Urinary Incontinence / Overactive Bladder
Over 30 million people in the United States suffer from urinary incontinence or overactive bladder (OAB). This condition is far more prevalent in women than men.
In the general population, age 15 to 64 years, 10-30% of women, versus 1.5% of men are affected. Those with OAB often experience urgency at inconvenient and unpredictable times and sometimes lose control before reaching a restroom. OAB, therefore, interferes with work, daily routine and intimacy, causes embarrassment, and can diminish self esteem and quality of life.
With (OAB), the bladder muscle contracts spastically, sometimes without known cause, resulting in elevated bladder pressure and the urgent need to urinate. Normal bladder function is restored when the bladder can relax and fill at low pressure to reasonable volumes before voluntarily contracting and emptying completely. Unexpected bladder emptying, or leakage, is defined as urinary incontinence. Of the several types of urinary incontinence, stress, urge, and mixed incontinence account for more than 90% of the cases.
Stress Incontinence
Urine loss during physical activity that increases abdominal pressure (coughing, sneezing, laughing).
Urge Incontinence
Urine loss with the sudden need to void, caused by an involuntary bladder contraction (also called detrusor instability).
Mixed
Both stress & urge components contribute to urine loss.
Medical (Pharamcologic) Treatments
- Myrbetriq
- Ditropan
- Detrol LA
- Vesicare
- Ditropan XL
- Sanctura
- Enablex
- Toviaz
- Oxytrol transdermal patch
Minimally – Invasive Approaches
- Bladder botox injection for severe urgency/urge incontinence
- Intravesical (bladder instillation) agents for interstitial cystitis treatment
Interstim Neuromodulation (sacral nerve stimulation)
The InterStim is an outpatient surgical treatment for severe urge urinary incontenence and pelvic pain resistant to oral medication. InterStim is an implantable device that stimulates the sacral nerves with mild electrical pulses.
Neurostimulation may offer several benefits, including freedom from the embarrassment of leaks. It may also help reduce the need to interrupt your sleep due to waking many times during the night to urinate. Side effects may include pain, skin irritation, infection, device problems, and lead (thin wire) movement. These conditions were generally resolvable in the clinical studies performed.
Injectable Bulking Agents
Surgical Treatments
- Mid-urethral sling for female urinary incontinence:
- Bone-anchored bladder neck sling (female)
- Simultaneous cystocele-sling repair for stress incontinence associated with vaginal prolapse (CAPS procedure)
Urinary Incontinence Links
- Facing Our Moments (FacingOurMoments.com)
- Laborie Urodynamics (laborie.com/products/urodynamics/)
- Resource Guide for: Stress Urinary Incontinence
- Everyday Freedom (everyday-freedom.com)
Pelvic Organ Prolapse
What is Pelvic Organ Prolapse?
Pelvic organ prolapse occurs when the tissues that hold the pelvic organs in place become weak or stretched, resulting in the drop (prolapse) of the pelvic organs from their normal position.
What Causes Pelvic Organ Prolaspe?
Prolapse is caused by muscles and ligaments that have been weakened or damaged. The most common causes of prolapse include:
- Pregnancy / Childbirth
- Obesity
- Childbirth
- Aging
- Menopause
- Genetics
- Previous surgery
What are the Types of Pelvic Organ Prolapse?
There are several specific types of prolapse that contribute to the overall condition of pelvic organ prolaspe:
- Cystocele - A cystocele is formed when the bladder bulges or herniates into the vagina.
- Enterocele - An enterocele is formed when the small bowel bulges or herniates into the vagina.
- Rectocele - A rectocele occurs when the rectum bulges or herniates into the vagina.
- Uterine prolapse - A uterine prolapse occurs when the uterus falls into the vagina.
- Vaginal vault prolapse - A vaginal vault prolapse occurs when the upper part of the vagina falls into the vaginal canal.
What are the Symptoms of Pelvic Organ Prolapse?
Symptoms of Pelvic Organ Prolapse include:
- A bulge or lump in the vagina
- The vagina protruding from the body
- A pulling or stretching sensation in the groin
- Difficult or painful intercourse
- Vaginal pain, pressure, irritation, bleeding or spotting
- Urinary and fecal incontinence
- Difficulty with bowel movements
- Delayed or slow urinary stream
How is Pelvic Organ Prolapse Treated?
Treatment may vary depending on the type of prolapse. The treatment chosen will depend on the severity of the condition as well as the woman’s general health, age, and desire to have children.
Non-Surgical Options
Exercise – Special exercises, called Kegel exercises, can help strengthen the pelvic floor muscles. This may be the only treatment needed in mild cases of uterine prolapse. For Kegel exercises to be effective they need to be done daily.
Vaginal Pessary – A pessary is a rubber or plastic device used to support the pelvic floor and maintain support of the prolapsed organ. A health care provider will fit and insert the pessary, which must be cleaned frequently and removed before sexual intercourse.
Estrogen Replacement Therapy (ERT) – Taking estrogen may help to limit further weakness of the muscles and other connective tissues that support the uterus. However, there are some drawbacks to taking estrogen, such as an increased risk of blood clots, gallbladder disease and breast cancer.
Surgical Options
Surgical options are used to help return prolapsed organs to a more normal anatomical position and to strengthen structures around the prolapsed area to maintain support. The surgical options, known as abdominal sacral colpopexy, can be done abdominally or vaginally, although vaginal usually involves less pain and the potential for a shorter recovery period.
Depending on your needs and type of prolapse, Dr. Cornell may choose either a synthetic polypropylene mesh or a biologic graft material to repair the prolapse. It is possible to repair more than one type of prolapse during the same surgery.
The procedure is minimally invasive amd is generally performed under general anesthesia. A small vaginal incision will be made. A piece of mesh is inserted through the incision and placed in the pelvic area where the repair is needed. The mesh is secured in your body through the use of self-fixating tips attached to the mesh that are inserted into the ligament or muscles to secure the mesh in place until the natural process of tissue in-growth can occur.
After the mesh is secured the vaginal incision is closed. The procedure does not involve any external incisions and should heal quickly. Depending on the nature of your work, you may be able to return to work after one to two weeks. You will need to refrain from sexual intercourse, heavy lifting and rigorous exercise for six to eight weeks.
Most women will see results immediately following the procedure or a short time after.
Interstitial Cystitis
Interstitial cystitis (IC) is a chronic inflammatory condition of the bladder wall characterized by urinary urgency, uncomfortable bladder pressure, and pelvic pain.
While interstitial cystitis — also called painful bladder syndrome — can affect children and men, women are most often affected. Interstitial cystitis can have an adverse effect on your quality of life.
While IC can affect children and men, women are most often affected, having an adverse effect on quality of life
The severity of symptoms caused by interstitial cystitis can fluctuate. Some people may experience periods of remission. A variety of medications and other therapies offer relief from this chronic and troublesome condition.
The symptoms of Interstitial cystitis include:
- Pelvic (suprapubic) pain
- Perineal Pain
- Urinary urgency
- Urinary frequency
- Painful sexual intercourse
How is interstitial cystitis diagnosed?
There is no single test that is specific for interstitial cystitic. Moreover, other conditions like urinary tract infection or bladder cancer can cause similar symptoms and, therefore, must first be excluded through in-office diagnostic tests. A diagnosis of interstitial cystitis is made only after all other possible diagnoses are ruled out.
Other conditions that can cause IC-like symptoms include:
- Bladder cancer
- Chronic prostatitis in men
- Endometriosis in women
- Kidney or bladder stones
- Sexually transmitted disease\
- Urinary tract infection
- Vaginal infection
Dr. Cornell will begin by gathering a complete history of your symptoms and performing a physical exam.
Tests may include:
- Urinalysis and urine culture
- Cystoscopy with bladder distention
- Biopsy
How is interstitial cystitis treated?
There is no cure for interstitial cystitis. Treatment focuses on the relief of symptoms and the establishment of an individualized “cocktail” that has been modified to minimize your particular symptoms . Treatments generally take several weeks to months to provide optimum relief.
Treatment options include:
- Bladder distention - Some patients report feeling better after the bladder is filled to capacity and held for several minutes. This can be done in the office or in the operating room where sedation or anesthesia can be used.
- Bladder distention is also helpful in establishing a diagnosis of IC, as direct inspection of the bladder through cystoscopy is required to exclude other diagnoses of these symptoms and to identify the characteristic bladder appearance of IC, which is that of a markedly vascular, reddened, and often bleeding bladder wall consistent with an active condition.
- The distention of the urinary bladder will heighten the appearance of these findings assisting in diagnosis, while providing relief of symptoms, likely through neural feedback through the brain and spinal cord.
- Bladder instillation - With bladder instillation a catheter is used to fill the bladder with a solution of topical anesthetic and medication that both alkalinizes the urine and coats the bladder wall. The solution is held in the bladder for an average of 30 - 45 minutes before the bladder is emptied through voluntary voiding. Treatment is administered on an as-needed basis and can be repeated as needed, as the medication exerts its effect locally on the bladder wall rather than through systemic absorbtion.
- Oral medications - Pentosan polysulfate (Elmiron) is the most common medication used to treat interstitial cystitis. In some patients, the drug may improve symptoms; however, pain relief may not occur for two to four months and can take up to six months before there is a decrease in urinary frequency. This medication is thought to exert its effect directly by coating the bladder lining and bladder wall.
- Tricyclic antidepressants and antihistamines have both been effective in treating interstitial cystitis. The mildly sedating properties of these medications likely helps in achieving a restful sleep. While coincident depression is not required to begin these medications, their effect on central nervous system hormone levels likely assists in the tolerance of the chronic pain associated with this condition.
- Electrical nerve stimulation - Mild electrical impulses used to stimulate nerves to the bladder may increase blood flow to the bladder, strengthen the bladder muscles, and trigger chemicals that block pain. The impulses can be sent through the skin using a transcutaneous electrical nerve stimulation (TENS) machine via wires placed on the lower back or just above the pubic area or can be delivered using a special device inserted into the vagina in women or into the rectum in men.
- If nerve stimulation works, there is a device that can be implanted under the skin to deliver regular impulses to the bladder.
- Surgery - Surgery is typically reserved for patients who have failed one or more of the non-operative treatment options. It is generally regarded as a final option after other treatments have failed. Surgical therapy may involve the implantation of a pacemaker-like device (InterStim sacral nerve stimulation) in the buttocks that serves to stimulate and regulate neural impulses to the sacral nerves responsible for bladder function. This option follows the successful testing of this treatment through an externalized battery-operated device connected to fine leads placed percutaneously into the sacrum and secured to the skin for a 3-7 day trial period.
- Success is considered as greater than 50% subjective symptomatic improvement in urinary urgency, frequency and/or urinary incontinence and pelvic pain.
- When these treatment options fail and urinary and pelvic symptoms remain severe and debilitating, urinary diversion or bladder augmentation surgical procedures represent the final, and most invasive, treatment options.
Interstitial Cystitis and Diet
The Interstitial Cystitis Network offers a Food List iPhone / iPad application that is designed to help patients struggling with urinary discomfort.
The application lists foods that soothe rather than irritate the bladder. Ideal for use when shopping or eating out, it contains a searchable database of more than 250 foods.
Foods are categorized into three categories:
- Bladder Friendly
- Try It
- Caution
Download the application here
Recurrent Urinary Tract Infections
Recurrent urinary tract infections are defined as having at least two infections of the lower urinary tract (bladder) within a six month period, or having three infections within one year.
Recurrent urinary tract infections are also known as chronic urinary tract infections (UTIs) or bladder infections. Many women suffer from recurrent urinary tract infections, usually representing the failure to cure the initial infection.
Chronic UTI statistics include the following:
- 20 percent of women who have had a UTI will have another
- 30 percent of women who have two UTIs will have another
- 80 percent of women who have more than two UTIs will have recurrences
What Causes Recurrent Urinary Tract Infections?
Urinary tract infections typically occur when bacteria enter the urinary tract through the urethra and begin to multiply in the bladder. The infecting bacteria usually reside as normal skin flora of the patient's own genitalia, maintaining specific receptors to the lining of the lower urinary tract that permit their migration and overgrowth.
Diabetic patients, especially those with poorly-controlled diabetes and those with urinary glucose (glycosuria), and post-menopausal women are at particular risk of recurrent lower urinary tract infections. Men with prostatic enlargement and incomplete bladder emptying are also more likely to develop lower urinary tract infection.
What are the Symptoms of Recurrent Urinary Tract Infections?
Urinary tract infections do not always cause symptoms, but when they do they may include:
- Persistent urge to urinate
- Burning sensation when urinating
- Frequent, small amounts of urine
- Urine that appears cloudy
- Urine that appears red, bright pink or cola-colored — a sign of blood in the urine
- Strong or foul-smelling urine
- Pelvic pain
How are Recurrent Urinary Tract Infections Treated?
Recurrent urinary tract infection treatment options include:
- A short course 3-5 days of antibiotics when symptoms appear. Clearing the initial infection is the mainstay of treatment.
- Low dose antibiotic such as Bactrim (TMP/SMZ), cephalosporin, or nitrofurantoin daily for 3-6 months or longer (prophylaxis)
- Single dose of an antibiotic befor or soon after sexual intercourse (post-coital)
Dr. Cornell will often complete a radiographic surveillance of the upper urinary tract to ensure that a source of recurrent bacterial infection does not exist, e.g., a kidney stone or upper urinary tract obstruction. This is most easily accomplished by an ultrasound of the kidneys, which can be completed in the office. Once clearance of the infection has been documented by a sterile urine culture or a sufficient culture-specific antibiotic regimen has been completed, the lower urinary tract will be cleared by office cystoscopy - a minimally-invasive inspection of the bladder and urethra to exclude lower urinary tract pathology that may serve as a source of recurrent infection. A physical examination of the pelvis and genitalia, as well as measurement of bladder emptying will occur at the first office visit. Should incomplete bladder emptying be identified without apparent bladder outlet obstruction, bladder function can be evaluated by office urodynamics.
Hormonal Therapy
Estrogens
Estrogens are a group of related hormones that are prescribed to re-establish a normal physiologic balance. The use of one or more of these hormones is know as Estrogen Replacement Therapy.
Estrogens have been clinically proven to be clinically effective:
- in the treatment of menopausal symptoms
- for the treatment of post-menopausal problems including vaginal atrophy, dryness or infections, and painful intercourse
- in decreasing the risk of osteoporosis and colorectal cancer
Progesterone
Progesterone is commonly prescribed perimenopausal women to counteract estrogen dominance.
Progesterone may also:
- reduce the risk of endometrial cancer in women who are taking estrogen
- enhance the beneficial effect of estrogen on lipid and cholesterol profiles
Androgens
Testosterone and dehydroepiandrosterone (DHEA) may be added to a women's hormone therapy to alleviate recalcitrant menopausal symptoms and further protect against osteoporosis, loss of immune function, obesity, and diabetes.
A decline in serum testosterone is associated with hysterectomy and htere are age-related declines in DHEA and DHEA-sulfate.
