Dr. Kielb is an Associate Professor of Urology at the Feinberg School of Medicine and a specialist in neurourology, female pelvic medicine and reconstructive surgery.
Betsy Haberl is the editor of QUEST.
BH: Why is female urinary incontinence an important topic?
SK: Incontinence is very common in women. About 30-40% of women will have incontinence at some point in their life. However, just because it’s common for women to leak urine doesn’t mean it’s normal.
BH: Who should seek treatment for incontinence?
SK: I encourage women with any degree of incontinence to talk to a doctor. My patients often wish they had sought help earlier after learning about available treatments.
“Incontinence has a huge impact on quality of life, and many women aren’t aware of the range of treatments, including non-surgical options.”
–Dr. Stephanie Kielb
BH: How is stress incontinence different from urge incontinence?
SK: Women with stress incontinence leak urine with abdominal pressure, such as from coughing or laughing. Women with urge incontinence have urgency of urination, during which they may leak urine. They can also have frequent urination and nocturia, or excessive nighttime urination. Often, the condition is called overactive bladder.
BH: What causes incontinence?
SK: Stress incontinence is usually caused by a weakening of the pelvic floor muscles, particularly the support underneath the urethra and bladder neck area. The weakened muscles allow the organs to swing down, like a hammock, with pressure from above. Instead of pinching closed, the urethra opens. Risk factors include pregnancy, vaginal delivery, pelvic surgery such as hysterectomy, loss of estrogen, excessive weight and chronic coughing and lifting. However, women without any of these risk factors can have stress incontinence.
Unfortunately, we don’t know why the bladder misbehaves and causes urge incontinence.
BH: How do you diagnose and evaluate incontinence?
SK: Often, I make the diagnosis based on a patient’s symptoms. I also check the urine for infection and blood and perform a pelvic exam. A residual measurement with an ultrasound checks if the bladder is emptying. I also ask about any fecal bowel issues, because 15-20% of women with urinary incontinence also have fecal or gas incontinence.
I’ll ask a woman with symptoms of stress incontinence to cough or strain. If she leaks, I can begin treating her. If she doesn’t, I may perform urodynamic testing. This uses a catheter to the measure bladder pressure.
I’ll ask a woman with symptoms of urge incontinence to keep a voiding log that tracks how much she’s drinking and urinating. This helps me identify behavioral changes as part of her treatment.
BH: How do you treat incontinence?
SK: It’s different for every woman. I always want to do the less invasive option first if possible.
BH: Where do you start with stress incontinence?
SK: Non-invasive treatments include behavior modification, such as urinating regularly, and pelvic floor physical therapy. Physical therapy helps women correctly identify the pelvic floor muscles and perform exercises to strengthen these muscles. Most women only need a few visits.
Another non-procedural option is the incontinence pessary, a ring with a knob that provides additional support under the urethra and bladder neck. A woman inserts the pessary vaginally. Women can wear them all the time or only when they’re prone to leakage, such as while exercising.
Other treatments require procedures to address the anatomical problem.
BH: What procedures are available for stress incontinence?
SK: A urethral injection can be helpful for mild forms of incontinence. Bulking material is injected under the lining of the urethra to close it tighter. The effects last for 18-20 months.
The gold standard treatment for stress incontinence is a sling procedure. A small piece of mesh or the patient’s tissue is implanted under the urethra to re-support it. It’s usually an outpatient procedure, although there are restrictions on lifting and strenuous activity for 3-4 weeks afterwards. Mesh slings have been used to treat incontinence in women for about 20 years and have 85-90% patient satisfaction rates.
BH: Are there any risks to the sling?
SK: There are the risks of surgery, such as infection, although the rate is extremely low. The risk of having difficulty urinating afterwards is fairly low (3% of women with mesh slings and 8% of women with tissue slings). Patients could develop new symptoms of frequency or urgency, possibly caused by the sling healing too tightly. However, this can be fixed. The bladder could be perforated during the procedure, but this doesn’t stop surgery or change the outcome. It does slightly increase the risk of bladder infection.
BH: What treatments are available for urge incontinence?
SK: Initial treatment includes behavior modification that reduces bladder irritation: reducing caffeine intake, examining drinking habits, not holding in urine and not straining to urinate. Also, it’s important to address bowl habits and stress.
Physical therapy is also a first-line treatment. Tightness or spasms in the pelvic floor muscles can affect the bladder. Strengthening the pelvic floor reflexively relaxes the bladder. Therapists look at alignment of the pubic bone, core strength and posture. All these things contribute to the bladder’s behavior.
BH: Are medications available?
SK: Most medications for urge incontinence are anticholinergic. They help the bladder stop contracting. About a year ago, a new drug came out for urge incontinence that is a betaadrenergic. It stimulates the bladder to relax. Both kinds of medication have potential side effects that patients should discuss with their doctors.
BH: Are there other options if the urge incontinence doesn’t improve?
SK: Two backup options are Botox injections and sacral nerve modulation, which I call the bladder pacemaker.
Botox is a neurotoxin. When injected into the bladder, it blocks signals from the nerve telling the bladder to contract. It can cause difficulty urinating for patients with a weak bladder, so it’s not right for everyone. The effects last about 6 months before needing to be repeated.
Sacral nerve modulation involves implanting a stimulator in the fatty part of the buttock cheek. The stimulator sends an on/off signal to the nerves that go to the bladder. It doesn’t cause pain. Some patients can’t feel it at all. It has to be implanted in the operating room, but there’s very little maintenance. The battery lasts 8-9 years. About 75% of patients with the stimulator have significant improvement with their leakage.