A common problem, urinary incontinence can be controlled

The mindset of just living with urinary incontinence is unfortunate because it is a common problem which, in many cases, can be treated or cured

By: Barry R. Rossman, M.D. in Collaboration with Gloria N. Beck
   The loss of bladder control is a difficult subject for many patients to discuss with their doctor. Some people do not consider it a valid medical complaint or dismiss it as a normal consequence of aging. Others may be too embarrassed to acknowledge that they sometimes leak urine when they lift heavy objects, or occasionally cannot make it to the bathroom because of the sudden need to urinate.
   An estimated 13 million Americans suffer from occasional or frequent loss of bladder control, including 1 in 10 people over age 65, according to the U.S. National Institutes of Health. The condition is much more common in women, but it can affect men.
   The mindset of just living with urinary incontinence is unfortunate because it is a common problem which, in many cases, can be treated or cured. New medications, minimally invasive surgical techniques and other therapies make it possible to manage the condition with little discomfort and few potential side effects.
   Bladder muscles contract during urination. This contraction forces urine out of the body through a tube called the urethra. Muscles around the urethra relax to let urine pass. Urinary incontinence happens when muscles in the bladder contract or muscles in the urethra relax unexpectedly or uncontrollably.
   The two most common types of urinary incontinence are:

  • Stress incontinence
    — the involuntary loss of urine during activities such as exercise, coughing or laughing, which causes an increase in intra-abdominal pressure, thus putting increased pressure on the bladder.
    Stress incontinence is typically related to weakening of the pelvic muscles that support the bladder or, alternatively, due to weakening of the urethral sphincter mechanism. It most often occurs in middle-aged women, and can be related to damage to muscles during childbirth or, occasionally, just the weakening of muscles over time. Men rarely suffer from stress incontinence, although it can be a side effect of prostate surgery.
  • Urge incontinence — the sudden, uncomfortable need to urinate, with the inability to suppress the urge in order to reach a bathroom in time. A misfire in the nervous system causes the bladder to contract and squeeze out urine involuntarily.

   Accidental urination can be sparked by drinking small amounts of liquid or even by sounds, such as running water. Urge incontinence can sometimes be linked to neurological diseases such as Multiple Sclerosis and Parkinson’s disease, but often the cause is unknown.
   Testing for both conditions begins with a medical history, followed by a urinalysis looking for microscopic blood (a possible sign of a stone or tumor), sugar (indicative of possible diabetes) or white blood cells (suggestive of possible infection). A physical exam is also done, including a neurological examination, as well as an assessment of the anatomic status of the bladder and urethra.
   With urge incontinence, the goal of treatment is to regulate involuntary contractions of the bladder. Common treatments include:

  • Biofeedback. Biofeedback uses a combination of electrical stimulation of the nerves leading to the bladder, in addition to behavior training, to help patients contract their pelvic floor muscles more efficiently. Patients are taught to manage the so-called "guarding reflex" that prevents accidental urination.
  • Medication. Medicines that suppress the motor response in the bladder have been available for decades; the older versions had undesirable side effects, however, including extreme dry mouth and constipation. New medications are equally, if not more, effective, with far fewer side effects.
  • Surgery. Surgery is typically the last resort, reserved for only the most severe cases of urge incontinence. A sacral nerve stimulator, similar to a heart pacemaker, can be inserted in the buttocks. It emits electrical currents that regulate nerves leading to the bladder.

   Surgery is often the best way to treat stress incontinence. Materials such as collagen, fat or synthetics can be injected into the neck of the bladder to bulk it up.
   Another technique, known as a "sling," uses natural or synthetic tissue to create a hammock-like reinforcement underneath the bladder neck and urethra, thus providing support and preventing urine leakage. The sling procedure can now be done using minimally invasive techniques — tiny incisions that reduce a patient’s recovery time.
   A third surgical option involves placing an artificial urinary sphincter around the urethra. It acts much like a tiny, mechanical blood-pressure cuff. The patient squeezes a pump that has also been inserted under the skin to open the cuff and release urine. The cuff then tightens automatically to prevent leakage.
   While treatment of urinary incontinence has improved dramatically in recent years, initial therapy still often involves behavioral and lifestyle changes.
   In mild cases, a few simple changes, such as timed voiding or dietary alterations, can even eliminate the problem. Eliminating drinks containing caffeine and alcohol, which tend to both irritate the bladder and act as diuretics, often helps significantly to reduce urinary frequency and urgency. Spicy foods, including tomatoes and citric fruits and artificial sweeteners, are also known to irritate the bladder. If the frequency of nighttime urination is a problem, cutting back on fluids before bedtime can make a difference.
   If lifestyle changes do not help, or if urinary incontinence is having an impact on daily activities, patients should not hesitate to contact a board-certified urologist. To find a University Medical Center at Princeton urologist, call (888) 742-7496) any time, day or night. For more information about urinary incontinence, visit www.urologyhealth.org, the Web site of the American Urological Association.