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Bladder Blues: Don't Let Urinary Incontinence Get You Down

Online Health Chat with Megan Tarr, MD

November 26, 2012

Introduction

Millions of women suffer from involuntary loss of urine, called urinary incontinence. Some women may lose a few drops of urine while running or coughing. Others may feel a strong urge to urinate just before losing a large amount of urine. Many women experience both symptoms. Incontinence can be slightly bothersome or totally debilitating. It keeps some women from enjoying many activities with their families and friends. Urine loss can also occur during sexual activity, causing tremendous emotional distress.

As you age, there is a greater risk of urinary incontinence. Pregnancy and giving birth also can lead to urinary leakage. Other medical conditions, such as urinary tract and bladder infections, hormonal changes, obesity, diabetes and certain physical activities, can also result in urinary incontinence. Men also can be affected by urinary incontinence, particularly after treatment for prostate cancer.

Beyond Kegel exercises, women may seek relief through lifestyle changes, medications, certain mechanical devices and surgery. If you are having incontinence issues, Cleveland Clinic specialists can help you take back control.

For More Information

On Cleveland Clinic
In addition to wellness exams, professionals within Cleveland Clinic’s Center for Specialized Women's Health offer a variety of services, including evaluation and/or treatment of urinary incontinence/urine leakage and urinary tract infections/bladder symptoms, among many other conditions.

Cleveland Clinic gynecology care is ranked third in the nation by U.S.News & World Report, and has top ranking in Ohio. We offer care at convenient locations throughout Northeast Ohio.

In the Section of Urogynecology and Reconstructive Pelvic Surgery, our physicians have been performing a number of innovative urogynecology techniques for the diagnosis and treatment of urinary and fecal incontinence and pelvic floor disorders. Our department has one of the first American Board of Medical Specialties®-approved Urogynecology/Reconstructive Pelvic Surgery Fellowships in the country, and it represents one of the only urogynecology fellowship programs in this region of the Midwest.

Incontinence Treatment
Non-surgical treatments for incontinence include physical therapy and exercise with use of biofeedback, behavioral therapy and medications. Other patients who have stress or urge incontinence or a combination of these may benefit from specialized bladder control devices, injectable bulking agents, sling procedures and a multitude of innovative minimally invasive procedures.

No matter what kind of urinary incontinence you have, our specialists can offer effective treatment to help you.

On Your Health
MyChart®: Your Personal Health Connection, is a secure, online health management tool that connects Cleveland Clinic patients with their personalized health information. All you need is access to a computer. For more information about MyChart®, call toll-free at 866.915.3383 or send an email to: mychartsupport@ccf.org

A remote second opinion may also be requested from Cleveland Clinic through the secure Cleveland Clinic MyConsult® website. To request a remote second opinion, visit eclevelandclinic.org/myConsult


For Appointments

If you would like to make an appointment with Dr. Megan Tarr, or any of our other specialists in the Ob/Gyn and Women’s Health Institute, please call 216.444.6601. or request an appointment online by visiting www.clevelandclinic.org/appointments. Visit us online at my.clevelandclinic.org/obgyn.


About the Speakers

Megan Tarr, MD is a staff physician at Cleveland Clinic, and an OB/GYN specialist in the Women’s Health Institute in the Section of Urogynecology. She specializes in prolapse and urinary incontinence, laparoscopic and robotic treatment of prolapse.

Dr. Tarr is board certified in obstetrics and gynecology. She completed her fellowship in female pelvic medicine and reconstructive surgery at Loyola University Medical Center, in Maywood, Ill after her residency in obstetrics and gynecology at University of Chicago Hospitals. Dr. Tarr is a graduate of Indiana University School of Medicine, in Indianapolis.


Let’s Chat About‘Take Back Control: Get Answers to your Urinary Incontinence Questions’

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Cleveland Clinic specialist Dr. Megan Tarr. We are thrilled to have her here today for this chat on urinary problems in women.


Urinary Incontinence Diagnosis

Grannyscott: During the day I can go for hours without needing to urinate, even during occasions where I may be drinking two or three cups of coffee at a meeting that lasts four or five hours. But, during the night I am up as often as six or seven times needing to urinate. Sometimes this urge occurs less than an hour after the last time I urinate—even though I empty my bladder as much as possible each time. I never have anything to drink after 7 p.m. or 8 p.m. I have joked to my friends that my bladder or my kidneys only work when I am in a horizontal position, but it is not funny to have such interrupted sleep. Do you have any thoughts about this?
Dr_Tarr: This is a common issue. You may be producing a greater amount of urine at night, and this is common as we age. We commonly ask women to keep a 24-hour diary of urine output to have this documented. We also commonly treat this condition with several of the same bladder medications that are used for daytime urge incontinence. In addition, there are other reasons that women awaken at night having to urinate. Other medical conditions, such as leg swelling, heart conditions and sleep apnea have to be ruled out.

goldfish: Is urge incontinence the same thing as an ‘overactive bladder’?
Dr_Tarr: Yes, these terms mean the same thing.

goldfish: Why does my problem of urge incontinence affect me only at night? I can go all day with no problem
Dr_Tarr: This is a difficult question to answer without knowing your full medical history. Please see my response to a previous question regarding night time urinary urgency and urge incontinence symptoms.

nancyh: Are usually weak muscles or possible nerve damage implicated in urinary leakage?
Dr_Tarr: Urinary incontinence can be due to both muscle and nerve damage.

Mad4U: At what point should I seek the advice of my doctor? I am 50 years old and have to wear pads everyday due to urinary leakage. I am annoyed with the problem!
Dr_Tarr: I usually tell women to see a doctor whenever they feel bothered by the symptoms. Often, a primary care physician or general gynecologist can start a treatment course for a woman. Urogynecologists and female urologists are also available to see a woman for an evaluation of urinary incontinence.

turtle: Does choice of beverage affect incontinence?
Dr_Tarr: In general, caffeine and carbonation (such as in coffee, tea, sodas and ‘energy’ drinks) are the major bladder irritants we identify when speaking with our patients. In addition, many women drink large amounts of water through out the day in an attempt to consume the recommended eight glasses of water per day. This ‘eight glass recommendation’ is not based upon much evidence, and consuming large volumes of fluid can make urge incontinence symptoms worse.


Urethral Prolapse

turtle: Is it normal for a slightly prolapsed urethra to bleed a little (spotting)? Will the regular use of topical estrogen heal this so that spotting will no longer occur? If not, then what if anything should be done? (Other tests have already ruled out blood in the urine and growths in the uterus.)
Dr_Tarr: Many conditions affecting the urethra can cause a small amount of bleeding. Several weeks of vaginal estrogen is commonly used to treat urethral prolapse and urethral caruncles (benign growths on the urethra). I agree with the evaluation of a bleeding source inside the uterus and in the bladder, ureters and kidneys.

turtle: Can you suggest anything to cure or fix a prolapsed urethra? Would Estring® be helpful?
Dr_Tarr: As I said before vaginal estrogen would be the correct treatment. Estring® may be helpful. My preference is to use a vaginal estrogen cream.


Prolapsed Bladder Diagnosis

Giles: What types of diagnostic tests are needed to determine if someone has a 'dropped bladder' or other organ? Can it be done without an MRI?
Dr_Tarr: Usually just a physical exam is sufficient. If a woman has an abnormality noted by her doctor on patient examination, we sometimes order a pelvic ultrasound or pelvic MRI. These tests can be helpful when an evaluation of fibroids, the uterine lining or the ovaries is needed.

nancyh: Can recurrent urinary infections be due to bladder prolapse?
Dr_Tarr: Yes, this can be true in some cases. If the prolapse involves the front wall of the vagina, the urethra (the tube through which we urinate) can become kinked, and cause a woman to not fully empty her bladder. This remaining urine could cause issues with recurrent infections.


Pelvic Floor Physical Therapy

Cat666: Can you suggest any exercises and/or medications that can help to empty the bladder?
Dr_Tarr: Many of the exercises that help the pelvic floor relax (for the purpose of bladder emptying) are taught by specialized pelvic floor physical therapists. One usually needs to first see a physician to obtain this referral. There are not many medications that are commonly used in women for this purpose.

klb: I have heard of a type of physical therapy to help with urinary leakage, but I’m not sure what is involved. Could you elaborate on this?
Dr_Tarr: Physical therapy, which is performed by specialized pelvic floor physical therapists, can be very helpful in treating stress incontinence, and, in some cases, urge incontinence. Women usually need to attend six to 12 weekly sessions where they work with a pelvic floor physical therapist who teaches them to contract their pelvic floor muscles. These physical therapists usually give my patients home exercises to perform daily. Success with physical therapy often depends on the woman's dedication to the therapy plan and the underlying severity of the urinary incontinence. Our pelvic floor physical therapists at Cleveland Clinic are excellent, and many of my patients return with marked improvement of their symptoms. Some even have a complete resolution of their symptoms.


Treatments for Urinary Incontinence

smbart: Is there any new, breakthrough medical treatment, besides medication to treat urinary incontinence?
Dr_Tarr: The treatment for urinary incontinence varies depending upon the type of urinary incontinence. Stress incontinence is urine leakage with anything that increases the pressure inside of your abdominal cavity (such as coughing, sneezing or lifting). Urge incontinence is leakage that is usually preceded by an urge to urinate. Many women have symptoms of both types of incontinence.

Urge incontinence is usually treated with behavioral modifications, some types of pelvic floor physical therapy, and medications as a first line of therapy. We also use sacral neuromodulation (an implantable pacemaker) and posterior tibial nerve stimulation for urge incontinence that does not respond to these first-line therapies.

In addition, botulinum toxin (Botox®) can also be injected into the bladder wall to treat severe cases. Stress incontinence can be treated with pelvic floor muscle exercises, continence pessaries (a device similar to a diaphragm that is inserted into the vagina), urethral bulking agents (injections meant to increase firmness) and surgery.

nancyh: What are your feelings on prolapsed bladder sling?
Dr_Tarr: There are several treatments for prolapse. Many women, after they have a child, have a degree of prolapse, even if they are not symptomatic. Depending on the degree of the prolapse and a woman's symptoms, we can treat with a pessary (a supportive device that is similar to a diaphragm), pelvic floor muscle exercises and surgery. The surgery performed for prolapse repairs can be performed vaginally or abdominally. In addition, this surgery can be performed with or without a permanent mesh. There are some risks and benefits associated with mesh use in prolapse repairs, and this is usually a long discussion I have with my patients. The American Urogynecology Society has an excellent patient education website that discusses many of the current concerns with mesh used in prolapse repairs (www.mypelvichealth.org).

smbart: If a person has numbness from the waist down due to back injuries, are there any special treatments you can suggest for both stress and urge incontinence?
Dr_Tarr: It sounds as if there is a neurological issue, given the numbness distribution. A full neurological exam with full history would need to be performed to better answer this question. In addition, further testing and imaging studies may be needed prior to answering your question.

You may wish to discuss this with our physicians in the spine center who deal frequently with these conditions. The web site is clevelandclinic.org/spine or you may call 866.588.2264 for an appointment.


Medications for Urinary Incontinence and Frequency

goldfish: My physician prescribed tolterodine tartrate (Detrol®) 2 mg, which I take at bedtime. This has helped a bit, and I'm able to sleep a little longer before having to get up. But I still have some urinary leakage. Do you have any suggestions? Should I switch medications?
Dr_Tarr: Tolterodine tartrate (Detrol®)is commonly used to treat urge incontinence, and we commonly use it to treat the bothersome nighttime symptoms. I would advise taking this medication two hours prior to bedtime. In addition, you may also find it helpful to stop drinking beverages three to four hours prior to bedtime. The medication dose also can be increased, if needed.

nancyh: Why would tramadol cut down on nighttime urination frequency?
Dr_Tarr: I am unaware of the medication tramadol being used to treat nighttime urination frequency. Tolterodine tartrate (Detrol®), especially if it is used several hours prior to bedtime, can be helpful.


Treatment for Bladder Prolapse

nancyh: What are your feelings on the prolapsed bladder sling?
Dr_Tarr: There are several treatments for prolapse. Many women, after they have a child, have a degree of prolapse, even if they are not symptomatic. Depending on the degree of the prolapse and a woman's symptoms, we can treat with a pessary (a supportive device that is similar to a diaphragm), pelvic floor muscle exercises and surgery. The surgery performed for prolapse repairs can be performed vaginally or abdominally. In addition, this surgery can be performed with or without a permanent mesh. There are some risks and benefits associated with mesh use in prolapse repairs, and this is usually a long discussion I have with my patients. The American Urogynecology Society has an excellent patient education website that discusses many of the current concerns with mesh used in prolapse repairs (www.mypelvichealth.org).


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Cleveland Clinic specialist Megan Tarr, MD is now over. Thank you, Dr. Tarr, for taking the time to answer our questions today about urinary incontinence in women.
Dr_Tarr: Thank you for attending this web chat today. I have enjoyed answering your questions.


Contact Information

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