Incontinence
Urge Incontinence
Urge incontinence, or bladder instability, is an extremely common form of incontinence affecting both children and adults. In many children, it may be severe enough to bring about some bedwetting also. Some girls may also complain that their wetting is more prominent at the beginning of their period.
Patients will complain of having to void urgently and leaking because of inability to get to the bathroom on time. They may also complain of frequency and suprapubic pressure. Usually, the urine is sterile; but this condition will often predispose to recurrent urinary tract infections in girls.
Adults may develop the condition spontaneously, or it may occur after prostate surgery in men or bladder neck suspension in women. Various other problems may cause urge incontinence in either men or women. These include stroke, Parkinsonism, brain surgery, etc. Associated back pain, sciatica, headaches, thirst problems or bowel problems in conjunction with urinary incontinence also demand additional neurological evaluation, probably with the aid of MRI studies.
Treatment of this condition relies on pharmacologic agents suppressing the bladder muscle (detrusor) spasms and hyperreflexia.
Various medications are employed, but usually initial treatment centers on one of several anticholinergic medications to suppress uninhibited bladder contractions. Examples of the anticholinergics are Ditropan, Pro-Banthine, Robinul, Detrol, Levbid and Cystospaz.
An example of a tricyclic antidepressant that has a significant effect on uninhibited bladder contractions and also has an effect on bedwetting is Imipramine (Tofranil).
A musculotropic relaxant that depresses smooth muscle activity directly rather than affecting the cholinesterase mechanism is Urispas.
Some medications have a mixture of useful agents, such as Urised and Prosed.
If a behavioral or pharmacalogical approach isn’t effective in controlling urinary urge incontinence, or nonobstructive urinary retention, then a reversible treatment called The InterStim Therapy, where a neurostimulator, lead and extension are implanted to electrically stimulate the sacral nerve that controls the voiding function, may be considered. (See InterStim Therapy.) Adverse events that may occur include pain, lead migration, and infection.
Stress Urinary Incontinence
This is usually due to weakness in the pelvic floor and bladder support mechanisms and is often related to vaginal deliveries. Pelvic muscle exercises after delivery may help in lessening urine loss after exercise. They are called Kegel exercises and can be done lying down after the bladder is emptied. With the knees slightly bent, you can focus on drawing the muscles about the vagina together as if trying to stop the urinary flow. Try holding this contraction for at least 10 seconds and then relaxing for 15 seconds. A series of these contractions can be done on alternate days, and benefits can be seen after several months.
Treatment options for stress incontinence are numerous, from non-surgical such as Kegel exercises, biofeedback techniques, medications and vaginal pessary to surgical procedures that range from endoscopic to vaginal or suprapubic.
Endoscopic collagen or endoscopic Teflon injections into the urethra act as a bulking agent and may be useful to increase bladder outlet resistance in those with relatively minor stress incontinence problems.
The suprapubic approach is common as either the Marshall-Marchetti-Krantz (MMK) retropubic suspension procedure or as the Burch, in which the anterior vaginal wall is fixed to Cooper's ligament. Both these procedures are performed through a small "bikini" incision.
The vaginal approaches, however, have been modified and have become the most popular. Both Stamey and Raz have popularized variations of suprapubic needle passage into the vagina for bladder neck suspension.
Currently,the most popular procedures to treat stress urinary incontinence utilize some sort of sling to elevate the mid urethral area. The Monarc subfascial sling treats stress urinary incontinence by placing a narrow band of synthetic mesh just below the mid urethra for support. After making a small incision in the roof of the vagina and beneath the mid urethra, a special trans obturator needle is then used to make a pass from each groin to this vaginal incision on either side of the mid urethra. The trans obturator needles are then removed back through the groin puncture wounds so that the band of mesh sits under the mid urethra. This mesh provides a tension free hammock for support of the urethra and prevent stress incontinence. The vaginal incision is then closed over the mesh and the redundant mesh that has been withdrawn into the groin wounds is excised at skin level. The patient goes home without a catheter.[Please also see http://www.visitams.com/about_product_detail_objectname_female_monarc.html]. This is a very short outpatient procedure and does not require a catheter. Similar procedures have been developed using autologous or cadaver tissue; long-term results are not available yet.
Overflow Incontinence
This type of incontinence is leakage from a bladder that fails to empty properly and may be the result of severe bladder or urethral obstruction, a neurologic lesion or diabetes.
Congenital Incontinence
This form of leakage is found in children with congenital anomalies. Examples include ectopic ureters, either in a duplicate or single system, and epispadias/exstrophy.
Giggle Incontinence
This form of leakage occurs when the patient giggles or laughs. The reason for this type of incontinence is unknown but appears to respond nicely to Ritalin, 5 mg po tid.
Neurogenic Incontinence
The type of leakage varies, depending on the type of nerve lesion and the level of the nerve lesion. It is common in children with spina bifida and may worsen in those with a tethered cord.
Traumatic Incontinence
This can be seen after a fractured pelvis or after surgical damage to the bladder neck, prostate or sphincter. Erosion of an artificial sphincter previously placed to bring about continence may also result in incontinence once more.
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