September 3, 2008
By DR. MARA HOLTON
After toilet training, individuals hold urine and empty their bladders at will. However, many adults experience incontinence, the involuntary leakage of urine.
Symptoms vary from minimal leakage requiring almost no behavior modification to continuous and significant leakage that can be physically and socially crippling.
Some patients experience incontinence with sudden "urges" for the need to void; some with abdominal strain. In other people, this leakage occurs without any notice whatsoever. Incontinence is a common problem, affecting millions of individuals both male and female.
Women, for a variety of reasons, are affected about two times more frequently than men. While incontinence is more prevalent among older women, women of all ages experience involuntary loss of urine.
A number of conditions can be associated with urinary incontinence. These include medical conditions such as diabetes, chronic constipation, urinary tract infections and neurologic conditions such as multiple sclerosis or strokes. Other causes include congenital conditions; menopause; pelvic prolapse, where the uterus, bladder or rectum have fallen down; pregnancy and labor; and obesity. Certain medications can also be associated with incontinence.
Urinary incontinence is generally divided into several types based on pattern and cause. Stress incontinence is leakage of which occurs with increased abdominal pressure. Some women may leak while jumping on a trampoline, with hearty laughing or with a bad cough while others experience leakage just rising from sitting to standing.
Stress incontinence is sometimes associated with pregnancy and delivery as well as the hormonal changes associated with menopause.
Urge incontinence occurs because of the involuntary contraction of the muscles in the bladder. This leakage may be triggered by running water or entering the bathroom or can occur spontaneously. In certain neurologic conditions, there may be contraction of the bladder in the absence of any sensation.
Urge incontinence often overlaps with a condition called overactive bladder (OAB). Patients with OAB have urinary frequency and often urgency and incontinence along with other symptoms. There are a number of other, less common, types of leakage. Additionally, all of the categories overlap and many patients have some combination of symptoms termed mixed urinary incontinence.
Your doctor will want to investigate the cause of your incontinence. He or she will take a careful medical and gynecologic history. A comprehensive physical exam will generally include a pelvic exam. Commonly ordered tests include microscopic evaluation of urine and radiologic imaging such as renal ultrasound or CT scan to evaluate for urinary tract abnormalities.
Your doctor may ask you to keep a voiding diary whereby you keep tract of fluid intake and amount and timing of urination or incontinence episodes. Additional tests might include direct visualization of the urinary tract by an office procedure called a cystoscopy and/or urodynamics, where small catheters are inserted to measure the pressure and "squeeze" of the bladder and bladder outlet.
A treatment plan will be designed in consultation with your physician and may include methods such as behavioral and voiding modification, physical therapy and biofeedback, sacral nerve stimulation, pharmacologic intervention, and placement of removable devices.
Surgical treatments include injection into the urethra with "bulking agents" like collagen, slings which support the urethra, and pelvic prolapse repair with or without hysterectomy.
Some combination of therapies is often required for optimal relief. The good news is that leakage can almost always be positively impacted by treatment and that most women are able to get significant relief through an integrated approach.
Dr. Mara Holton is a urologist with Anne Arundel Urology and Baltimore Washington Medical Center. To contact Dr. Holton, please call 410-768-0036.
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