Cover Story
Urinary Incontinence: A Problem No One Wants to Talk About
A patient has to first discuss urinary incontinence with her doctor before she can take advantage of new treatments.
By Howard Bell
Most who endure incontinence don’t think it’s funny. Eighty-five percent of people who suffer from this condition are women, according to the American Urological Association. Half of all women have bothersome urinary incontinence at some time in their lives. A University of Iowa study showed 10 percent of middle-aged women report having daily incontinence, and one-third say they have it weekly. About 20 percent of incontinent women have pure stress incontinence, which is caused by a combination of poor sphincter function and the underlying ligaments and tissues inadequately supporting the urethra. It can be brought on by coughing, laughing, sneezing, or sexual intercourse. About 40 percent have urge incontinence, a type of overactive bladder caused by unwanted contraction of the detrusor muscle, which as the name suggests, causes a sudden strong need to go often before there’s time to reach the bathroom. Another 40 percent have a combination of stress and urge incontinence.
The risk for both types of incontinence increases with age, and incontinence is most likely to occur after menopause, according to epidemiologic studies. That’s because a decrease in estrogen, Nakib explains, causes a decrease in blood flow to the vaginal area, which in turn thins the urethra and atrophies tissues that support it. Other risk factors include being Caucasian, having experienced vaginal childbirth, and being obese. Women with body mass indices of 30 or higher are twice as likely as leaner women to have urinary incontinence. Men can have stress or urge urinary incontinence, or a combination of both. It’s often caused by aging, urethral obstruction from benign prostate enlargement, or a complication from treatment of prostate cancer.
Incontinence is a problem neither physicians nor patients like to talk about—but should, according to Steven Siegel, M.D., a urologist with Metro Urology who has devoted most of his 30-year career to treating incontinence and other pelvic floor conditions. “Many physicians still don’t understand how common and disruptive to a person’s life incontinence is,” says Siegel, who decided to specialize in incontinence while in residency when the problem forced his grandfather into a nursing home and caused stress and disruption in the family. “It’s not the kind of problem that can kill you, but sometimes you wish you were dead. It’s embarrassing, psychologically distressing, and it colors a person’s whole impression of themselves. As one of my patients told me, ‘It’s not like you can put on a diaper, then feel normal.’”
Pads are not a treatment—and they’re expensive. “Many of my patients spend more than $100 per month on these products,” Siegel says. Insurance doesn’t pay for absorbent products, although Medicaid does in some circumstances. Unfortunately, fewer than half of incontinent women seek treatment, according to epidemiological studies. “They think it’s their fate, a natural part of aging,” says Nakib, who completed a fellowship in female incontinence at Metro Urology in 2008 because “as a woman I expected that other women would come to me with this problem, and I wanted to be prepared to help them as best I can. Some are too embarrassed to get help…. Some are fearful of surgery or they think surgery won’t work. Maybe they heard from their mom or their mother’s friends that one of the older surgeries didn’t work or caused complications.”
Nakib admits she doesn’t go a single clinic day without someone breaking into tears. Like the woman who loved to go dancing with her husband but stopped because she leaked every time she did. She also began avoiding intimacy because she was embarrassed and feared she smelled of urine. “This drastically affected her relationship with her husband and made her depressed.”
Nakib says some women don’t seek help because their symptoms come and go or worsen with colds and allergies. Even some women with persistent incontinence aren’t troubled enough to seek treatment. When it comes to urinary incontinence, bothersomeness is highly subjective.
“A lot of patients try to cope with pads, diapers, fluid restriction, and social isolation partly because we haven’t had great treatment options until the last 10 years,” says John Gebhart, M.D., a Mayo Clinic urogynecologist.
Coaxing Incontinence Out of the Closet
Before physicians can help patients, they have to get them to talk about the problem. Primary care physicians play a crucial role in coaxing incontinence out of the closet so it can be treated, according to Gebhart. “The most important thing primary care physicians can do is ask patients if they’re ever incontinent. It’s a vastly under-treated problem because patients vastly under-report it.”
So that neither the patient nor the physician becomes uncomfortable, Nakib recommends easing into the subject by saying something like, “You know, as we grow older, many of us have problems with urination. Maybe we leak a little. Maybe we have a sudden strong urge to go. Are you having any problems like this? Because if you are, you don’t have to put up with it. We’ve got much better solutions than we used to and some of them are pretty simple.” The key, she says, is to frame the issue as something lots of people experience and for which much can be done. Siegel adds that as baby boomers age, they want to remain fully functional, “so physicians need to be prepared to talk to patients about incontinence.”
Incontinence specialists
Mayo Clinic and Metro Urology in the Twin Cities both offer incontinence fellowships. Mayo’s urogynecology and reconstructive pelvic surgery fellowship is a three-year program that covers the gamut of female pelvic floor issues, “but a good portion of time is spent evaluating and managing urinary incontinence,” says John Gebhart, M.D., a urogynecologist at Mayo and fellowship director.
One new fellow is accepted into the program each year. Fellows complete a year of research, during which they also obtain a master’s degree. They spend the remaining two years on clinical rotations, dealing primarily with incontinence, pelvic organ prolapse, and other pelvic floor conditions. Mayo’s fellows do rotations at Metro Urology and Metro’s fellows rotate through Mayo.
Metro’s female urology fellowship is a one-year program that focuses on urinary incontinence and other voiding dysfunctions—for men as well as women. It’s open to two qualified physicians per year who’ve completed a residency in urology and are licensed to practice in Minnesota. Steven Siegel, M.D., a urologist with Metro who started the program, estimates 30 to 40 incontinence fellowships are offered in the United States. Some are urology-based; others are gynecology-based; still others are a combination of both. Mayo and Metro Urology offer the only incontinence fellowships in Minnesota.
Metro’s program has trained 14 fellows since it began in 1998, according to Siegel. Several have remained in the Twin Cities. Nissrine Nakib, M.D., who completed the fellowship in 2008, is the only incontinence-trained specialist at the University of Minnesota. “I wanted to be great at what I do, not just adequate, and I feel that my fellowship helped me accomplish that goal,” she says.—H.B.
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When a patient does admit to having a problem with incontinence, Gebhart recommends doing a history and physical to rule out urinary tract infections and to check for prolapse of the bladder, uterus, or rectum. (Approximately 30 percent of people who have urinary incontinence also have bowel leakage.) Siegel recommends performing a stress test by having the patient cough with a full bladder and observing for leakage. “It may sound silly,” he says, “but you need to see the stress incontinence.”
To determine whether stress or urge incontinence is the primary problem, Deborah Lightner, M.D., a Mayo Clinic urologist and pelvic floor reconstructive surgeon asks her patients about the conditions that cause leakage. “If they leak when they turn the water on or go out in the cold, you can be pretty sure it’s urge. If they leak when they cough, sneeze, or go about their daily activities, that’s stress.” Another question Lightner asks is, “What does your leakage keep you from doing?” This helps determine how bothered they are by the problem.
Lightner says many of her patients have severe incontinence, such as the elderly woman who leaked every time she stood up. Even though she wore a heavy pad, she still could leave a puddle on the church pew or her friend’s sofa. Embarrassed, the woman would make up excuses so she didn’t have to go anywhere. When she was finally coaxed into seeing Lightner, the woman told her that she had mentioned the problem to her regular doctor, who checked her urine for infection, found none, then dropped the subject.
Nakib says after determining incontinence is an issue, physicians need to tell patients that although it does become more common as people get older, treatments are less invasive and far more effective than they used to be. “We have new and better treatments that, in some cases, can make them completely dry,” she says. These treatments include behavioral therapies, medications, nerve stimulation, and surgery.
Behavorial Treatments
Behavioral treatments include weight loss for the obese, monitoring fluid consumption, timed voiding, Kegel exercises, and physical therapy. These work best for urge incontinence, although they also work for mild to moderate stress incontinence. Siegel, Lightner, Nakib, and Gebhart agree that behavioral treatments along with medications are well-handled in the primary care setting In fact, Lightner, who serves on the American Urological Association’s stress incontinence practice guidelines committee, says 60 percent to 75 percent of incontinent patients get good outcomes from conservative strategies provided in a primary care setting. She adds that when behavioral treatments succeed, the results have been shown to last for five to 10 years. “The beauty of these treatments is that they work for both stress and urgency, so the primary care physician doesn’t even need to know which type is affecting the patient most,” she says.
Perhaps the simplest way to begin treating incontinence is to have patients keep a diary of what they drink, how much, and when. This can help determine possible solutions, such as fluid schedules (drinking a certain amount at a certain time) and timed voiding. Not drinking enough concentrates urine, which in some people irritates the bladder and worsens urge incontinence. So does too much caffeine. “Incontinence has subtleties that need to be picked apart,” Siegel says. “It can be a combination of types with more than one cause requiring more than one treatment.”
Weight loss alone can be very effective for those with a BMI over 35, according to Lightner, who is currently training five residents in incontinence evaluation and management. Obese women who had moderate stress or urge incontinence who lost an average of eight percent of their body weight had 50 percent fewer episodes of incontinence, according a study published in 2009 in the New England Journal of Medicine. “This is a remarkable improvement,” says Lightner, “and an additional motivator for patients trying to lose weight.” Kegel exercises, which help patients strengthen their pelvic muscles, are another simple treatment. However, 50 percent of incontinent women are unable to do a Kegel contraction, even after being shown how to do it, according to Lightner, who recommends teaching women to use finger biofeedback. “When you feel your vagina tighten around your finger, you know you just did a Kegel.” Kegels also work well for men with stress or urge incontinence caused by prostate surgery, Nakib says. In addition to Kegels, she and the others also teach male and female patients with urge incontinence a set of contractions and holds that turn off the feeling of having to go.
“Kegels are great,” Nakib says, “but patients often don’t stick with them or do them correctly.” Physicians can refer these patients to physical therapy for electronic biofeedback, which teaches patients when they’ve properly contracted their pelvic floor muscles. Physical therapy also can correct problems with the muscles and bones in the lower back and pelvis that might worsen or cause incontinence. Nakib says a “good number” of urgency patients can be successfully treated this way.
Although Kegels work for light-to-moderate urge and stress incontinence, Siegel warns that they can sometimes backfire in patients with urge incontinence who already have tight pelvic floor muscles that are partly responsible for the urge incontinence to begin with. In this case, getting the muscles to relax somewhat is more important than teaching them to contract.
Anticholinergic medications are another first-line treatment for urge incontinence. They block the cholinergic receptors in the bladder wall that cause contraction, thereby decreasing the degree of urgency and allowing the bladder to be fuller before the urge is felt, according to Siegel. “Patients still have the same problem,” he says, “but they have more warning time and more bladder volume to work with.”
Anticholinergics also block receptors in other parts of the body, so they often cause dry mouth, dry eyes, blurry vision, and constipation. “You really can’t achieve a good therapeutic effect for the bladder without also getting some of these side effects,” he says, “which is why less than half of patients refill their initial prescription and less than 20 percent continue after one year. But anticholinergics do not correct the underlying problem, and they must be taken indefinitely to maintain benefit.” Siegel says he prefers biofeedback or physical therapy as a first-line treatment for urge incontinence, but he admits drugs combined with behavioral therapy can be a good initial strategy because the drugs give immediate benefit, while the behavioral therapy corrects voiding reflex problems over several months. Once the problems are corrected, the drugs can be discontinued.
When to Refer
When conservative treatments aren’t working, it makes sense to refer the patient to a urologist, urogynecologist, or gynecologist with incontinence expertise, according to Siegel. Lightner says she’s “a huge believer in conservative treatments provided in the primary care setting, but I want to see patients who fail conservative treatments, who’ve had pelvic floor surgery, pelvic radiation, or who have neurologic disease.” Patients with blood in their urine, frequent urinary tract infections, bladder stones, or bladder tumors should also be referred, says Nakib, who says it’s reasonable for primary care physicians to treat urge incontinence for one or two months with behavioral therapies and anticholinergic medications, then refer if they’re not working or the drug side-effects are too bothersome. Specialists have surgical and nonsurgical options for addressing the issue. All offer hope to patients who haven’t had success with more conservative treatments.
Mid-urethral and Autologous Slings
Surgical placement of mid-urethral slings made of open-weave polypropylene monofilament mesh have revolutionized treatment of stress incontinence. Most women with stress incontinence are candidates for these slings, according to Gebhart. “They’ve largely replaced retropubic and autologous sling procedures,” he says. Retropubic procedures are still valid, says Lightner, “when you need to be in the abdomen for some other reason to justify the invasiveness. But many of the older procedures are no longer done because they just didn’t cure the problem for very long.”
Slings can be used for women and men. For women, mid-urethral slings are much less invasive than older bladder neck slings, as they require only a 1-cm vaginal incision. The procedure takes 15 to 20 minutes under local anesthesia and conscious sedation, Siegel says. “Patients are back to work in three to five days instead of four to six weeks for the older procedures.” Men, however, need a longer transperineal incision that requires general or spinal anesthesia and a longer recovery time.
Mid-urethral slings work best for patients with hypermobile urethras, according to Siegel, as they support the urethra dynamically without putting tension on it the way the older sling procedures can. “That tension can cause urinary retention or urge incontinence,” he says. Autologous slings, which have been used for decades, are made from the patient’s own fascia. They’re most commonly used for women with stress incontinence who have poor urethral function caused by pelvic radiation or spinal cord injury, or for women who’ve failed multiple surgical procedures, according to Lightner. “Autologous slings don’t cause vaginal tissue erosion,” she says, “which is a known, though uncommon, complication from synthetic materials” (see “Slings and Safety”). In addition, she says, autologous slings work best for patients who primarily suffer from poor sphincter function.
When complications do occur, they’re usually easy to correct, according to Nakib. Too much sling tension, for example, blocks urine flow or causes urge incontinence. On rare occasion, the mesh used in mid-urethral slings erodes or extrudes into the vaginal tissue. This can be corrected if it causes persistent vaginal discharge, bleeding, or pain during intercourse. To further reduce complication rates, a smaller “mini-sling” is now available, according to Gebhart. He says they work well, although “it’s not yet been shown that these work any better.”
Siegel says 90 percent of his patients with moderate to severe stress incontinence choose sling surgery. “Many of my patients say they wish they’d had the surgery a lot sooner,” he says. Nakib says 95 percent of her mid-urethral sling patients end up dry all the time if their incontinence was caused by hypermobility. An 80 percent to 90 percent success rate one to two years after surgery is common for mid-urethral slings, according to Lightner, who says that most poor outcomes happen because patients were improperly selected.
Pessaries
Pessaries and tampons sometimes help women with stress incontinence caused by prolapse. These intravaginal rings are placed beneath the urethra to support it and thereby reduce leakage. Studies show tampons are equally effective. Nakib says she offers pessaries to patients with prolapse as an alternative to surgery. Siegel does, too. He also uses them to predict the outcome of surgery. “Sometimes when a pessary temporarily corrects the prolapse by elevating the prolapse bulge above the urethra, it creates or worsens symptoms of stress incontinence. In these cases, a surgical fix for the incontinence along with the prolapse will likely be needed.” The downsides to pessaries are that they often don’t stay put and they require frequent cleaning. Prolonged use can cause vaginal pressure ulcers. For those reasons, Nakib says, most of her patients don’t choose this option.
Bulking Agents
Another effective option for treating stress incontinence is injecting silicone or other bulking agents into the urethra. These increase outlet resistance of the urethra, thereby reducing leakage. The five-minute procedure done in the exam room can be a good option for patients who don’t want or can’t have surgery. “They’re wonderful,” says Lightner, “for the sedentary elderly nursing home resident who has co-morbidities and really shouldn’t have surgery.” She says they also work well for some patients with neurogenic bladder dysfunction caused by spinal cord injury.
Bulking agents work for about one to two years, and must then be re-injected. Lightner, who sees the most severe incontinence cases in her practice, says after her patients have been treated six months to two years with bulking agents one-third have significant improvement, one-third have moderate improvement, and one-third have no improvement. “If they don’t work, move on to something else,” she says.
Nerve Stimulators
Implantable nerve stimulators that modulate the tibial or sacral nerves controlling the bladder, rectum, and pelvic muscles work well for severe
Slings and Safety
In October 2008, the Food and Drug Administration issued a warning that the synthetic mesh used in some mid-urethral slings can cause serious complications, including erosion into vaginal tissue and bladder or urethral pelvic pain. Steven Siegel, M.D., a urologist with Metro Urology in the Twin Cities served on a Washington, D.C.-based advocacy group called the “pelvic health coalition” that sent a letter to the FDA asserting that its warning was “skewed and unbalanced” and that using the FDA’s own numbers, the complication rate was only 0.1 percent.
Deborah Lightner, M.D., a Mayo urologist and pelvic floor reconstructive surgeon, says that more than a decade ago various sling products were brought to market before adequate safety and effectiveness testing was completed. “For a while, some of the most unhappy patients I saw had synthetic mesh complications,” she says. Some of the problems were caused by slings made of a microporous mesh that was not well-tolerated inside the body and has since been taken off the market.
Synthetic meshes are now made of type 1 macroporous polypropylene. In addition, urologists, gynecologists, and urogynecologists who do sling procedures are now more familiar with the procedures, according to Siegel. Mid-urethral vaginal mesh slings are now widely considered the gold standard for surgical repair of stress incontinence.—H.B.
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urge incontinence that has failed drugs, Kegels, and other conservative treatments. They offer most patients significant improvement, according to Lightner, who says the peer-reviewed literature shows that half of patients have at least a 50 percent improvement in symptoms. Siegel says that in his experience, “it’s definitely more than half.”
“Stimulators have been an absolute life-changer for those with the most bothersome urge incontinence,” he says. “With nerve stimulation, we often can hit a home run even for those with the most debilitating symptoms. And we’ve seen dramatic and positive effects on fecal incontinence as well because the same nerves control both functions.” Private insurance and Medicare pay for the device and procedure.
Percutaneous nerve stimulation is a less invasive type of nerve stimulation that uses an acupuncture needle placed above the ankle. It relieves urgency incontinence as effectively as do drugs, according to the Overactive Bladder Innovative Therapy trial, a multi-center study. “Seventy percent of patients improved significantly,” Siegel says, “and they preferred percutaneous stimulation over drugs because there aren’t any side-effects.” The procedure is FDA-approved and in the process of getting a reimbursement code. Once that happens, Siegel says percutaneous nerve stimulation “may emerge as a first-line treatment for urge incontinence.” For now, most insurers, including Medicare, don’t pay for the treatment, “which is a really unfortunate decision,” he says. “Many older patients, in particular, are good candidates for this minimally invasive technique.”
Botox
Injecting Botulinum toxin A (Botox) is another minimally invasive technique that works well for urge incontinence. When injected into the bladder, Botox turns off bladder spasms that contribute to urge incontinence. “We’re disabling bladder nerves so the bladder can work normally,” explains Siegel. He adds that it works well but is, $1,500 or more per treatment, expensive and must be re-injected every six to nine months. Botox is not yet FDA-approved for urge incontinence, and it’s not covered by most insurance, including Medicare.
A Different Game
Athough urinary incontinence is coming out of the closet and more men and women are seeking help, the condition is still under-treated because patients still under-report it. Physicians can do their part by raising the issue with their patients and making sure they understand that when it comes to incontinence treatment, the game has changed—many will greatly improve with conservative behavioral therapies. And for those who don’t, surgical procedures have greatly improved. “It’s very rare,” Siegel says, “that we see a patient with any type of incontinence who can’t do better when given the right treatment.” MM
Howard Bell is a medical writer in Onalaska, Wisconsin.