Appointment Information
Urology University of Cincinnati Medical CenterUniversity of Cincinnati
Robotic Surgery

Urinary Incontinence

Introduction

The bladder is a hollow organ located behind the pubic bone. The bladder has an inner lining that is impermeable to urine and an outer lining composed of three layers of specialized muscle. Near the bottom of the bladder, the ureters enter through the muscle layers bringing urine from the kidneys to the bladder for storage. At the bladder outlet which leads to a tube called the urethra, a muscle circles the bladder-urethra connection which is contracted during the storage phase but relaxes at the time of voiding. Thus the bladder has both a storage and an emptying function.

During storage, the bladder muscle normally relaxes and stretches to accommodate urine produced by the kidneys while the sphincter maintains pressure on the bladder outlet to prevent leak. When the bladder reaches maximum capacity, the stretching of the bladder wall signals the need to void. In general, we are able to suppress bladder contraction, allowing time to get to a rest room. When appropriate, we can relax the urethral sphincter and the bladder contracts to empty.

What is urinary incontinence

Urinary incontinence is loss of control of the storage function of the bladder-urethral sphincter mechanism. This results in an unwanted loss of urine which is uncomfortable and embarrassing. It can affect men and women and at any age. Although incontinence is frequently associated with the elderly, it is not a normal consequence of aging, nor is it an inevitable condition following pregnancy or menopause.

Incontinence affects over 14 million Americans and contributes to social and health issues, interfering with quality of life and the activities of daily living.

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Types of Urinary Incontinence

Stress incontinence is loss of urine during activities which increase abdominal pressure due to contraction of the abdominal muscles (sneezing, coughing, and laughing). Stress incontinence is typically due to failure of the sphincter to maintain its closure at the point where bladder and urethra join. Increased abdominal pressure overwhelms the sphincter mechanism and urine leakage results. This condition is usually associated with pelvic floor weakness after pregnancy, urologic surgery such as prostate removal, or neurologic conditions.

Urge incontinence is described by patients as the sudden urge to void but loss of ability to postpone urination leading to unwanted urine leak. This is a failure of the bladder’s ability to store urine at low pressure. Bladder contractions that are not suppressed by the patient (also known as uninhibited bladder contractions or over-active bladder OAB) occur in men and women and increase with age. Urge incontinence is associated with neurologic diseases (Parkinson’s disease, strokes), diabetes, and urinary tract infection.

Overflow incontinence is the result of bladder stretching over a long period of time during which the bladder outlet (typically due to benign prostate enlargement in men) maintains a pressure sufficient to prevent normal bladder emptying. Over time, the bladder “decompensates”, losing the normal bladder contraction. However, once the bladder's volume reaches is maximum volume, pressure within the bladder will overcome the sphincter and the patient suffers continuous loss of urine. This loss of bladder muscle function can occur over years and may not prompt evaluation. Besides prostate enlargement, overflow incontinence may be caused by diabetes, neurologic disease or nerve injury.

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Evaluation of Urinary Incontinence


History: The description of symptoms provides information that will distinguish the several types of incontinence in most cases.
Physical exam: Physical exam, including pelvic exam in women, will provide information regarding changes in pelvic floor anatomy that may contribute to loss of voiding control. In men, digital rectal exam can provide information about the prostate and the pelvic floor neurologic integrity.
Urodynamic testing: Often, the description of symptoms and physical exam may be insufficient to distinguish the type of voiding disorder that is the primary contributing cause of incontinence. In these situations, urodynamics (UDS) provides objective and quantitative measures of bladder capacity and bladder pressures with subjective input from the patient to confirm duplication of symptoms. UDS requires insertion of a small catheter into the bladder, insertion of a pressure monitor into the rectum, and placement of EKG electrical monitor skin pads in the area of the pelvis. Bladder pressure is monitored during filling and emptying with simultaneous monitoring of electrical signals from the pelvic floor musculature. Combined with real-time sensations perceived by the patient, the physician can identify the type of bladder abnormality, distinguish bladder from urethra factors (i.e. evidence of prostate obstructive issues or stricture) and provide a comprehensive treatment plan.

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Treatment of Urinary Incontinence

Women

Medical: Many patients will benefit from medical therapy that broadly include behavioral (pelvic floor exercises, biofeedback), medications which decrease over-active bladder (OAB) or increase tone of urine sphincter to decrease leak.
Surgical: Surgical treatments of incontinence vary from simple (urethral sling procedures) to complex (pelvic floor reconstruction with anterior and posterior repair of vaginal wall to reduce weakness of structures supporting the bladder and rectum.

Men

Medical: Treatment options in men include medical therapy for over-active bladder as well as medications that will reduce prostate size or contraction- these may contribute to symptoms of slow stream, frequency, and bladder decompensation.
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The University of Cincinnati Urology Division is one of the leading urology programs, not just in Cincinnati, but in the U.S. UC Urology provides quality health care using the most advanced technology and state-of-the-art diagnostic treatments. Many of our urologists are recognized in multiple national and local "Best Doctors" and "Top Doctors" listings. We provide minimally invasive surgical treatments which include laparoscopic, robot-assisted laparoscopic and endourologic procedures as well as comprehensive care for all urologic conditions.