Urinary incontinence


New diagnostic and treatment options

By Ron Mjanger, MD

From Minnesota Physician
From Volume XXVII, No. 10, January 2014

Urinary incontinence isn’t new. Women have been plagued by both urge and stress incontinence
for years. In fact, between 30 percent and 50 percent of women experience some leakage after childbirth. Today, however, there are new diagnostic techniques, new medications, and new
treatment options that make an old problem more manageable.

Urinary incontinence is either stress incontinence (sphincteric dysfunction), urge incontinence (bladder dysfunction), or a combination of the two. Assuming there is no underlying bladder infection, family medicine physicians usually refer a patient to a specialist for further diagnosis and treatment. This can be a urologist, but many times the problem is gynecologic in nature, necessitating an ob-gyn specialist.

Diagnostic techniques
Several diagnostic techniques can help determine the cause and severity of urinary incontinence.

Postvoid residual (PVR) measurement. For this procedure, women urinate into a container to measure output, after which the physician checks the quantity of residual urine using a catheter or ultrasound test. A significant quantity of leftover urine in the bladder might signal an obstruction in the urinary tract or a problem with bladder nerves or muscles.

Pelvic ultrasound. Physicians also may use an ultrasound to check for abnormalities in other parts of the urinary tract or pelvic region.

Stress test. For this test, a woman is asked to cough vigorously or bear down as the physician tests for loss of urine.

Urodynamic testing. In this newer test, the bladder is filled with water as a monitor measures bladder strength and urinary sphincter health, as well as the pressure at rest and when filling. Urodynamic testing can help a physician distinguish the type of incontinence
experienced by the patient.

Cystogram. This X-ray of the bladder is taken as a patient urinates a fluid containing a special dye, helping to identify problems in the urinary tract.

Cystoscopy. Using a cystoscope inserted into the urethra, a physician can see and remove certain abnormalities in the urinary tract.

Topical estrogen. Postmenopausal women are prone to bladder infections because
of their low estrogen levels. The vagina of a younger woman has a certain pH level caused by good lactobacillus that live there. When estrogen levels decrease, these bacillus quantities decline, causing the pH level in the vagina to rise, and harmful bacteria to increase. Low-dose topical estrogen in the form of creams, rings, or patches, can be helpful. Women with a history of cancer are understandably nervous about introducing estrogen into their system, but there is very little danger in vaginal estrogen creams because so little is absorbed into the bloodstream.

Several medications have been approved to calm an overactive bladder. They include oxybutynin
(Ditropan, Oxytrol, Gelnique), tolterodine (Detrol), solifenacin (Vesicare), fesoterodine fumarate (Toviaz), trospium (Sanctura), and darifenacin (Enablex). Side effects may include dry mouth, blurred vision, constipation, and urinary retention.

Antidepressants. Sometimes antidepressants improve incontinence. Imipramine (Tofranil) is a tricyclic antidepressant used to treat a combination of urge and stress incontinence. Duloxetine (Cymbalta) sometimes is used to treat stress incontinence.

Bulking material injections. Bulking agents, such as carbon-coated zirconium beads (Durasphere), calcium hydroxylapatite (Coaptite), polydimethylsiloxane (Macroplastique), and collagen, can be injected into tissue around the urethra. This five-minute office procedure can help keep the urethra closed and reduce urine leakage. Repeat injections, however, are usually needed.

Botox injections. While botox injections are not yet approved by the U.S. Food and Drug Administration for incontinence, some research physicians have used botulinum toxin type A (Botox), the same substance dermatologists use on facial muscles, to relax an overactive bladder. The substance is injected into the bladder muscle with a needle inserted via a cystoscope that goes up into the bladder. Effects last about nine months and may require self-catheterization to empty the bladder.

Treatment options
When medications don’t work and first-line treatment options, such as Kegel exercises, physical therapy, and biofeedback don’t provide satisfactory results, physicians consider other options, starting with the least invasive.

Pessary. A pessary, a stiff ring worn in the vagina, helps to hold up a prolapsed bladder or uterus and prevent urine leakage.

Slings. Much has been written recently about mid-urethral sling procedures, in which synthetic materials or mesh are used to create a hammock around the bladder neck and urethra. The sling was designed to keep the urethra closed, especially when a woman coughs or sneezes.

Sometimes mesh is used to hold up the vagina in an attempt to reduce incontinence. For many women, this mesh offered a good solution, but others experienced significant scarring and
pain, necessitating mesh removal and surgery to reconstruct the anatomy. Recently, the U.S. government issued warnings about the use of certain transvaginal nylon mesh used in the treatment of urinary incontinence. As a physician who has performed a large number of these vaginal mesh removals, I can attest to the fact that the removal can be tricky. I have found that using the da Vinci Surgical System for mesh removal and reconstructive surgery has changed the process considerably.

In the past, the mesh was inserted vaginally. Every time a physician operates through the vagina, however, he or she needs a seam allowance, and the vagina gets smaller. Eventually, it becomes too small for intercourse. With the da Vinci, we can now perform sacrocolpopexy laparoscopically. Using the da Vinci, I can go through a woman’s naval, with a camera, and get down behind the vagina without cutting into it. There is no further vaginal shrinkage, making it a nice option to offer women.

This procedure, combined with newer, smaller pieces of mesh, has become the state-of-the-art repair for vaginal prolapse. Minimally invasive surgeries result in faster recovery, along with less pain, bleeding and scarring.

Electrical stimulation. While not yet a mainstream treatment, electrical stimulation is becoming more prevalent in the treatment of urinary incontinence. Percutaneous tibial nerve stimulation (PTNS), for example, is a procedure that can be conducted in a physician’s office.
Following the insertion of a tiny needle electrode into the tibial nerve just above the ankle, the physician generates a mild electrical impulse to nerves of the spine that control bladder function. Physicians report improvement within the first couple of weeks. With this option,
however, a patient will require a series of approximately 12 treatments over 12 weeks.

Another option is stimulation of the sacral nerve, in which mild electrical impulses are sent to the sacral nerve near the lower back. A device similar to a pacemaker is surgically implanted under the skin in the upper buttocks, providing electrical pulses that influence bladder function. The procedure to implant the device is minimally invasive and reversible.

Bladder augmentation. Bladder augmentation is a major, complex surgical procedure used to increase the size of a woman’s bladder. Physicians open the bladder through an incision in the abdomen and attach a strip of tissue, usually from the intestine or stomach, to the bladder opening, thus enlarging it. Recovery may take up to six weeks, and lifelong use of a catheter to empty the bladder may be necessary.

More women seeking treatment
Urinary incontinence has come out of the closet, with more women talking to their physicians about the problems of urge and stress incontinence. As a result, more women are seeking help and receiving relief from the problem.

Ron Mjanger, MD, Metro OBGYN, practices at several locations, including the Apple Valley Medical Center. He has performed more than 10,000 pelvic surgeries and more than 700 da Vinci procedures. Mjanger was the first regional surgeon to perform da Vinci prolapse procedures, and currently teaches new procedures to other physicians.