Doc Talk: Get the Facts on Urinary Incontinence
We sat down with Dr. Robert K. Gildersleeve of Mansfield Ob/Gyn Associates, a Women's Health Connecticut practice, to talk about urinary incontinence, its causes, and what can be done about it.
Do many of your patients come to you with concerns about urinary incontinence?
Sometimes women won’t mention it at all because it’s embarrassing. It’s my job to try to expose those issues, so I ask about it with every patient I see. Do you have any urinary symptoms? Do you leak with coughing, sneezing, lifting, or laughing? Are you always going to the bathroom? Do you get up at night to urinate more than once or twice? Those are the kinds of questions that open the door and get the conversation started.
What part of the population experiences incontinence the most?
It frequently happens after childbirth, but can occur in anyone and gets more common as we age. Perimenopausal and menopausal women are the patients that tend to experience a lot of incontinence. It’s quite common with women in their 40s, too.
What are the most common causes of incontinence?
There are two major types of incontinence that affect women, and they’re treated differently.
Urgency incontinence, also referred to as overactive bladder, is a functional over-activity. The second type, stress incontinence, is an anatomic weakness. The pelvic support defects that go along with childbirth are probably the major cause.
How do you make a diagnosis and determine the best course of treatment?
In some patients it’s difficult to say what exactly the problem is. It can be complex if they have more than one complaint, or if they have had prior surgery. To figure out what the problem is, urodynamic testing is a way to look into that more deeply.
We can test the neurologic function of the pelvis, the support structures of the pelvis, and the functional status of the bladder to make sure there’s no retention, nerve injuries, or other damages that might be important to know about before deciding on a treatment.
How does urodynamic testing work?
We use pressure catheters that go in the bladder and the vagina to measure pressures in the abdominal cavity as well as in the bladder. By doing that you can figure out if the bladder’s contracting when we don’t want it to, the pressures that the bladder is able to tolerate and generate, how the bladder fills and empties, and the pressures along the urethra to see if they’re appropriate.
A lot of different information can be culled from these tests, and that’s something that we can do right in the office. For someone who has simple complaints of stress incontinence, we don’t need to do this kind of testing. We just want to make sure they’re not retaining urine and that they don’t have an infection, and then we can proceed with any treatment course we want.
How do you treat urgency incontinence?
Typically, we’ll try to do behavioral therapies first, like looking at dietary adjustments that can minimize the over activity, and talking about timed voiding and training the bladder to hold off a little bit more as the first steps in managing overactive bladder. Very frequently that’s done in conjunction with the use of medications that can help to make the bladder less overactive.
An option beyond that or at the same time is use of bladder Botox injections which block the muscular function to a degree so you don’t have that over activity. It’s a temporary blockage which can last from six months up to a year. Botox is very unlikely to cause significant problems like retention.
How do you treat stress incontinence?
There are a number of different options to treat it, starting with pelvic floor physical therapy, which are Kegel exercises. A patient can also choose to see a physical therapist. Biofeedback is a way of utilizing a device to tell you you’re doing things properly. You can learn how much pressure you’re applying while doing pelvic floor therapy, and determine if your Kegel has improved in its strength. Typically, like physical therapy, it’s an ongoing treatment regimen: a few treatments a week for a number of weeks.
Other treatment options include using biofeedback, devices that stimulate the pelvic floor, and surgery. The use of mid-urethral slings is considered the gold standard for the treatment of stress incontinence.
Periurethral bulking agents are another method of treating stress-related incontinence. This procedure is done with a camera. A little bit of a collagen material or a spherical bead is injected around the urethra to bulk it up and close off the opening a little bit more so that it’s easier to maintain continence.
What are the procedures that you perform the most?
The most common procedure for stress incontinence is the mid urethral sling. A mid urethral sling typically uses a synthetic mesh which is a weave of suture material that goes underneath the urethra and provides a floor for it to close off against. The procedure can be done with other materials as well, but that’s the one that has the best science behind it.
About how long does a mid urethral sling procedure take, and what is the recovery time like?
I perform what’s known as single incision sling procedures. The recovery is extremely fast, probably on the order of a few days. People feel a little swollen but have no post-op pain, and that’s one of the great benefits of single incision slings. Even compared to other mid urethral slings which are pretty minor procedures, it’s much easier to recoup from. There’s much less bruising and discomfort afterwards.
How long does a sling last? Do they ever have to be replaced?
There is at least five-years data out on these that indicates that they hold up well. Symptoms can creep back, but most people do very well for a long time.
Are there any drawbacks to meshes? Recent daytime TV commercials have made them sound potentially dangerous.
The FDA put out a warning about the use of all meshes and it didn’t distinguish very clearly between urinary incontinence meshes and pelvic support meshes. The vast majority of the problems that have been elucidated come from pelvic support meshes. The market has changed dramatically since all these problems came to light.
In properly selected patients, with proper performance and procedure, the risks are very small for mid-urethral slings, and even for the pelvic support meshes used to treat pelvic organ prolapse.
What are some things that patients have said in response to having the procedure?
There are a couple things I’ve done over the course of the past 20 years which inspire people to come back to the office and say “it’s the best thing I’ve ever done”, and mid urethral slings are one of them. Freeing patients from a really embarrassing situation that they no longer have to live with any more is very satisfying.
Is there anything that women can do to prevent or stave off incontinence?
Kegels are a good thing, sometimes enough that people don’t complain about stress incontinence developing. With overactive bladder we don’t have any simple solutions other than behavioral modifications which include timed voiding and changing your diet to try and get rid of bladder irritants.
What is something you wish women knew about incontinence?
I think an important message is you’re not alone. It’s a super common complaint and you don’t have to live with it. There are easy things to do that are very effective in making you feel significantly better, if not improving it completely.
Where are treatments headed?
Good data are coming out displaying the effectiveness of the single incision slings, making the bigger procedures unnecessary for success.
If you are experiencing any issues with incontinence please contact your Women's Health Connecticut provider to discuss what treatment options may be right for you. All of our practices specialize in the diagnosis and treatment of urinary incontinence.