September 17, 2014


URINARY INCONTINENCE

Overview Classification Therapy for urge incontinence Therapy for stress incontinence Conclusion Faculty


THERAPY FOR URGE INCONTINENCE

Therapy for urge incontinence usually begins with attempts to retrain the bladder and its behavior. Awareness and strengthening exercises are used to develop proper function of the pelvic muscles, bladder and sphincter valve. These muscles play an important role in the conscious and unconscious control of bladder emptying. These exercises are generally referred to as Kegel's exercises and require mastery of movements of the pelvic floor muscles. Retraining the bladder and voiding habits takes dedicated practice and time but is associated with a high success rate in those who expend the effort.

Coupled with bladder and pelvic floor retraining, certain medicines have proven helpful in controlling urgency and urge incontinence. A class of medicines called anticholinergics help to decrease the number of voiding and incontinence episodes as well as the volume of any leakage. Oxybutinin (Ditropan®) and tolterodine (Detrol®) are the most commonly used. While these medicines are helpful for bladder control, certain side effects can be bothersome. Dry mouth, dizziness and blurred vision can decrease the tolerability of these agents. Other medicines helpful in controlling the bladder muscles and sphincter are hyoscyamine (Levsin®), amitriptyline (elavil®), imipramine (tofranil®), and flovoxate (urispas®).

As an adjunct to pelvic floor training and medication, biofeedback modalities are often helpful for managing urgency and urge incontinence. This technique uses audible or visual reinforcement in developing control of the pelvic floor muscles. A device that can measure pelvic muscle pressure or activity is inserted into the vagina or rectum. Conscious contraction of the pelvic floor muscles causes a bell or beep to sound, or a series of lights to flash. This sequence helps to reinforce the proper responses for building muscle and bladder control. Therapy is usually started in the office setting and continues with a home program. Certain devices are portable and suitable for home therapy.

Results of biofeedback vary from about 50-80%. This wide variation among studies is likely due to the heterogeneity of incontinence disorders in participating patients. Nevertheless, many people find benefit in this therapy which is essentially non-invasive and free from side effects.

For those patients with persistent urgency, frequency and urge incontinence in the face of conservative therapy, an exciting new therapy called Sacral Neuromodulation is proving effective. This therapy is directed at the nerves controlling the bladder. By using a small electrical current similar to that in a heart pacemaker, bladder behavior can be improved. The therapy is first tested temporarily as an outpatient, and if successful, is followed by permanent implantation of a small stimulator near the tailbone. Results of this therapy have been outstanding with excellent durability.

In certain cases, bladder surgery can be helpful to control the most difficult symptoms of urinary frequency and urge incontinence. Augmentation cystoplasty is one such operation associated with satisfactory results.

Therapies for urge incontinence continue to emerge as we continue to enhance our understanding and appreciation of the causes, severity and prevalence of the condition.

Kegel's exercises

In 1956, Arnold Kegel described the exercises that bear his name. The technique begins by identifying the muscles of the pelvic floor (levator ani). In women, this can be done by feeling with a finger, the muscles to the side and floor of the vagina (pubococcygeus). Contraction of these muscles will cause the floor of the pelvis to rise. One should be able to do this without contribution from the abdominal or buttock muscles. It is helpful to begin learning the technique with practice in the supine (lying-down) position and progress to sitting and standing. While supine, the abdomen should not contract and the buttocks should not elevate with initiation of a Kegel's contraction. One can also localize this movement by attempting to slow or stop the urine stream during voiding.

When the correct movement is learned, two different types of contractions can be performed.

    Quick contractions: Tighten and relax the muscles as rapidly as possible
    Slow contractions: Tighten the muscle and hold it for a count of 3-10 as you improve.

Be sure to completely relax the pelvic floor before initiating another contraction. One can perform sets of exercise in the morning and evening. The important thing is to set aside dedicated time for practice. This skill takes time to acquire and is only as valuable as the effort put towards mastering it. Results can be seen after as little as 2-3 weeks but may not be fully appreciated for 3-6 months.

Pelvic floor training helps one develop strength and awareness of the supporting muscles of the pelvis which are intimately related to bladder and rectal function. Regarding urge incontinence, it helps to unmask and facilitate local reflexes that inhibit unwanted bladder contractions. For stress incontinence due to slight weakness of the sphincter, increasing pelvic floor strength may help to combat exertional leakage if one can initiate contraction prior to cough, sneeze, lifting or other exertion.

Reference:
Kegel, AH. Stress incontinence of urine in women: physiologic treatment. J. Int. Coll. Surg. 1956, 25:487.


Sacral Neuromodulation

Sacral nerve modulation (Interstim®, Medtronic Inc., Columbia Heights, MN) is an exciting new therapy for intractable urinary urgency, frequency, and urge incontinence. It is also effective for reversing cases of idiopathic urinary retention (failure to empty the bladder). This therapy borrows many of the concepts and technology of heart pacemakers. In a similar fashion to a pacemaker, a device delivers small repetitive electrical impulses to stimulate nerves to the bladder. These nerves travel just beneath the sacrum (tail bone).

The value of this therapy was recognized more than a decade ago and has gradually developed to its current state. Experience in Europe over the last five years has contributed to growing success in this country.

One of the advantages of this therapy is that the stimulation can be given on a temporary basis following a minor office procedure. A trial of therapy, called a "test stimulation" can be conducted for up to one week to allow assessment of success and suitability for permanent implantation. The results can be dramatic, with significant resolution of frequency episodes and leakage. This procedure takes about 30 minutes and involves placement of a thin wire lead near a nerve to the bladder. This lead is then connected to a device similar in size to a pager that delivers the impulses.


Equipment for test stimulation of sacral nerves

During the test phase a diary is kept charting the frequency and volume of urination as well as leakage episodes and any pain symptoms. When completed, the test stimulation lead is removed painlessly, the stimulator returned and the results reviewed.

If test stimulation is successful, one can consider permanent device implantation. This latter phase involves a short surgery to place a more durable stimulator lead near the nerve previously tested.

This lead is then tunneled under the skin of the lower back and connected to a pulse generator similar in size to a pocket watch with a thickness of ˝ an inch. This "IPG" is positioned beneath the skin of the upper buttock below the belt line.


Schematic of neural stimulator in position

It does not impair sitting, sleeping, exercise or other activities. Both patient and physician can control device performance to achieve optimal results.

Important aspects of this therapy are its reversibility and minimal invasiveness. It does not change any of the body's structures and uses the intrinsic "wiring" of the body and bladder to achieve the desired effect.

References:

  1. www.medtronic.com/neuro/interstim/
  2. Weil, EH et al, Sacral Root Neuromodulation in the Treatment of Refractory Urinary Urge Incontinence: A Prospective Randomized Clinical Trial. Eur Urol. 37(2):161, 2000.
  3. Shaker H, Hassouna MM: Sacral root neuromodulation in the treatment of various voiding and storage problems. Int Urogynecol J Pelvic Floor Dysfunct 10(5):336, 1999.
 

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