▷ Definition
Incontinence is the inability to control the flow of your urine and when and where your bladder empties. We all learned bladder control as young children and especially in social situations. We have come to depend on this control as adults.


Urgency and frequency of urination is the persistent sensation of needing to urinate during the daytime, nighttime (waking you from sleep more than 1-2 times per night), or both (day and night). This sensation may be associated with bladder spasms or a sensitive bladder. Urgency and frequency alone may not necessarily cause leakage of urine. It is sometimes referred to as `overactive bladder`.


▷ Urge Incontinence
If you suddenly lose urine at the wrong time and place, you may have urge incontinence. This is usually associated with feeling the need or urge to urinate. Because this urge cannot be stopped, this type of incontinence is called urge incontinence. When the bladder is healthy, we are in control and can decide when and where to urinate. When the urge to urinate is actually strong enough, we need to stop what we are doing and walk to the bathroom and empty our bladders voluntarily.


The most common cause of urge incontinence is a spasm or contraction of the bladder muscle, which squeezes at the wrong time, earlier than it normally would and cause leaks. This loss of urine often begins before we reach the toilet. The wetness can be any amount from dribbling up to soaking our clothes.


Urge incontinence is the leakage that can occur when you put your hands under running water, when you hear running water, after drinking a small quantity of liquids, or when you rush home and put your key in the lock of your door and experience a bladder contraction and leakage. This last situation is so common that it is called `Key-in-lock syndrome`. In the great majority of women suffering from urgency and/or urgency incontinence, there is no known cause. Occasionally, urge incontinence and the spasm of the bladder muscles happen because of damage to the nerves of the bladder, nervous system or the bladder muscles themselves.


▷ Incidence
People of all ages have bladder control problems. Many young women may find that they cannot hold their urine after having a baby. Others may have problems when they stop having their period. Urgency/urge incontinence is common among these postmenopausal women and becomes still more common as women become older. Thirteen million Americans experience incontinence and eleven million are women. This is because women have babies and our urethras are shorter than the urethras of men. The urethra is the tube that leads from the bladder to the outside world. Women depend on estrogen, a hormone that is produced in the ovaries (these are organs which lie on either side of the uterus). Estrogen helps the nerves, muscles, and support tissue of the pelvic organs and muscles have good tone and function well.


One in four women ages 30-59 have experienced at least one episode of urinary incontinence. One-half of the people living in nursing homes are incontinent. Billions of dollars are spent each year in America on disposable paper products (diapers) for adults who are incontinent. Incontinence may effect you and your family, your friends, or most importantly, your health and quality of life.


▷ Risk Factors
Women experience incontinence two times more than men do. Women are most likely to develop incontinence during pregnancy, childbirth or after hormonal changes that occur with menopause. The structure of the female urinary tract may account for this difference. Older men can become incontinent as the result of prostate surgery. Both women and men can become incontinent from excessive caffeine, urinary tract infections, several neurologic disorders or certain medication.


Incontinence can be improved in 8 out of 10 women but less than one-half discuss this with their physicians. The condition often goes unnoticed. Many women are embarrassed. More often, women are told that bladder control problems (urinary incontinence) are a normal part of aging and that they should learn to live with it. These statements are untrue. Urinary incontinence is not normal. It can be cured or markedly improved in the great majority of cases.


▷ Symptoms
The symptom of urge incontinence is that you lose urine for no apparent reason while suddenly feeling the need or urge to urinate.


The most common cause of urge incontinence is inappropriate bladder contractions. Doctors describe such bladders as `unstable`, `spastic`, or `overactive`. Urge incontinence may mean that your bladder empties without your permission during sleep, drinking water, when you touch or hear water running (as when someone else is taking a shower or doing the dishes).


What basically causes urgency and frequency of urination is a bladder, which squeezes too soon and too much. This is felt as bladder pressure. Urgency and frequency is a problem which can easily be diagnosed by your doctor and, generally, easily treated.


▷ Evaluation Tools
The first step toward getting better is to see a doctor who is knowledgeable about incontinence and can learn the type that you have. A urologist specializes in the urinary tract, and the urogynecologist focuses on bladder and other pelvic problems in women.


Your doctor will first ask you about your symptoms, medical history, family history, surgical history, and your medications. He or she will question you on your degree of discomfort, use of medications and recent illnesses. Your doctor will do a physical, gynecologic and neurologic examination. A urine sample will be sent for tests to determine if any infection or other problems are present. During the physical exam, your physician will also examine you for signs of medical conditions causing incontinence. You may be asked to keep a voiding diary to record your normal urination and any leakage you may have. You may be asked to indicate the volume of liquids you drink as well as recording the times. The urine volume can be measured with a special basin that you place under the toilet seat. The basin`s ounces are written on it and you simply read off the amount and record it in your voiding diary.


A Urodynamic Evaluation may be performed. It is slightly uncomfortable but not painful, lasts 20 to 40 minutes and will determine the cause of the leakage. It uses simple and computerized tests to measure pressure in the bladder, the flow of urine and other measurements of bladder and urethral function. One of the Urodynamic tests, the Cystometrogram, usually shows the bladder contractions of an Overactive Bladder. It is also called Unstable Bladder or Detrusor Instability. A stress test where you cough vigorously with a full bladder is used to diagnose the simultaneous spurt of Genuine Stress Incontinence. This is the other common cause of urine leakage.


▷ How is Urge Incontinence Treated?
A bladder infection will be treated with antibiotic medications. Excessive intake of citrus, some spices and alcohol can increase urgency/frequency symptoms. You can alter your intake of beverages and foods that may cause your bladder to be overactive. Caffeine, present in coffee, tea and cola beverages, as well as in some cold medications, irritates the bladder causing earlier, more frequent and stronger contractions. Some prescription drugs may cause or aggravate leakage. If your medications cause incontinence, your doctor may want to change these medications. Your Urogynecologist can confer with your regular doctor (Primary Care Physician). Your voiding diary can be used to keep a record of your actual fluid intake level and timing of this intake. For example, you may suffer from nighttime bladder urgency/frequency and not know that you are drinking excessive fluids in the evening. Your physician will see this in the voiding diary. Simply by lessening your evening fluid intake, your symptoms may improve.


▷ Bladder Retraining
Timed voiding or bladder retraining drills are very helpful and usually the first line of therapy for Overactive Bladder. This excellent treatment is free, completely safe and effective in curing or improving symptoms in two thirds of women suffering from this very common disorder. In timed voiding you may fill out a chart of voiding and leaking such as the voiding diary mentioned in the last paragraph. From the patterns that appear in the voiding chart, you can plan to empty before you would otherwise leak. The intervals that you urinate at can gradually be lengthened by 15 minutes each week while you are awake. In this way, you may stretch or increase the intervals at which you void. Another similar approach to bladder drills is to begin voiding every hour on the hour, except while in bed, whether the urge is felt or not. This pattern is continued for two weeks. Then, you move up to voiding every hour and a half. Every two weeks, you increase the interval between voids by 30 minutes, until you have retrained yourself up to voiding at a comfortable interval of, for example every three to four hours. This biofeedback technique known as bladder training can alter or change the bladder s schedule for storing or emptying urine. These techniques are effective for urge incontinence, urgency, and frequency of urination and overactive bladder.


▷ Kegal Exercises
Pelvic muscle exercises (Kegel) are used to strengthen or retrain the muscles of the pelvic floor. Regular daily exercising of the pelvic muscles can improve and even prevent urinary incontinence. This is helpful for younger woman. The Kegel exercises should be performed 30-80 times daily for eight weeks before you may notice any difference. Most Kegel exercises do not require equipment. One technique involves the use of weighted cones which indicates which muscles need strengthening. These cone-shaped objects are placed in the vagina. They look like smooth white vaginal suppositories or tampons and vary in weight from less than one ounces to a few ounces. They are inserted for 10-30 minutes per day. Your pelvic muscles will naturally grip the cones in a tight contraction so that the cone will not fall out. Over a period of time, your pelvic muscles will strengthen and your symptoms of urgency, frequency, and urge incontinence may decrease. Both Kegel exercises with and without the cones have a very good chance of improving the bladder function.


▷ Pelvic Floor Stimulation
Other biofeedback techniques such as pelvic floor electrical stimulation also improve urge incontinence. This technique will help women identify their pelvic muscles. It works with a little bit of effort on your part. The electrical stimulation exercises the pelvic muscle for you. A small instrument is inserted into the vagina to deliver a tiny electrical pulse that causes the pelvic muscles to contract for you.


It feels like a hum and a pull in your pelvic muscle and is not uncomfortable. This technique may reduce urgency, frequency symptoms, overactive bladder and especially urgency incontinence.


▷ Medications
Some medications prevent contractions of an overactive bladder and tighten muscles at the neck of the bladder and urethra preventing leakage. Your physician to improve your urgency, frequency and urge incontinence symptoms may utilize several effective prescription medications. Estrogen or HRT (Hormone Replacement Therapy) is believed to cause the muscles and nerves in urination to function normally. Estrogen must be used with progesterone, if you have not had a hysterectomy, because estrogen therapy alone has been associated with an increased risk of cancer of the uterus. Talk to your doctor about the risks and benefits of long-term use of hormone replacement therapy.


HRT may improve the way your muscles and nerves of the pelvic floor and bladder function and may reduce incontinence. HRT is available in pill form, patch, vaginal form pill, cream, or ring and used under the direction of your doctor.


▷ Devices


→ Interstim
This electronic device can be used to treat severe urge incontinence when it is not improved with medical, dietary and behavioral therapy. It consists of a battery-powered stimulator connected to a wire, which is placed near the root of one of the sacral nerves in the back. It is meant to `down regulate` the bladder muscle s sensitivity and thereby decrease bladder contractions and the resulting urgency, frequency and urge incontinence.


→ Pessary
You doctor can place a PESSARY in the vagina. This flexible, plastic device, usually used for Prolapse (descent of pelvic organs/floor) will help hold the bladder and vagina up, sometimes preventing leakage. Pessaries also come with an incontinence modification. Surgery (other than Interstim) is very rarely used to treat urge incontinence. It is very useful for Stress Incontinence.


Several tips you can use to reduce incontinence: improving your access to toilets, urinating on a schedule, decrease excess fluids, avoid caffeine. Disposable garments/paper incontinence products are used to keep people dry. They do not cure bladder control problems. You may wish to consider having a carpenter make changes to your house. A hallway light or downstairs bathroom can be helpful. Make your floor less slippery, putting down a safety carpet.


Do not let embarrassment, fear or wrong information about incontinence prevent you from speaking to your doctor. The great majority of women suffering from urinary incontinence can be cured or, at least become far less wet. Call your physician and ask about referral to a Urogynecologist.