Incontinence Care- What Can be Done?
Treatment of incontinence is entirely elective. In other words, no treatment is necessary at all unless you find the symptoms bothersome enough.
Treatment should be individualized based on your symptoms, goals, and overall medical condition. Some patients with very severe incontinence are quite satisfied if treatment reduces the amount of incontinence to the point where they can manage with absorbent pads.
Others are very distressed at the loss of even a few drops of urine and want to be perfectly dry at all times.
Incontinence care treatment options are varied and run the gamut from absorbent pads, medications, exercises, and electrical stimulation to surgery. Some therapies are of proven efficacy; others are entirely experimental.
Surgical treatment, which is widely available, is the most effective, and there have been many scientific studies that evaluate the results of surgery. For this reason, surgical treatment will be discussed first to provide a baseline for comparison with the other forms of therapy.
Incontinence Care With Surgical Treatments
Although over 125 operations have been designed to treat stress incontinence, they fall into six general categories.
All of the operations are based on the same common principles:
(1) to restore the support of the bladder and urethra so that they don’t fall down again and (2) to provide a kind of backboard against which the urethra is compressed during stress.
The goal of surgery for stress incontinence is to create a backboard against which the urethra is compressed during stress.
The six categories of operations for stress incontinence include (1) vaginal suspensions, (2) “needle” suspensions, (3) retropubic suspensions, (4) pubovaginal sling operations, (5) prosthetic sphincters, and (6) periurethral injections (I’ll explain what these words mean a little later).
As you might have guessed, the proponents of each kind of operation think that the operation they do is the best.
The incontinence care and treatments depend on many factors. It depends on you-your wants and needs, your overall health, the cause of the incontinence and your weight.
Your weight has a lot to do with it. The fatter you are, the more difficult the surgery, the greater the chances of complications, and the greater the chance of failure.
After your doctor does a thorough evaluation, he or she should discuss the treatment options with you and the pros and cons of the different surgeries. Your doctor may be very experienced with a lot of operations, but it’s not very likely that he or she is experienced with all of them.
Most people do some things better than others. In football, some players are better at quarterbacking and others are better at blocking. You wouldn’t choose the blocker to be the quarterback and you shouldn’t choose a surgeon to do an operation he or she is not very good at.
Urinary Incontinence Care Nonsurgical Treatment
Nonsurgical treatments include medications, biofeedback, electrical stimulation, prostheses, urethral plugs, and absorbent pads.
There are three kinds of medicines that have been prescribed for stress incontinence-alpha-adrenergic agonists, tricyclic antidepressants, and estrogen. All of these medications are prescribed because, theoretically at least, they may help to keep the sphincter closed.
The sphincter is composed of, in part, a nearly circular smooth muscle that is supposed to stay closed until it is time to urinate. This sphincter muscle is located in the bladder neck and proximal urethra (the part closest to the bladder).
The chemical messengers that signal the muscle to stay closed belong to a class of neurotransmitters called alpha-adrenergic (ad-rin-urge-ic) agonists. Alpha-adrenergic agonists are medications that mimic the effects of these chemical messengers and tell the sphincter to stay closed.
Various medications are available that produce alpha-adrenergic stimulation. Potential side effects of all of these medications include high blood pressure, rapid and/or irregular heartbeat (cardiac arrythmias), anxiety, and difficulty sleeping (insomnia).
That means that these medications should be used with extreme caution (or not at all) in patients with hypertension, cardiovascular disease, or hyperthyroidism.
Biofeedback, Electrical Stimulation, and Pelvic Floor Exercises
All three of these treatments offer helpful incontinence care and are intended to work by the same mechanism, that is, by strengthening the muscles of the sphincter and of the pelvic floor that supports the sphincter.
It makes perfectly good sense to try these treatments, and if you’re willing to do what it takes, the chances are that you’ll notice an improvement in your stress incontinence with any one of these therapies.
The muscles of the urethra and the pelvic floor are pretty much like muscles anywhere else in the body. If you’re going to exercise them, you first must learn what exercises to do. In the middle of urinating, try to stop.
If you can do that, you know how to do the exercises. If you can’t do that, try to squeeze the muscles that you’d use to try to prevent passing gas. Contracting those muscles are the way you do pelvic floor exercises.
Pelvic floor exercises are also called Kegel exercises, named after the gynecologist who first described them and was a specialist in incontinence care. If you do the exercises on your own, you should do them regularly and forever, because no matter how hard you exercise a muscle, once you stop, it weakens again.
As it is with many other kinds of exercise, like aerobics, there are many different schedules you can use. I like to keep things simple, so I just recommend that you make a conscious effort to contract those muscles in two or three sessions a day. In each session you should do both sudden fast squeezes and prolonged maximal ones.
For the fast ones you can just count quickly 1, 2, 3, 4, 5, up to 10 or 20, contracting and releasing your pelvic floor muscles with each count. For the slow, maximum effort ones, squeeze as hard as you can for a count of 5 or 10, and repeat it 10 to 20 times. At the very least, you should do the exercises every other day.
If you are unable to do the exercises on your own, you may need to be instructed using biofeedback techniques and if that is not successful, you might want to try electrical stimulation.
Electrical stimulation of the sphincter muscle has been advocated as a method of treatment for urinary incontinence. The theory behind this treatment is that stimulating the sphincter muscle to contract will strengthen it, increase its tone, and help keep it closed.
Electrical stimulation is performed by placing a stimulation electrode either in or near the vagina, rectum, or beneath the scrotum. The electrode may be a surface patch, like an EKG electrode, held in place with adhesive, or it may be shaped like a balloon (for the vagina) or an hourglass (for the rectum).
These electrodes are not painful at all, and there is no pain (or danger) during stimulation. The stimulation sessions are usually scheduled at weekly or biweekly intervals. In some instances, home stimulation units may be rented.
Behavior modification is intended to treat urinary incontinence by “teaching” the patient to regain control of her bladder and sphincter. Some of the principles are quite simple. For example, the less fluid you drink, the less urine your body makes and the less chance there is for incontinence.
In addition to this, specific pelvic floor strengthening exercises such as the time-honored Kegel exercises may be utilized. Behavioral therapy generally consists of 8-12 weekly sessions with the behavioral therapist. At each session a weekly diary is reviewed with the therapist, and a voiding schedule and recommendations are made for the subsequent week.
Although behavioral therapy results in cure of urinary incontinence in no more than 10% of patients, a much larger number derive enough improvement that they do not think further therapy is necessary.
Bladder Neck Prosthesis
The bladder neck prosthesis is actually a pessary with two prongs that stick up and support the bladder neck. A pessary is a plastic or rubber-like device usually shaped like a circle or doughnut that goes into the vagina and prevents prolapse.
It comes in 24 different sizes and must be “fit” to your vagina by your doctor, who will estimate the width and depth of your vagina and then choose an appropriately sized bladder neck prosthesis.
She’ll then put it in the vagina and have you stand and walk with it in place to see how it feels. If the size is OK, she’ll send you home with it for a few days, and if everything is OK, you may purchase the prosthesis. It may take several fittings before the proper size is found.
You can use the prosthesis virtually all of the time, taking it out only to clean it, or you may just use it when you are going out or when you think that incontinence may be a problem. This device is quite new, and there haven’t been any long-term studies on it, but it’s very unlikely to cause any major problems.
Of course, if it’s too big or too tight, it can cause abrasion or erosion to the vagina, but this potential complication is quite preventable by proper surveillance.
Absorbent pads are very useful for incontinence care, and may be worn at your own discretion. You may wear them only when you’re going out or playing tennis or dancing, or you may wear them all of the time.
There is a great variety of pads and they come in all sorts of sizes, absorbent qualities, and with and without devices to hold them in place. Some pads are lined with “hydrophillic” substances that absorb the urine immediately and, through a chemical reaction, change it into a jellylike substance that no longer feels “wet.”
There are several brand-new incontinence products on the market, but there is so little research on them that we really need to take a wait-and-see attitude. Some are urethral inserts, little plugs that go in the urethra and block the urine from coming out.
Some of these need to be changed every time you urinate; others stay in place and have a valve mechanism, activated by a battery pack or magnet, that opens when you want to urinate and closes afterwards. Another new product works like a piece of tape that goes over the urethra and blocks urine from leaking out.
When considering these new devices, remember: The latest, newest gadget is not necessarily better. The best approach would be to discuss it with your physician as he is the professional when it comes to incontinence care. From there, use trial and error in order to determine if its right for you.