Incontinence Evaluation and Treatment Including Urodynamics
What are Incontinence and Urodynamics?
There are a number of different causes of incontinence in women including abnormalities of the pelvic floor due to the trauma of pregnancy, weak urinary sphincter muscle activity, irritability of the bladder or abnormal nerve control. On occasion the cause of incontinence may be quite difficult to determine. For these patients, a sophisticated evaluation of the nerves and muscles of the bladder and urethra is necessary. Urodynamics is the office procedure used in the evaluation of bladder leakage. The procedure takes about thirty minutes. You may be asked to complete a 24 hour bladder diary beforehand. Urodynamics is helpful in determining what kind of bladder leakage is present which can help guide appropriate treatment.
How is it done?
When you arrive you will be asked to empty your bladder. Your bladder will then be emptied with a catheter to check what is called a residual. The amount of urine in your bladder after voiding should be less than 100-150 milliliters. If the residual is higher than that it may be a sign that leakage is related to poor bladder function. Next, the urethral pressure profile (UPP) will be measured. A device will be placed against the urethra. Fluid will then be released from the device into the urethra toward the bladder. The amount of pressure it takes to open the urethra where it connects to the bladder can then be measured. The lower the pressure the more likely there is leakage due to stress incontinence. Stress incontinence is the type of leakage associated with coughing, sneezing and laughing.
After the UPP, a cystometrogram (CMG) will be performed. During the CMG a leak point pressure (LPP) will be determined as well. For the CMG a very thin catheter is placed into the bladder. Fluid is then slowly instilled into the bladder. You will be asked to say when you feel something in your bladder, when you would usually go to the bathroom, and when you definitely need to go. The CMG helps determine bladder capacity and is used to look for the presence or absence of unusual bladder contractions. If these contractions are present leakage may be due to urge incontinence. Urge incontinence is leakage associated with a sudden strong need to go to the bathroom. For the LPP you will be asked to cough or bear down several times until leakage is noted. The bladder pressure when leakage occurs can be measured. If stress incontinence is severe the pressure will be low.
Urodynamics sounds worse than it is. Women generally tolerate the test very well. As noted above the results can be helpful for determining the right treatment which may include procedures, medication, physical therapy, or no treatment at all.
What treatments are available for Incontinence?
A variety of treatments are available to correct incontinence in women, including:
- Exercises. Kegel exercises to strengthen or retrain pelvic floor muscles and sphincter muscles can reduce or cure stress leakage. Women of all ages can learn and practice these exercises, which are taught by a health care professional.
- Electrical Stimulation. Brief doses of electrical stimulation can strengthen muscles in the lower pelvis in a way similar to exercising the muscles. Electrodes are temporarily placed in the vagina or rectum to stimulate nearby muscles. This will stabilize overactive muscles and stimulate contraction of urethral muscles. Electrical stimulation can be used to reduce both stress incontinence and urge incontinence.
- Biofeedback. Biofeedback uses measuring devices to help you become aware of your body's functioning. By using electronic devices or diaries to track when your bladder and urethral muscles contract, you can gain control over these muscles. Biofeedback can be used with pelvic muscle exercises and electrical stimulation to relieve stress and urge incontinence.
- Timed Voiding or Bladder Training. Timed voiding (urinating) and bladder training are techniques that use biofeedback. In timed voiding, you fill in a chart of voiding and leaking. From the patterns that appear in your chart, you can plan to empty your bladder before you would otherwise leak. Biofeedback and muscle conditioning—known as bladder training—can alter the bladder's schedule for storing and emptying urine. These techniques are effective for urge and overflow incontinence.
- Medications. Medications can reduce many types of leakage. Some drugs inhibit contractions of an overactive bladder. Others relax muscles, leading to more complete bladder emptying during urination. Some drugs tighten muscles at the bladder neck and urethra, preventing leakage. And some, especially hormones such as estrogen, are believed to cause muscles involved in urination to function normally.
- Pessaries. A pessary is a stiff ring that is inserted by a doctor or nurse into the vagina, where it presses against the wall of the vagina and the nearby urethra. The pressure helps reposition the urethra, leading to less stress leakage. If you use a pessary, you should watch for possible vaginal and urinary tract infections and see your doctor regularly.
- Implants. Implants are substances injected into tissues around the urethra. The implant adds bulk and helps to close the urethra to reduce stress incontinence. Collagen (a fibrous natural tissue from cows) and fat from the patient's body have been used. Implants can be injected by a doctor in about half an hour using local anesthesia.
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Procedures. Doctors usually suggest procedures to alleviate incontinence only after other treatments have been tried. Many procedural options have high rates of success. Most stress incontinence results from the bladder dropping down toward the vagina. Therefore, a common procedure for stress incontinence involves pulling the bladder up to a more normal position. Working through an incision in the vagina or abdomen, the surgeon raises the bladder and secures it with a string attached to muscle, ligament, or bone.
For severe cases of stress incontinence, the surgeon may secure the bladder with a wide sling. This not only holds up the bladder but also compresses the bottom of the bladder and the top of the urethra, further preventing leakage.
In rare cases, a surgeon implants an artificial sphincter, a doughnut-shaped sac that circles the urethra. A fluid fills and expands the sac, which squeezes the urethra closed. By pressing a valve implanted under the skin, you can cause the artificial sphincter to deflate. This removes pressure from the urethra, allowing urine from the bladder to pass. - Catheterization. If you are incontinent because your bladder never empties completely (overflow incontinence) or your bladder cannot empty because of poor muscle tone, past procedures, or spinal cord injury, you might use a catheter to empty your bladder. A catheter is a tube that you can learn to insert through the urethra into the bladder to drain urine. Catheters may be used once in a while or on a constant basis, in which case the tube connects to a bag that you can attach to your leg. If you use a long-term (or indwelling) catheter, you should watch for possible urinary tract infections.
- Other Procedures. Many women manage urinary incontinence with pads that catch slight leakage during activities such as exercising. Also, you often can reduce incontinence by restricting certain liquids, such as coffee, tea, and alcohol.
Finally, many women who could be treated resort instead to wearing absorbent undergarments, or diapers—especially elderly women in nursing homes. This is unfortunate, because diapering can lead to diminished self-esteem, as well as skin irritation and sores. If you are an elderly woman, you and your family should discuss with your CHCW physician the possible effectiveness of treatments such as timed voiding, pelvic muscle exercises, and electrical stimulation before resorting to absorbent pads or undergarments.
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