Once the cause of the urinary incontinence can be discovered the woman can begin treatment. There are three major treatment areas: medications, surgery and behavioral techniques. Medications to treat incontinence again depend on the cause of the incontinence. If the patient's bladder is contracting inappropriately, medicines can be used to slow down these contractions. Certainly, medications can be used to treat infections that may be stimulating the bladder to contract or causing irritation. Muscle medications also exist which help tighten the muscles of the sphincter area.
Surgery is often needed to help incontinence. There are a variety of surgical options for women with stress incontinence. As mentioned earlier, many cases of stress incontinence are a result of vaginal delivery. Because of stretching of the vaginal opening and the muscles of the pelvis from pregnancy and delivery, the vagina and bladder lose support and tend to fall. Surgical procedures involve some form of suspension or lifting of the vagina and bladder. A new development from Bard Urological is the use of injectable collagen. Collagen is a safe material that can be injected just outside the sphincter to create increased resistance and hopefully achieve better control. In some patients who have very small bladders because of infections or inflammation or radiation, augmentation of the bladder size using intestine can be used to treat incontinence.
Behavioral techniques are now available that allow improved coordination of voiding function and strengthening of the muscles. Biofeedback is a way of learning exactly how the bladder muscles and sphincters contract, and by using biofeedback techniques increased resistance can be achieved. Also pelvic exercises called Kegel's exercises can be used to help strengthen the muscles around the neck of the bladder.
Urgency-frequency is characterized by the uncontrollable urge to urinate, resulting in very frequent small-volume voids. Sometimes referred to as the urgency-frequency syndrome, interstitial cystitis and urethral syndrome are debilitating conditions most often characterized by urinary frequency, urgency, dysuria and related pain without objective urologic findings. Patients complain that they never feel empty after voiding and may present with pain or discomfort with their urinary condition and possibly, incontinent episodes that result from an inability to control the overriding urge to void. It is estimated that approximately 2 million people in the U.S. struggle with symptoms of urgency-frequency. While urgency-frequency primarily affects females, males can present with identical voiding symptoms.
Quality of Life Reduced Substantially
Some patients experience the urge to void as often as every half-hour and three to four times a night. If they try to postpone urination, they may leak urine. These symptoms are very disruptive to activities of daily living. Patients cannot drive long distances without stopping, attend meetings, or socialize normally. Their sleep is often impaired by nocturia, so they often feel tired and run down. Though not all urgency-frequency patients experience pain, many find those symptoms even more debilitating than the frequency and urgency. In an effort to manage their condition, patients may resort to dehydration. They may also withdraw from work and social activities, becoming isolated, depressed and even suicidal.
Traditional Treatments Not Effective for All
The typical course of medical treatment includes behavioral programs, pharmacologics and nonsurgical interventions. Though these treatments provide relief for some patients, a significant group of challenging patients do not respond or experience uncomfortable side effects. Disappointment and frustration may cause patients to seek help from one physician after another. It is important for patients to understand that there are options available to address their bladder problems.
New Therapy Available for the More Challenging Patients
In April 1999, the Food and Drug Administration (FDA) approved InterStim Therapy, sacral nerve stimulation for urinary control for the treatment of significant symptoms of urgency-frequency and urinary retention. This reversible therapy involves electrical stimulation of the sacral nerves that control voiding function. A diagnostic screening test is performed in our clinic to assess the therapy's effectiveness. The patient is given a local anesthetic, a test stimulation lead is placed percutaneously near the appropriate sacral nerve, and an external device provides stimulation for several days. If the patient experiences 50% improvement in voiding symptoms, the InterStim system can later be implanted under general anesthesia.
Clinical Study Demonstrates Efficacy and Safety
The clinical study results bear out the efficacy of this therapy for carefully selected patients who have failed conservative treatments. At twelve months post implant, 31% of urgency-frequency patients achieved a normal number (4-7) of voids per day, and an additional 33% experienced at least a 50% reduction in the number of voids per day. 61% reported at least a 50% increase of volume voided per void. 82% increased voided volumes with either the same or a reduced degree of urgency before voiding. However, no treatment is without risks. Complications from the surgery are minor; none resulted in permanent injury.
There have been significant advances in the techniques for repairing the various potential weaknesses that can develop in the vagina (called vaginal prolapse). Many women with pelvic prolapse are very uncomfortable with a feeling of heaviness or weight in the vaginal area, a feeling of "sitting on a ball," discomfort during sexual activity, difficulty with bowel movement, or loss of urine. Besides these symptoms, significant pelvic prolapse can also result in kidney damage or damage to the bladder, making it difficult for the bladder to empty and predisposing to urinary infection. With new techniques of repair utilized at Desert Incontinence Center, these problems can usually be corrected without the need to continue to live with the problem or wearing a ring (pessary) in the vagina. These advanced techniques of repair include:
Repair of the Anterior Vaginal Wall: When the urethra drops (the tube that carries the urine from the bladder to the outside) women frequently have loss of urine with coughing, sneezing, or change in position (stress incontinence). Returning the urethra to its proper position with a sling procedure can now restore long-term urinary control. We have developed a new sling technique with minimal postoperative discomfort to allow the sling to be entirely performed via the vagina without the need to harvest any tissue for the sling.
Dropping down of the urethra is frequently accompanied by dropping of the bladder as well (called a cystocele). When these problems coexist, it is important that both be repaired simultaneously. With current techniques of cystocele repair, the defect through which the bladder herniates into the vagina is closed with strong tissue with excellent long-term success.
Repair of the Top of the Vagina: Most commonly, weakness at the top of the vagina occurs after hysterectomy. This bulge from the top of the vagina is called an enterocele. Frequently, an enterocele is associated with the entire vagina dropping down, known as vaginal vault prolapse. These weaknesses at the top of the vagina are repaired through the vagina by closing the defect in the ligaments at the top of the vagina and fixing the top of the vagina to these ligaments. Also, the hernia sac which contains the intestine is closed. These reconstructive procedures are performed entirely through the vagina without causing loss of vaginal length or narrowing of the vagina.
Repair of the Back and Opening of the Vagina: Weakness at the back of the vagina usually involves the rectum bulging through the back wall of the vagina (called a rectocele) causing a feeling of the bowel movement getting stuck and the need to push excessively to evacuate the bowel movement. Frequently, a rectocele coexists with weakness of the muscles at the opening of the vagina. This muscular weakness can lead to loss of sensation during sexual activity or a general feeling of the vagina being "too loose." Repair of weakness in this area involves bringing the separated muscles back together to strengthen both the back of the vagina and restore the muscle tone at the vaginal opening.
Summary: Symptoms of vaginal weakness are effectively treated with new surgical techniques performed entirely via the vagina with minimal postoperative discomfort and excellent results. These successful vaginal techniques now make it possible to repair any combination of vaginal weaknesses that used to require major abdominal surgery and prolonged recovery. Thus, many women who previously opted for the option of avoiding surgery or wearing a ring (or pessary) in the vagina may now elect to repair the problem and significantly improve their quality of life.
Second Opinion from Desert Urology
Many urologic problems are very complex, and frequently multiple treatment options are available to the patients. It is therefore, not surprising that patients are frequently left confused and unsure about their options.
One of our doctors will be happy to provide second opinions regarding any urologic topic. Please contact us at Info@DesertUrology.com to find out if we can help you with your urologic problem.
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