Diagnosing and Treating Urinary Incontinence in Women

Joseph Khoury, MD, FACS, Urology of Virginia

Urinary Incontinence (UI) is a widespread and devastating symptom afflicting close to 30 million people in the United States, the majority of whom are women. Many patients are too embarrassed to discuss this problem with their doctor and suffer emotional disturbances, such as, depression and isolation from family and friends. For many, activities that were enjoyed on a daily basis, such as, a walk or a ride in the country, are no longer possible.

UI is responsible for health problems like urinary infections, prolonged hospitalizations, dermatitis, and fractured hips from falls – particularly when trying to toilet at night. Over 30 million dollars is spent to try and manage this symptom with most of the expense covered by individuals for products to help keep them dry, such as pads and diapers.

It is unfortunate that there is a significant stigma to this symptom as the majority of UI can be cured or significantly improved. It is not a part of the aging process, although aging may predispose one to UI. For example, pregnancy, neurologic disease (i.e. stroke or multiple sclerosis), and menopause may be elements predisposing to UI.

Do I have Urinary Incontinence?
The most important factor is to determine the type of UI that exists and the evaluation should include a well-focused history, physical examination (including pelvic & rectal), a voiding diary (record of intake and output for three days), urinalysis, and post-voiding volume. Generally, there are some basic strategies that may be helpful to decrease the number and volume of incontinent episodes. Toileting frequently every 2-3 hours (Timed Voiding), limiting fluids to 50-60 ounces per day, avoiding caffeinated and carbonated beverages, and strengthening the muscles of the pelvic floor (Kegel exercises) are simple first attempts to manage UI, and can be successful –over 50 percent of the time.

In women, there are four types of UI. These may exist individually or in combination. Diagnosing the correct type of UI is crucial as each type is managed differently. For example, bladder overactivity may be treated optimally with medication, whereas stress incontinence may be managed with a minimally invasive surgical procedure – a suburethral sling. Best outcomes occur when the correct type of UI is documented and appropriate remedy applied. The four types of incontinence are:

  1. Stress Urinary Incontinence: This occurs with laughing, coughing, sneezing, and activities as a result of weak pelvic muscles, or a weak sphincter that does not effectively compress the urethra. The patient will have no warning signal before leaking and wetting
  2. Bladder Overactivity: This results in urinary frequency, urgency, frequent toileting at night, and urge incontinence. This results when the bladder muscle does not stretch or accommodate appropriately. The patient knows it’s time to go to the bathroom but cannot get there in time before leaking occurs
  3. Overflow Incontinence: This occurs from incomplete bladder emptying as a result of a blockage in the lower urinary tract, such as a dropped bladder or uterus in the female, and an enlarged prostate in the male, or a weak bladder muscle. The bladder gets very full and finally dribbles or spurts small amounts of urine
  4. Mixed Incontinence: This is basically a combination of the other types.

Urodynamics, bladder function tests, are helpful to correctly diagnose the type of incontinence that is present and identify voiding problems. These tests usually involve placing a narrow child’s catheter in the bladder and filling the bladder slowly with water. Bladder pressures during bladder filling are recorded to measure capacity,sensation, and to identify bladder overactivity. Voiding around the catheter and measuring the velocity of the urinary stream simultaneously will identify if one has bladder outlet obstruction, normal voiding pressures or a weak bladder muscle. Other tests may be performed to determine the integrity of the urethra; these tests are helpful to identify stress urinary incontinence in women and men.  Sometimes x-ray is used during these tests to visualize the site of urinary obstruction or to document incontinence. This test is called video urodynamics.

The Devine-Jordan Center for Reconstructive Surgery and Pelvic Health
The Devine-Jordan Center for Reconstructive Surgery and Pelvic Health is a state of the art facility dedicated to diagnose and treat pelvic floor problems in women to include: urinary incontinence, vaginal prolapse, overactive bladder, and voiding dysfunction. The Center offers contemporary therapy such as, single incision urethral slings, both peripheral & central neuromodulation, and bladder injections with Botox for overactive bladder. Our ancillary services include flouro-urodynamics to diagnose voiding problems, and a physical therapy department dedicated solely to manage all pelvic floor issues, including pelvic pain.

In summary, UI is a significant health problem with which many women suffer in silence as a result of embarrassment and shame. Fortunately, there are strategies that may cure or significantly improve a women’s quality of life. It is just a matter of taking that first step for evaluation.

– Joseph M Khoury, MD, FACS

About Dr. Khoury
Dr. Joseph Khoury earned his medical degree from Georgetown University. Following medical school, he entered the Army where he completed, at Walter Reed Army Medical Center, a flexible internship, a general surgery residency, and his urology residency. Upon completion of his army career, Dr Khoury was a Fellow in Reconstructive Urology and Urodynamics at Duke University Medical Center. Finishing his formal training in urology, Dr Khoury became a professor at Georgetown University, a position followed by a professorship at UNC School of Medicine, Chapel Hill. After these teaching appointments, he opened a solo practice in Raleigh, NC dedicated to urinary incontinence, reconstructive surgery, and neuro-urology. He now practices urology in Virginia Beach and Portsmouth, Virginia.

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