Incontinence
Urinary incontinence is a common problem in both men and women. It is seen frequently in children in both sexes. It is common in women during mid life and again in both sexes in later years. There are several types and causes. Our goal is to identify the type and cause of the leakage and then use whatever methods are required to resolve or manage the problem as expeditiously as possible.
Evaluation
Evaluation always begins with a good history of the problem. This includes not only issues related to the incontinence itself but also other medical conditions, dietary history, voiding habits and physical limitations. Physical examination including the abdomen, pelvis, rectum, vagina and prostate are often pertinent. Examination gives clues as to the physical abnormalities and tissue changes that may be contributing to the problem. In women, cystocoele, pelvic prolapsed or pelvic vault prolapsed associated with bladder hyper mobility are common especially after childbirth. Type I, Type II, and Type III stress incontinence are in part determined by physical examination and history.
Urinalysis is done to identify other conditions that may be causing or contributing to incontinence. Bacteria in the urine indicate an infection. Purina, the presence of pus or white blood cells in the urine can indicate infection or other inflammations. Glucosuria indicates too much sugar in the urine and probably in the blood stream. Occasionally, we diagnosis cases of diabetes in this way. Hematuria, blood in the urine can indicate infections, stones, tumors and other problems in the urinary tract. Proteinuria, protein in the urine can indicate kidney disease and other conditions.
After the above evaluation, specialized testing can be used to further define issues that may impact the diagnosis and treatment of the incontinence condition. These tests are chosen individually given each patient’s complaints and situation. Additional testing may include:
- Cystoscopy – Special scopes are used to look inside the bladder to define anatomy and look for bladder wall changes (cystitis), inflammation, stones, and bladder cancer.
- Post void Residual Volume (PVR) – We use a bladder scanner machine to look at the bladder with ultrasound, and in a noninvasive way determine the amount of urine remaining in the bladder after urination. This is a good way to determine incomplete voiding and urinary retention.
- Urodynamic Testing – A newly acquired, state of the art, Mediscan urodynamic machine is often used in cases to determine how the bladder is functioning. Several tests may be involved from simple cystometry, to multi channel complex urodynamic testing. We use subtracted pressures to separate bladder (detrussor) pressures from abdominal pressures, leak point pressures and other parameters to assist in diagnosing and treating each patient’s condition.
- Radiological Examinations - Sometimes ultrasound and x-ray examinations are useful in evaluation on incontinence.
Treatment
Treatment is highly dependent on the cause and the results of the above examinations and testing.
Sometimes simply treating an unrecognized infection is all that is needed. Dietary modification, Kegel exercises, alteration of voiding habits can be helpful in some cases. Biofeedback and other pelvic floor exercises, sometimes using the assistance of physical therapy is available.
Treatment of prostate disorders, enlarged prostate may resolve incontinence issues. This may be done with medications or surgery or other minimally invasive treatments like TUNA (PROSTIVA) done in the office.
Treatment of Neurogenic Bladders is often directed at managing incontinence and preserving the function of the kidneys.
Female incontinence is occasionally treated with injection therapy, either with Collagen or Durasphere. Surgical options are numerous and varied. Selection is based upon severity, anatomic changes and other factors. They include Marshall Marchetti Kranz (MMK), Birch Culposuspension, Stamey, Gittes or Raz needle suspensions. Pubovaginal Slings are frequently used to lift the lower vaginal wall and stop stress incontinence. There are many types of sling procedures including the newer mesh slings (Gynecare TVT, Sparc, Monarc,). Transvaginal, suprapubic and transobturator approaches can be used in this category of cases. Major pelvic prolapse cases are handled by more involved and often combined procedures.