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Urinary Incontinence: Treatments to Take Control of Your Bladder

Urinary Incontinence: Treatments to Take Control of Your Bladder

January 24, 2014
12:00 p.m. – 1:00 p.m. (EST)

  • Sneha Valsh, MD

Urinary incontinence affects between 13 and 17 million adult Americans every day. The severity of urinary incontinence can range from leaking a little when you sneeze or cough to having an urge to urinate so strong that you aren’t able to make it to a bathroom in time. Many times it is both symptoms. The risk of public embarrassment can keep people away from doing social activities with their family and friends. If you’re frustrated by bladder control problems, getting help might be easier than you think.

Incontinence usually happens because of problems with muscle and nerves that help to hold and release urine. Urine may escape with less pressure than usual if the muscles of the wall of the bladder contract are damaged, causing a change in the position of the bladder. Stress incontinence refers to instances where coughing, laughing, sneezing, exercising, or other movements put pressure on your bladder and cause you to leak. This type of incontinence is most common among women and often develops as a result of childbirth or pregnancy. 

Individuals who have a sudden urge to urinate followed by an involuntary loss of urine, may be experiencing urge incontinence. A common cause of urge incontinence is inappropriate bladder contractions or abnormal nerve signals. This can mean that your bladder empties while you are sleeping after only drinking a small amount of water or if you hear or touch running water. Overactive bladder occurs when abnormal nerves send signals to the bladder at the wrong time, causing its muscles to squeeze without any sort of warning. Overflow incontinence is a term used when people cannot completely empty their bladders. They constantly feel as if they have a full bladder at all times. This is often a result of diabetes caused by weakening muscles.

There are a few risk factors that increase your chances of developing urinary incontinence. Being obese puts more pressure on the muscles around your bladder, which weakens them causing more leakage. Urinary incontinence is more common in women due to certain facets of their lives such as pregnancy, childbirth and menopause. However, there is a higher incidence of bladder control problems for men who have an enlarged prostate. Smokers are more likely to develop a chronic cough, which places stress on the urinary sphincter, leading to incontinence. There are also some other medical conditions such as multiple sclerosis, Alzheimer’s disease, Parkinson’s disease, stroke, urinary tract infections or injury that can harm bladder nerves or muscles. 

Here at Cleveland Clinic Florida, we offer many treatments to help control your bladder. Sacral nerve stimulation can help when other therapies such as Kegel exercises, medication and diet changes don’t. This type of treatment involves the electric stimulation of the nerves that control the bladder. A neurotransmitter device is implanted under the skin and transmits mild electric impulses through a wire close to the sacral nerve. These impulses influence the bladder sphincter and pelvic muscles, controlling the bladder. This treatment does not cure urinary incontinence but reduces the number of wetting episodes. 

About the Speaker

Sneha Vaish, MD is a board-certified urologist and Head of the Section of Female Urology and Voiding in the Department of Urology at Cleveland Clinic Florida. She completed her completed her residency in urology at the Mayo Clinic Arizona in Scottsdale followed by a fellowship in urinary incontinence and voiding dysfunction at the Metro Urology Group in St. Paul.  Dr. Vaish graduated from medical school at Rush University Medical College in Chicago. Her special interests include female incontinence, neuromodulation, pelvic disorders, urinary incontinence, uterine prolapse, voiding dysfunction in adults and vaginal reconstructive surgery.
Let’s Chat About Urinary Incontinence
Welcome to our chat ‘Urinary Incontinence: Treatments to Take Control of Your Bladder’ with Cleveland Clinic Florida urology specialist, Sneha Vaish, MD.  Dr. Vaish is now joining us and we are thrilled to have her today for this chat.  Let’s begin with the questions.

Overactive Bladder

goldfish: I use Oxybutynin to successfully control an overactive bladder, but I produce a lot more urine at night than during the day. How can I use this drug to balance out the urine production more evenly so that I don't have to get up so often at night..
Sneha_Vaish,_MD: Initial treatment should be a change of fluids and types of fluids. Decrease caffeine in general, drink more at daytime, stop drinking 3 hours before bed, rest your legs (elevate for 20 min) in the middle of the day to get more fluid off.  Most people do make more urine at night, this is normal.  So, we try to shift the intakes. Taking the medications at night can help as well.
goldfish: Oxybutynin no longer controls my overactive bladder. What are your thoughts about using a homeopathic medication such as URI-CONTROL by Heel, Inc?
Sneha_Vaish,_MD: I am not familiar that any of the homeopathic drugs are helpful at this point. I am never opposed to trying a new remedy if it works and has no side effects. There are other drugs that have been proven to help. Oxybutynin came out about 30 years ago, and we have newer more improved drugs since that time.
Diana53: I cannot feel when my bladder is full-until it is almost too late (sometimes I don't make the MAD DASH!) What do I do???
Sneha_Vaish,_MD: Evaluate how often you are voiding. Normal is every 3 hours, retrain your bladder to ensure you are voiding in this time frame. Start performing Kegel exercises to help control the urge if the above fails. We can add medications and a formal biofeedback program.  Also avoid bladder irritants (coffee, tea, soda)
goldfish: You mentioned that Oxybutynin is over 30 years old. What newer medications do you recommend for over-active bladder?
Sneha_Vaish,_MD: There are a number of medications on the market: VESIcare®, Sanctura®, Toviaz®, Detrol®, Gelnique®, Enablex®, Myrbetriq®, BOTOX®. I choose to change medications based on your drug plan and side effects

Stress and Urge Incontinence

RMB118720: My 78 year old mother suffers with stress and urge incontinence. She has been to several different doctors for the past 10 years and has tried VESIcare®, TVT procedure, biofeedback, and a specialized diet. Unfortunately, she still has not seen any improvement. She cannot make it to the restroom, and now uses a portable toilet set up by her chair. She seldom leaves her home and her entire quality of life is affected. Are there any treatments that might provide her some relief?
Sneha_Vaish,_MD: We can often augment the sling with a bulking agent in the office that improved the stress incontinence.  Medications can help, she may need to try another drug or consider more aggressive treatment for her overactive bladder.  We are using a new acupuncture/needle treatment in the office to improve urge or BOTOX to help improve overactive bladder.   
Sylvia24: My husband has Multiple Myeloma and had a tumor pressing against the nerve that controls urination and bowel. He has had radiation to the area and has still not regained any feeling, so he has in continence of both bladder and bowel. Is there anything that could be done for him, and could you tell me who would be of greater help to him, a urologist, neurologist, or gastroenterologist? Could you tell me the best thing to do, and refer me to a doctor that could help him? He has to have x- rays and MRIs to follow his disease so I am pretty sure the stimulation device will not work for him.
Sneha_Vaish,_MD: A stimulator is not is his best interest as he will continue to need MRI's in the future.  What is the next step from the oncologist? Unfortunately, he/she needs to give you a realistic future about the tumor and amount of success moving forward.  The urologist -- we can divert his urine and help to control the incontinence in other ways, but with a large tumor pressing on the spine -- relief will likely only come from removal or shrinkage.  Is it time to see a Neurosurgeon?  These are the questions you have to ask your oncologist?
clingner: I am 55 and have both stress and urge incontinence- I have been tested and would well qualify for surgery. I have Ehlers Danlos- feel I would stretch ligament back out and fearful the urge would get worse- tell me about fillers and their success - risks and benefits
Sneha_Vaish,_MD: Ehlers Danlos will stretch your ligaments, won't stretch a sling made of polypropylene mesh.  Bulking agents are good to help augment slings and appropriate for patients with a intrinsic sphincter deficiency.  When used in younger patients (you are younger) are not going to be long lasting. Only 50% of patients are still dry at 2 years.  Also, the bulking agents will not help the urge component of the leakage. 

Incontinence after Prostate Surgery

howlandl: After prostate surgery in 2007, my bladder problems have escalated. I have tried tamsulosine with no success. I have heard that oxybutynin and Detrol® may help. Any opinions?
Sneha_Vaish,_MD: My first question would be what kind of prostate surgery?
The question is whether or not your bladder problems related to leakage or urinary frequency/urgency?
howlandl: Urinary urgency
Sneha_Vaish,_MD: If the urgency is an issue, you should be changed to a medication to treat overactive bladder including Detrol® or Oxybutynin.
kth: I am now 74, robotic radical prostatectomy 7 yrs ago. Incontinent ever since, post surgery my incontinence pad usage is rising from 1 to the current 2-3/day with urge and stress incontinence with constant dribbling. PSA is still undetectable. What are the most recent success rates and risks associated with the male sling and what are other key factors is selecting an urologist to perform the procedure?
Sneha_Vaish,_MD: Male sling are best suited for patient with 1-2 pads per day, but there is a new sling (VIRTUE) that can get patients who are wetter dryer. The success rates I tell my patients are between 75-80% dry.  Most people want to hear 100%. That just does not exist. Male sling are really a great surgery, and have improved quality of life for many patients tremendously. When evaluating a surgeon, ask how many they have done the procedure, the success rates, and decide if you like the surgeon. In your case, you do have mixed incontinence and you may need medications post sling to get you dryer, so be aware.
kit: Would Urgent®PC be considered for post prostate surgery, or is male sling preferable?
Sneha_Vaish,_MD: No, Urgent®PC is to treat overactive bladder and urge incontinence, it will not help stress incontinence for either male or female patients. Post prostatectomy incontinence is still best served by either a male sling or artificial sphincter. 

Kegel Exercises

cyclist: Is the Kegel maneuver applicable to both women and men?
Sneha_Vaish,_MD: Kegel exercises are recommended for both male and female patients and often improve symptoms’ for both Stress incontinence and urge incontinence at about 50%
RMB118720: I'm 48 years old, mother of 2 children, and experience some leakage when I cough and sneeze. If I'm running a 5K, and really push myself, I'm unable to control my urine and have had accidents. The condition is still mild. Do you recommend treatment at my age before the condition becomes worse?
Sneha_Vaish,_MD: You are describing classic stress urinary incontinence. Initial treatment should be with Kegel exercise if it is still mild, and often working with a therapist you will see more improvements.  The gold standard treatment would be placement of a sling, either with your own tissue or with mesh and this would correct the problem with 80 - 90% success rates. I do recommend treatment sooner than later, but mostly to improve your quality of life.  Why would you want to spent another 10 - 15 years being wet especially if you are active?

Acupuncture and Urinary Incontinence

RunnerChick: Can you elaborate on the acupuncture? I'm all for a treatment that doesn't involve drugs.
Sneha_Vaish,_MD: It’s called Urgent®PC -- a small needle is placed near the posterior tibial nerve and delivers 30 min of electrical stimulation to the never that controls the bladder. This is done once a week for 12 weeks then a maintenance dose is done every 4-6 weeks. People tolerate this well and rates of success are 60% improvements.

Bladder Control Devices

Skippy: I had an AMS Urinary Control System implanted about 20 months ago. It worked perfect for about 12 months (no leakage at all) then I started leaking and currently up to two Depend pads a day. No leaking at rest. I have consulted four different Urologists and all have different opinions on how to stop the leaking. My question is what are the possible causes that are causing the AMA system not to work and are their experienced Urologists who successfully trouble shoot the implanted AMS Urinary Control Systems?
Sneha_Vaish,_MD: The AMS system can stop functions for various reasons - fluid can escape the devise, and it’s too low.  Tissue atrophy can happen at the level of the cuff and cause recurrent incontinence.  Yes, there are many ways to trouble shoot the devise.  But, if you talk to 10 different doctors, you will get 10 different answers. Also, did you have a bladder function test prior to the procedure to ensure that this is not a side effect of overactive bladder?
marilynmann: My husband had a prostatectomy for early stage prostate cancer in August 2012. He has urinary incontinence and is considering whether to have surgery. Can you tell me the pros and cons of the artificial sphincter versus the sling. I read some reviews of the sling and apparently perineal pain is more common after the sling than the artificial sphincter surgery, and also more likely to still have incontinence.
Sneha_Vaish,_MD: Sling versus AUS -- this is very debated by many of my patients. Slings: no devise to activate better for low level of incontinence preferred by patients -- but lower continence rates (80%)AUS: more parts and more points that can go wrong gold standard -- 90 - 95% dry. Both:  take 1.5 hours to place both are foreign bodies. Both can be infected and have to be removed. Perineal pain is higher in sling (but were the first generation ones that had bone anchors -- these are not used as often)

Bowel Incontinence

Sylvia24: Radiation has been done on the tumors last month. There has been no relief and he is now using disposable catheters. The bowel is our major situation now. He has not regained any feeling and this has greatly interfered with our ability to live a regular lifestyle. Can you recommend a Doctor to help us with this?
Sneha_Vaish,_MD: I would recommend seeing a colorectal surgeon. 


Moderator: I'm sorry to say that our time with Sneha Vaish, MD, is now over. Thank you again, Dr. Vaish for taking the time to answer our questions today about urinary incontinence and treatments to take control of your bladder.

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