Cleveland_Clinic_Host: Millions of women experience 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, sudden 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. Women experience urinary incontinence twice as often as men due to pregnancy and childbirth, menopause and the structure of the female urinary tract. At Cleveland Clinic, the nature and mix of treatment options are tailored to each individual patient and range from exercises to medication to surgery.
Courtenay Moore, MD, a female urology specialist, is one of only 30 board-certified fellowship trained women in female urology in the United States. She joined Cleveland Clinic after having completed a fellowship in female pelvic medicine and reconstructive surgery here. She received her medical degree from Albany Medical College in Albany, N.Y. She completed her residency training in urological surgery at Albany Medical Center in Albany, N.Y. Dr. Moore received several honors and awards during her training, including the American Foundation for Urologic Disease Research Scholar Grant and the Pfizer Scholar in Urology award.
Describing her practice in her own words, Dr. Moore says, “Being one of eight children has taught me many things, patience, flexibility, independence and the importance of individualism. But more importantly, it has taught me the value of listening. This holds true for medicine. One of the most important things that we can do for our patients is to listen and try to truly understand what they are saying.” Dr. Moore directs the Female Sexual Dysfunction Initiative at Cleveland Clinic and specializes in the treatment of incontinence. Dr. Moore sees patients at Cleveland Clinic’s main campus and Hillcrest Hospital. To make an appointment with Dr. Moore, call 216.444.5600.
For additional information about urinary incontinence, other urological conditions, and Cleveland Clinic Glickman Urological and Kidney Institute, please visit us on our website clevelandclinic.org/urology. To make an appointment with Dr. Moore, or any of the other specialists in our Glickman Urological and Kidney Institute, please call 216.444.5600 or toll-free 800.223.2273 x45600. You may also request an appointment online at www.clevelandclinic.org/appointments.
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Courtenay Moore, MD. We are thrilled to have Dr. Moore here today for this chat. She is considered an expert in the field of female urology, pelvic medicine and reconstructive surgery and directs the Female Sexual Dysfunction Initiative at Cleveland. Let’s begin with some general questions about urinary incontinence.
Urinary Incontinence Overview & Diagnosis
rosko: Would you please define urinary incontinence? Is it just minor leakage with coughing?
Speaker_-_Dr__Courtenay_Moore: Incontinence is the involuntary leakage of urine- any amount- small or large. Stress urinary incontinence is the involuntary leakage of urine with coughing or laughing. Urge incontinence is the involuntary leakage of urine after a sudden urge.
dialm: Is it unusual for incontinence to develop after a hysterectomy?
Speaker_-_Dr__Courtenay_Moore: No. It can occur in upwards 30% of patients. Luckily there are minimally invasive outpatient procedures to correct this problem.
stevieh: Is there any connection to allergies to ingested food or drink and increased frequency of urination?
Speaker_-_Dr__Courtenay_Moore: Caffeine and alcohol are considered to be bladder irritants and may cause urinary frequency.
ksp: Does IBS have an effect on my bladder?
Speaker_-_Dr__Courtenay_Moore: IBS can definitely affect the bladder. Once IBS is treated effectively, the bladder symptoms seem to resolve.
buckles: Are decaffeinated coffee and tea to be avoided to prevent urgency & frequency? What can you drink that doesn’t affect it?
Speaker_-_Dr__Courtenay_Moore: Caffeinated substances should be avoided. Water, juices, any drink that does not contain caffeine is fine.
Mary: In the past I have not had a big problem with incontinence. While showering I felt a pimple while washing, upon inspection with a mirror, I noticed the interior bulge not outside. I also have been sick for 3 weeks with a deep cough and during this time incontinence has been much more prevalent. I went on line to read about this and am trying to figure out what to do.
My question is with rest and no lifting will it correct itself or once you have this bulge will it always be there with out surgery or some type of procedure/medical intervention. I read about doing exercises, but it never mentioned if they are beneficial after a person has this visible bulge and the incontinence is now more constant along with lower back pain and some leakage with relations. Should you have them at all with this? Your comments would be greatly appreciated.
Speaker_-_Dr__Courtenay_Moore: When people are ill with upper respiratory infections and coughing, incontinence can get worse. The bulge that you are referring to is most likely pelvic organ prolapse. When less active, the bulge is not as pronounced. You should see a specialist to be evaluated.
wiseoldowl: What, if anything, can be done for an 83 year old female with severe degenerative spinal disease which has affected the nerves to the bladder?
Speaker_-_Dr__Courtenay_Moore: It depends on how the degenerative spinal disease has affected your bladder. It could cause overactive bladder or underactive (hypotonic) bladder. There are treatment options for both.
gnewt: Any suggestions re: dealing with the neurogenic bladder?
Speaker_-_Dr__Courtenay_Moore: Neurogenic bladder is a vague term basically referring to the bladder symptoms due to a neurologic injury. It depends on what symptoms you are experiencing.
newshound: Does the nerve controlling the bladder run along the sacrum? If so, does a cyst in that area of the sacrum impact loss of control?
Speaker_-_Dr__Courtenay_Moore: A skin cyst does not affect the sacral nerves.
newtonm: What can be done for women who have had mild stroke or have MS?
Speaker_-_Dr__Courtenay_Moore: This depends on the urinary symptoms. Many individuals with both conditions have been successfully treated.
ccs: I have recurrent UT infections that I think are due to water exercise for knee/hip joint replacements. I seem to contract UTIs a lot . I choose pools carefully and one’s that are well maintained. I have had bladder prolapse surgery repair but continue to have UTIs . I practice good hygiene - I know hot to “wipe” etc., but still have UTI every 1-2 months. Tend to have adverse effects to sulfa and guinalone meds. Any suggestions or comments?
Speaker_-_Dr__Courtenay_Moore: There are many reasons this could be occurring. It would be best to be evaluated by your physician.
springtime: To clarify are the incontinence and pelvic organ prolapse two separate issues that need separate treatments?
Speaker_-_Dr__Courtenay_Moore: Yes. These are two entirely different disease processes, but they can (and often do) occur simultaneously.
Urinary Incontinence Types
Stress Incontinence occurs commonly in women. It is the result of physical changes from pregnancy, childbirth and menopause. Coughing, laughing and sneezing can put pressure on the bladder resulting in urine leakage.
Urge Incontinence is commonly caused by inappropriate bladder contractions which leads to uncontrolled urine leakage.
cookie001: I have both urge and stress incontinence due to a lower back spinal injury. My doctor says I can’t take any drugs for it, and the Kegel exercises only work to a point. I have kept control by drinking less water. Any other suggestions? I don’t want surgery.
Speaker_-_Dr__Courtenay_Moore: When you have both urge and stress incontinence it is called 'mixed incontinence.' Kegel exercises do work however there are medications and surgical options that can be explored.
retrage95: I don't know if it is considered incontinence, but for the last 10-15 years I have to get up to go to the bathroom 4-6 times a night, but can, and often do, go 5 or 6 hours between bathroom visits. Have tried all the recommended medications but nothing helps. Clinic urologist said only possible thing left to try would be to implant a pacemaker on my bladder. Is this something you would recommend?
Speaker_-_Dr__Courtenay_Moore: This is technically not incontinence, but is considered to be nocturia. Nocturia is often related to venous insufficiency. Suggestions nocturia include limiting fluid intake after 7pm, lower extremity elevation above the level of the heart for hour in the afternoon and taking anti-cholinergic medications in the evening.
Urinary Incontinence Treatment Options
bushhytailed: Please explain collagen injections. How are they done? How often is it given in the pelvic floor muscles?
Speaker_-_Dr__Courtenay_Moore: Collagen acts as a bulking agent. It is used in patients with stress incontinence. It is an outpatient (office-based) procedure. Collagen is injected into the urethra to prevent urine leakage. It is not given into the pelvic floor muscle but is injected into the urethra every 8-12 months.
verymerry: With Collagen Injections, what are the chances of rejection? What is the frequency of injections?
Speaker_-_Dr__Courtenay_Moore: One month before administering collagen a skin test is performed to determine if there is any sensitivity. Repeat injections are performed every 8-12 months.
gem3: Are there any new drugs out there? Any with fewer side effects?
Speaker_-_Dr__Courtenay_Moore: There are no FDA approved medications for stress incontinence. There are however several new drugs for urge incontinence including botulinum toxin (Botox). At this time, Botox is not FDA approved.
leskri: How effective is the antidepressant Imipramine® at helping stress incontinence?
Speaker_-_Dr__Courtenay_Moore: Imipramine® can help patients with stress incontinence; however it can have serious cardiac side effects.
newtonm: Your opinion about use of Ditropan? Will it get less effective when frequently used?
Speaker_-_Dr__Courtenay_Moore: Some people notice decrease in efficacy when on the medication for a long period of time. If this occurs, we recommend either trial of another medication or stopping medication for 6 months and then restarting the medication. This is called a 'drug holiday'. Some patients notice a return of the benefit of the drug after this period of time.
springtime: Are the estrogen creams used to help the prolapse and or the incontinence?
Speaker_-_Dr__Courtenay_Moore: Topical estrogen therapy can in some patients improve incontinence. It will not improve pelvic organ prolapse. It does improve vaginal tissue quality and decrease risk of urinary tract infections.
Maddiew: When do you recommend patients consider Medtronic’s implants for incontinence - when there is definite incontinence after a delivery or just after poor response to medications?
Speaker_-_Dr__Courtenay_Moore: Medtronic Interstim (sacral nerve stimulation) is FDA approved for refractory urinary urgency frequency, urge incontinence and idiopathic urinary retention. This treatment option is for patients that fail conservative therapy.
newtonm: How do you do a proper Kegel exercise?
Speaker_-_Dr__Courtenay_Moore: To engage the proper muscles, stop urination mid-stream. These are the muscles that need to be engaged.
ladyjfla: Do exercises really work and how often and which ones should be done to prevent this condition? I am 52 years old and currently have no problems, but I am curious if the exercises help prevent this from coming on. What other benefits might the exercises contribute to?
Speaker_-_Dr__Courtenay_Moore: Yes- pelvic floor exercises do work for both stress and urge incontinence. Most patients notice a 50-70% improvement in symptoms. Patients should do 10 repetitions 10 times per day. Like any exercise, if you do not do them, it won't work.
Pelvic Organ Prolapse
noname: I have been having pressure down in the genital area. I am wondering if I could have a dropped bladder. I have no female organs left due to surgery. If it is this how you do repair it?
Speaker_-_Dr__Courtenay_Moore: A bulge or pressure sensation in the genital or pelvic area could be pelvic organ prolapse. Although you have had a hysterectomy, the vagina, bladder or rectum can prolapse.
springtime: I just noticed this bulge, I do not really experience pain, but a pressure in that area along with back pain. What can be done for this? By me or M.D.? Should sexual relations be avoided?
Speaker_-_Dr__Courtenay_Moore: There are several treatment options. The least invasive is a pessary. More invasive treatment options are surgery. Sexual relations do not need to be avoided unless they cause discomfort. I would advise you speak with a physician about your treatment options.
CLSTAR: With this pelvic organ prolapse, does it require cutting for repair or can it be done vaginally?
Speaker_-_Dr__Courtenay_Moore: Pelvic organ prolapse can be corrected either abdominally or vaginally. Both require incisions.
CLSTAR: What about those of us who are in congestive heart failure. Are these surgeries safe?
Speaker_-_Dr__Courtenay_Moore: The surgeries are safe but any patient with congestive heart failure must be cleared by a cardiologist prior to surgery.
springtime: If you have already noticed the bulge interior is it too late for the exercises?
Speaker_-_Dr__Courtenay_Moore: Pelvic floor physical therapy is beneficial for incontinence. This type of physical therapy is not typically used for pelvic organ prolapse. With prolapse, some individuals will notice a reduction in the bulge when they are not as active.
highcost: What is your take on wearing a Pessary?
Speaker_-_Dr__Courtenay_Moore: A pessary is a good non-surgical option for pelvic organ prolapse.
springtime: If using the pessary will that help with the incontinence? Also have heard that using a tampon was suggested do you agree?
Speaker_-_Dr__Courtenay_Moore: A pessary sometimes may exacerbate incontinence. A tampon will help with incontinence but not with the prolapse.
Pelvic Mid-Urethral Slings
leskri: What is the difference between a TVT and a "sling"?
Speaker_-_Dr__Courtenay_Moore: TVT is a mid-urethral sling.
leskri: What are the possible complications of a TVT? How long do the benefits of a TVT last?
Speaker_-_Dr__Courtenay_Moore: TVT (retro-pubic mid urethral sling). Complications of a TVT include bowel, bladder or vascular injuries. Currently we have 15 year data on TVT with 89-92% cure rate at 15 years.
leskri: Can there be a problem with a TVT due to the fact that it is a foreign body?
Speaker_-_Dr__Courtenay_Moore: Anytime mesh is used, there is the risk of erosion. In most series, it is less than 3%.
leskri: Does a procedure like the mid-urethral sling only last for a period of time?
Speaker_-_Dr__Courtenay_Moore: Currently there is 15 year data showing 89-92% cure rate at 15 years.
colex: How long is the recuperation time from the various surgical treatments available? Is the recuperation painful? If so, what is used to control pain?
Speaker_-_Dr__Courtenay_Moore: The recuperation period depends on the type of procedure performed. The mid-urethral sling, which is an outpatient procedure, typically takes one hour. Most patients return to work in two days and take oral pain medicine for 1-2 days post-operatively.
klingon: Prolapsed Surgery (Cystocele Retrocele) - what is the longevity of surgery? Does it have to be repeated depending on the age it is done?
Speaker_-_Dr__Courtenay_Moore: The longevity of the surgery depends on the type of surgery. Again, the duration of the surgical repair depends on which surgery is performed.
Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Courtenay Moore is now over. Thank you again Dr. Moore for taking the time to answer our questions today.
Speaker_-_Dr__Courtenay Moore: You are very welcome. Please do not hesitate to contact us.
For more information about Cleveland Clinic Glickman Urological and Kidney Institute, you may visit clevelandclinic/urology. To make an appointment with Dr. Moore, or any of the other specialists in our Glickman Urological and Kidney Institute, please call 216.444.5600 or toll-free 800.223.2273 x45600. You may also request an appointment online at www.clevelandclinic.org/appointments.
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This chat occurred on April 3, 2009.
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