Home of the first board accredited Female Pelvic Medicine
and Reconstructive Surgery Fellowship Program in the nation!
Urogynecology Associates, PC
Douglass S. Hale, MD, F.A.C.O.G, FACS | Michael H. Heit, MD, PhD, FACOG, FACS
You may choose to start on the “first step” for your therapy and move up
only if needed or you may start on a “higher step” if appropriate for your condition.
Conservative Treatment for Overactive Bladder
Stress urinary incontinence is leakage of urine during activities such as coughing, sneezing, or laughing. It occurs as the intra-abdominal pressure increases and “squeezes” the bladder forcing urine to escape through the urethra. We often describe it like a balloon with a weak knot. If a balloon with a weak knot is squeezed hard enough, the air will escape from the balloon. In stress incontinence, the knot is the urethral sphincter. If the sphincter is not strong enough, when the bladder is squeezed, urine will escape. It usually results from nerve damage to the urethral sphincter muscle. Different therapies to help this condition are described below.
Most patients have heard of Kegel exercises. These were described in 1950 by Dr. Arthur Kegel who described strengthening the pelvic floor muscles. Many different techniques have been described to teach patients how to properly contract these muscles which are a muscle group called the levator ani or pelvic floor muscles. Proper muscle terminology refers to these muscles as the puborectalis, pubococcygeus, and iliococcygeus muscles. Strengthening these muscles is aided by working with a physical therapist who specializes in the the treatment of pelvic floor disorders. If these muscles are weakened and can be treated by physical therapy, nearly 50% of women show enough improvement that no other treatment is needed.
A second option is using an intravaginal device called a continence ring or a continence dish. These are very much like a diaphragm in that they are placed vaginally and made of silicone or latex. These devices have a “knob” on them that mechanically blocks the urethra and prevents leakage. When fit properly, these are comfortable and easily placed and removed by you. The nursing staff in the office instructs you on how to do this. These devices are often successful for “situational incontinence” where urine leakage occurs during a very predictable activity. An example of this would be placing the continence dish before participating in an exercise program. You have the option of using it as you need it. Pictured below the continence ring along with a picture showing of where it is placed.
Other changes in your lifestyle may be of benefit in treating your incontinence and can be discussed at the time of you visit.
Pharmacologic Management of Overactive Bladder
Medical therapy for stress urinary incontinence is of variable success. Medicines directed at increasing the tone of the urethral sphincter (alpha-agonists) may have some success. Some of these medicines are the same as those available in over the counter cold medicines. Others are prescription medicines like imipramine. Although in higher doses this medicine is used to treat depression, in lower doses it may affect the urethral sphincter and help in treating stress incontinence. (Uniquely, imipramine may help patients with overactive bladder as well by also blocking acetylcholine receptors.) Certain medical conditions like hypertension prevent using these medications. Some medicines may also contribute to stress urinary incontinence. Certain medications used to treat hypertension by blocking alpha-receptors, alpha-antagonists, such as Cardura, Prazosin, Hytrin, Methyldopa, and Clonidine, may also block the urethral sphincter leading to stress incontinence. Never stop a medicine before talking to your physician, but changing the type of anti-hypertensive medication you take may effect your incontinence.
A new medicine for the treatment of stress incontinence has been approved in Europe but not in the United States. However, you may choose to use this medicine “off-lable.” Cymbalta (in the United States approved for treatment of depression and in Europe called Duloxetine) has been shown to help approximately 40% of patients of who take it.
Other medicines will become available as their testing is completed. Ask your physician if you are a candidate for using any of these to treat your condition.
Surgical Management of Overactive Bladder
There are over 100 operations described to treat stress urinary incontinence. Recent advances in therapies have dramatically changed how this condition is treated. With the advent of the TVT[picture] (transvaginal tape) in this country in 1997, midurethral slings have become the overwhelming choice of physicians to treat stress urinary incontinence. These procedures are outpatient procedures done under intravenous sedation and local anesthesia. A slightly different version of the TVT is available and named the TOT (transobturator tape)[picture]. It involves a modification as to where the slings travels but serves the same purpose as the TVT. The latest variation on slings is the TVT Secure which involves only 1 incision. Data on this procedure are being collected. With all of these procedures, most patients are back to normal activities within 5-10 days. Intercourse or vaginal activity is stopped for 6 weeks to allow the small vaginal incision to heal. Many different types of slings are now available and not all slings are the same. Slings are made of different types of materials and not all of these act the same when placed in your body. Certain risks exist anytime a foreign material is placed your body. You and your surgeon need to discuss these risks when deciding if this procedure it right for you.
Seven year data on the TVT shows that nearly 97% of patients are satisfied with their treatment with nearly 86% being “dry” by urodynamic testing. These impressive numbers will continue to be scrutinized as time goes on. The images show the TVT midurethral sling in place.
Other surgical therapies include the Burch retropubic urethropexy, the Marshall-Marchetti-Krantz, and pubovaginal slings. All these procedures work by blocking the urethra when the stress to the bladder occurs. The downward push of the bladder caused by the cough, sneeze, or Valsalva is met by the support of the urethra by either the sling material or vaginal wall. This can effectively “block” the urethra and stop urine from leaking during those times of stress. Using in office procedures, injectable materials such as collagen can be placed around the urethra to help with certain types of incontinence.
If surgery is required for your condition, you and your doctor will decide which surgical option is best for you.
Urogynecology Associates, PC
1633 North Capitol Avenue. | Indianapolis, IN 46202 | Phone: 317.962.6600 | Fax: 317.962.2049