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Stress urinary incontinence
Common condition has many treatments

By Arnaldo Trabucco, MD, FACS

Photo of Arnaldo Trabucco, MD, FACS Arnaldo Trabucco, MD, FACS

Arnaldo Trabucco, MD, FACS, a Diplomate of the American Board of Urology, is opening Urology Institute, LLC on the campus of Northern Nevada Medical Center in Suite 102, Sparks Medical Building (connected to the hospital). Please call 359-7008 for more information or an appointment. Dr. Trabucco will be speaking about urinary incontinence at the April 13 Senior Advantage Series.
Urinary incontinence affects more than 13 million Americans and is twice as common in women as in men. Yet only one in four women with incontinence seeks medical help. Some incorrectly believe that incontinence is untreatable or is a normal consequence of aging. Others are too embarrassed to talk about it with their doctors.

Stress urinary incontinence (SUI) is an involuntary loss of urine that occurs during physical activity, including coughing, sneezing, laughing or exercise. Studies have documented that about 50 percent of all women have occasional urinary incontinence, and as many as 10 percent have frequent incontinence. Nearly 20 percent of women older than 75 experience daily urinary incontinence.

SUI now has evolved to being a highly curable disease that need not go untreated or undiagnosed.

Types of incontinence

Stress incontinence -- Caused by poor bladder support from pelvic muscles or a weak or damaged sphincter. Urine leaks when you strain or stress the abdomen, including coughing, sneezing, laughing or walking.
Urge incontinence -- A sudden, strong urge to urinate, along with a sudden, uncontrollable rush or leakage of urine. Occurs when an overactive bladder contracts involuntarily.
Mixed incontinence -- A combination of urge and stress incontinence.
Overflow incontinence -- Characterized by a frequent or constant dribble of urine. Patients exhibit a weak urinary stream and the bladder does not empty completely. This occurs when the bladder becomes so full that it overflows due to a weak bladder muscle or urethra blockage.

Risk factors

Childbirth -- SUI often is related to pregnancy and childbirth, which can weaken pelvic floor muscles that provide support to the bladder neck and urethra and are important in continence. If incontinence continues after six weeks, contact a urologist. For some women, bladder control problems occur months or years after they have had children.

Incontinence also may be caused by the changed position of the bladder and urethra, episiotomy (a cut in the pelvic floor/vagina made to ease childbirth) or damage to the nerves that control the bladder. The more vaginal births a woman has had, the more prone she is to leak urine during physical activity.

Menopause -- Between ages 45 and 55, most women's ovaries stop making estrogen, the hormone that regulates monthly menstrual periods. Lack of estrogen can result in a urethra with a thin lining (mucosa) that does not close properly, and it also weakens the bladder's sphincter muscles. This combination can cause the urethra to open unexpectedly during physical activity.

Pelvic surgery -- Pelvic surgery can weaken and damage pelvic floor muscles so they no longer provide the necessary support to the bladder neck and urethra. These structures may drop freely when downward pressure is applied. This condition, known as hypermobility, causes incontinence during physical activity, when the urethra cannot close tightly enough to resist increased abdominal pressure.

Treatment Options
Between 85 percent and 90 percent of all SUI cases can be treated successfully by urologists. Effective management requires an individualized approach in which the physician helps the patient formulate reasonable goals and suggests appropriate treatment.

Medical treatments

Injectables -- Injectable agents can increase the bulk around the urethra. They compress the urethra near the bladder outlet and can improve the function of the urethral sphincter muscle. Injectables include collagen (a naturally occurring protein found in skin, bone and connective tissues), various synthetic materials and fat. Injectable agents are a good choice for older women who are not good surgical candidates.

Hormonal replacement/estrogen therapy -- Estrogen therapy helps to maintain and restore the health of urethral tissues in women who have undergone menopause. Estrogen appears to reduce SUI and increase bladder outlet resistance by increasing blood flow, tone and nerve response in the urethral muscle.

Estrogen therapy is not recommended for patients with diagnosed or suspected cancer of the breast or uterus, or for patients with undiagnosed vaginal bleeding or blood-clotting disorders.

Photo of a woman on a bike With treatment, stress urinary incontinence is a highly curable disease that can allow women and men to maintain active lives.
Nonsurgical treatments
Numerous forms of treatment are available after a particular type of urinary incontinence is diagnosed.

Kegels -- These exercises can be used to regain bladder control, especially if the pelvic floor muscle and/or sphincter muscles have been weakened by childbirth or other factors.

To identify these muscles, women perform muscle contractions to stop the flow of urine in midstream. If the flow stops, you've located the correct muscles. Performing 10 Kegel exercises (for 30 seconds each) every hour during the day has proven effective.

Biofeedback/electrical stimulation -- Biofeedback helps patients gain awareness and control of their urinary tract muscles. Numerous instruments are used to record small electrical signals that are given off when specific muscles are squeezed during contraction. Biofeedback usually is performed in conjunction with Kegel exercises, since it helps reinforce proper techniques.

Alternative devices -- Vaginal pessaries -- ring, cube or doughnut-shaped devices made of rubber or silicone -- are inserted into the vagina to support the bladder neck for women with stress incontinence. The major side effects of pessaries are erosions of the vaginal skin and vaginal infection. Therefore, people who use pessaries need frequent examinations.

Surgical treatments
Two standard suspension procedures requiring abdominal incisions are the Marshall Marchetti Krantz (MMK) procedure and the Burch procedure. The MMK procedure is offered in many medical centers, but no longer favored because the sutures (stitches) are placed around the urethra, creating the potential for obstruction.

The Burch procedure often is performed when the abdomen already is open for another purpose, including an abdominal hysterectomy. Surgeons place the sutures laterally (sideways), which avoids urethral obstruction.

Needle suspension -- These procedures are simpler than abdominal suspension procedures and require smaller/fewer incisions. Sutures are placed to anchor tissues on each side of the bladder neck. The bladder neck then is supported by the sutures, which are threaded on a needle and tied to the fascia (fibrous tissue) or the pubic bone. Operative times and recovery periods also are shorter.

Sling procedures -- Patients with severe stress incontinence and Intrinsic Sphincter Deficiency are good candidates for a sling procedure, which can create the urethral compression necessary to achieve bladder control. Several techniques are available, some without incisions.

Northern Nevada Medical Center
2375 E. Prater Way, Sparks, NV 89434
775-331-7000