Urinary Incontinence

Description

Alternative Names

Behavioral Treatments

With the exception of functional incontinence, most cases of incontinence will almost always improve with behavioral techniques. There are a variety of methods, but the focus is usually on strengthening or retraining the bladder. Studies indicate that such exercises are very effective, even for men recovering from surgery for prostate cancer.

For incontinent patients who are in nursing rooms, regular reminders to urinate and checks for dryness may be needed to enhance bladder training. As an extra tip for older people with severe incontinence, keeping a pan or portable commode near the bed may prevent injuries from falling as well as improve general convenience.

Combination of Kegel Exercises and Bladder Training

Perhaps the best first-line approach for any form of incontinence is a combination of Kegel exercises and bladder training. In one study, women who used this combination approach experienced an average 50% reduction in incontinence episodes, with nearly 40% of them achieving complete continence. It was equally effective for urge, stress, or mixed incontinence.

Studies also reported that between 50% and 75% of patients who perform only Kegel exercises experience a substantial improvement in their symptoms, including elderly people who have had the problem for years. One study suggested that Kegel exercises were more effective than electrical stimulation and vaginal cones for women with stress incontinence.

Pelvic Floor Muscle (Kegel) Exercises. Kegel exercises are designed to strengthen the muscles of the pelvic floor that support the bladder and close the sphincters.

Stress incontinence is an involuntary loss of control of urine that occurs at the same time abdominal pressure is increased as in coughing or sneezing. It develops when the muscles of the pelvic floor have become weak.

Dr. Kegel first developed these exercises to assist women before and after childbirth, but they are very useful in helping to improve continence for both men and women. Kegel exercises are particularly useful for the following:

• Stress incontinence. Some experts believe that Kegel exercises should be the primary treatment for stress incontinence.
• Urge incontinence. They can also be helpful for urge incontinence in cases that are not caused by nerve damage. In one study, 85% of women reported satisfaction with this program.

The general approach for learning and practicing Kegel exercises is as follows:

• Since the muscles are sometimes difficult to isolate, the best method is to first learn while urinating. The patient begins to urinate and then contracts the muscle in the pelvic area with intention of slowing or stopping the flow of urine. Women should contract the vaginal muscles as well. They can detect this by inserting a finger inside the vagina. When the vaginal walls tighten, the pelvic muscles are being contracted correctly.
• An alternate approach is to isolate the muscles used in Kegel contractions by sensing then squeezing and lifting the muscles in the rectum that are used in passing gas. (Again, women should contract the vaginal muscles as well.)
• Patients should place their the hands on their abdomen, thighs, and buttocks to make sure there is no movement in these areas while exercising.
• In order to achieve success, some experts recommend performing two exercises that have different timing for the hold and release of the contraction. Both should be done regularly.
• The first method is used for strengthening the pelvic floor muscles. The patient slowly contracts and lifts the muscles and holds for five seconds, then releases them. There is a rest of 10 seconds between contractions.
• The second method is simply a quick contraction and release. The object of this exercise is to learn to shut off the urine flow rapidly.
• In general, patients should perform five to 15 contractions, three to five times daily.

Some notes of caution:

• Once learned, Kegel exercises should not be performed while urinating more than about twice a month, since this practice may eventually weaken the muscles.
• In women, incorrect or overly vigorous exercises may cause vaginal muscles to tighten excessively, resulting in pain during sexual intercourse.
• Over-exercise can also tire muscles and cause more leakage.
• Incontinence will return to its original severity if these exercises are discontinued, so commitment to the program must be high and possibly life-long.
• It may be several months before the patient sees significant improvement.

Bladder Training. Bladder training involves a specific, graduated schedule for increasing the time between urinations:

• Patients start by planning short intervals between urinations and then gradually progressing with a goal of voiding every three to four hours.
• If the urge to urinate arises between scheduled voidings, patients should remain in place until the urge subsides. At the time, the patient moves slowly to a bathroom. (In a small study, 73% of women with stress incontinence were helped by an absurdly simple and obvious movement: crossing the legs whenever a cough or sneeze was coming on.)

Vaginal Cones

This system uses a set of weights to improve pelvic floor muscle control. The cones are inexpensive, relatively simple to use, and evidence suggests that they are as effective as Kegel exercises or electrostimulation:

• The typical set includes five cones of graduated weights ranging from 20 grams (less than one ounce) to 65 grams (slightly over two ounces).
• Starting with the lightest, the woman places the cone in her vagina while standing and attempts to prevent the cone from falling out. The muscles used to hold the cone are the same ones needed to improve continence.

As with standard Kegel exercises, frequent repetition is required, but most women will eventually be able to use the heavier weights and build up the ability to prevent stress and urge incontinence.

Biofeedback Devices

Women who are unable to learn Kegel muscle contraction and release with verbal instructions can be helped with the use of biofeedback:

• Biofeedback uses a vaginal or rectal probe inserted by the patient that relays information to monitoring equipment.
• The patient isolates the pelvic floor and bladder muscles and performs Kegel exercises.
• The monitor emits auditory or visual signals that indicate how strongly the patient is contracting the proper pelvic floor muscles and how effectively the bladder muscles are being released.
• The apparatus is designed for home use.

As with any Kegel exercise regimen, biofeedback must be used for several months before it is effective. In one major study, 75% of women with urge incontinence reported satisfaction with biofeedback, although women who were simply given verbal cues were even more satisfied (85%). Biofeedback that teaches control of pelvic muscles even may be very helpful in children who have daytime wetting, frequent urinary tract infections, or both.

Extracorporeal Magnetic Innervation Therapy for Stress Incontinence

A treatment called extracorporeal magnetic innervation therapy stimulates pelvic muscles to automatically perform Kegel exercises:

• The patients stay fully dressed and sit on a special chair during the treatment.
• Highly focused magnetic fields penetrate the pelvic area to stimulate the nerves.
• Sessions are twice a week for about six weeks, although it may take more than eight weeks to build up the muscles.

Studies are reporting that patients experience fewer leaks, need fewer pads, and have fewer voiding episodes throughout the day and night. Comparison studies of with magnetic therapy and sham or "dummy" treatments are mixed, however, with some reporting no differences. More studies are needed to determine whether extracorporeal magnetic innervation therapy has any value.

Electrical Stimulation of the Pelvic Floor

Electrical stimulation of the pelvic floor muscles has been a common treatment for years. The procedure uses a probe inserted into the anus or vagina, which produces a contraction in the pelvic floor muscles. Success rates range from 50% to 90% for urge incontinence. (It is may also be useful for some patients with stress incontinence.) A recent study regarding patient-adjusted intermittent electrostimulation in women with stress or mixed urinary incontinence using a new implanted stimulator found the concept promising, but encouraged further investigation regarding its effectiveness and safety. The procedure requires frequent visits, and it takes between two to three months before the benefits are felt. It is often not covered by insurance. Side effects can be distressing and include abdominal cramps, diarrhea, bleeding, and infection.