Normal bladder function requires a coordinated effort between the brain, spinal cord, and the bladder.

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1 .. Urinary Incontinence Urinary incontinence is not an inevitable part of aging, and it is not a disease. The loss of bladder control - called urinary incontinence - affects between 13 and 17 million adult Americans, with close to half of all women in the United States experiencing some degree of urinary incontinence. Approximately 11 percent of patients seeking treatment for urinary incontinence will undergo surgery. Many people endure urinary incontinence in silence, thinking they are the only ones who have a problem or that no urinary incontinence treatments exist. Incontinence is common, and it can be treated. There are a variety of urinary incontinence treatments. What causes urinary incontinence? Normal bladder function requires a coordinated effort between the brain, spinal cord, and the bladder. Urinary incontinence can appear as a side-effect of a medication prescribed for a non-urinary problem, or it can be caused by such conditions as a bladder infection. Pelvic muscle weakness after childbirth or thinning of the urethral lining after menopause cause urinary incontinence to be more common in women than men. In other situations, the bladder outlet simply may not stay closed. What are the different types of urinary incontinence? There are several types of urinary incontinence, each classified by its symptoms or by the circumstances that occur at the time of urine leakage. Stress incontinence - allows urine to leak during activities which strain or "stress" the abdomen. Stress incontinence is often caused by poor bladder support or a weak or damaged sphincter. Urge incontinence - results when an "overactive" bladder contracts unexpectedly. For example, an infection that irritates the lining of the bladder often causes it to become overactive. Overflow incontinence - occurs when the bladder weakens or a blocked urethra (the canal that carries urine from the bladder) prevents normal emptying. This type of incontinence most often develops in people with diabetes, in people who are heavy users of alcohol, or in people with certain neurological conditions. Problems with Retention - this occurs when urine is retained in the bladder and cannot be released. o You have difficulty initiating a void or only partially empty your bladder o You spend a long time in the bathroom and only produce a weak dribble or require a catheter to empty o You often lose small amounts of urine during the day (overflow incontinence) o You cannot feel when your bladder is full

2 ., Problems with Urgency-Frequency - occurs when an uncontrollable urge to urinate results in frequent, small amounts of urine voided as often as every 15 minutes. o You almost always have the feeling you need to use the bathroom (urgency) o You use the bathroom more often than the normal 4 to 7 times per day (frequency) o You have to get up several times during the night to use the bathroom o If you cannot make it to the bathroom in time, you may leak urine o You usually void very small amounts each time How is urinary incontinence evaluated? To determine the most effective urinary incontinence treatment for each patient's condition, specialists at the Women's Center for Pelvic Disorders at Cleveland Clinic offers individualized evaluations for urinary incontinence. The evaluation begins with a comprehensive history and physical examination, including a pelvic examination. To confirm the diagnosis, some of the diagnostic tests mentioned below also may be ordered: Urinalysis - A sample of your urine is examined for the presence of infection, blood or other abnormalities. Post-void residual urine measurement - This test determines whether any urine remains after you have tried to empty your bladder completely. A small, soft tube, called a catheter, may be inserted into the bladder to drain and measure remaining urine. Or, an ultrasound bladder scan may be performed. Cystoscopy -An examination of the inside of the bladder with a small viewing telescope called a cystoscope enables the physician to visually check for problems. Stress test - To find out whether stresses on the bladder cause leakage, you may be asked to cough, stand or do other activities while your bladder is full. Urodynamic testing - These tests examine bladder and urethral sphincter muscle function by inserting a small tube into the bladder or examining the bladder with X-rays. Through several such tests, it can be determined whether you have normal bladder sensation and capacity and whether your bladder fills and empties normally. Can urinary incontinence be treated? Incontinence can almost always be treated - and urinary incontinence treatment does not always mean surgery. Specialists at The Cleveland Clinic can recommend the urinary incontinence treatment that is best suited to your condition. Options include: Behavioral therapy By following an individually designed regimen of exercises and instruction, you may be able to improve your bladder control. Our physical therapists may prescribe exercises that aid in strengthening the pelvic muscles to help you regain and maintain continence and improve pelvic support. Education regarding reasonable fluid intake and advice for bladder retraining, such as

3 scheduling visits to the toilet, has helped many people with urinary incontinence. Behavioral therapy can be an effective urinary incontinence treatment. Urodynamic Testing Medication Drug therapy may be prescribed to relax the bladder. Your bladder control also can be adversely affected by certain medications that you may be taking for other conditions. In this case, our physicians will work with your primary care doctor to determine the best way to manage all of your conditions, including your urinary incontinence treatment. Collagen or other bulking agent implant This effective urinary incontinence treatment procedure, performed with a local anesthetic on an outpatient basis, helps many people avoid major surgery. Collagen injections into the lining of the urethra or the neck of the bladder act as a bulking agent by either bringing the walls of the urethra closer together or sealing off the base of the bladder. This allows the urethra to close tightly enough to prevent urine from leaking out. The result is similar to the way the body functions naturally, and in most cases, urinary control will be improved and restored. If a patient is allergic to collagen, other bulking agents are available.

4 Surgery Surgery is another urinary incontinence treatment option available to correct poor bladder support and help the urethra close properly. In women, surgery may be required to restore the support of the pelvic floor muscles or to reconstruct or compress the sphincter. Sling procedures: Sling procedures are outpatient surgeries indicated for treatment of stress urinary incontinence. The Urogynecology Team offers the full spectrum of mid urethral and bladder neck sling procedures with high cure rates. These include retropubic sling procedures (the TVT sling procedures and traditional fascial sling procedure), the transobturator tape procedures (Monarc sling, TVT-O procedure, and other transobturator sling procedures), and mini-sling procedures (TVT-Secur and Mini-Arc). Tension-Free Transvaginal Tape (TVT): When a woman has finished having children, a minimally invasive treatment can fix stress urinary incontinence (SUI), allowing her to return to a full and active life. TVT can stop urine leakage by supporting the urethra with a tape-like strip of mesh. Used in an approximately 30-minute outpatient procedure, it has shown proven results for the treatment of SUI. A mesh-like tape is inserted under the urethra to create a supportive sling. This provides support and allows the urethra to remain closed when appropriate, preventing urine loss during sudden movements or exercise. Patients may be able to go horne as early as a few hours after the procedure and patients can expect a short recovery period. The best way to determine if you are a candidate for this treatment is to ask your doctor. Transobturator Tape (TOT) Sling: First developed in Europe, the transobturator tape (TOT) sling procedure is meant to eliminate stress urinary incontinence by providing support under the urethra. The minimally-invasive procedure involves inserting a mesh tape under the urethra through three small incisions in the groin area. Studies have shown that the safer, more efficient tot sling procedure decreases the risks of bowel and bladder injury and major bleeding and has an excellent cure rate. Mini-Sling: The Mini Sling procedure is the latest and least invasive treatment for stress urinary incontinence. The five to IO-minute procedure utilizes the same concepts of the tension-free tape mid-urethral slings, but involves a single incision. This procedure has displayed a high cure rate and reduces the risk of bowel injury, bladder injury, and major bleeding because it bypasses retropubic needle passage altogether.

5 Tension-Free Vaginal Tape (TVT) Transobturator Sling

6 .. Sacral Nerve Stimulation (InterStim) This outpatient surgical procedure uses an external device to stimulate the muscles of the bladder and pelvic floor. The external device is tested for one to two weeks. If successful, the device is implanted beneath the skin. InterStim has been FDA-approved since 1997 for urge incontinence and since 1999 for urinary retention and significant symptoms of urgency-frequency. In 2011, InterStim was approved for the treatment of chronic fecal incontinence in patients who have failed or are not candidates for more conservative treatments. InterStim Therapy is not intended for patients with a urinary blockage. How It Works Sacral neuromodulation works with the sacral nerves, located near the tailbone. InterStim Therapy modulates the sacral nerves with mild electrical pulses. This helps the brain and the nerves to communicate so the bladder and related muscles can function properly. The treatment works similar for patients with fecal incontinence. The sacral nerves help control the muscles related to bowel function. If the brain and sacral nerves don't communicate correctly, bowels will not function properly. This can lead to symptoms of bowel incontinence. Medtronic Bowel Control Therapy targets these symptoms by modulating the sacral nerves with mild electrical pulses. InterStim Therapy is a reversible treatment that can be discontinued at any time by turning off or removing the device.

7 . Sacral neuromodulation may help you resume normal activities and help you avoid frustrating or embarrassing experiences associated with overactive bladder and fecal incontinence.

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