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G. Willy Davila, MD, is the Chairman of the Department of Gynecology and head of the section of Urogynecology and Reconstructive Pelvic Surgery at Cleveland Clinic Florida, Weston, Florida. He is also the Director of the Fellowship training program in Urogynecology at the same institution. Dr. Davila is on the Editorial Board of the International Urogynecology Journal. His research interest has focused on conservative therapy of urinary incontinence. He has participated in multiple panels and multi-center studies evaluating physiotherapeutic approaches to urinary incontinence as well as multiple device trials. His work has resulted in many publications on the topic of conservative therapy for stress urinary incontinence.

Jennifer Pollak, MD received her medical degree from the University of Florida College of Medicine. She is a clinical fellow in the department of gynecology, section of urogynecology and reconstructive pelvic surgery at Cleveland Clinic Florida. She specializes in the surgical and nonsurgical treatment of bladder dysfunction, urinary incontinence, and pelvic organ prolapse.

Treatment Options for Stress Urinary Incontinence

In the course of prime time television viewing, we may watch multiple commercials for bladder control medications. We are also inundated with advertisements for disposable undergarments and protective underwear. That such a strong marketing campaign for these products exists highlights that fact that millions of people suffer from loss of bladder control, or urinary incontinence.

Urinary incontinence is a common quality of life problem seen in women. Most women experience urinary incontinence for several years before they come forward and speak to their physicians.  Some women consider it a part of aging but urinary incontinence is not considered normal at any age.

Not only is urinary incontinence a quality of life issue, it also may lead to a variety of health concerns.  Women may develop skin infections and irritations in the genital region from chronic urine contact.  There may be associated urinary tract infections.  Furthermore, women may limit their physical and social activities in order to avoid accidental urine loss in public.

As this problem is so pervasive, it is important that women know that there are multiple treatment options.  The first step, however, is to determine the type of incontinence present.  Your physician may begin the evaluation and recommend some simple therapies, or you may be referred to a urologist, gynecologist, or urogynecologist who specializes in the treatment of incontinence.

One of the most common types of urinary incontinence in women is stress incontinence.  Women with this type of incontinence have loss of urine that occurs with coughing, sneezing, laughing, exercising, and position changes.  In contrast, women with urge incontinence suffer from spontaneous urine loss with a strong urge feeling and the need to urinate frequently during the day or night.  This type of incontinence is caused by inappropriate bladder contractions.  Women can have both stress and urge incontinence and this is termed mixed incontinence.  Other women may have damage to the nerves that control bladder function so that the bladder does not empty properly.  This results in overflow incontinence.  These women are unable to sense bladder fullness and they may have abnormal urinary flow.

There are a variety of mechanisms that the body uses to maintain continence, and urinary incontinence may occur when these factors fail.  In normal conditions, the neck of the bladder and the urethra maintain a watertight seal.  This allows urine to fill and remain in the bladder.  Once we are in the bathroom and it is a socially appropriate time, the neck of the bladder and urethra open so that urine is released from the bladder.  If the bladder neck and urethra fail to maintain the watertight seal at times when voiding is not appropriate, urine may leak, and stress incontinence results.  Stressful activities like coughing and laughing may overcome the seal and cause leakage.

How do the bladder neck and urethra maintain a watertight seal?  The urethra contains muscles and elastic tissue filled with blood vessels.  The interaction between these components creates pressure within the urethra contributing to the seal.  The bladder neck is also positioned behind the pubic bone overlying strong elastic tissue.  In times of stressful physical activities, the bladder neck is held in place by the pelvic muscles to prevent leakage.  If the muscle or elastic tissue is weak or damaged, urinary continence is compromised as the bladder neck opens during physical activity.

There are several reasons why these physical components can become weak and damaged.  Increasing age is related to muscle weakening.  In women, menopause results in declining estrogen levels, causing thinning of the elastic tissue filled with blood vessels.  Vaginal childbirth can impact the supportive tissue, muscles, and change the position of the bladder neck.  Chronic cough from smoking and other lung diseases, long-standing constipation, obesity, and chronic heavy lifting can also result in damage to this area.  Previous pelvic surgery or radiation therapy for cancer may compromise the function of this area as well.  These factors may also cause prolapse, or dropping, of the pelvic organs through the vagina, which also contributes to urinary dysfunction and incontinence.

Before treatment can be initiated, a complete history must be taken including all the bladder symptoms.  You may be asked to record a diary of your bladder function as well as your fluid intake.  You may need to wear a pad so that the amount of urine loss can be measured.  Further evaluation might involve laboratory tests of the urine to identify a bladder infection.  Depending on the initial evaluation, you may need further testing including X-rays, ultrasound, or cystoscopy.  You may also need urodynamic studies that evaluate urinary function and voiding.  These tests will allow your physician to confirm the reason for the urinary incontinence.

There are several treatment options for stress urinary incontinence, both surgical and non-surgical.  One of the first modalities is modifying fluid intake and voiding habits.  For many women who drink an excessive amount of fluid, it may be appropriate to decrease intake during the day.  A timed voiding pattern for women who void infrequently may eliminate leakage that occurs mainly with a very full bladder.  Minimizing caffeine intake is also helpful, as caffeine increases urine production.

Another non-surgical treatment option involves pelvic floor exercises.  This includes Kegel exercises to reeducate and strengthen the pelvic floor muscles that aid in bladder and urethral function.  The correct muscles used with Kegel exercises may be difficult to find.  You can isolate them by placing two fingers in the vagina and then tightening the muscles around your fingers.  You may also find the correct muscle by stopping your urine flow while you are urinating; however, you should do this only initially in order to identify the correct muscle.  It is important when performing these exercises not to use the buttock, leg, or abdominal muscles.  Some women are unable to identify these muscles or adequately strengthen them on their own, and therefore require biofeedback training.  Biofeedback uses equipment that monitors the pelvic floor muscle contraction.  Women can use this equipment to learn to use the correct muscles and visualize the strength of their exercises.  A physiotherapist should be involved to help educate the patient about the strength of the pelvic floor muscles.  Electrical stimulation involves using a device that sends electrical impulses to the muscles and nerves of the pelvis to improve their function.  Weighted cones may be placed in the vagina, requiring the woman to contract her pelvic floor muscles to keep the cone in place.  Gradually, as the muscles are strengthened, the weight of the cones is increased.  This modality supplements Kegel exercises or biofeedback.

Medications may also be used to treat urinary incontinence.  One modality involves the use of estrogen suppositories placed in the vagina.  The tissue of the urethra is sensitive to estrogen, and after menopause, the tissue can become thin and lose some of its blood flow, resulting in poorer function.  With the use of estrogen, these changes can be reversed.  Even women taking oral or patch hormone replacement may benefit from additional estrogen in the vagina, which can be given in cream or tablet form.  Other available oral medications can increase the tone and function of the urethra and bladder neck.  This helps to keep the area closed so that urine may not leak out of the bladder so easily.  Such medications include imipramine and some cold and flu medications.  In addition, there are clinical trials in progress to study a new medication that also increases the tone of the urethra and bladder neck.

Pessaries may be worn in the vagina to treat stress incontinence.  These are devices that are typically used for prolapse, or dropping, of the pelvic organs, but they can also be used to support the neck of the bladder.  These devices must be fitted in a medical office and must be properly cared for.  Frequent removal and cleaning help prevent infection and sores, or ulcers, in the vagina.  Vaginal estrogen should be used in conjunction with pessaries to prevent these problems.  Pessaries may be cleaned and changed by a women herself, or she may need to visit her physician's office frequently to have this done.

Stress urinary incontinence may be treated with bulking injections into the tissue surrounding the urethra in order to close the bladder neck.  This is most commonly done with collagen.  This may be done as an outpatient office procedure under local anesthesia.  Since the collagen is not permanent, patients may require multiple injections.  There are several other permanent materials currently being researched for use in this way.

If non-surgical treatments have not been successful, stress urinary incontinence can be treated with surgery.  These surgeries are usually performed by a urologist, gynecologist, or a urogynecologist.  There are several different types of surgeries that can be performed, depending on the status of the patient.  These surgeries may be done through an abdominal or vaginal incision.  Two of the most common abdominal surgeries for stress incontinence are the Burch Colposuspension and the Marshall-Marchetti-Krantz Procedure, or MMK.  These surgeries lift and stabilize the front wall of the vagina and the layer of tissue that supports the bladder neck and urethra.  Most studies on these surgeries report a cure rate in the range around 85%. 

Suburethral sling procedures use a strip of material to support the bladder neck like a hammock and create a backboard to support the urethra during stressful physical activities.  The strip of material used in these operations may be synthetic, or man-made, and permanent, or strong tissue from other areas of the patient's own body.  Many variations of sling procedures exist.  Simplifications of sling techniques have led to the development of minimally invasive procedures such as the Tension-Free Vaginal Tape (TVT) procedure.  Cure rates of suburethral slings range from 70-95%. 

Stress urinary incontinence is extremely common in women.  Treatment of incontinence begins with a thorough evaluation of the problem.  Once the cause is discovered, therapy can be initiated.  Fortunately, there are many successful treatment options that include medication, pelvic floor muscle exercises, and surgery.

Click here for more information about stress urinary incontinence.

Created: 9/25/2002  -  Jennifer Pollak, MD and G. Willy Davila,

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