Urinary incontinence is the involuntary loss of urine. It affects millions of Americans, especially women over the age of 40, men following prostate cancer surgery, and patients with neurologic diseases such as spinal cord injury and stroke.
The most common type of urinary incontinence in adults occurs during coughing, sneezing, and physical exertion and is called stress incontinence. In women, it is usually due to loss of bladder support resulting from multiple childbirths, aging, obesity, or lack of estrogen. Men often suffer from stress urinary incontinence following prostate cancer surgery.
The second most common type of incontinence in patients is called urge incontinence. Patients with urge incontinence commonly complain of frequent urination, both day and night, associated with an intense desire to urinate. It is usually associated with frequent urination, both day and night, and is commonly referred to as an overactive bladder. Common triggers of urge incontinence include running water, "key-in-the-door syndrome," and laughing. Many women suffer from a combination of both stress and urge incontinence.
Incontinence in men is most commonly seen in patients who have had previous prostate surgery, especially surgery for prostate cancer. They usually complain of different degrees of stress incontinence and may even dribble urine continuously. Incontinence following prostate cancer surgery is often due to injury to the patient's urine control valve or urinary sphincter and occurs in 3% to 10% of cases.
Many children suffer from urinary incontinence. It may represent a delay in the maturation of the normal bladder control mechanisms. Bedwetting is common, especially in children who are deep sleepers and those whose parents suffered from the condition. The diagnosis and treatment of incontinence may be important for a child's self-esteem.
The ill effects of incontinence are numerous, and its impact on the patient's quality of life is significant. Incontinence is a daily annoyance to most patients afflicted, and in some it may lower self-esteem and aggravate depression. Many incontinent patients dramatically limit their normal daily activities and avoid public places to prevent potential embarrassment. It can result in urinary tract infections and skin breakdown. Commonly, elderly patients are admitted to chronic care facilities because they become incontinent. The cost of incontinence, both to the patient and to the American healthcare system, can be overwhelming. Unfortunately, these problems are sometimes accentuated by the fact that many incontinent people never seek medical attention, or when they do, their problem is either minimized by their physician or not properly assessed and treated.
Fortunately, in experienced hands, 70% to 90% of incontinent patients can either be cured or significantly improved. High success rates are highly dependent upon physician expertise, both in the diagnosis and the treatment of incontinence. Incontinent patients require an in-depth history and physical examination, and in most cases, a urodynamic evaluation. Video urodynamics give the physician state-of-the-art diagnostic capability by combining conventional urodynamics and x-ray.
The Alliance Urology Specialists Bladder Control and Pelvic Pain Center has 2 video urodynamic suites, offering patients state-of-the-art diagnosis for bladder dysfunction and urinary incontinence. Ultimately, better diagnosis leads to improved patient care and treatment success.
TREATMENT OF URINARY INCONTINENCE:
Fortunately, the majority of adults and children with incontinence can be improved or cured with appropriate treatment. The treatment of incontinence varies dependent on the underlying problem and general health issues of the patient.
Treatment options include supportive measures, nonsurgical therapies, and surgery. The Alliance Urology Specialists Bladder Control and Pelvic Pain Center has expertise in all facets of incontinence care.
Most patients with urinary incontinence benefit from nonsurgical therapies, including medication, bladder drills, pelvic floor strengthening exercises, and biofeedback therapy. In the majority of cases, the success of nonsurgical therapy is very good. Our Bladder Control and Pelvic Pain Center has its own full-time physiotherapist who specializes in the management of adults and children with bladder dysfunction and/or pelvic pain.
If surgical management is needed, expertise and experience in performing surgery is necessary in order to maximize success. When patients are properly selected, surgery is effective in approximately 85% to 90% of the cases. Our center offers the most up-to-date surgical therapies, including sling cystourethropexy (bladder suspension), sophisticated pelvic floor reconstruction, botulinum toxin injection therapy, periurethral injectable treatments, neuromodulation (InterStim), and implantation of artificial urinary sphincters.
Supportive measures (catheter, pads, etc.) are sometimes required in people who cannot be helped by other treatments. Patient support and education is especially important and is provided by our team of incontinence nurse specialists.
What is urodynamics?
Urodynamics is a computerized bladder test that helps determine the cause of urinary incontinence and bladder dysfunction. It requires a small catheter, lasts for approximately 30 minutes, and does not require special preparation.
Video urodynamics combines x-ray capability with conventional urodynamics studies, and when performed by an expert, provides state-of-the-art diagnosis. Ultimately, this improves patient care and treatment success. The Alliance Urology Specialists Bladder Control and Pelvic Pain Center has 2 state-of-the-art video urodynamics labs.
URINARY INCONTINENCE FOLLOWING PROSTATE CANCER SURGERY:
Prostate cancer is the most common cancer in men in the United States. Nearly 10% of men develop prostate cancer, and it is more common in African Americans and in men with family members with the disease. Prostate cancer "confined to the prostate" is most commonly treated by surgical removal of the gland, an operation known as a radical prostatectomy. The surgery offers well-selected patients the best chance of cure. It may result in loss of urine control or urinary incontinence.
Urinary incontinence following prostate cancer surgery is not uncommon. Approximately 3% to 10% of the patients who undergo radical prostatectomy suffer from postoperative incontinence.
Incontinence following prostate cancer surgery can be from a number of causes. Most commonly, it results from injury to one of the urethral sphincters or "valves" that normally maintain dryness. Other causes of incontinence may also be present and they may be diagnosed by thorough evaluation, including urodynamics.
Most incontinent patients complain of urine leakage with coughing, straining, or with increased activity. This leakage is referred to as stress incontinence. The patients most severely affected often dribble urine continuously while standing, but most patients are dry when lying down. Others complain of urgency and the inability to reach the restroom before wetting occurs. This is called urge incontinence and is often associated with frequent urination, both day and night. Most men who have had a prostatectomy can urinate with a good stream, allowing them to empty their bladder efficiently.
Incontinence can be one of the most debilitating and devastating complications following prostate cancer surgery. It can result in skin breakdown, recurrent urinary tract infections, lowered self-esteem, and even depression. Unfortunately, incontinence and its resulting adverse effects are sometimes minimized by physicians who are less familiar with its proper assessment and treatment and who are primarily focused on the cancer. In our experience, most patients want to recover from surgery and get back to their normal activities as soon as possible. They do not want to wear Depends or a condom catheter appliance. They want to be dry.
The majority of patients with incontinence following prostate cancer surgery can be significantly improved or cured as a result of a thorough investigation and appropriate treatment selection. Fortunately, many patients spontaneously regain urine control within 9 to 12 months following surgery as a result of healing, and this may be helped by regular performance of Kegel or pelvic floor exercises. The patients who remain incontinent can be offered various treatment options, depending upon the underlying cause, the degree of wetness, and, most importantly, the patient's motivation to become dry. Some patients may respond to methods that either "tightens the valve" or "relaxes the bladder," but, unfortunately, these medications are only beneficial in a minority of cases.
Urethral injectable therapies are also available, which occlude, or close, the urethra, resulting in improved urinary control. The procedure is simple to perform and is generally done on an outpatient basis with or without formal anesthesia. Though injectables often help in the short-term, long-term benefit is only seen in a small percent of cases.
The artificial urinary sphincter is a hydraulic device composed of silicone rubber and is the gold standard in the treatment of incontinence following prostate cancer surgery. It consists of 3 parts: A fluid-filled, golf ball-sized balloon reservoir inserted into the lower abdomen responsible for pressure regulation; a small inflatable cuff place around the urethra; and a pump, approximately 1/2 the size of one's fifth finger which is placed into the scrotal sac next to the testicle.
At rest, the fluid-filled cuff occludes the urethra, maintaining dryness. When the patient desires to urinate, he squeezes the pump 2 or 3 times, transferring fluid from the cuff to the balloon reservoir, resulting in opening of the cuff and urethra, allowing for urination. The fluid automatically refills the cuff within 3 to 4 minutes. The patient maintains his normal sensation to urinate. Approximately 90% of patients who are treated with an artificial sphincter are greatly improved, with approximately 30% to 40% of them achieving dryness. Many patients continue to have some stress incontinence with increased activity, but overall they are much dryer and pleased with the results of surgery.
The artificial sphincter gives good results, but this obviously cannot replace our natural valve system. It is a mechanical device that can malfunction; the seven-year malfunction rate requiring operation to repair is approximately 10%. The 2 most important complications of sphincter surgery are infection and erosion of the cuff through the urethra, both occurring in 1% to 2% of the cases and both requiring surgical removal of the sphincter.
Placement of an artificial sphincter generally takes approximately 60 to 90 minutes. Most patients stay in the hospital overnight. The device is activated 6 weeks following surgery.
Urinary incontinence following prostate cancer surgery can be devastating, and its adverse effects on the patient must not be underestimated. In experienced hands, the artificial sphincter offers patients the greatest chance of cure and, in my opinion, should be offered to most patients.