Treatment For Bladder Control Issues
What kind of doctor can help me with bladder control?
Often a primary physician, such as an internist, primary care doctor or family practitioner can begin the early treatment regiments for overactive bladder. There are many very good medications out there, specifically what we call "anticholinergic agents" that can help calm the bladder down and reduce leakage episodes that occur with urge. Stress incontinence can often be helped surgically, and at that point one would see either an urologist or a gynaecologist. There are specialists that have done specialty training in incontinence, specifically what we call a reconstructive urologist or a female urologist, as well as an urogynocologist, who is a gynaecologist who has done extra training in gynaecology. Many general urologists and general gynaecologists also treat incontinence in women.
What treatments are available for women who have stress incontinence?
For stress incontinence in women, we start with Kegel exercises, and maybe some fluid restriction. If that doesn't work, then we offer surgery. Minor procedures that can be done in the office include bulking agents, which bulk the urethra and help stress incontinence temporarily. Such agents include collagen, and there are newer products such as Coaptite which can help bulk up the urethra, but these are temporary. I usually reserve these procedures for people who really don't want surgery. Surgery is very effective for stress incontinence. My preferred surgical treatment is the sling procedure, which involves a small piece of synthetic mesh that is placed through an incision in the vagina, and comes out through two tiny incisions that are in the abdominal area, the very low abdominal area. The two little incisions come out through the area just above the pubic bone. The sling is quite effective for stress incontinence. The procedure itself takes about half an hour. The patients usually go home the same day. There are risks to any surgical procedure, but they tend to be very low. There is also the Birch procedure, which is a commonly performed procedure and was the gold standard until the slings have sort of taken over. The Birch procedure is performed, often, at the time of a hysterectomy. It is an abdominal procedure, and that also has very good efficacy for treating stress incontinence.
What treatments are available for men who have stress incontinence?
For men with stress incontinence due to a prostate procedure, there are excellent surgical treatments available, and I would recommend seeing a urologist to discuss different treatment options. The gold standard is the artificial urinary sphincter device, which is an excellent procedure and can really cure stress incontinence in men. There also are some new sling devices designed for men that show a great deal of promise and avoid the need to pump any device in order to urinate.
What treatments are available for urge incontinence?
For urge incontinence, we start with food restriction and Kegel exercises. If that doesn't work, we go to the gold standard first line therapy, which is anti-cholinergic medication. There are multiple, different medications available, and they vary to some degree in efficacy, but some patients respond better to certain medications than other. The biggest drawback to this medication is that they have to take it everyday and if they stop medications, the symptoms come back. And the side effects can be bothersome. Although the medicine calms the bladder down and allows the patients to be drier, it also has side effects in the GI tract as well as the eyes and salivary gland. Specifically, the patient can develop constipation, dry eyes and dry mouth. And those can be bothersome. Some patients, I put on a stool softener at the same time as the anti-cholinergic medication to prevent the constipation. These medications do help about 50%, which in some patients they help more than others. For patients who don't respond well to the medication or who don't like the idea of staying on a chronic medication, or if they're bothered by the side effects, we then offer the gold standard 2nd line of therapy which is neuro-modulation. This involves a test procedure - where we place a little lead in the S3 foramen, which is the hole in the 3rd sacral - where the 3rd sacral nerve root comes out of the sacrum. We float a little lead and we do a 1 week test. The patient wears a temporary pager. If the patient notices good improvement, then 1 week later we put in a permanent battery. It's like bladder pacemaker, but we don't like to use that term because patients don't like the idea of having a pacemaker. But that is what it is; it lasts about 5 years then would need to be replaced. That works quite well for patients who don't respond well to medication. There's also a great option, although it's not yet FDA approved, and that is Botox. Botulinum toxin, which is often used for stopping the wrinkling that occurs, works by paralyzing the muscles, often in the forehead for example. We use it in the office; we inject it into the bladder. Because it's not FDA approved, it's not always covered by insurance, which is one drawback. The other drawback is that it's temporary; it won't last long term and needs to be repeated in 3-6 months. It is often preferred by patients who don't want to have a device. But the risk of Botox can be temporary urinary retention, where they actually can't pee without a catheter. That is temporary and will usually go away in a few weeks, and it only happens in a small fraction of patients. So that also is quite a popular treatment, next to the neuro-modulation. I personally tend to prefer the neuro-modulation because I think it lasts longer and it doesn't place patients at risk for developing retention.
What will my doctor ask me if I bring up incontinence issues?
It depends on the physicians knowledge about incontinence. When I see a patient with leakage, my first questions center around trying to determine what type of leakage the patient has. Does he or she leak with stress; cough, laugh, sneeze? Or with urge; urge on the way to the toilet? I try to get a sense of how severe the leakage is, how many pads a patient wears, how often the patient gets up at night. So a lot of the questions involve characterizing the leakage. And then also I try to find out how aggressive the patient wants to be. I had a patient that said, "My doctor told me to see you because I have incontinence", and that patient, if she doesn't mind the leakage, I check her urinalysis, I also do a catheterization to make sure she's emptying completely, and there's not necessarily a need to anything if she doesn't mind the leakage. I do like to find out what the patients expectations are; how much do they want to be dry? Today I saw a patient who had pretty severe stress incontinence and I said, "Are you ready for surgery? 'Cause that's the best next step for you." So I think it's important to find out what the patient wants.
When should I talk to a doctor about incontinence?
Again, I think it should be early, because we want to make sure that there's not anything untreated going on that's the true cause of incontinence, such as a bladder infection, a bladder stone, or even a bladder tumor. Most of the time, it's not any of those things, but I think it's important to rule out anything that is bad, for example. Then, I think it's important because of that reason. I think it's important to bring it up early to a physician. It doesn't necessarily need to be treated, but we have a lot of treatments available. A primary doctor, such as an internist, or a family practice doctor, can make good medication recommendations, and can often treat patients with incontinence, without the need to go to a specialist. When it comes time for surgical treatment of stress incontinence, it is often a specialist who would see that patient at that time. A specialist is often necessary when a patient doesn't respond to medications for urge incontinence, such as anticolon urging medication. At that point, it's the specialist that would perform another procedure such as Botox into the bladder or neuromodulation.
