Incontinence of either urine and stool or gas is a socially disabling condition that becomes more common as women age. It affects upwards of 16 million American adults and is 5 times more common in women. The exact causes of incontinence are not always known but it is felt that a combination of damage to the muscles and connective tissue of the pelvic floor that can occur with childbirth and the natural consequences of aging lead to the majority of incontinence women experience. In the past women with incontinence were often reluctant to seek medical care and even when they did seek out therapy they were often told this is a normal part of aging and they should learn to accept it. This attitude of acceptance of incontinence should be a thing of the past. There is a currently push toward many new therapies to treat incontinence that now allow for the physician and patient to tailor make a treatment plan based on the patients wishes.
| Urinary incontinence is an inability to hold your urine until you get to a toilet. More than 16 million people in the United States--male and female, young and old--experience incontinence. |
Forms of Incontinence
In women there are essentially two types of urinary incontinence, stress or urge incontinence. Stress incontinence is urine loss that occurs with activity (abdominal stress) such as coughing, sneezing, lifting or laughing. The name “stress incontinence” can be confusing as most people associate the term stress with emotional stress, but this type of incontinence has nothing to do with emotions. It is usually the result of a weakening of the muscles that hold the urethra or bladder neck closed. Not surprisingly it is treated with techniques that strengthen or support the urethra or bladder neck. These techniques can take many forms from surgery to “elevate or tack the bladder neck” to exercises that strengthen the pelvic floor to medications that improve the tone of the urethral sphincter mechanism. This area of treatment is undergoing a rapid expansion. There are newer and minimally invasive surgeries being developed. In addition, for the first time there are medications that are being tested to specifically treat stress incontinence.
Urge incontinence
Urge incontinence is exactly what it sounds like-the loss of urine before reaching the commode when you first have the urge to void. The incontinence occurs when the bladder contracts and the individual can’t control it. Most individuals have a “grace period” after they first sense the urge to void. Patients with urge incontinence get the urge to void rush to the bathroom and leak urine before they get there. In essence they have lost their “grace period”. Currently, there is no known cause for urge incontinence; it is probably due to any one of a hundred subtle changes in the central nervous system that interrupts the individual’s ability to consciously control their bladder contractions. This is another area where treatment options are varied and several new therapies are always emerging. Generally urge incontinence therapy is aimed at restoring bladder control or the “grace period”. This can be done with medications that relax the bladder muscles or by retraining the bladder through drills. Mixed incontinence
Some patients will have both stress and urge incontinence and this is termed mixed incontinence. Treatments will be based on which symptom is worse. Fecal Incontinence
Fecal incontinence is a very socially disabling and embarrassing condition. It is the uncontrolled loss of gas, liquid or formed stool from the rectum. Fortunately, it is a fairly uncommon condition affecting only 1-2% of the population. It is difficult to determine the exact cause of fecal incontinence, but pregnancy and vaginal delivery with large obstetrical lacerations are most frequently implicated. Fecal incontinence has not undergone the intense evaluation that urinary incontinence and pelvic organ prolapse have, therefore, the treatment options are somewhat limited. The most important treatment option for fecal incontinence is increasing dietary fiber. If a patient can increase their daily intake of dietary fiber up to 20-25 grams per day, they can expect that 50-60% of the time they will be cured of their fecal incontinence. In the patients who are not cured by dietary fiber, surgical correction is often recommended. This surgery involves identifying the ends of anal sphincter, freeing them up from surrounding tissue and overlapping the two ends in an operation referred to as an overlapping sphincteroplasty. In addition to this procedure, there are some centers around the country that are putting in artificial anal sphincters, but these operations have a high complication rate. On the horizon, there are several medical device companies that are currently looking at various techniques for treating fecal incontinence. Hopefully in the near future we will have many more options to offer our patients. Pelvic Organ Prolaspe
Pelvic organ prolapse is a condition in which the walls of the vagina or the cervix of the uterus bulge out beyond the opening to the vagina. Patients often present with the symptom of a vaginal bulge that can be seen or felt, particularly when cleaning themselves after using the commode or in the shower. It is a fairly common condition and it is thought that over $1 billion US healthcare dollars are spent each year treating this condition. We don’t know all the causes of pelvic organ prolapse, but it is more common in women who have had at least one vaginal birth, and it increases with age. There are also some studies to suggest that it may be due to a lot of heavy lifting either through work or recreational activities. It may also be more prevalent in patients with chronic conditions such as constipation or chronic cough. Finally, there are some investigators who feel that it is more common after a hysterectomy. The treatment options for pelvic organ prolapse are basically three. The first treatment option is no therapy whatsoever. Pelvic organ prolapse generally is not a life-threatening condition. If after all of the options have been explained to the patient and they decide to do nothing, this is an acceptable choice. The second option is non-surgical management in the form of a pessary. Pessaries are devices that come in a variety of shapes and sizes and are worn in the vagina as a brace. The most common pessary is a ring pessary, and this looks very similar to a diaphragm which some women use during their reproductive years for contraception. Typically pessaries are worn 24 hours a day. They are taken out one night each week, left out overnight, and replaced the following morning. About two-thirds of patients who come into the office with prolapse and wish to try a pessary can be fit. The other third cannot wear one usually because of anatomic changes in the size and shape of the vagina. Of the two-thirds that can be successfully fit and go home with the pessary initially, about half end up using it long term. In our office we have had patients using pessaries for upwards of 12 years. The final option is surgical correction. There are a myriad of surgical procedures to correct pelvic organ prolapse and it depends on which part of the vagina is prolapsing as to which surgical procedure the physician will recommend. Surgical curates for pelvic organ prolapse run in the 80-90% range, with worse and larger prolapses having failure rates closer to 20% and smaller isolated prolapses having success rates closer to 90%, or failure rates closer to 10%. Most of the surgeries to correct pelvic organ prolapse can be done as a transvaginal operation requiring only a short overnight stay in the hospital. If you think you may have problems with prolapse and would like to speak with somebody, please feel free to contact Dr. Swift’s office at 792-5300 and ask to come in for an initial consultation. What to expect when you talk to your doctor about your incontinence.
Your physician will first take a good history to determine how often and under what circumstances you lose urine. Next a complete pelvic exam and a urinalysis are performed. The urinalysis is done by having the patient collect a sample of their urine. A strip of chemical reagents is placed into the urine specimen to determine if you have an infection. At this point your physician may elect to try a medication or bladder drills to treat your incontinence. If this doesn’t improve your incontinence you will undergo further testing. This usually involves a cystometrogram and cough stress test. The cystometrogram is done by having you empty your bladder, then placing a catheter into your bladder and filling the bladder through the catheter with sterile saline. After the bladder is filled the catheter is removed and you are asked to stand-up and cough. Following these two tests generally your physician will be able to recommend a definitive treatment. MUSC Bladder and Pelvic Health Program  Our Faculty
Dr. Steven Swift
Treatment Option Tools for Female Urinary Incontinence:
Nexcura Treatment Option Tools for Women's Health
Other Online Resources:
Urinary Incontinence (National Library of Medicine)
Bladder Control for Women (National Kidney and Urologic Diseases Information Clearinghouse)
Incontinence: Frequently Asked Questions (National Association for Continence)
Pregnancy, Childbirth and Bladder Control (National Kidney and Urologic Diseases Information Clearinghouse)
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