This presentation will address the causes and types of urinary incontinence and explain how it is evaluated and can be treated. Learn about effective new approaches to help manage and resolve urinary incontinence in women of all ages!

1. Urinary Incontinence- the
Basics
Presented by:
Rhonda Walsh, MD
February 26, 2015

2. About Me
• Urology Residency at University of Texas-
San Antonio
• Fellowship in Female Urology/Voiding
Dysfunction at NYP-Columbia
• Operate at St. Barnabas, Overlook,
Morristown
• Also treat pelvic pain, prolapse, UTIs,
kidney stones, bladder and kidney cancer

3. What is incontinence?
• Incontinence is defined as “the inability
to restrain natural discharges or
evacuations of urine or feces”
• For our purposes, it refers to the
involuntary leakage of urine

5. Female Bladder

6. What does the bladder do?
• The function of the bladder is to store
urine
• In theory, the bladder should hold urine,
without leakage, until you say it is time
to empty
• This process can fail either because of
the urethra not holding urine in, or the
bladder squeezing to get urine out

7. Female Pelvis

8. Different types of incontinence
• Stress
• Urge
• Mixed
• Overflow
• Associated symptoms like frequency,
urgency, nocturia

9. Stress Incontinence
• Leakage of urine with increases in
abdominal pressure
• Often described as happening when
coughing or sneezing, or bending to lift
an object
• Caused by a lack of urethral support
• Often seen in women after childbearing
years- extended labor can damage the
perineal nerve worsening incontinence
in those prone to it

11. Urge Incontinence
• Leakage of urine when there is an urge to go to
the bathroom and one does not get there in
time
• Thought to be caused by overactive bladder
(OAB)- the bladder muscle squeezing without
permission
• Possible to have urgency without incontinence-
OAB wet vs. OAB dry
• OAB is a symptom complex that can include
urgency, frequency, incontinence, and nocturia

12. Other types
• Mixed incontinence- stress and urge
together
• Overflow incontinence- Leakage of
urine because bladder is full and cannot
be emptied
• Constant urine leakage following pelvic
surgery or childbirth can be due to a
fistula

13. How common is incontinence?
• The prevalence of incontinence in
studies ranges from 11% to 72%,
depending on the definition used
• A more accurate assessment may be
21% of women over 70 having at least
weekly incontinence
• Stress is most common (49%), followed
by mixed (29%) and urge (22%)

14. Risk factors
• Exercise
• Childbirth
• Obesity
• Aging
• Back injuries and neurologic problems
can contribute to bladder dysfunction

15. Other causes of incontinence
• Urinary tract infections sometimes cause
incontinence
• Very rarely, bladder cancer will cause the
bladder to be overactive
• It is important to see your doctor about
incontinence as it may be a sign of
another problem (sudden)
• Some medications (lithium, SSRIs)
• Diabetes can cause urgency and
frequency

16. Nocturia
• Defined as waking from sleep to void
• More common with age
• Caused by increased urine production
at night due to hormonal changes as
well as sleep apnea, cold
• Difficult to treat

17. Workup
• Making sure you empty your bladder
(ultrasound)
• Checking for urine infection
• Physical examination including pelvic exam to
make sure there are no abnormalities
• Voiding diary
• Possibly cystoscopy (looking in the bladder with
a camera)
• Urodynamic testing (looking at how the bladder
squeezes)

18. Physical Exam

19. Voiding diary

20. Cystoscopy

21. Urodynamics

22. How is incontinence treated?
• Behavior changes
• Exercises
• Medication (URGE)
• Surgery (STRESS)

23. Why is incontinence treated?
• “No one ever died from wetting their
pants”
• Caveat: sometimes increases injury and
infection in the elderly
• If incontinence is limiting your ability to
live your life, it should be treated

24. Treatment Algorithm
Leaking
Urge
Neuro-
modulation
Medication Botox
Stress
Biofeedback Surgery
Overflow
Behavior
Modification

25. Behavioral Changes
• Quitting smoking- less coughing!
• Losing weight
• Managing fluid intake- what goes in
must come out
• Managing constipation
• Managing stress and depression

26. Exercise Therapy
• In conjunction with behavioral
modification, can work for both types of
incontinence
• Special pelvic floor physical therapists
teach kegel exercises and do muscle
stimulation/biofeedback

27. Urge incontinence treatment
Urge
incontinence
Medication Urodynamics
Neuro-
modulation
Botox

28. Antimuscarinics
• Most common medications/least expensive
• Work on the bladder to relax it and reduce
involuntary contractions
• Reduce urgency episodes by 2-3/day and
incontinence episodes by 2/day
• Drawbacks are side effects of dry mouth
and constipation
• Used with caution in elderly due to
cognitive side effects

29. Mirabegron (Myrbetriq- Astellas)
• B3 agonist
• Works to increase bladder capacity
• Significantly reduces voids by 1.75/day
and incontinence episodes by 1.5/day
• NO constipation and dry mouth
• Most common side effect is elevation of
systolic blood pressure, but no more
than other bladder medications

30. Posterior Tibial Nerve Stimulation
• Treats frequency, urgency, and urge
incontinence
• Involves 12 weeks of 1-30 minute session a
week, then monthly maintenance
• Needle inserted into ankle stimulates the tibial
nerve
• Results are similar to medications- Decreases
incontinence episodes by 3 a day and urge
episodes by 5

31. PTNS (Uroplasty)

32. Interstim (Medtronic)
• A device placed for overactive bladder
that does not respond to medication
• Stimulates the pelvic nerves to reduce
overactivity
• Like a pacemaker for the bladder,
providing constant low-level stimulation
to override errant signals

34. Botulinum toxin
• Injected through a cystoscope into the
bladder wall
• Partially paralyzes the bladder
• Works for 3-6 months the first time, then
6-12 months with subsequent injections
• Decreases urge episodes by 3 and
incontinence episodes by 2/day
• Risk of urinary retention

35. Stress incontinence
Stress
incontinence
Mid-urethral
sling
Injectibles
Kegels

36. Pelvic floor muscle exercises
• 10 slow-twitch contractions and 10 fast
5 times daily
• Learn to contract these muscles at
times of increased abdominal pressure
• Works for urge incontinence as well
• 70% improvement rate, but must keep
doing them

37. Mid-urethral Sling
• Multiple surgeries have been done over
the years for stress incontinence
• In the past, women had open abdominal
surgery to “lift the bladder”
• Now the most common is a sling put in
through the vagina
• Often will help with mixed incontinence
• Successful in 80-90% of women

38. Mid-urethral sling
TVT
TOT

40. Vaginal Mesh
• YES it is safe in properly selected
patients
• The FDA warning is for PROLAPSE
REPAIR, not for slings

41. Injectibles
• Macroplastique (Uroplasty) and
Coaptite (Boston Scientific)
• Injected into the bladder neck with a
cystoscope
• Not as successful as slings,
work 40% of the time after 2
injections

42. Summary
• Incontinence is a common problem
• Incontinence can be treated with
minimal side effects
• If your urine leakage is bothering you,
please get it treated

43. Thank you
• Questions???