experience urinary incontinence.

These incontinence questions were designed to show the different symptoms that indicate the various types of incontinence. Talk with a doctor to discuss your responses from this self-test.

Effects

Incontinence is a seldom-talked-about condition that can change lives dramatically. It affects millions of women, often limiting their lifestyles, activities and relationships because they fear embarrassment of odor and wetness. For you, that might mean missing out on golf, running, swimming, dancing, playing with the grandkids...or any number of other activities you used to enjoy. Typically, symptoms worsen over time. Incontinence can keep you:

- In costly adult diapers
- In constant search of public restrooms
- Homebound and constrained
- Embarrassed and depressed
- Isolated from friends and family
- Frustrated in your relationship with your partner

But it doesn't have to be that way. Treatment options are available.

Treatment

For some patients, behavioral therapy, which includes maintaining a strict schedule of avoiding and monitoring fluid intake, can reduce the occurrence of incontinence. Many patients use absorbent products such as pads, liners, undergarments and adult diapers to manage their problem.

For people who want to restore continence rather than simply manage it, there are treatment options that vary in invasiveness and effectiveness, depending on the cause and the severity of the incontinence.

Depending on the severity of your incontinence, you and your doctor can work together to find the best way to cope with your urinary incontinence.

It is important that you understand all the treatment options available to you, and that you share your thoughts and any concerns with your doctor.

Behavior Therapies: For those who suffer from stress urinary incontinence, behavior therapy can be a treatment option. Techniques can teach you to control your bladder and sphincter muscles by:
      - Decreasing fluid intake
      - Prompting or scheduling voiding
      (used in women who can recognize some degree of bladder fullness)

Pelvic muscle exercises: These exercises are commonly called Kegel exercises and are used to strengthen the weak muscles surrounding the bladder.

Protective Undergarments: Products such as pads, undergarment liners and absorbent underwear are worn to absorb urine that has leaked from the bladder.

Catheter: Some women require an indwelling catheter, which is left in place 24 hours a day to continually collect urine in an external drainage bag.

External Devices: Some women with urinary incontinence use a pessary device, a stiff ring that is inserted into the vagina where it presses against the wall of the vagina and the urethra. The pressure helps reposition the urethra, preventing leakage.

Bulking Injections: A bulk-producing agent, such as collagen, is injected to bulk up the urethral lining so the urethra can close more tightly.

Medication: A number of medications can help bladder control problems due to urge incontinence. However, there are presently no medicines currently available to treat stress incontinence. If your doctor determines you have mixed (stress and urge) incontinence, you may find drug therapy helpful in addressing the urge component of your incontinence.

Surgery: There are surgical options to treat urinary incontinence. These include:
Retropubic Suspensions—These surgical options treat hypermobility and often are referred to as the Burch procedure. They elevate and restore the urethra and bladder neck to a higher anatomical position. 

Slings: A sling procedure is used to treat both hypermobility and ISD. The sling serves as support for the urethra during increased abdominal pressure.

Bone fixated slings treat incontinence by supporting the urethra with a graft material that is secured to the pubic bone, such as the AMS In-Fast Ultra.

Self-fixating slings treat incontinence by supporting the urethra. The sling is secured in place by friction and natural tissue in growth, rather than by sutures or screws. The AMS SPARC™, AMS Monarc™, AMS BioArc™ SP and AMS BioArc™ TO all are examples of self-fixating slings.

SPARC™ Sling System

The SPARC™ Sling System treats female stress urinary incontinence by placing a narrow strip of material—called a "sling"—in your body to support the urethra. The SPARC system uses a suprapubic approach in which narrow sling carriers are passed from above the pubic bone to the vagina. The sling mesh then is attached to the carriers and pulled into place.

A self-fixating polypropylene sling cradles your urethra and gives it support during normal daily activities.

Most patients are continent immediately following the procedure and can resume normal, non-strenuous activities within a few days.

Benefits

The SPARC™ provides many benefits:

It is an outpatient treatment suitable for a wide variety of patients and can be performed using a minimally invasive approach.
The sling can be loosened or tightened during and immediately after the procedure.
Incisions in the abdomen and vagina are small.
Patients generally recover quickly and experience immediate continence.

Monarc™ Subfascial Hammock

The Monarc™ Subfascial Hammock treats female stress urinary incontinence by placing a narrow strip of mesh in your body to support the urethra. The monarc™ uses what is called a transobturator approach to place the supportive mesh. The transobturator approach avoids the retropubic space, the area of loose connective tissue between the bladder, pubic bone and abdominal wall. With this approach, narrow mesh carriers are passed through an area near the groin at the obturator of the pubic bone. The mesh is then attached and pulled into place under the urethra.

Once placed, the hammock cradles your urethra and gives it a point of support.

Most patients are continent immediately following the procedure and can resume normal, non-strenuous activities within a few days.

Benefits

The monarc™ offers several benefits:

- Patients generally recover quickly and experience immediate continence.

- It is minimally invasive and suitable for a wide variety of patients.

- Incisions in the groin area are small.

- Can be used in patients who have retropubic scarring resulting from prior pelvic surgery.

- The hammock can be loosened or tightened during and immediately after the procedure.

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