Information on problems with the urinary bladder.

Surgical Management of Urinary Incontinence

Bladder control is a common yet complex problem that can seriously affect a person's life. Fortunately, with today's high-tech procedures and powerful drugs, a diagnosis may simply mean the road to bladder control is challenging, rather than impossible. So read below to learn more about the available treatment options so you are better prepared when talking with your urologist.

What can be expected under normal conditions?

The urinary tract is similar to a plumbing system, with special pipes that allow water and salts to flow through them. The urinary tract includes the kidneys, two ureters, the bladder and the urethra.

The kidneys act as a filtration system for the blood, cleansing it of poisonous materials and retaining valuable glucose, salts and minerals. Urine, the waste product of the filtration, is produced in the kidney and flows through two 10- to 12-inch long tubes called the ureters, which connect the kidneys to the bladder. The ureters are about one-fourth of an inch in diameter and their muscular walls contract to make waves of movement that force the urine into the bladder. The bladder is expandable and stores the urine until it can be conveniently disposed of. It also is a one-way flap valve that allows unimpeded urinary flow into the bladder but prevents urine from flowing backward (vesicoureteral reflux) into the kidneys. It also closes passageways into the ureters so that urine cannot flow back into the kidneys. The tube through which the urine flows out of the body is called the urethra.

Urinary incontinence is the involuntary loss of urine. It is not a disease but rather a symptom that can be caused by a wide range of conditions. Incontinence can be caused by diabetes, a stroke, multiple sclerosis, Parkinson's disease, some surgeries or even childbirth. More than 15 million Americans, mostly women, suffer from incontinence. Although it is more common in women over 60, it can occur at any age. Most health-care professionals classify incontinence by its symptoms or circumstances in which it occurs. In the normal population, the incidence of incontinence in the female over 65 is more than 25 percent and in the male it is about 15 percent.

Stress incontinence: Stress urinary incontinence is the most common type of leakage. This occurs when urine is lost during activities such as walking, aerobics or even sneezing and coughing. The added abdominal pressure associated with these events can cause urine to leak. The pelvic floor muscles, which support the bladder and urethra, can be weakened, thus preventing the sphincter muscles from working properly. This can also occur if the sphincter muscles themselves are weakened or damaged from previous childbirth or surgical trauma. Menopausal women can also suffer from small amounts of leakage as a result of decreased estrogen levels. In men, the most common cause of incontinence is surgery on the prostate. This is more frequent after radical prostatectomy for cancer than after transurethral surgery for BPH.

Urge incontinence: Also referred to as "overactive bladder," urge incontinence is another form of leakage. This can happen when a person has an uncontrollable urge to urinate but cannot reach the bathroom in time and has an accident. At other times, running water or cold weather can cause such an event. Some people have no warning and experience leakage just by changing body position (e.g., getting out of bed). Overactive bladder is also associated with strokes, multiple sclerosis and spinal cord injuries.

Overflow incontinence: This type of incontinence occurs when the bladder is full, is unable to empty and yet leaks. Frequent small urinations and constant dribbling are symptoms. This is rare in women and more common in men with a history of surgery or prostate problems.

Functional incontinence: This type of incontinence is the inability to access a proper facility or urinal container because of physical or mental disability.

Mixed incontinence: Mixed incontinence refers to a combination of types of incontinence, most commonly stress and urge incontinence.

As with any medical problem, a good history and physical examination are critical. A urologist will first ask questions about the individual's habits and fluid intake as well as their family, medical and surgical history. A thorough pelvic examination looking for correctable reasons for leakage, including impacted stool, constipation and hernias will be conducted. Usually a urinalysis and cough stress test will be conducted at the first evaluation. If some findings suggest further evaluation, other tests may be recommended — such as a cystoscopy or even urodynamic testing. This outpatient test is usually done with a tiny tube in the bladder inserted through the urethra and sometimes with a small rectal tube, as well.

In most cases of incontinence, minimally invasive management (fluid management, bladder training, pelvic floor exercises and medication) is prescribed. However, if that fails, surgical treatment can be necessary.

Stress incontinence: One of the surgical treatments for this condition in males is the use of urethral injections of bulking agents to improve the function of the sphincter. The injections are done under local anesthesia and can be repeated. Unfortunately, the cure rate is only 10 to 30 percent. Another alternative is to perform a urethral compression procedure with the use of a vascular graft or a segment of cadaveric tissue to compress the urethra in the area between the scrotum and the rectum. The results are very preliminary and at this time only experimental. The most effective treatment for male incontinence is implantation of an artificial sphincter. The device is inserted under the skin and consists of a cuff around the urethra, a fluid-filled, pressure-regulating balloon in the abdomen and a pump in the scrotum which is controlled by the patient. The fluid in the abdominal balloon is transferred to the urethra cuff, closing the urethra and preventing leakage of urine.

Stress incontinence in the female is treated at the beginning with behavior modification and pelvic exercise. Sometime techniques like biofeedback or electrical stimulation of the pelvic muscles can help. But when the symptoms are more severe and conservative measures are not helping the treatment is surgery. In selected cases bulking agents can be used to increase continence. The operation is done under local anesthesia and is minimally invasive but the cure rates are lower compared to open surgical procedures.

Anterior repair (Kelly plication) is a common option used by gynecologists but has not given good long-term results. Another option is abdominal surgery (Burch suspension) in which the vaginal tissues are affixed to the pubic bone. The long-term results are good but the surgery requires longer recuperation time and is generally only used when other abdominal surgeries are also required. The most common and most popular surgery for stress incontinence is the sling procedure. In this operation a strip of tissue is applied under the urethra to provide compression and improve urethral closure. The operation is minimally invasive and patients recuperate very quickly. The tissue used to create the sling can be a segment of the patient's abdominal wall, specially treated fascia, skin from a cadaver or a synthetic material.

Urge incontinence: For urge incontinence there is a large array of treatment options available. The first step should be behavior modification — drinking less fluids; avoiding caffeine, alcohol or spices; not drinking at bedtime and urinating around the clock and not at the last moment. Exercising the pelvic muscle (Kegel exercises) also helps. It is important to keep a log on the frequency of urination, number of accidents, the amount lost, the fluid intake and the number of pads used if required. The mainstay of treatment for overactive bladder is medication. This consists of the use of bladder relaxants that prevent the bladder from contracting without the patient's permission. The most common side effect of the medication is dryness of the mouth, constipation or changes in vision. Sometimes, reduction of medication takes care of the side effects.

Other alternatives can be considered in patients who fail to respond to behavior modification and/or medication. A new and exiting technology is the use of a bladder pacemaker to control bladder function. This technology consists of a small electrode that is inserted in the patient's back close to the nerve that controls bladder function. The electrode is connected to a pulse generator and the electrical impulses control bladder function. There is more than 60 to 75 percent cure or improvement with this technology. In more difficult cases, the bladder can be made bigger using a segment of small intestine. This operation, called augmentation cystoplasty, is very successful in curing incontinence but its main drawback is the need in 10 to 30 percent of the patients to perform self-catheterization to empty their bladder.

Overflow incontinence: For overflow incontinence, the treatment is to completely empty the bladder and prevent urine leakage. Patients with diabetic bladder or patients with prostatic obstruction often develop this type of incontinence. Overflow incontinence due to obstruction should be treated with medication or surgery to remove the blockage. If no blockage is found, the best treatment is to instruct the patient to perform self-catheterization a few times a day. By emptying the bladder regularly the incontinence disappears and the kidneys are protected.

The goal of any treatment for incontinence is to improve quality of life for the patient. In most cases, great improvements and even cure of the symptoms are possible. Medical therapy is usually effective, but not if the patient sips fluids all day and does not time their urination. Similarly, large shifts in weight gain and activities that promote abdominal and pelvic straining put any repair to the test and cannot be expected to stand the test of time. Positive, long-term outcomes can almost be assured with common sense, proper body mechanics and care.

Medical treatment of overactive bladder (urgency and urge incontinence) can be very successful, but factors like prior surgery, lack of hormones, neurological conditions and age may make the treatment less effective. There are mild complications from medications, including constipation and dryness of the mouth that some patients cannot tolerate. Surgery, like the insertion of a bladder pacemaker, can result in 50 to 70 percent cure or great improvement of the symptoms. Enlargement of the bladder using a segment of intestine may cure the urgency incontinence in more than 80 percent of the cases but the main drawback is the need in 10 to 30 percent of the patients to perform self-catheterization for the rest of their life. It is sometimes the only choice when other treatments fail.

Surgery for urinary incontinence in the male like the artificial sphincter can cure or greatly improve more than 70 to 80 percent of the patients. Prior radiation, bladder malfunction and/or scar tissue in the urethra may result in a deterioration of the results. Being a mechanical device, it may require modification over time.

Surgery for urinary incontinence (stress incontinence) in the female is in general very successful, but choosing the proper procedure is important. Many patients with stress incontinence also have other conditions like bladder prolapse, rectocele or uterine prolapse that must be treated at the same time. The combination of urgency incontinence symptoms requires medical treatment first to try to improve the symptoms. The procedure of choice will depend on multiple factors, like the need for abdominal surgery for other conditions, the degree of incontinence, the degree of mobility of the urethra and bladder and the surgeon's personal experience. For simple stress incontinence with mild to moderate urethral incontinence, a sling is the procedure of choice. The patient can expect more than 80 to 90 percent cure or great improvement. Injectables can cure 30 percent of patients but may require multiple applications.

It is a substance used to inject under the urethra to improve urinary continence.

An artificial sphincter is a patient-controlled device made of silicone rubber that has:

• an inflatable cuff that fits around the tube through which urine leaves the body (urethra) close to the point where it joins the bladder
• a balloon that regulates the pressure of the cuff
• a bulb to control inflation and deflation of the cuff

The balloon is placed within the pelvic space, and the control bulb is placed in the scrotum of a male or the external vaginal lips of a female.

The cuff is inflated to keep urine from leaking. When urination is desired, the cuff is deflated, allowing urine to drain out.

What are bladder relaxants?

They are medications used to improve the urgency and frequency of urination.

Where can I get more information?

AUA Guidelines Patient Guides: Female Stress Urinary Incontinence

Common misspellings: prostrate

Reviewed September, 2003

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Glossary Terms

abdomen:
	Also referred to as the belly. It is the part of the body that contains all of the internal structures between the chest and the pelvis.
anesthesia:
	Induced loss of sensitivity to pain in all or a part of the body for medical reasons.
artificial sphincter:
	Device used for treatment of urinary incontinence. Consists of three components: a pump, balloon reservoir and a cuff that encircles the urethra and prevents urine from leaking out.
biofeedback:
	A procedure that uses electrodes to help an individual gain awareness and control of their pelvic muscles.
bladder:
	The balloon-shaped pouch of thin, flexible muscle in which urine is temporarily stored before being discharged through the urethra.
bladder control:
	The ability to control the timing of urination. Also referred to as continence.
bladder prolapse:
	When the bladder slips out of its correct position.
bladder relaxants:
	Medications used to improve urgency and frequency to urinate.
bladder training:
	A behavioral technique that teaches the patient to urinate on a regular schedule and to empty the bladder completely.
bulking agent:
	Substance injected under the urethra to improve urinary control (continence).
cadaver:
	A dead body; especially one intended for dissection.
cadaveric:
	Deceased.
cancer:
	An abnormal growth that can invade nearby structures and spread to other parts of the body and may be a threat to life.
catheter:
	A thin tube that is inserted through the urethra into the bladder to allow urine to drain or for performance of a procedure or test, such as insertion of a substance during a bladder X-ray.
catheterization:
	Insertion of a narrow tube through the urethra or through the front of the abdominal wall into the bladder to allow urine drainage.
constipation:
	A condition in which a person has difficulty eliminating solid waste from the body and the feces are hard and dry.
continence:
	The ability to control the timing of urination or a bowel movement.
contract:
	To shrink or become smaller.
cyst:
	An abnormal sac containing gas, fluid or a semisolid material. Cysts may form in kidneys or other parts of the body.
cystoscopy:
	Also known as cystourethroscopy. An examination with a narrow, flexible tube-like instrument passed through the urethra to examine the bladder and urinary tract for structural abnormalities or obstructions, such as tumors or stones.
diabetes:
	A medical disorder that can cause kidney failure.
diabetic:
	Having diabetes, a medical disorder that causes the body to produce an excessive amount or urine.
estrogen:
	Female hormone produced by the ovaries.
fascia:
	A band of connective tissue covering or binding together parts of the body.
gene:
	The basic unit capable of transmitting characteristics from one generation to the next.
glucose:
	A simple sugar produced in animals by the conversion of carbohydrates, proteins and fats.
graft:
	Healthy skin, bone or tissue taken from one part of the body to replace diseased or injured tissue removed from another part of the body.
gynecologist:
	A physician who specializes in treating female health.
hernia:
	Condition in which part of an internal organ projects abnormally through the wall of the cavity that contains it.
hormone:
	A natural chemical produced in one part of the body and released into the blood to trigger or regulate particular functions of the body. Antidiuretic hormone tells the kidneys to slow down urine production.
impacted stool:
	Feces pressed together so tightly in the intestines that they cannot be eliminated in a bowel movement.
incontinence:
	Loss of bladder or bowel control; the accidental loss of urine or feces.
intestine:
	The part of the digestive system between the stomach and the anus that digests and absorbs food and water.
invasive:
	Having or showing a tendency to spread from the point of origin to adjacent tissue, as some cancers do. Involving cutting or puncturing the skin or inserting instruments into the body.
ions:
	Electrically charged atoms.
kidney:
	One of two bean-shaped organs that filter wastes from the blood and discharge these waste products in urine. The kidneys are located near the middle of the back. The kidneys send urine to the bladder through tubes called ureters.
kidneys:
	One of two bean-shaped organs that filter wastes from the blood and discharge these waste products in urine. The kidneys are located near the middle of the back. The kidneys send urine to the bladder through tubes called ureters.
local anesthesia:
	Loss of sensation only in one part of the body induced by application of an anesthetic agent.
multiple sclerosis:
	A serious progressive disease of the central nervous system.
neurologic:
	Pertaining to the nervous system.
neurological:
	Pertaining to the nervous system.
overactive bladder:
	A condition in which the patient experiences two or all three of the following conditions: urinary urgency, urge incontinence or urinary frequency--defined for this condition as urination more than seven times a day or more than twice at night.
pelvic:
	Relating to, involving or located in or near the pelvis.
pelvic examination:
	Assessment of the inner organs of the pelvis by vaginal examination.
pelvic floor muscles:
	Muscles that support the bladder.
pelvic muscles:
	Muscles around the rectum.
prostate:
	In men, a walnut-shaped gland that surrounds the urethra at the neck of the bladder. The prostate supplies fluid that goes into semen.
prostatectomy:
	Surgical procedure for the partial or complete removal of the prostate.
prostatic:
	Pertaining to the prostate.
prostatism:
	A disorder of the prostate gland, especially enlargement that block or inhibits urine flow.
pubic bone:
	Also referred to as the pubis. Lower front of the hip bone.
radiation:
	Also referred to as radiotherapy. X-rays or radioactive substances used in treatment of cancer.
radical:
	Complete removal.
rectal:
	Relating to, involving or in the rectum.
rectocele:
	A herniation of the rectum into the vagina.
rectum:
	The lower part of the large intestine, ending in the anal opening.
reflux:
	Backward flow of urine. Also referred to as vesicoureteral reflux (VUR). An abnormal condition in which urine backs up from the bladder into the ureters and occasionally into the kidneys, raising the risk of infection.
scrotum:
	Also referred to as the scrotal sac. The sac of tissue that hangs below the penis and contains the testicles.
self-catheterization:
	Inserting a thin, flexible tube into the bladder through the urethra to allow drainage of urine.
sling:
	Creation of a hammock through the vagina to improve closure of the urethra.
sling procedure:
	Surgical methods for urinary incontinence involving the placement of a sling, made either of tissue obtained from the person undergoing the sling procedure or a synthetic material.
sphincter:
	A round muscle that opens and closes to let fluid or other matter pass into or out of an organ. Sphincter muscles keep the bladder closed until it is time to urinate.
sphincter muscle:
	Circular muscle that helps keep urine from leaking by closing tightly like a rubber band around the opening of the bladder.
stool:
	Waste material (feces) discharged from the body.
stress incontinence:
	Also referred to as stress urinary incontinence. The most common type of incontinence that involves the leakage of urine caused by actions--such as coughing, laughing, sneezing, runnig or lifting--that put pressure on the bladder from inside the body. Can result from either a fallen bladder or weak sphincter muscles.
tissue:
	Group of cells in an organism that are similar in form and function.
transurethral:
	Through the urethra. Several transurethral procedures are used for treatment of BPH. (See TUIP, TUMT, TUNA or TURP.)
transurethral surgery:
	Surgical procedure where a lighted tube is inserted through the urethra into an organ. Serves as a diagnostic and therapeutic role in the treatment of various conditions.
ureter:
	One of two tubes that carry urine from the kidneys to the bladder.
ureteral:
	Pertaining to the ureter. Also referred to as ureteric.
ureters:
	Tubes that carry urine from the kidneys to the bladder.
urethra:
	In males, this narrow tube carries urine from the bladder to the outside of the body and also serves as the channel through which semen is ejaculated. Extends from the bladder to the tip of the penis. In females, this short, narrow tube carries urine from the bladder to the outside of the body.
urethral:
	Relating to the urethra, the tube tha carries urine from the bladder to outside the body.
urge incontinence:
	Also referred to as urge urinary incontinence. Wetting. Involuntary urinary leakage when the bladder contracts unexpectedly by itself. The inability to hold urine long enough to reach a restroom.
urinalysis:
	A test of a urine sample that can reveal many problems of the urinary system and other body systems. The sample may be observed for physical characteristics, chemistry, the presence of drugs or germs or other signs of disease.
urinary continence:
	Ability to control urination.
urinary incontinence:
	Involuntary loss of urine associated with a sudden strong urge to urinate.
urinary incontinence:
	Inability to control urination.
urinary tract:
	The system that takes wastes from the blood and carries them out of the body in the form of urine. Passageway from the kidneys to the ureters, bladder and urethra.
urinate:
	To release urine from the bladder to the outside. Also referred to as void.
urine:
	Liquid waste product filtered from the blood by the kidneys, stored in the bladder and expelled from the body through the urethra by the act of urinating (voiding). About 96 percent of which is water and the rest waste products.
urodynamic test:
	Measures the bladder's ability to hold and release urine.
urodynamic testing:
	Procedures designed to provide information about a bladder problem. Measures of the bladder's ability to hold and release urine.
urologist:
	A doctor who specializes in diseases of the male and female urinary systems and the male reproductive system.
uterine prolapse:
	The displacement of the uterus from its normal position within the pelvis.
vagina:
	The tube in a woman's body that runs beside the urethra and connects the uterus (womb)to the outside of the body. Sometimes called the birth canal. Sexual intercourse, the outflow of blood during menstruation and the birth of a baby all take place through the vagina.
vas:
	Also referred to as vas deferens. The cordlike structure that carries sperm from the testicle to the urethra.
vascular:
	Having to do with blood vessels.
vascular graft:
	Transplanted tissue used to replace damaged or diseased blood vessels.
vesicoureteral reflux:
	Also referred to as VUR. An abnormal condition in which urine backs up from the bladder into the ureters and occasionally into the kidneys, raising the risk of infection.
void:
	To urinate, empty the bladder.

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