Urinary incontinence, or the involuntary leakage of urine is one of the most common problems treated in female urology. It is important for the clinician to realize that there are several different types of urinary incontinence, each with a different cause and potential treatment options. These include stress incontinence, urge incontinence, overflow incontinence, mixed incontinence (simultaneous stress and urge incontinence), total incontinence and functional incontinence.
Improper diagnosis of the type of urinary incontinence is probably the most common reason for treatment failure. A detailed history and physical examination is of paramount importance in the proper diagnosis and sub typing of urinary incontinence. In select cases, urodynamic testing or cystoscopy may be useful. A neurologic history and physical examination should be obtained in order to rule out neurogenic bladder.
Patients with “pure” stress urinary incontinence report activity-related urinary leakage which interferes with their quality of life. Any increase in abdominal pressure such as coughing, sneezing, laughing, exercising, jumping, running, or event sexual activity may precipitate urinary leakage. Stress incontinence may or may not co-exist with pelvic organ prolapse. In most cases urethral hypermobility is noted with rotational descent of the urethra upon straining. The need for treatment is largely dictated by the degree that it affects the quality of life of the patient . Pad usage and pad weight are sometimes used to gauge disease severity.
The current most popular surgical treatment to treat stress urinary incontinence is the sub-urethral sling. Transurethral bulking agent is another less successful and shorter duration treatment option. The suburethral sling can be performed using a synthetic mesh (mono-filament macroporous Type I mesh) or biologic allograft, autologous rectus fascia. Abdominal procedures such as Burch urethropexy are effective but remain more invasive than the transvaginal sling procedures. Currently, there is no approved medication for stress urinary incontinence. There is no evidence that estrogen therapy is effective in the management of stress urinary incontinence.
Patients with urge urinary incontinence report involuntary urinary leakage with bladder spasm and strong urges to void. Urge incontinence is one of the symptoms associated with overactive bladder. Overactive bladder is not necessarily related to aging or prior surgery. Most cases of overactive bladder and urge incontinence are idiopathic. Urge urinary incontinence is often associated with urinary urgency and frequency. However, a neurologic cause should always be ruled out especially in younger patients. The treatment algorithm of urge is very different from that of stress incontinence.
Behavioral therapy, fluid management, timed voiding, avoiding bladder irritants, pelvic floor exercises, Kegel exercises are useful in many cases. In more severe cases, anticholinergic medications can be used. Anticholinergics are plagued with adverse side effects such as dry mouth, constipation, cognitive side effects, and potential for urinary retention. The newest anticholinergic drugs have a better safety profile but yet remain far from being free from side effects. The newly developed beta-adrenergic agonists are promising. They are effective free from anticholinergic side effects but are associated with hypertension. The procedure is minimally invasive and can be performed in the office without general anaesthesia. A urinary retention rate of 6 % and poor bladder emptying are potential side effects of Botox. Urinary retention is rare in our personal practice and in well selected patients with a This option is FDA approved in the USA.
Another option is Implant of sacral nerve stimulator. It is possible to stimulate the third (S3) sacral nerve via an implantable neuro-stimulator. Medtronic (Interstim) manufactures the most popular device. The procedure is performed under local anaesthesia with the patient awake. A staged procedure (First -stage lead implant) and second stage (implantable pulse generator- IPG) implant is often required to obtain the best results. The device is expensive and the battery (IPG) half-life is 3-7 years. Patients who require infra-cranial MRIs can’t have the procedure performed. A few long term studies have documented the safety and efficacy of Intersim. Recently, posterior tibial nerve stimulation (PTNS) has been added to the armamentarium of urge incontinence treatment with very reasonable outcome data. Long term studies are needed. No implant is necessary for PTNS but multiple weekly office visits are required.
Dr. Angelo Gousse is a Urologist with offices in Aventura and Miramar serving all South Florida (Miami, Fort Lauderdale, West Palm Beach, Kendall, South Miami, Sunny Isles, Brickell, Boca Raton) and international clients. Dr. Gousse has been selected as an honored member of Trademark Top Doctors of America Honors Edition 2018.