Fwd: eMedicine Incontinence Feature Series Newsletter

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eMedicine's Incontinence Feature Series delivers the latest information.

Series 1, Issue 4

Ramon Lansang, Jr, MD

Consulting Staff

Department of Orthopedics

ton Area Medical Center

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INCONTINENCE AFTER PROSTATE SURGERY

WHY PEOPLE HAVE PROSTATE SURGERY

Prostate cancer

Prostate cancer is the second most common cancer in men and the second leading cause of death in men in the United States. In some patients, prostate cancer can be treated with radiation. However, like any other treatment, radiation therapy has risks and potential complications. Another treatment option is surgery. Common surgical procedures to treat prostate cancer include prostatectomy (removal of a part of the prostate) and transurethral resection (scraping away the inner core of the prostate with a telescope inserted in the urethra). The major complications of such surgeries include urinary incontinence and impotence.

Urinary incontinence occurs in less than 5% of people who have had surgery to treat prostate cancer. The sphincter at the neck of the bladder usually holds the bladder shut and prevents urine from leaking. After some prostate surgery, the sphincter is not strong enough to hold urine; therefore, urine dribbles out involuntarily.

The most common type of urinary incontinence following prostate cancer surgery is urge incontinence, followed closely by stress incontinence. In urge incontinence, the individual cannot consciously control the bladder muscles. The bladder contracts on its own to expel urine, often without warning. Stress incontinence is the loss of urinary control when abdominal pressure is increased from coughing, lifting, straining, or laughing.

Benign prostatic hyperplasia

Benign prostatic hyperplasia (a type of enlarged prostate) is a common condition that typically affects men who are older than 50 years. The symptoms of this condition include straining to urinate, weak urine stream, and intermittent dribbling of urine. If the prostate enlarges too much, it may eventually obstruct the urethra and the flow of urine.

This condition is sometimes treated with medications that slow or suppress the enlargement of prostate tissue. Most of these medications work by affecting hormone levels. Some others affect molecules found on the cells in the urinary tract that increase urinary flow. If medication doesn’t solve the problem, surgery is also an option.

PROSTATE SURGERY AND INCONTINENCE

Causes of incontinence

Surgery is often an option to treat enlargement of the prostate, whether the prostate is enlarged because of cancer or because of benign prostatic hyperplasia. However, since the prostate is in such a small space within the body, its nerves and blood vessels are often inadvertently injured or severed during prostate surgery.

With prostate cancer in particular, the cancer cells in the prostate may grow very close to the blood vessels and nerves that coordinate and control urinary flow. During the prostate surgery, the muscle valves or nerves that control the sphincter muscles can be damaged. This may affect the bladder's capacity to hold urine. If the sphincter is damaged, it may be unable to fully close and control urinary flow. This, in turn, results in dribbling and leakage of urine.

Removal of the prostate gland can also cause specific complications. The prostate gland surrounds the urethra and helps the bladder hold in the urine. When the prostate is removed, an empty space remains in its place. As the bladder then fills with urine, the bladder shifts to fill in the space where the prostate used to be. This disturbs the flow of urine and may cause urine leakage.

Radiation treatments for prostate cancer may also lead to urinary incontinence. Radiation can cause bladder spasms, which decrease the bladder’s ability to hold urine.

Symptoms of incontinence

Incontinence after prostate surgery is seen in 1 out of 4 men who have such surgery. Incontinence after surgery can be temporary or permanent. The degree of incontinence can range from mild to severe.

Urge incontinence (caused by bladder muscle damage) is associated with prostate surgery and radiation therapy. When the muscles in the bladder contract too often or without the conscious control of the patient, urge incontinence occurs. Injury to the bladder nerves can cause urge incontinence after surgery.

Stress incontinence (caused by sphincter muscle damage) is commonly associated with removal of the prostate gland. It is caused by damage to the sphincter muscle during prostate surgery. A patient with stress incontinence usually experiences leakage of urine while laughing, sneezing, and exercising.

The need to urinate too often during the day or night is also seen in individuals who have had the prostate gland removed. These conditions are caused by increased bladder pressure within the bladder as it fills with urine.

During some prostate surgeries, both the bladder muscles and the sphincter muscles may be damaged. This leads to a combination of both urge incontinence and stress incontinence. This combination is called mixed incontinence.

Diagnosis of incontinence

If a patient is older than 50 years and has symptoms of incontinence, a physician may diagnose incontinence. This diagnosis may also depend on urodynamic studies, which measure the urine stream and bladder volume, and ureteroscopy, during which a thin tube with an attached light is inserted in the urethra so the physician can see inside.

Treatment of incontinence

Incontinence can be treated in many ways. The physician’s evaluation of the patient’s history determines the choice of treatment. An immediate treatment option is the use of pads that absorb excess urine. This is the easiest way to prevent further complications. When the skin is dry and clean, the risk of skin irritation and infection is smaller. Absorbency also prevents potential embarrassment and loss of self-esteem.

Medications are also an option to treat incontinence. Anticholinergic medications work against the nerves that cause the bladder to contract or squeeze down. They stop the bladder wall from contracting on its own and decrease the pressure associated with urge incontinence. Another group of medications are the alpha-adrenergic drugs. They work by constricting the sphincter muscle and, at the same time, relaxing the bladder wall. This dual action helps control the sudden pressure and leakage of stress incontinence.

Changes to the patient’s diet can be a part of incontinence treatment. Patients with incontinence should avoid excessive fluid intake. They should also avoid substances that irritate the bladder, such as alcohol, coffee, and tea, and other substances that may increase urination, such as caffeine. Constipation can worsen urge incontinence and lead to urine leakage. A diet high in fiber can help reduce the risk of constipation.

Some incontinence treatments work to physically alter the bladder and sphincter. Physicians may instruct patients to exercise the pelvic muscles. Strengthening these muscles helps the sphincter stay closed and keep urine from leaking. In biofeedback, an electrical patch is connected to the pelvic muscles to monitor when the muscles are contracting. This can help patients learn how to contract the pelvic muscles on their own.

Surgery is also a possible treatment for incontinence. An injection of collagen around the urethra compresses the urethra. This procedure can work to limit urine flow and urine leakage. If the sphincter is damaged beyond repair, an artificial sphincter can also be implanted. Finally, a sling can be implanted around the muscles in the area to support the urethra.

References

Braunewald E, Fauci AS, Kasper DL, et al. Incontinence and lower urinary tract systems.In: Braunewald E, Fauci AS, Kasper DL, et al, eds. on’s Principles of Internal Medicine. 15th ed. Columbus, OH: McGraw-Hill Professional Publishing; 2001:268-270.

Kaplan SA, Te AE, Blaivas JG. Urodynamic findings in patients with diabetic cystopathy. J Urol. 1995;153(2):342-4.

Lifford KL, Curhan GC, Hu FB, et al. Type 2 diabetes mellitus and risk of developing urinary incontinence. J Am Geriatr Soc. 2005;53(11):1851-7.

KN, Gray M. Urinary incontinence in men: current status and future directions. Nurs Res. 2004;53(6 Suppl):S36-41.

Nitti VW, Kim Y, Combs AJ. Voiding dysfunction following transurethral resection of the prostate: symptoms and urodynamic findings. J Urol. 1997;157(2):600-3.

Rigby D. Regaining continence after radical prostatectomy. Nurs Stand. 2003;18(8):39-43.

Yerkes A. Urinary incontinence in patients with diabetes mellitus. Diabetes Spectrum. 1998;11(4):241-7.

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[Guest guest]

Just in case you are interested.

Ron

PS There is no need to feel ashamed of this condition. I have been incontinent for 10 years now and still counting. The good thing is to know that there is help, cures and relief.

eMedicine's Incontinence Feature Series delivers the latest information.

Series 1, Issue 5

Lazarou, MD

Assistant Professor of Obstetrics and Gynecology

Division Director of Urogynecology

Weiler Hospital

Albert EinsteinCollege of Medicine

Bronx, NY

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UNDERSTANDING FEMALE URINARY INCONTINENCE

An estimated 1 in 10 people aged 65 years or older experience bladder control problems that can range from a little leakage to uncontrollable wetting. This condition is known as urinary incontinence. An estimated 13 million people in the United States experience some degree of urinary incontinence, and this number is actually believed to be an underestimate. Although urinary incontinence occurs in both men and women as they age, the condition affects more women than men. Studies suggest that 15-35% of women older than 60 years and living at home have some form of incontinence.

Bladder control problems in women have many possible causes, including reduced levels of estrogen in the body, past tissue or nerve damage from childbirth, pelvic surgery, and weakened pelvic floor muscles. The most common types of urinary incontinence are urge incontinence (an overwhelming urge to void) and stress incontinence (sudden urine leakage because of abdominal pressure from laughing, coughing, or heavy lifting). Women struggling with urinary incontinence should know that seeking medical care as early as possible not only provides answers but also can greatly improve quality of life.

Consider the case of , a 45-year-old woman who had problems with leaking urine when she coughed. She often felt an uncontrollable urge to urinate and had multiple accidents every day. She also woke up to urinate 3-4 times per night. This disrupted her sleep and she felt tired in the morning. At work, she was embarrassed about her incontinence and wore absorbent pads to guard against accidents. Her coworkers made fun of her for having to run to the bathroom. When she had a bad cold, she was embarrassed by urinary leakage every time she coughed. She wanted to stay home from work during this time to avoid embarrassment.

Her urinary problems had been present for years but were now worse. Her incontinence was now affecting her quality of life and also contributing to marital problems because her condition led to less intimacy. She was too embarrassed to discuss this with health care providers and thought that nothing could be done to improve her condition. When she told her family doctor about her condition, the doctor told her to do pelvic exercises. She wasn’t sure if she was doing them correctly and didn’t notice much improvement. She then searched on the Internet and found a specialist who performed a complete evaluation. She tried behavioral modifications, medication, and biofeedback. After a couple of months, her incontinence is much improved. She wishes she had seen a specialist sooner.

Some lifestyle changes can help minimize the symptoms of bladder control problems. Women with urinary incontinence can try some or all of the following steps:

Avoid foods and drinks that irritate the bladder. These include alcohol, caffeine, carbonated drinks, chocolate, spicy foods, citrus fruits, and acidic fruit juices.

Drink plenty of fluids, but do not drink too much. Unless exercise or excessive heat is causing a woman to lose fluids, 6-8 cups a day is enough.

Urinate regularly, and do not delay urinating or having a bowel movement.

Practice Kegel exercises to strengthen pelvic floor muscles.

Incontinence is a common problem in women. Those who experience incontinence are often reluctant or afraid to seek help because they are embarrassed or think that incontinence is an inevitable effect of aging. Many people tolerate a lower quality of life because they don’t seek help. However, incontinence is a treatable condition. If the lifestyle changes listed above do not solve the problem, seeking help from a physician can drastically improve the quality of life. A proper diagnosis of the type of incontinence is an important part of the treatment process.

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Series 1, Issue 6

Photo not available

Breyer, MD

Staff Physician

Department of Urology

University of California – San Francisco

Donna Y Deng, MD

Assistant Professor

Pelvic Reconstructive Surgery and Female Urology

Department of Urology

University of California – San Francisco

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LIVING WITH INCONTINENCE

Urinary incontinence can take a devastating mental and physical toll on your life. It is one of today’s most common medical problems; 10-35% of adults experience the symptoms of incontinence. This newsletter addresses methods of living with the emotional and physical impact of incontinence.

Urinary incontinence can negatively affect mental health. Several studies have shown a relationship between urinary incontinence and depression. Patients with incontinence are more likely to experience anxiety, shame, and embarrassment, all of which can lead to low self-esteem. Depression and low self-esteem can lead to social isolation, which inhibits patients from seeing family, keeping in touch with friends, and being involved in their communities. Embarrassment can inhibit patients from seeking medical assistance.

In addition to emotional harm, incontinence can also affect physical health. The fear of urinary leakage causes decreased participation in exercise and sexual activity, which can lead to a decrease in physical conditioning and worsening of overall health. Patients with incontinence must frequently rush to the bathroom. These same patients often have impaired mobility, leading to increased risk of falls and fractures. Urinary leakage can cause bothersome skin irritation and skin breakdown and can potentially lead to severe wound formation.

Changes to the home surroundings can help people with impaired mobility. To avoid falls, make a safe and easy path to the bathroom. Remove clutter and throw rugs on slippery floors. If the bathroom is only accessible by stairs, a commode placed nearby could prevent an accident. Make the bathroom easy to find at night by placing a light in the hallway or bathroom. Changes like these can minimize the risk of complications from incontinence.

Absorbent pads are an effective method to stay dry, if they are changed regularly. Pad selection should be made based on the level of absorbency required, size, and fit. Change pads regularly and as needed to remain as dry as possible. Chronic exposure of the skin to moisture can lead to yeast infections, skin irritation, and skin breakdown. If excellent hygiene is not practiced, potential exists for the formation of severe wounds.

The first step of coping with the emotional and physical effects of urinary incontinence is talking to a doctor. Doctors can provide education about the numerous urinary incontinence treatment options, such as muscle strengthening, biofeedback, dietary modifications, medications, and surgery. Understanding the problem and how it is treated helps empower patients to take control of their health. The Internet is also a good source of information. Many organizations and companies have Web sites that provide tips and information for patients on the topic of incontinence, including the following:

eMedicineHealth.com: Incontinence Center

The National Association for Continence

The Simon Foundation for Continence

The American Urological Association

The Depend official Web site

Patients with incontinence must learn that they are not suffering alone. More than 19 million adults in North America have some form of incontinence. Joining an incontinence support group can be an effective method of overcoming the embarrassment, anxiety, and depression that may stem from incontinence. Support groups can frequently be found locally at an area hospital or on the Internet. Finally, obtaining personal counseling from a therapist may be helpful.

References

Dugan E, Cohen SJ, Bland DR, et al: The association of depressive symptoms and urinary incontinence among older adults. J Am Geriatr Soc. 2000;48:413-6.

Payne CK: Urinary Incontinence: nonsurgical management. In: Walsh PC, ed. ’s Urology. 8th ed. Philadelphia, PA: WB Saunders; 2002:1069-81.

Wagner TH, Hu TW: Economic costs of urinary incontinence in 1995. Urology. 1998;51:355-61.

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eMedicine's Incontinence Feature Series delivers the latest information.

Series 1, Issue 8

Lazarou, MD

Assistant Professor of Obstetrics and Gynecology

Division Director of Urogynecology

Weiler Hospital

Albert Einstein College of Medicine

Bronx, NY

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UROLOGIC DYSFUNCTION AFTER MENOPAUSE

Women who experience menopausal symptoms commonly report hot flashes, night sweats, palpitations, skipped periods, and vaginal dryness; they don’t typically report specific urologic symptoms. However, certain urologic conditions can occur around the time of menopause. These conditions include urinary incontinence and frequency, recurrent lower urinary tract infections (UTIs), and symptomatic pelvic organ prolapse (sinking of the pelvic organs or vagina because of lost function in the muscles that surround and support these organs).

The levels of estrogen in a woman’s body decrease around the time of menopause. Collagen, which is one of the major connective tissues that prevent pelvic organ prolapse and support the urethra, demonstrates significant changes as estrogen levels drop. In addition, estrogen receptors are found throughout the urogenital tract and, because estrogen is involved in the urogenital tract, lower levels of estrogen may influence a woman’s urologic function. Although the exact causes of urologic dysfunction after menopause are not clear, proper evaluation and early treatment allow improvement of symptoms and quality of life.

Urinary incontinence and frequency

Possible causes for urinary incontinence in women include damage to nerves and muscles from giving birth or pelvic surgery. The lowered estrogen levels during menopause may also be a cause of incontinence. The most common types of incontinence are urge incontinence (patient feels a strong urge to urinate when the bladder may or may not be full) and stress incontinence (urine leakage is caused by sudden intra-abdominal pressure from coughing, laughing, or heavy lifting). The symptoms of incontinence can be managed with medication, physical treatments such as absorbable inserts or underwear, surgery, or any combination of these treatments.

Recurrent UTIs

UTIs are most often caused by bacteria entering the urinary tract. Inflammation of the bladder is a lower UTI called cystitis. This infection may spread to the kidneys and cause pyelonephritis (infection and inflammation of the kidneys), bacteremia (infection in the blood), or sepsis (widespread infection).

Patients with lower UTIs may experience painful, frequent, and urgent urination, and the urine may appear cloudy and have a foul smell. A simple urine culture can detect a lower UTI. Once the diagnosis is made, appropriate oral antibiotics are prescribed to clear the infection. A complete urologic workup is required for patients with recurrent UTIs. Some patients who have recurrent UTIs but have a negative workup may benefit from a short course of oral suppressive antibiotic treatment.

Some evidence has shown that genetics and lowered levels of estrogen may play a role in frequent UTIs in women. Also, topical estrogen may lower the number of recurrent lower UTIs in some patients. Topical estrogen is often a cream applied to the inside wall of the vagina, but it is also available in other forms (like tablets or rings that are inserted into the vagina).

Symptomatic pelvic organ prolapse

The pelvic organs (uterus, rectum, bladder) and vagina are susceptible to prolapse around the time of menopause. Prolapse can range from mild (lost muscle function causes organs to sag) to severe (organs may be visible outside the body). Although this condition can happen in younger patients, it is more common in perimenopausal women. Pelvic organ prolapse has multiple causes. However, the low levels of estrogen that occur around the time of menopause may contribute to this condition. Although the evidence is in no way conclusive, other factors, such as the effects of childbirth, chronic constipation, or heavy lifting, may contribute to incontinence and pelvic organ prolapse. When properly diagnosed, prolapse can be treated successfully.

A simple physical examination can usually diagnose pelvic organ prolapse. When the front wall of the vagina is prolapsed (called cystocele), the patient may experience urinary frequency, urinary hesitancy, pelvic discomfort, back pain, painful sexual intercourse, or incomplete voiding (urine remains in the bladder after going to the bathroom). In those cases, a correction of the pelvic organ prolapse through exercises or surgery can improve the urinary symptoms and offer relief. If a woman has mild pelvic organ prolapse, her doctor may recommend avoiding heavy lifting or straining as well as performing pelvic floor exercises (Kegel exercises). For more severe cases, pessaries (implanted devices to support the organs) or surgery may be indicated.

References

American Urogynecologic Society

National Association for Continence

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