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Incontinence

Incontinence by Krisha McCoy, MS

Anatomy and Physiology
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Your urinary system includes the kidneys, ureters, bladder, and the urethra. Its main function is to produce urine and excrete it from the body.

Your kidneys work to filter your blood of poisonous substances and waste, while retaining glucose, salts, and minerals. This function also helps control the amount of water retained by the body or lost into the urine.

The urine, which consists of water and filtered waste, flows through the ureters to the bladder. The bladder is an expandable, muscular organ that stores urine until it is excreted during urination. During urination, urine leaves the body through the urethra at the bottom of the bladder.

The bladder is controlled by two opposing nerve and muscle systems-one helps it to relax and hold urine, the other directs the bladder to contract and push urine out.Loading image. Please wait...

Special muscles, or sphincters, at the base of the bladder help control when urine is released. When these sphincter muscles contract they stop the flow of urine by closing off the opening between the bladder and urethra. When they relax and the bladder wall contracts, urine flows out of the urethra.

Reasons for Procedure
Urinary incontinence is an involuntary loss of urine. The two most common types of urinary incontinence are: urge incontinence, stress incontinence. Women are twice as likely as men to have urinary incontinence.

Urge incontinence is sometimes referred to as an overactive bladder. It occurs when the bladder contracts involuntarily, resulting in an uncontrollable urge to urinate. This can be caused by something as simple as a bladder infection or as complex as problems with the nerves that control the bladder. For example, urge incontinence may occur as a result of strokes, multiple sclerosis, or spinal cord injuries.

In stress incontinence, urine leaks out when something stresses the abdomen, such as coughing, sneezing, laughing, or exercising. This leakage can be caused by weakened pelvic floor muscle support, or by lax or damaged sphincters. Stress incontinence may be associated with previous childbirth, surgical trauma, and hormonal changes during menopause.

Your doctor may use one or more of the following tests to evaluate the cause of urinary incontinence: cystoscopy, to view the inside of your bladder, urinanalysis, a microscopic test on a urine sample to check for an infection, post-void residual assessment, to measure how much urine is left behind after each void, ultrasound, which uses high-pitched sound waves to render images of the bladder, urodynamics test, to check for abnormal bladder sensations and contractions.

Treatments
In most cases, non-invasive treatments, such as behavioral therapy and/or medications, can help alleviate urinary incontinence. Behavioral therapies include: going to the bathroom on a schedule, such as every 2 hours, limiting the consumption of caffeine or a lot of fluids before activities, avoiding lifting heavy objects, performing exercises, called Kegel,Aeos exercises, to strengthen the pelvic floor muscle. Other non-surgical therapies include: medications to relax the bladder or tighten the sphincter muscles, absorbent products that adhere to underwear, a pessary, or device inserted into the vagina to support the neck of the bladder and improve urinary control.

Sometimes, the injection of bulking agents, such as collagen, into the lining of the urethra can help alleviate urinary incontinence. Bulking agents work to increase pressure on the walls of the urethra, allowing for better control of urine flow.

If less invasive therapies fail to improve your symptoms, your doctor may recommend surgery, which is usually reserved for the treatment of stress incontinence. The most common surgeries for stress incontinence are: abdominal bladder suspension, sling procedure, or vaginal suturing. These procedures discourage leaking of urine by changing the location of the urethra and base of the bladder, or bladder neck. This tutorial will focus on the first two: bladder suspension and sling procedure.

Procedure
In the days leading up to your procedure: Arrange for a ride to and from the hospital, and for help at home as you recover. The night before, eat a light meal. Do not eat or drink anything after midnight except for medications that you may be told to take. You may be given antibiotics to take before the procedure to help prevent infection. If you regularly take medications, herbs, or dietary supplements, your doctor may recommend temporarily discontinuing them. Do not start taking any new medications, herbs, or dietary supplements without consulting your doctor.

Most uncomplicated surgeries for urinary incontinence take about one hour and require spinal or general anesthesia. For spinal anesthesia, a medication will be administered into the area surrounding the spinal cord, rendering the lower half of your body numb.

In general anesthesia, you will be put to sleep for the duration of the operation. This will involve the insertion of a breathing tube through your mouth and into your windpipe to help you breathe.

In an open abdominal bladder suspension, your surgeon will begin by making an incision in your abdomen, over your bladder.

Your surgeon will then stitch the urethra and nearby bladder neck to the lining of the pelvic bone or other nearby structures. By changing the location and angle of the urethra, urine has less of a tendency to easily flow through under stress.

As an alternative to traditional, open surgery, laparoscopic bladder suspension is sometimes performed. In a laparoscopic procedure, a lighted scope, a camera, and small surgical instruments are inserted through tiny incisions in the abdomen. Laparoscopic surgeries usually require less recovery time than open surgeries, but under some circumstances surgeons still prefer to use open procedures.Loading image. Please wait...

In a sling procedure, your surgeon will begin by making two small incisions: one in the vagina and one in the abdomen. The vaginal incision will expose the urethra and nearby bladder. The abdominal incision will expose a tough piece of tissue near the surface called the rectus fascia.

Your surgeon will then attach one end of a sling-made of your own tissue or synthetic material-under the urethra and nearby bladder. He or she will attach the other end around the rectus fascia to form a hammock-like support for the urethra.

After your procedure is complete, your doctor will stitch the incisions closed. Oftentimes, he or she will insert a catheter to help drain your bladder until you can easily urinate on your own.

Risks and Benefits
Possible complications of bladder suspension surgery include: damage to the bladder, urethra, ureter, or neighboring structures, persistent incontinence, overactive bladder, blocked urine flow, with possibly unrecognized damage to the kidney, hemorrhage, with accumulation of blood or fluid in the wound, wound infection, adverse reactions to general anesthesia, and/or blood clots in the legs.

Potential benefits of bladder suspension surgery include: improved or cured urinary stress incontinence, elimination of the inconvenience, worry, and embarrassment associated with incontinence.

In an abdominal bladder suspension, sling procedure, or any other surgery, you and your doctor must carefully weigh the risks and benefits to determine whether it is the most appropriate treatment choice for you.

After the Procedure
After your procedure, you will be: Taken to the recovery area for monitoring, given antibiotics and other medications, as necessary. Most patients will remain in the hospital for 1-3 days after an open bladder suspension procedure. Patients who have the laparoscopic procedure often go home the same day as the surgery.

After an abdominal bladder suspension, you should plan to limit your activities for 1-2 weeks. After a laparoscopic suspension or sling procedure, you usually can begin resuming activity within 1-2 days. Following any of these procedures, your doctor may recommend not lifting anything heavier than 15 pounds for three months. After abdominal bladder suspension, you may be advised to never lift anything more than 25 pounds.

If your surgeon placed a catheter, he or she will schedule an appointment to remove it once you are able to urinate easily on your own, which may take several days.

After you leave the hospital, be sure to contact your doctor promptly if you experience: signs of infection, such as fever or chills, increased or persistent swelling, redness, bleeding, or discharge from your incision sites, persistent nausea and/or vomiting, cough, chest pain, or shortness of breath, pain and/or swelling in your feet, calves, or legs, a plugged catheter that causes you to stop passing urine, recurrent or persistent bleeding in the urine, and/or abnormal bleeding from your vagina.

Sources:

  • Can surgery be used to treat incontinence? American Urogynecologic Society website. Available at: http://www.augs.org/i4a/pages/index.cfm?pageid=214. Accessed September 24, 2004.
  • Incontinence. American Foundation for Urologic Diseases website. Available at: http://www.afud.org/education/bladder/incontinence.asp. Accessed September 21, 2004.
  • New developments for treating incontinence. The Cleveland Clinic website. Available at: http://www.clevelandclinic.org/health/health-info/docs/0700/0790.asp?index=6275. Accessed September 21, 2004.
  • Surgical management of urinary incontinence. UrologyHealth.org website. Available at: http://urologyhealth.org/adult/index.cfm?cat=03&topic=133. Accessed September 21, 2004.
  • Treatment options for incontinence. National Association for Continence website. Available at: http://www.nafc.org/about_incontinece/treatment.htm. Accessed September 21, 2004.
  • Treatments for urinary incontinence in women. National Kidney and Urologic Diseases Information Clearinghouse website. Available at: http://kidney.niddk.nih.gov/kudiseases/pubs/treatmentsuiwomen/index.htm. Accessed September 21, 2004.
  • Urinary incontinence. American Foundation for Urologic Diseases website. Available at: http://www.afud.org/printrelated.asp?PrintPage=conditions/ui.asp,conditions/ui1.asp. Accessed September 21, 2004.
  • What are the surgical procedures for treating stress incontinence? New York Methodist Hospital website. Available at: http://www.nym.org/healthinfo/docs/050/doc50full.html. Accessed September 24, 2004.


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