Dr. Shaw and Dr. Law have seen many men and women over the last decade with stress incontinence. The evaluation and management has had huge advances over that time, and the results have often shown dramatic improvement of the people he has treated.

Many times, treatment does not require medication or surgery. Pelvic floor biofeedback/physical therapy along with lifestyle-dietary changes can be significant. Urologists Dr. Koushik Shaw and Dr. Lawrence Tsai, team up with Dr. George Shashoua, a well respected Austin Uro-Gynecologist, to provide the ONLY Austin and Central Texas team to work under one roof to provide the best of two specialties to achieve optimum results.

Urinary Incontinence Information

What can be expected under normal conditions?

The urinary tract is similar to a plumbing system, with special pipes that allow water and salts to flow through them. The urinary tract includes the two kidneys, the two ureters, the bladder, and the urethra. The kidneys act as a filtration system for the blood, cleansing it of poisonous materials and retaining valuable sugars, salts, and minerals. Urine, the waste product of the filtration, is produced in the kidney and flows through two 10 to 12 inch long tubes called the ureters, which connect the kidneys to the bladder. The ureters are about one-quarter of an inch in diameter and their muscular walls contract to make waves of movement that force the urine into the bladder. The bladder is expandable and stores the urine until it can be conveniently disposed of. It has one-way flap valves that allow unimpeded urinary flow into the bladder but prevents urine from flowing backward (vesicoureteral reflux) into the ureters and kidneys. When the bladder contracts it passes urine into a tubular structure, called the urethra, which transports the waste out of the body.

What is urinary incontinence?

Urinary incontinence is the involuntary leakage of urine. It is not a disease but rather a symptom that can be caused by a wide range of conditions. Incontinence can be caused by diabetes, stroke, multiple sclerosis, Parkinson’s disease, spinal cord injury, pelvic surgery or even childbirth. More than 15 million Americans, mostly women, suffer from incontinence. Although it is more common in women over 60, it can occur at any age. In the normal population, the incidence of incontinence in females over 65 is more than 25% and in males, it is about 15%.

What is the cause of incontinence?

Multiple factors have been found to be associated with urinary incontinence. Neurologic disease, prostatic disease, and obstetric factors have been the leading culprits. Studies have found that pregnancy, mode of delivery and parity are all factors that can increase the risk of incontinence. Women who delivered babies (particularly vaginal deliveries) have much higher rates of stress incontinence than women who never delivered a baby. Women who developed incontinence during pregnancy or shortly after delivery have higher risk of sustained incontinence than those who did not. Increased parity (having more babies) or prolonged labor also increases the risk. Age is also known to be a factor, as the human body ages muscle loss and weakness occur and the urinary tract is not spared. Menopausal women can also suffer from urine loss as a result of decreased estrogen levels. As women age, after having children, the pelvic floor losing its support can result in the bladder dropping. This loss of muscular support , with the bladder and urethra not being the appropriate positions, can lead to incomplete bladder emptying that can leak out. Many medications have been associated with urinary incontinence. These include diuretics, benzodiazepines, tranquilizers, antidepressants, hypnotics, and laxatives. Poor overall general health has been associated with incontinence. Specifically, diabetes, stroke, high blood pressure, smoking history, Parkinson’s, back problems, obesity, Alzheimer’s, and pulmonary disease have all been associated with incontinence. In men, the most common cause of stress incontinence is surgery on the prostate. This is more frequent after radical prostatectomy for prostate cancer than after transurethral surgery for benign prostatic hypertrophy, or BPH.

What are the various types of urinary incontinence?

Most health-care professionals classify incontinence by its symptoms or circumstances in which it occurs. Stress Incontinence Stress urinary incontinence is the most common type of leakage. It is defined as urine loss as a result of effort or exertion. This is typically noted with exercise, sneezing, laughing, straining, or coughing. It tends to occur during activities such as walking, running, jumping or aerobics. The increased abdominal pressure associated with these activities causes urine to leak out through the urethra. The pelvic floor muscles, which support the bladder and urethra, are often weakened in this condition allowing mobility or movement of the urethra thus preventing it from working properly. Urine leakage also occurs as a result of a damaged urethral sphincter resulting in poor sphincter tone and function. Damage in these areas may be caused by many things, including prior surgery or previous childbirth. Urge Incontinence Also referred to as overactive bladder, urge incontinence is another form of leakage. This can happen when a person has an uncontrollable urge to urinate but cannot reach the bathroom in time and has an accident. At other times, running water or cold weather may cause such an event. Some people have no warning and experience leakage just by changing body position (e.g., getting out of bed). Overactive bladder is associated with neurologic disease including stroke, multiple sclerosis and spinal cord injuries as well as aging, diabetes and back injury. Mixed Incontinence Mixed incontinence refers to a combination of stress and urge incontinence. Many patients experience symptoms of both types. Overflow Incontinence Overflow incontinence occurs as a result of poor bladder emptying and an always full bladder. In these patients, leakage occurs because the cup is already full and as more urine is produced it overflows and leaks out. Frequent small urinations and constant dribbling are symptoms. This is rare in women and more common in men with a history of surgery or prostate problems. Functional Incontinence This type of incontinence is the inability to access a proper facility or urinal container because of physical or mental disability.

How is the diagnosis made?

As with any medical problem, a good history and physical examination are critical. A urologist will first ask questions about the individual’s habits and fluid intake as well as their family, medical and surgical history. A thorough physical examination looking for correctable reasons for leakage, including impacted stool, constipation, prostate disease and prolapse or hernias will be conducted. Usually a urinalysis and cough stress test will be performed at the first evaluation. If findings suggest further evaluation is necessary, tests such as cystoscopy or urodynamics may be recommended. Cystoscopy is performed by placing a small scope or camera through the urethra and into the bladder. Urodynamics is an outpatient test that is done with a tiny tube in the bladder inserted through the urethra and often with a second small tube in the rectum. The bladder is filled and the patient is asked to void while pressure measurements are recorded.

What are the treatment options for stress incontinence in women?

In most cases of incontinence, conservative or minimally invasive management is tried initially. This may include fluid management, bladder training, pelvic floor exercises and/or medication. However, when the symptoms are more severe or when conservative measures are not helping or are unsatisfactory the treatment is surgery. Your treatment plan also depends on the source of incontinence. Often times there is an anatomical defect that can be surgically corrected. Conservative Treatment options

  • Behavioral Modification: Mild to moderate stress incontinence in the female is treated initially with behavior modification. Decreasing the volume of fluid ingested as well as eliminating caffeine and other bladder irritants can help significantly. Timed voiding can be helpful in preventing accidents by scheduling frequent trips to the toilet before leakage occurs.
  • Pelvic Floor Muscle Training: Strengthening or Kegel exercises can fortify the pelvic floor and sphincter muscles and improve urinary control. These exercises include repeated contractions of isolated muscles several times a day. Sometimes techniques including biofeedback, electrical stimulation of the pelvic muscles, and weighted vaginal cones can be helpful in teaching the patient how to isolate these muscles.

Surgical Treatment Surgical treatment depends on severity of symptoms as well as any anatomical abnormalities noted on the pelvic exam. Different procedures are aimed at correcting different types of defects. If the only symptom you have is stress incontinence (leakage with exercise, coughing, laughing, etc.), the urethral sling or bulking injections may be appropriate. If you also have bladder prolapse, the bladder itself will need to be lifted back into position. Read below for more detail on these different surgeries.

  • Mid-urethral Sling: The most common and most popular surgery for stress incontinence is the sling procedure. These may also be referred to as a TVT or TOT (transvaginal tape, and transobturator tape). In this operation a narrow strip of material is used either from: cadaveric tissue (from a cadaver), autologous tissue (from your own body), or soft mesh (synthetic material). The most common type of sling used is the mesh sling. It is applied under the urethra to provide a hammock of support and improve urethral closure. The operation is minimally invasive, completed through the vagina, and patients recuperate very quickly. It is completed outpatient and under general anesthesia. For many years it was thought that biologic materials, the patient’s own fascia or cadaveric fascia, would create better more sustainable outcomes. We have found however that synthetic meshes have both the ease of use with no need for harvest as well as superior long term results.
  • Periurethral Injections: One of the surgical treatments for this condition, used in both males and females, is urethral injections of bulking agents to improve the coaptation of the urethral mucosa. The injections are done under local anesthesia with the use of a cystoscope and a small needle. Bulking material is injected into the urethral submucosal layer under direct vision. Unfortunately, the cure rate with this treatment is only 10 to 30 percent despite multiple formulations on the market for use. This treatment can be repeated and sometimes acceptable results are seen after multiple injections. The operation is minimally invasive but the cure rates are lower compared to the other surgical procedures.
  • Bladder Prolapse/ Cystocele Repair: This is completed if the bladder is not emptying well and out of its normal position. Many patients will have urgency or urge incontinence with this type of defect. A synthetic mesh is used to provide support to anterior vaginal wall where the bladder sits. Most of the time this can be accomplished through the vagina, however, we also utilize the Da Vinci Surgical Robot to complete the surgery through the abdomen. The potential adverse outcomes of surgical treatment include bleeding, infection, pain, urinary retention or voiding difficulties, de novo urgency, recurrent pelvic organ prolapse, and failure of the surgery to fix the leakage. With the use of mesh materials there is a very small risk of erosion of the material into the bladder, urethra or vagina.
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