Questions about Incontinence and Pelvic Disorders

What is urinary incontinence?

Urinary incontinence is involuntary loss of urine. If you have this problem, you are not alone. There are nearly 20 million adult Americans with urinary incontinence; two-thirds of these people are women. Many women with this condition are so embarrassed by it that they never tell their family or their doctor about it and never seek help. Urinary incontinence can almost always be improved or even cured.

What causes urinary incontinence? Are there different types?

Urinary incontinence is more common as people age, but it is not part of normal aging and it can occur at any age. The most common types of urinary incontinence are stress incontinence and urge incontinence.

In stress incontinence (the most common type among women), involuntary loss of urine occurs with anything that increases intra-abdominal pressure, such as coughing, sneezing or exercise. A sudden rise in intra-abdominal pressure puts extra stress on the bladder which cannot remained closed, and so a squirt of urine is forced out through the urethra. Most commonly this occurs because the normal support of the urethra has become defective (often as a result of childbirth), so the urethra cannot close properly under conditions of physical stress. This is often called anatomic or hypermobility stress incontinence. Sometimes the urethra itself has become weakened and no longer closes properly. This condition is often called intrinsic sphincter weakness or deficiency.

In urge incontinence, involuntary loss of urine occurs in association with a strong desire to void. Frequently a woman says "When I have to go, I have to GO THEN! If I don't go right away, I can't make it to the bathroom." This type of urine loss is due to a sudden, uncontrolled contraction of the bladder muscle.

Many women have both stress and urge incontinence together. In other cases, the bladder may not be emptying properly, which can cause either stress incontinence or urge incontinence when the bladder becomes overly full and overly distended. Incontinence is also found in association with various neurological diseases. It is important to have a thorough evaluation to find out what type of incontinence is present, why it is occurring and how it can best be treated.

How can urinary incontinence be treated?

There are many different treatments used for urinary incontinence. Finding the right treatment depends upon the nature of the problem. Some women merely need adjustments in their diet and fluid intake, or treatment of a coexisting medical problem (such as diabetes). Incontinence frequently responds to changes in bladder habits or behavioral modification. Incontinence may be treated by medications to strengthen the urethra or help relax an overactive bladder muscle. Pelvic muscle rehabilitation and strengthening is almost always helpful. Surgical procedures to help support the bladder neck, reposition the urethra or take care of other forms of prolapse may be indicated. To find the right treatment, it is important to have an accurate diagnosis from a physician who is willing to get to know you, to understand your problem and help guide you towards the most beneficial kind of therapy.

What is pelvic muscle rehabilitation?

The base of the pelvis is made up of several groups of muscles, often called the muscles of the "pelvic floor." These muscles are the bottom of the pelvic "container" that holds all of the pelvic organs. The urinary tract, gastrointestinal tract and the genital tract all exit through this muscular structure. The urethra is the outlet for the urinary tract, the anus and rectum are the end portion of the gastrointestinal tract, and the vagina is the outlet for the female genital tract. The pelvic muscles help close all of these outlets. In so doing they help contain urine and stool. They are also important for keeping the uterus and cervix up in their proper positions, as well as for aiding and improving sexual function.

If muscles are weak, have poor tone or cannot contract properly, they can have an adverse effect on all three organ systems. Pelvic muscle rehabilitation simply refers to retraining, strengthening, toning, and improving the function of these muscles. Pelvic muscle rehabilitation is similar to Kegel exercises, which were named after the California gynecologist who developed them, Arnold Kegel. Unfortunately, clinical studies have shown that many (if not most) women do these exercises incorrectly. For pelvic muscle rehabilitation to work (just as with any other form of exercise therapy), you need a coach or a trainer who can set up an exercise regimen, put you on a program and make sure you get the help you need to strengthen and rehabilitate your pelvic muscles.

At Cedars-Sinai we work in partnership with a trained physical therapist whose expertise is in this type of muscle rehabilitation. It works! It can help you with urinary incontinence, anal incontinence and a whole range of other pelvic disorders.

What is ExMI?

Extra-corporeal magnetic innervation (ExMI) therapy is a form of pelvic muscle exercise in which the muscles are made to contract by passing a magnetic field through them. ExMI is carried out using the NeoControl therapy system. The treatment is carried out while the patient sits fully clothed in a chair that contains a powerful electromagnet in the seat. When activated, the electromagnet passes a strong magnetic current through the muscles of the pelvic floor, making them contract. (Think of a chair that "does your Kegels" for you!) A normal course of treatment is two 25-minute sessions per week for 16 weeks. The treatment is painless. It works to strengthen the two types of muscle fibers in the pelvic floor and may be useful in treating stress incontinence, urge incontinence, anal incontinence or combinations of these conditions. It may be especially useful in combination with a regiment of supervised pelvic muscle rehabilitation.

What is urodynamic testing?

A urodynamic test is any test that provides objective information about bladder function. Urodynamic testing commonly refers to a test called a cystometrogram or CMG. In this test a small catheter is placed into the bladder to measure bladder pressure while the bladder is filled slowly with sterile water. Another small tube is used to help measure abdominal pressure. As the bladder is filled, the person undergoing the test is asked to note when she first feels a change in bladder sensation, when she feels like she would empty her bladder if she were at home and when she feels like her bladder is completely full. The behavior of the bladder muscle (detrusor muscle) is studied to see whether or not it is overactive. During bladder filling, the patient undergoing the test is asked to cough to see whether or not she has stress incontinence, and if she does, to determine how much pressure is required for the leakage to occur (leak-point pressure.)

At the end of the test the patient is allowed to empty her bladder, and the mechanics of how her bladder empties are studied. Other tests can help evaluate the strength of the urethra. The test is not painful, requires no anesthesia or special preparation and takes only a few minutes to perform. It provides very useful information on bladder function that is helpful in planning future therapy. Women with urinary incontinence should not undergo an operation to cure this condition without a urodynamic evaluation.

What is anal incontinence?

Anal incontinence refers to involuntary loss of gas (flatus), liquid stool or solid stool.

What causes anal incontinence?

As with urinary incontinence, anal incontinence can be caused by many different factors, including problems with foodstuffs, infection, abnormalities of colonic muscle activity, inflammatory bowel disease or colonic tumors. In women, one of the most common causes of anal incontinence is injury to the anal sphincter muscle during childbirth.

How is anal incontinence treated?

The treatment of anal incontinence depends on what is causing it. Some conditions can be handled with medication or adjustments in diet. Often the condition responds to pelvic muscle rehabilitation. If there is a large, unrepaired tear from a childbirth injury, often the injured muscle can be sewn back together during an operation called "anal sphincteroplasty."

What is anorectal physiology testing?

Anorectal physiology testing involves several individual tests, including anorectal manometry, endoanal ultrasonography and pudendant nerve terminal motor latency.

Anorectal manometry helps measure rectal sensation, compliance (stretchiness), muscle function and reflexes. It is carried out by inserting into the rectum a small tube that measures pressures. During the test, the tube is moved up and down a short distance to measure pressures in various parts of the rectum, both at rest and while the patient squeezes the pelvic muscles.

Endoanal ultrasonography is an imaging study that looks at the anal sphincter muscle using sound waves, just like the kind of sonograms used in viewing fetuses. A small ultrasound probe is inserted into the rectum and takes an ultrasound picture of the muscle to see whether or not it has been torn. The test is not painful.

Pudendant nerve terminal motor latency (PNTML) testing is a neurophysiological test in which a small electrode on a gloved finger is inserted into the vagina to stimulate the pudendal nerve in the pelvis. Small sensors placed on the skin next to the anus pick up the stimulus signal. The time it takes for the signal to travel down the nerve from the electrode on the examiner's finger to the electrode on the anal muscle helps tell if the nerve has been injured or not. There are no needles involved in this test.

What is pelvic organ prolapse?

The word "prolapse" means "to fall down out of place." Pelvic organ prolapse means that one or more of the pelvic organs (bladder, uterus, vagina or rectum) has fallen out of position. Women with prolapse may notice a heaviness or "dragging" sensation in the pelvis. As prolapse worsens, the affected woman may notice a "bulge" at the front of the vagina. In more severe cases, something may protrude well beyond the vaginal opening. Such women may have trouble passing urine or moving their bowels, have discomfort with sexual relations or even have trouble walking due to interference with the prolapsed organ.

When the problem is a "dropped bladder," it is commonly referred to as a cystocele. If the womb is prolapsing, it is referred to as uterine prolapse. A bulge involving the rectum is called a rectocele. In women who have previously had a hysterectomy, the top of the vagina may be pushed out by loops of small intestine, a condition that is known as an enterocele or a post-hysterectomy vaginal vault prolapse.

How is prolapse treated?

In mild cases sometimes nothing needs to be done, and the condition can simply be watched to see if it progresses. Many times women with prolapse can be made perfectly comfortable by the use of a pessary, a silicon-rubber support device that is placed in the vagina to reduce the prolapse and hold it in a more normal position; the pessary can be removed, cleaned and reinserted periodically. Using a pessary is a lot like buying shoes: one size, shape, and style doesn't fit everybody. There are many different kinds of pessaries, some more suited to certain kinds of prolapse than others. It is important that a woman with a pessary be fitted properly, and that she be seen periodically to ensure that the pessary is doing its job. Many women use a pessary for years without difficulty.

Another treatment for prolapse is surgery. The precise kind of surgery needed depends upon the nature and extent of the prolapse. Some operations can be done through the vagina, while others require abdominal incisions. Often the best operation involves removal of the uterus and cervix and repair of the other affected parts of the vagina.

How can I choose the right doctor?

Urinary incontinence is commonly treated by gynecologists and urologists. Some internists, family practitioners, and geriatricians also have an interest in this field. A urogynecologist is an obstetrician-gynecologist with a special interest in disorders of the female urinary tract.

Unfortunately, many doctors have little experience or expertise in the evaluation and treatment of urinary incontinence. How do you know if you are in the right place? Ask questions. A doctor with interest in and knowledge of urinary incontinence will be a member of the American Urogynecology Society, the International Continence Society, the Urodynamics Society or the Society for Female Urology. These are the major specialty societies whose members deal with urinary incontinence. The best doctors will have had sub-specialty training in urogynecology and urodynamics. Find out where the doctor trained and whether or not he or she had a fellowship in this area.

You should get a thorough evaluation before treatment is started. The doctor should take a history of your incontinence problem, review your general past medical and surgical history, review your medications and perform a good physical examination. You should have a urine sample checked to make sure you do not have an infection or some other urinary condition. You should be checked with a full bladder to see if you lose urine when coughing or straining. Your bladder should be checked after you void to make sure that you empty your bladder completely. In many cases further testing may be required. This may involve something as simple as keeping a "bladder diary" or "frequency/volume bladder chart" to see how much urine you produce and how often you empty your bladder during everyday life. Some patients may need a cystoscopy, an examination in which a small viewing instrument is passed into the bladder through the urethra. Quite often urodynamic tests are performed; these are tests that help evaluate bladder sensation, bladder muscle activity, bladder capacity, the bladder's response to stress, the strength of the urethral closure mechanism and the way in which the bladder empties. Urodynamic tests are particularly important if you might need surgery for a bladder problem.

Most importantly, you need to feel comfortable with your doctor. He or she should listen to you and should help tailor treatment to your specific needs. Not everybody is the same, nor are all therapies appropriate for everybody. Beware a doctor who wants to schedule you for a surgical operation immediately or who is only interested in "the latest operation" or "the latest treatment." "Latest" doesn't necessarily mean "best." New operations are often developed, tried and abandoned because of failures or complications within a very short time. Commercial companies often develop products or kits that they push to treat incontinence, with the same experience. If you are uncertain or uncomfortable with what you have been told, get another opinion, and keep looking until you are satisfied!