OakLeaf Medical Network Healthy Viewpoints, Winter 2003
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Dr. James S. Iwakiri

Urethral hypermobility. the arrow indicates direction of pressure from an activity such as coughing, causing the bladder neck and urethra to open briefly

Sling in place, secured to the pubic bone

Urinary Incontinence in Women

By James S. Iwakiri, MD, FACS, DPM, FACFAS
Western Wisconsin Urology, Eau Claire

It is estimated that urinary incontinence (involuntary loss of urine) in women accounts for more than 1.1 million office visits and $450 million annually in healthcare expenditures. Many of these expenditures are for absorbent products which are not covered by insurance and must be paid for by the patient.

There are three main reasons for female urinary incontinence. A given patient may have one or a combination of all three reasons causing their incontinence.

The first reason is an overactive bladder. The bladder itself is an empty muscular sphere which slowly fills with urine. Typically, a bladder will hold approximately 15 ounces of urine at low pressures. However, in many women with urinary incontinence, the bladder will have a much smaller capacity and will have involuntary muscle contractions which result in urinary incontinence. Standard therapy for this type of incontinence includes medication to calm the bladder down, restriction of fluids, and minimization of caffeine and alcohol intake, which are bladder irritants and diuretics. A bladder retraining program, which may involve biofeedback therapy or electrical stimulation, may also be recommended.

There are a large number of medications for overactive bladder on the market including Detrol LA, Ditropan XL, Oxytrol patches, Sanctura, Enablex and Vesicare. Potential side effects of these medications include dry mouth, constipation, blurry vision and on infrequent occasions, changes in mental status.

A second reason is anatomic stress urinary incontinence, which occurs because of weakening of the pelvic support of the bladder due to childbirth, aging and prior gynecologic surgery such as a hysterectomy. Even women with none of the aforementioned risk factors can develop anatomic stress urinary incontinence. When pelvic support of the bladder is weakened, physically stressful maneuvers such as coughing, sneezing, laughing or lifting can result in descent of the bladder neck into the pelvis and a leakage of urine. Treatments for stress urinary incontinence can include reduction of fluid intake, scheduled urination to minimize bladder fullness and pelvic floor exercises (Kegel exercises) to strengthen the pelvic floor muscles. If these measures are not beneficial, consideration can be given to surgery. Currently, the standard surgical therapy for stress urinary incontinence consists of an operation known as a pubovaginal sling procedure. In this surgery either a synthetic or non-synthetic material is wrapped around the neck of the bladder like a hammock and then anchored to the patient’s pubic bone or abdominal wall muscles to hold the bladder in place during times of physical stress. This surgery typically has an 85 percent success rate, with relatively few complications and can be performed on an outpatient basis. There are a wide variety of different sling techniques available which appear to have fairly equivalent rates of success.

A new medication, Duloxetine, should soon be available. This will be the first drug ever approved specifically for stress urinary incontinence.

A third reason that women can develop urinary incontinence is known as intrinsic urinary sphincter deficiency or Type III stress urinary incontinence. This refers to the urethra itself not being completely closed so that urine drips out of the bladder. Typically the urethra (the urine channel through which the bladder empties) is a closed tube that opens only during urination. However, in some women the urethra is not completely closed, allowing urine to leak with physical stress, especially with standing up. This type of incontinence typically does not respond to conservative therapy and is treated either with a pubovaginal sling procedure or with a minimally invasive procedure known as a collagen injection. A collagen injection is an outpatient procedure where a telescope is placed into the urethra and a small amount of liquid collagen is injected in the urethra to tighten up the sphincter. This procedure has an 80 percent success rate in improving or curing Type III stress incontinence, but the effects of a collagen injection often wear off after 12 to 18 months necessitating a repeat injection. A pubovaginal sling procedure typically results in more long-lasting relief of Type III stress incontinence, but is more invasive than a collagen injection.

There are several reasons for urinary incontinence in women and many available treatments. The important thing for women to realize is that they do not need to allow urinary incontinence to affect their quality of life, because many well tolerated and effective surgical and non-surgical therapies are available.

For more information, or to schedule an appointment with Dr. Iwakiri » 715.835.6548 Western Wisconsin Urology or visit www.eauclaireurology.com