Incontinence of Urine

Urinary incontinence affects about 13 million people in the United States, predominantly women. This includes 10-35% of adults and 50% of the 1.5 million residents in nursing homes. As many as 60% of nursing home patients are incontinent, while 30% of elderly people living at home are incontinent.

• Urinary incontinence is an underdiagnosed and underreported medical problem. About 50-70% of women with urinary incontinence do not go to the doctor for treatment because of social stigma. People with incontinence often live with this condition for six to nine years before seeking medical therapy. Living with urinary incontinence puts you at risk for rashes, sores, and skin and urinary tract infections. Effective treatments for this common problem are available in many cases.
• Urinary incontinence is an underdiagnosed and underreported medical problem. About 50-70% of women with urinary incontinence do not go to the doctor for treatment because of social stigma. People with incontinence often live with this condition for six to nine years before seeking medical therapy. Living with urinary incontinence puts you at risk for rashes, sores, and skin and urinary tract infections. Effective treatments for this common problem are available in many cases.

Treatment with Exercise

• Anti-incontinence exercises are designed to strengthen the pelvic floor muscles (the muscles that hold the bladder in place). These muscles are also called the levator ani muscles. They are named levator muscles because they hold (elevate) the pelvic organs in their proper place. When the levator muscles weaken, the pelvic organs move (prolapse), and stress incontinence results. Physical therapy is usually the first step to treat stress incontinence caused by weakened pelvic muscles. If aggressive physical therapy does not work, surgery may be necessary.
• There are special exercises to strengthen the pelvic muscles. Exercises can be done alone or with vaginal cones, biofeedback  therapy, or electrical stimulation. In general, exercise is a safe and effective treatment that should be used first to treat urge and mixed incontinence. These exercises must be performed correctly to be effective; if you are using abdominal muscles or contracting the buttocks, these exercises are being performed improperly. If you have difficulty identifying the levator muscles, biofeedback therapy can help. For some people, electrical stimulation further enhances pelvic muscle rehabilitation therapy.

Pelvic Floor Exercises

• The first step in pelvic muscle rehabilitation is to establish a better awareness of the levator muscle function. Pelvic floor exercises, sometimes called Kegel exercises, are a rehabilitation technique used to tighten and tone the pelvic floor muscles that have become weak over time. These exercises strengthen the sphincter muscle to prevent urine from leaking out due to stress incontinence. These exercises can also strengthen the pelvic floor muscles to prevent pelvic prolapse (improper movement of pelvic organs). Kegel exercises can also eliminate urge incontinence. Contracting the urinary sphincter muscle makes the bladder muscle relax. Pelvic floor muscle rehabilitation may be used to reprogram the urinary bladder to decrease the frequency of incontinence episodes.
• People who tend to benefit most from pelvic floor exercises alone are younger women who can identify the levator muscles accurately. Older adults who may have difficulty recognizing the right muscles need biofeedback or electrical stimulation in addition. Pelvic floor exercises work best in mild cases of stress incontinence with urethral hypermobility but not intrinsic sphincter deficiency. These rehabilitation exercises may be used for urge incontinence as well as mixed incontinence. They also benefit men who develop urinary incontinence following prostate surgery.
• Pelvic floor muscle exercises are performed by drawing in or lifting up the levator ani muscles. This movement is done normally to control urination or defecation. Be sure to avoid contracting the abdominal, buttock, or inner thigh muscles. Use one of the following techniques to learn how to squeeze these muscles: (1) try to stop the flow of urine while in the middle of going to the bathroom; (2) squeeze the anal sphincter as if to prevent passing gas; and (3) tighten the muscles around the vagina (for example, as during sexual intercourse).
• For treatment of stress incontinence, beginners should perform the squeezing exercise five times, holding each squeeze for a count of five (you may have to start with a count of two or three). Do this one time every hour while awake. You can even do them while driving, reading, or watching television. After practice, you may be able to hold each contraction for at least 10 seconds, then relax for 10 seconds. The pelvic floor exercises must be performed every day for at least three to four months to be effective. If you do not notice an improvement after four to six months, you may need additional help, such as electrical stimulation.
• For urge incontinence, pelvic floor muscle exercises are used to retrain the bladder. When you contract the urethral sphincter, the bladder automatically relaxes, so the urge to urinate eventually goes away. Strong contractions of the pelvic floor muscles suppress bladder contractions. Whenever you feel urinary urgency, you can try to stop the feeling by strongly contracting the pelvic floor muscles. These steps may give you more time to walk slowly to the bathroom with urinary control.
• This technique may be used for stress and urge symptoms (mixed incontinence). Be sure that you are not contracting your abdominal muscles when performing these drills. This can worsen urinary incontinence.
• Practice contracting the levator ani muscles immediately before and during situations when leakage may occur. This is known as the guarding reflex. Involuntary urine loss is stopped by tightening the urinary sphincter at the appropriate time (for example just as you are about to sneeze). By making this muscle squeeze a habit, you can develop a protective mechanism againststress and urge incontinence.
• Success in reducing urinary incontinence has been reported to range from 56-95%. Pelvic floor exercises are effective, even after multiple anti-incontinence surgeries.

Vaginal Weights

• Vaginal weight training can be used to strengthen the pelvic floor muscles and treat stress incontinence in women. Vaginal weights look like tampons and are used to enhance pelvic floor muscle exercises. Shaped like a small cone, vaginal weights are available in a set of five, with increasing weights (for example, 20 g, 32.5 g, 45 g, 60 g, and 75 g). As part of a progressive resistive exercise program, a single weight is inserted into the vagina and held in place by tightening the muscles around the vagina for as long as 15 minutes. As the levator ani muscles become stronger, the exercise duration may be increased to 30 minutes.
• This exercise is performed twice daily. With the weight in place, you can feel the appropriate muscles working so you know you are contracting the pelvic floor muscles. The contraction needed to keep the weight in place within the vagina increases the strength of the pelvic floor muscles. The best results are achieved when standard pelvic muscle exercises (Kegel exercises) are performed with intravaginal weights. In premenopausal women with stress incontinence, the rate of cure or improvement is approximately 70-80% after four to six weeks of treatment. Vaginal weight training also may be useful for postmenopausal women with stress incontinence; however, vaginal weights are not effective in the treatment of pelvic organ prolapse.

Biofeedback

Biofeedback therapy uses an electronic device to help individuals having difficulty identifying the levator ani muscles. Biofeedback therapy is recommended for treatment of stress incontinence, urge incontinence, and mixed incontinence. Biofeedback therapy uses a computer and electronic instruments to let you know when the pelvic muscles are contracting.

• Biofeedback is intensive therapy, with weekly sessions performed in an office or a hospital by a trained professional, and it often is followed by pelvic floor muscle exercises at home. During biofeedback therapy, a special tampon-shaped sensor is inserted in the vagina or rectum and a second sensor is placed on the abdomen. These sensors detect electrical signals from the pelvic floor muscles. You will contract and relax the pelvic floor muscles when the specialist tells you. The electric signals from the pelvic floor muscles are displayed on a computer screen.
• With biofeedback, you know that you are strengthening the pelvic muscles that need rehabilitation. The benefit of biofeedback therapy is that it provides minute-by-minute feedback on the quality and intensity of your pelvic floor contraction.
• Studies on biofeedback combined with pelvic floor exercises show a 54-87% improvement with incontinence. Biofeedback also has been used successfully in the treatment of men with urge incontinence and intermittent stress incontinence after prostate surgery.
• Medical studies have demonstrated significant improvement in urinary incontinence in women with neurologic disease and in the older population when a combination of biofeedback and bladder training is used.
• Female urinary incontinence is reduced more with biofeedback than with pelvic muscle exercises alone.

Electrical Stimulation

• Electrical stimulation is a more sophisticated form of biofeedback used for pelvic floor muscle rehabilitation. This treatment involves stimulation of levator ani muscles using painless electric currents. When the pelvic floor muscles are stimulated with these small electrical currents, the levator ani muscles and urinary sphincter contract and bladder contraction is inhibited. Similar to biofeedback, electrical stimulation can be performed at the office or at home. Electrical stimulation can be used with biofeedback or pelvic floor muscle exercises.
• Electrical stimulation therapy requires a similar type of tampon-like probe and equipment as those used for biofeedback. This form of muscle rehabilitation is similar to the biofeedback therapy, except small electric currents are used to directly stimulate the pelvic floor muscles.
• As in biofeedback, pelvic floor muscle electrical stimulation has been shown to be effective in treating female stress incontinence, as well as urge and mixed incontinence. Electrical stimulation may be the most beneficial in women with stress incontinence and very weak or damaged pelvic floor muscles. A program of electrical stimulation helps these weakened pelvic muscles contract so they can become stronger. For women with urge incontinence, electrical stimulation may help the bladder relax and prevent it from contracting involuntarily.
• Research indicates that pelvic floor electrical stimulation can reduce urinary incontinence significantly in women with stress incontinence and may be effective in men and women with urge and mixed incontinence. Urge incontinence that is caused by neurologic diseases may be decreased with this therapy. Electrical stimulation appears to be the most effective when combined with pelvic floor exercises. The rate of cure or improvement with electrical stimulation ranges from 54-77%; however, significant benefit occurs after a minimum of four weeks, and you must continue pelvic floor exercises after the treatment.

Bladder Training

Bladder training involves relearning how to urinate. This method of rehabilitation is usually used for active women with urge incontinence and sensory urge symptoms known as urgency. Many people who have urge incontinence sense that they have to urinate, but their bladder is not full and they do not urinate much when they return to the bathroom frequently. This means that, although their bladder is not full, it is signaling for them to void.

• Bladder training generally consists of self-education, using the bathroom according to a schedule, consciously delaying going to the bathroom, and positive reinforcement. Although bladder training is used primarily for symptoms of urgency and findings of urge incontinence, this program may be used for simple stress incontinence and mixed incontinence. For bladder training to work, you must resist or inhibit the feeling of urgency and wait to go to the bathroom. You must urinate according to a scheduled timetable rather than every time you have the feeling that you need to urinate.
• This plan incorporates dietary changes such as adjusting how much you drink and avoiding dietary stimulants. In addition, there are distraction and relaxation techniques to delay voiding to help expand the urinary bladder. By using these strategies, you can train the bladder to accommodate more stored urine.
• The initial goal is set according to your current voiding habits and is not followed at night. Whatever your voiding pattern is, the first goal for time between trips to the bathroom (voiding interval) may be increased by 15-30 minutes. As the bladder becomes accustomed to this delay in voiding, the interval between voids is increased. The ultimate goal is usually two to three hours between voids, and it may be set further apart if desired.
• Another method of bladder training is to maintain the prearranged schedule and ignore the unscheduled voids. In this method, regardless of whether you make an unscheduled trip to the bathroom, you still have to maintain the prearranged voiding times and go to the bathroom as scheduled. This program must be continued for several months.
• Another method of bladder training uses ultrasound to prove to that your bladder is not full even though you feel the need to urinate. A bladder scanner is a portable ultrasound machine that measures the amount of urine present in your bladder. With this method, you can void when your bladder fills to a certain volume visible on ultrasound rather than you feel the need to go to the bathroom. Each time you feel the need to void, you check your bladder using the scanner to see how much urine is being stored. If your bladder is shown to be empty, then you should ignore that sensation.
• Bladder training has been used primarily to manage symptoms of urgency and the findings of urge incontinence; however, it also may be used for stress and mixed incontinence. With bladder training, the cure rate for mixed incontinence is reported to be 12%, while the improvement rate was 75% after six months.

Anti-Incontinence Products

• Anti-incontinence products, such as pads, are not a cure for urinary incontinence; however, using these pads and other devices to contain urine loss and maintain skin integrity are extremely useful in selected cases. Available in both disposable and reusable forms, absorbent products are a temporary way to stay dry until a more permanent solution becomes available.
• Do not use absorbent products instead of treating the underlying cause of incontinence. It is important to work with your doctor to decrease or eliminate urinary incontinence. Also, improper use of absorbent products may lead to skin injury (breakdown) and UTIs.
• Absorbent products used include underpads, pant liners (shields and guards), adult diapers  (briefs), a variety of washable pants and disposable pad systems, or combinations of these products. More than 50% of the members of the National Association for Continence (NAFC), a national support group for people with incontinence (800-252-3337), use some form of protective garment to remain dry. In addition, 47% of all elderly men and women use some type of absorbent products.
• Unlike sanitary napkins, these absorbent products are specially designed to trap urine, minimize odor, and keep you dry. There are different types of products with varying degrees of absorbency. These products may absorb 20-300 mL (1-10 ounces), depending on the brand and the absorbent material of the product.
• For occasional minimal urine loss, panty shields (small absorbent inserts) may be used. For light incontinence, guards (close-fitting pads) may be more appropriate. Absorbent guards are attached to the underwear and can be worn under usual clothing. Adult undergarments (full-length pads) are bulkier and more absorbent than guards. They may be held in place by waist straps or snug underwear. Adult briefs are the bulkiest type of protection, they offer the highest level of absorbency, and they are secured in place with self-adhesive tape. Absorbent bed pads also are available to protect the bed sheets and mattresses at night. They are available in different sizes and absorbencies.

Urethral Occlusive Devices

• Urethral occlusive devices are different for males and females. Female devices are artificial implements that may be inserted into the urethra or placed over the urethral opening to prevent urine from leaking out.
• Inserts include the Reliance Urinary Control Insert® and the FemSoft® device, while patches include the CapSure® and Re/Stor® devices. Urethral occlusive devices tend to keep people drier; however, they may be more difficult and expensive to use than pads. Urethral occlusive devices must be removed after several hours or after each voiding. Unlike pads, these devices may be more difficult to change.
• Male devices are usually clamps that constrict the penis and decrease the amount of urine leakage. They are usually used in severe incontinence which are resistant to other treatments and are variably effective.