Variety of Treatment Options for Incontinence

Incontinence, which refers to a loss of bladder or bowel control, is not a disease in itself. Rather, it is a symptom of a medical condition or disorder that could include spinal cord injury, pregnancy, neurological disease, infection and the degenerative changes associated with aging.

Incontinence affects 25 million Americans and can strike people of all ages-from children to the elderly to fit adults. Women are more at risk--21 million suffer from incontinence, compared with 4 million men. In some situations, the cause may be pregnancy or the decreased production of estrogen after menopause. But experts say the condition can be treated successfully--a variety of medications, behavioral modifications and surgical options are now available.

To learn more, Health spoke to Dr. Jenelle Foote, a urologist who serves on the board of the National Assn. for Continence. Foote practices at Midtown Urology in Atlanta and is a clinical assistant professor of urology at Emory University School of Medicine and Morehouse School of Medicine, both in Atlanta.

Question: Let’s discuss the different types of incontinence and what options exist for sufferers.

Answer: There are four basic types. And it’s very important that patients, their families and doctors understand what type of incontinence a person has, because the treatments are very different. The first is called urge incontinence, that’s probably the most common. In those circumstances, a person feels the urge to urinate and can’t keep it from happening.

There are three categories of treatment for urge incontinence: behavioral modification, medical and surgical treatment. One type of behavioral modification is called “timed voiding.” In “timed voiding,” one goes to the toilet, say, every two hours. The idea is to get to the toilet and empty one’s bladder before one has an “accident.” Many foods and drinks are associated with urinary urgency. These include caffeinated and carbonated drinks, citrus drinks, alcohol and chocolate. Kegel exercises can also help prevent urge incontinence. Kegel exercises are voluntary contractions of the pelvic floor muscles that one tightens when one stops one’s urinary stream or tries not to pass gas. These are also the muscles a woman uses to tighten her vagina. Additionally, these are the muscles that both men and women contract during an orgasm.

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Q: Could you describe the medical management for urge incontinence?

A: With urge incontinence, the bladder muscle contracts and pushes out the urine without the person’s ability to prevent the leakage. Today there are several drugs to prevent the contractions. Some have been around a long time. Two have been released in the past two years. You may have seen some of the ads on TV. Pharmaceutical companies are realizing that there is a huge population out there that could benefit from these drugs. People should ask their doctor what is the best drug for them. The main side effect of this class of medications is a dry mouth.

A new device that can be surgically implanted for urge incontinence is called the “Interstim.” The technique was originally developed at UC San Francisco. The company that perfected the device also makes pacemakers. The device is implanted and affects the nerve that controls bladder function. This is “bionic” technology and very exciting.

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Q: What is the second type of incontinence?

A: Incontinence when a person coughs, strains or bends over is known as stress incontinence. This type of incontinence is more common in women, especially if they’re pregnant or have had vaginal deliveries.

During and after pregnancy, the muscles and ligaments that support the pelvic organs are more relaxed. This relaxation can make it easy for these women to leak with coughing.

Another cause can be that the urinary sphincter, the muscle that holds in the urine, has been damaged because of surgery or a neuromuscular condition such as a spinal cord injury. Some medications used for high blood pressure also have the side effect of relaxing the sphincter and can create stress incontinence.

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Q: Why don’t all pregnant women develop stress incontinence?

A: We don’t know. Many women who have had stress incontinence with pregnancy get better, but not all. It may have something to do with exercise, with the intrinsic strength of the connective tissue in the pelvic floor. Sometimes bladder control problems can run in families.

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Q: What options are available for someone with stress incontinence?

A: A common, nonoperative treatment is the use of Kegel exercises. As for surgery, the most common type is called sling surgery. This involves putting a piece of tissue or synthetic material to support the bladder neck via a vaginal approach.

There is also an abdominal approach called a retropubic suspension in which a surgeon will put in stitches to hold up the bladder via the abdomen. Bladder neck suspension is a general term used to describe this class of operation.

According to a recent study co-authored by Dr. Gary Leach, at Cedars-Sinai Medical Center in Los Angeles, the most successful operations are the sling operations and the retropubic suspensions. After five to 10 years, these surgeries had a success rate of 85% to 90%. The other operations had lower success rates. There is, therefore, a difference in regard to success rates and surgeries.

Those considering such surgery should research the physicians they’re considering. Medicare generally pays for these operations.

Another treatment for stress incontinence used primarily in men is the implantation of a silicone device called an artificial urinary sphincter. It’s implanted under the skin of the scrotum and allows a man to open and close the artificial sphincter to give him bladder control. With women, it’s implanted in the labia.

Another operation for stress incontinence involves injecting collagen around the urethra. It plumps up the urethra to increase the resistance to urine flow in the urethra. The success rates are not as good as for the sling or the artificial urinary sphincter, but for people who want a simpler type of operation, it offers another option.

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Q: What about the third type of incontinence?

A: That is overflow incontinence, which is characterized by a bladder that can’t empty. Ironically, what leaks out is the urine that exceeds the capacity of the bladder.

An example would be a man who has a very enlarged prostate that is blocking off the urine flow, making it impossible for him to empty the bladder and fix the problem.

Think about a glass you fill up to the rim. If you add extra water, it can’t be held by glass and it overflows. People who are diabetic sometimes can’t empty their bladders and can suffer from overflow incontinence. With overflow incontinence, we have to find out why the person isn’t able to empty the bladder. The treatment might be medications or surgery.

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Q: Which brings us to the fourth type.

A: That’s what we call functional incontinence. In that condition, the problem is with the act of toileting itself. It can relate to physical, mental or emotional problems.

For example, someone with really bad arthritis could have difficulty getting undressed in time. A person with Alzheimer’s disease might not urinate in the toilet because of confusion. The treatment for functional incontinence usually involves coming up with some common sense ways to enable that person to toilet effectively.

For instance, taking that person to the toilet and helping them void every two hours. Or modifying their clothing. Or placing a commode or urinal near their bed at night.

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Q: What about bedwetting, which is most common in children but also affects adults?

A: The technical term for that is enuresis. And you’re right, this can affect people of all ages. There are two safe and effective medical treatments. The medicines are taken at bedtime. One is called imiprimine and the other is desmopressin. Side effects are rare.

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Q: What is the connection between prostate trouble and incontinence?

A: Prostate problems can lead to incontinence. Frequency and urgency in urination are sometimes the first symptoms a man has that he’s got an enlarged prostate, the gland that sits in between the sphincter and the bladder. If that happens, he should have his prostate evaluated.

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For more information, contact the National Assn. for Continence at (800) BLADDER or https://www.NAFC.org.