Incontinence Specialists  Shlomo Raz, MD Larissa Rodríguez, MD Ongoing Clinical Trials Female and Male Stress Incontinence Female and Male Urge Incontinence Related Research Projects Stem Cell Research For The Treatment of Incontinence and Vaginal Prolapse Polypropylene Sling For The Treatment of Stress Urinary Incontinence

General Information

Urinary control relies on the finely coordinated activities of the smooth muscle tissue of the urethra and bladder, skeletal muscle, voluntary inhibition, and the autonomic nervous system.

Urinary incontinence can result from anatomic, physiologic, or pathologic (disease) factors. Congenital and acquired disorders of muscle innervation (e.g., ALS, spina bifida, multiple sclerosis) eventually cause inadequate urinary storage or control.

Acute and temporary incontinence are commonly caused by the following:

• Childbirth
• Limited mobility
• Medication side effect
• Urinary tract infection

• Birth defects
• Bladder muscle weakness
• Blocked urethra (due to benign prostate hyperplasia, tumor, etc.)
• Brain or spinal cord injury
• Nerve disorders
• Pelvic floor muscle weakness

Types
Of the several types of urinary incontinence, stress, urge, and mixed incontinence account for more than 90% of cases. Overflow incontinence is more common in people with disorders that affect the nerve supply originating in the upper portion of the spinal cord and older men with benign prostate hyperplasia (BPH). The primary characteristics of these types are as follows:

• Stress-urine loss during physical activity that increases abdominal pressure (e.g., coughing, sneezing, laughing)
• Urge-urine loss with urgent need to void and involuntary bladder contraction (also called detrusor instability)
• Mixed-both stress and urge incontinence
• Overflow-constant dribbling of urine; bladder never completely empties

Incidence and Prevalence
The U.S. Department of Health and Human Services reported in 1996 that approximately 13 million people in the United States suffer from urinary incontinence. The condition is far more prevalent in women than men. In the general population aged 15 to 64 years old, 10-30% of women versus 1.5-5% of men are affected. At least 50% of nursing home residents are affected. Of that number, 70% are women.

Diagnosis

A complete medical history, which includes a voiding diary and incontinence questionnaire; physical examination; and one or more diagnostic procedures help the physician determine the type of urinary incontinence and an appropriate treatment plan.

Medical history
The medical history provides clues about the type of incontinence. Bowel habits, patterns of urination and leakage (when, how often, how severe), and whether there is pain, discomfort, or straining when voiding are important indicators. The patient's history of illnesses, pelvic surgeries, pregnancies, and medications currently used also supply the physician with information relevant to making a diagnosis. In the elderly, a mental status evaluation and assessment of social and environmental factors may be performed.

Physical examination
A physical examination includes a neruologic status evaluation and examination of the abdomen, rectum, genitals, and pelvis. The cough stress test, in which the patient coughs forcefully while the physician observes the urethra, allows observation of urine loss. Instantaneous leakage with coughing indicates a diagnosis of stress incontinence. Leakage that is delayed or persistent after the cough indicates urge incontinence.

The physical examination also helps the physician identify medical conditions that may be the cause of incontinence. For instance, poor reflexes or sensory responses may indicate a neurological disorder.

Urinalysis
Examination of the urine may identify medical conditions associated with urinary incontinence, such as the following:

• Bacteriuria-presence of bacteria in urine; indicates infection
• Glycosuria-excess glucose in urine; may indicate diabetes
• Hematuria-blood in urine; may indicate kidney disease
• Proteinuria-excess protein in urine; may indicate kidney disease, cardiac disease, blood disease
• Pyuria-presence of pus in urine; indicates infection

Postvoid residual volume (PRV)
This procedure requires catheterization or pelvic ultrasound. The patient voids just before the PRV is measured. This initial void should be observed for hesitancy, straining, or interrupted flow. A PRV less than 50 mL indicates adequate bladder emptying. Repeated measurements of 100 to 200 mL or higher represent inadequate bladder emptying. The clinical setting and the patient's readiness to void may affect the test result; therefore, repeated measurements may be necessary.

Urodynamic Testing
Cystometry may be used to measure the anatomic and functional status of the bladder and urethra. The cystometer is an instrument that measures the pressure and capacity of the bladder; thus evaluating the function of the detrusor muscle. Simple cystometry detects abnormal detrusor compliance, but abdominal pressure is not included and the results must be evaluated with caution.

The multichannel, or subtracted, cystometrogram simultaneously measures intra-abdominal, total bladder, and true detrusor pressures. This allows involuntary detrusor contractions to be distinguished from increased intra-abdominal pressure. The voiding cystometrogram detects outlet obstruction in patients who are able to void.

Uroflowmetry identifies abnormal voiding patterns. Urethral pressure profilometry measures the resting and dynamic pressures in the urethra.

Endoscopic Tests
Cystoscopy may be performed when urodynamic testing fails to duplicate symptoms, when the patient experiences new symptoms (e.g., cystitis, pain), or when urinalysis reveals a disease process (e.g., menaturia, pyuria). Cystoscopy identifies the presence of bladder lesions (e.g., cysts) and foreign bodies.

Imaging Tests
X-rays and ultrasound may be used to evaluate anatomic conditions associated with urinary incontinence. Imaging of the lower urinary tract before, during, and after voiding is helpful in examining the anatomy of the urinary bladder and urethra.

Management

There are several things patients can do to help improve continence.

• Avoid overconsumption of diuretics, antidepressants, antihistamines, and cough-cold preparations.
• Perform Kegel exercises daily.
• Practice double voiding (urinate, wait a few seconds, urinate again).
• Eat fruits, vegetables, and whole grains daily to prevent constipation.
• Retrain the bladder (urinate only every 3 to 6 hours).
• Stop smoking (nicotine irritates the bladder).

• Bed pads
• Combination pad-pant systems
• Disposable or reusable adult diapers
• Full-length absorbent undergarments
• Male incontinence drip collectors
• Underwear liners (pads, guards, shields, inserts)

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Used with Permission

Incontinence and UCLA

If you are one of the estimated thirteen million Americans who suffer from incontinence, then you already know the impact this condition can have on living your life to the fullest. Urinary Incontinence and Voiding Dysfunction specialists at UCLA are able to provide an individualized, comprehensive approach to treating urinary incontinence and voiding dysfunction in men and women through the latest surgical, non-surgical, minimally invasive and alternative treatments. Treatment focuses on restoring quality of life for patients in a caring, sensitive environment.

A Wide Range of Options

A service of the Division of Female Urology, Reconstructive Surgery and Urodynamics at the UCLA School of Medicine’s Department of Urology, the Center for Female Urology offers a range of diagnostic and treatment services from noninvasive techniques like biofeedback to complex, state-of-the-art surgery. New treatments are under investigation on an ongoing basis. Because the Center participates in clinical trials, patients have access to the newest treatments before the general public.

Available Diagnostic Services

• Multichannel-video Urodynamics
• Cystoscopy
• Dynamic MRI
• Other radiologic evaluation (VCUG, RGU)
• Transrectal ultrasound (prostate evaluation and sizing)
• Flow/PVR

• Medical Treatment - for stress incontinence, urge incontinence, voiding dysfunction, obstruction, pain - both Pharmacologic & Non-pharmacologic (herbal, etc.) treatments
  
  
• Behavior Therapy - for stress incontinence, urge incontinence, voiding dysfunction, obstruction, pain
  
  
• Biofeedback - for stress incontinence, urge incontinence, voiding dysfunction, obstruction, pain
  
  
• Myofascial Release - for stress incontinence, urge incontinence, voiding dysfunction, obstruction, pain
  
  
• Minimally Invasive Treatments (TUNA, Microwave, Interstim, Neuromodulation (for non-obstructive and iatrogenic retention, refractory frequency, urgency, urge incontinence, pain)
  
  
  
• Surgical treatments for:
       • Vaginal Prolapse
       • Urethral Diverticuli
       • Stress Incontinence
       • Urge Incontinence
       • Stool Incontinence
       • Neurogenic Bladder
       • Pelvic Reconstruction
       • Urethral Reconstructive Surgery
       • Bladder Substitutions and Urinary Diversions