Urinary Incontinence (Involuntary Loss of Urine) A Patient Guide

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1 Urinary Incontinence (Involuntary Loss of Urine) A Patient Guide Urinary Incontinence (Urine Loss) This booklet is intended to give you some facts on urinary incontinence - what it is, and is not, and why it occurs. A. Urinary Incontinence The involuntary loss of urine in small or large amounts at the wrong time and/or place % of women over 30 years of age suffer from urinary incontinence. It is not a disease but is a symptom of some other problem with the body. It is not caused by being female. It is not caused by aging (but changes with age may add to the problem). There are two types of urinary incontinence which make up most of the cases in women: stress incontinence urge incontinence All women with incontinence can be helped - some women will be cured and others will at least have their quality of life improved. B. Possible Causes for Urinary Incontinence Weakening of the pelvic floor muscles (a "hammock" of muscles that support the pelvic organs, such as the bladder and womb or uterus, and influence urine control). A chronic illness such as Multiple Sclerosis, diabetes, asthma, or Parkinson's Disease. A blockage in the urinary system. A side effect of medication or surgery. C. The Urinary System - how does my bladder work? Urine forms in the kidneys and flows down narrow tubes (ureters) to the bladder where it is stored. The bladder expands as it fills, and tightens (contracts) to empty (like a balloon). Urine is carried from the bladder to the outside of the body by a tube called the urethra. Page 1

2 A sphincter muscle at the neck of the bladder closes the bladder to store urine. The sphincter muscle relaxes and the bladder contracts when you urinate. The urinary system is controlled automatically by the nerves in the spinal cord. The brain overrides these nerves telling the body when to empty the bladder and when to hold urine. D. Types of Urinary Incontinence -Symptoms & Causes Stress Incontinence: Symptoms: The involuntary loss of small amounts of urine in response to increased pressure on the bladder (for example, when a person coughs, sneezes, laughs, or lifts heavy objects). Causes: Stress Incontinence results from weakened pelvic support of the urethra and/or weakness of the sphincter muscle of the urethra. It may be due to the effects of childbirth or menopause on the pelvic structures. Urge Incontinence: Symptoms: A loss of urine that is associated with a strong desire to urinate and an inability to delay long enough to get to a toilet. It usually involves a large amount of urine loss at one time (soaked clothing, running down legs). It may include urine loss on the way to the bathroom or the "key in the lock" / "hand on the doorknob" syndrome (no urge to urinate until the key is in the doorlock or the hand is on the knob and then it is impossible to wait). Causes: A condition called "an unstable bladder" often causes urge incontinence. It may be caused by irritation to the bladder (for example, a urinary tract infection) or because of abnormalities in the nerve control of the bladder. However, in 85% of cases no abnormality is found. Page 2

3 E. Tests to Investigate Urinary Incontinence: What Are They? Why are They Done? Urinalysis & Urine Culture: A sample of urine is sent to the lab to be tested for a urinary tract infection. A urinary tract infection can cause both types of incontinence. Treatment of the infection may clear up the incontinence. Urolog: This is a diary of bladder function for one 24-hour period (one day) - see the page opposite. It measures your liquid intake, urine leakage, and the frequency and amounts of urine output. The information from the Urolog helps us to identify changes in your lifestyle that may help your urinary incontinence problem. Pelvic Examination: This exam assesses the strength of the pelvic floor muscles and the position of the pelvic organs (bladder, uterus). We can teach you how to do the Kegel's (pelvic muscle) exercises and we can decide if a pessary (a vaginal insert to support the pelvic organs) would help your incontinence problem. Post-Void Residual: This test measures how effectively the bladder empties during urination (voiding). After urination, a catheter (thin tube) is inserted into the opening of the urethra and the amount of urine remaining in the bladder is measured. Pad Test: This test will show if there is urine leakage with activity and if so, how much leakage. The bladder is filled with sterile water through a catheter (a thin tube) and the patient is asked to perform some simple activities (such as walking and coughing). A pad is worn to absorb any urine that may leak and the pad is weighed to see how much urine leaked. Q-tip Test: A small Q-tip is placed in the urethra at the bladder neck. This test shows whether there is a loss of support to the urethra. Page 3

4 This helps determine the best treatment for your incontinence problem. 7. Urodynamics: Urodynamics is a more advanced evaluation of bladder function and pelvic floor strength. It uses small catheters (thin tubes) with electronic sensors placed in the bladder and the vagina. A computer program identifies the type of incontinence. It also evaluates the extent of weakness in the urethra that is contributing to your urine problem. F. Conservative Management Options for Stress Incontinence. Education & Lifestyle Modification: Education about the pelvic floor muscles and how to strengthen them. Dietary guidelines to help with proper bladder and bowel function. Voiding (urinating) guidelines to reduce urine loss. Pelvic Physiotherapy: Therapy designed to strengthen the pelvic floor muscles and prevent or reduce urine loss. Kegel's Exercises: Pelvic muscle exercises to assist in bladder and bowel control. They help the pelvic floor muscles become firmer, thicker, broader and stronger which increases bladder support. They strengthen the muscle that closes the urethra. Biofeedback: A vaginal probe and a computer are used to help you find and control your pelvic muscles. It helps in proper Kegel's exercise technique. A teaching tool only. Electrical Stimulation: Used with biofeedback to help pinpoint the location of the pelvic floor muscles and teach proper Kegel's exercise technique. Using a vaginal electrode, a mild electrical current is applied to the muscle fibres in the pelvic floor which causes an involuntary tightening of the muscles. Page 4

5 Vaginal Cones: A set of vaginal weights that can be inserted into the vagina. They are used with Kegel's exercises to increase the strength of the pelvic floor muscles. Advanced Physiotherapy: More advanced pelvic muscle exercises done with a physiotherapist. 3. Mechanical Support: Mechanical devices used to prevent or reduce urine loss. Pessary: A device inserted into the vagina to support sagging pelvic organs and reduce urine leakage. Pessaries come in various shapes and sizes. Other Devices: Various other mechanical devices are available which may be useful in the reduction of urine loss (such as an external urethral barrier, the Conti ring). 4. Medical Therapy: A variety of medications may be useful in preventing or reducing urine loss due to HRT: Estrogen in various forms such as a pill, a skin patch, gel, a vaginal cream, vaginal ring supplements the body's natural supply of the hormone. It improves function of the muscles of the urethra. It thickens the lining of the urethra and vagina. It increases blood flow to the urethra. It may improve pelvic nerve response. Other Medications: Alpha Agonists ("-adrenergic agonists) (such as"entrex LA", "Sudafed" ) help contract the sphincter muscles. They increase the tone and function of the urethral smooth muscle and reduce urine loss. Page 5

6 G. Conservative Management Options for Urge Incontinence Education & Lifestyle Modification: Education about your bladder habits. Dietary guidelines for type and amount of liquid consumed. Voiding (urinating) guidelines to reduce urine loss. Bladder Drill (Training): Bladder training involves learning about your bladder's limits and developing the habit of regular trips to the bathroom to avoid "accidents". This drill helps you to reestablish normal bladder control and reduce the symptoms of frequency and urgency of urination. This drill reeducates your bladder to hold more urine by gradually increasing the length of time between voids (urination). The time between voids is gradually increased to approach a normal interval of about four hours. Scheduled (Timed) Voiding (Urination): Voiding times are picked (about 2 hours apart) and do not change. Voiding "triggers" (such as running water) can be used to encourage urination. Prompted (Directed) Voiding (Urination): Voiding times may vary. A time interval for urination (perhaps hourly) that can be managed without accidents is established. Medical Therapy - Discuss your medications with your health care professional Functional Electrical Stimulation: This treatment is used with biofeedback. A probe with a mild electrical current stimulates the pelvic floor muscles. This treatment is done with the urogynaecology nurses. Medical Therapy: A variety of medications may be useful in preventing or reducing urine loss due to urge incontinence. Page 6

7 Anti-cholinergic Medications: These medications discourage tightening of the bladder muscles before the bladder is full. They reduce the feeling of urgency. Examples:"Pro-Banthine" (Propantheline Bromide) and "Detrol" (Tolterodine). Smooth Muscle Relaxants: These medications cause the smooth muscle in the bladder to relax. They discourage the bladder muscles from tightening before the bladder is full. They reduce the feeling of urgency. Example: "Urispas" (Flavoxate). Combined Anti-cholinergics & Smooth Muscle Relaxants: These medications relax smooth muscle and reduce excessive bladder tightening. They reduce the feeling of urgency. Example: "Ditropan" (Oxybutynin Chloride). H. Surgical Treatment Options for Incontinence Patients who do not experience a marked improvement in their incontinence problem after conservative management of their urinary problems may be considered for surgical treatment. There are various surgical techniques available. The choice of surgery is dependent upon the cause of your urine loss. 3. Anterior Repair and Needle Suspension Surgeries: These surgical procedures are sometimes used to treat stress incontinence but they have not been found to work well or last for a long time. Burch Procedure: This procedure is the best procedure for stress incontinence. The space behind the pubic bone is entered through a horizontal incision in the lower abdomen and sutures are placed on both sides of the urethra and are attached to a strong ligament in the pelvis. Tension-Free Vaginal Tape (TVT) Procedure: This procedure is used for stress incontinence. Page 7

8 It is a new procedure that is done under local anaesthetic (you don't have to go to sleep for the surgery). Most patients go home the same day as the surgery and can return to normal activities sooner than with other surgeries. 4. Sling Procedure: This procedure for stress incontinence is done through the vagina with two small incisions above the pubic bone. It is usually used for patients who have had previous surgery which is no longer working, or in special circumstances where the muscles of the patient's urethra are not strong. Page 8

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