As a urologist, I treat a lot of men and women who suffer from urinary incontinence. By the time they see me, they have gathered the courage to see a specialist and find out what can be done.
Statistics show, however, that many more people suffer in silence. Whether it’s leaking urine during exercise, sneezing, laughing, etc., or a sudden uncontrollable urge to pee that results in wet pads or pants, millions of Americans are perhaps too afraid or ashamed to seek treatment. They often resort to wearing protective garments, planning their day around access to bathrooms, or giving up activities they love as a result.
Health care providers need to do a better job informing patients and the public that urinary incontinence is actually highly treatable and not necessarily a part of aging or a foregone conclusion.
Where to start?
First, understand that there are generally two types of incontinence: Stress Urinary Incontinence (SUI) and Urge Incontinence (UI). Many patients have both, and in these cases, I usually try to identify which is more bothersome to the patient.
- Stress Urinary Incontinence (SUI): this is defined as leakage which occurs with cough, laugh, sneeze, sex, exercise, etc.. This is related to a weakness of the pelvic floor muscles that often results from pregnancy and childbirth. It is the most common cause of incontinence in women under 60 and can get worse with menopause. It can also be seen in men who have undergone prostate cancer surgery.
- Urge incontinence: this is the involuntary leakage of urine associated with a sudden, intense urge to urinate. It is usually part of a spectrum of “Overactive Bladder (OAB)” with urinary urgency, frequency (often day and night), and urge incontinence. An estimated 33 million Americans suffer from OAB, of which approximately 17 million having daily urge incontinence.
Patients who see me for incontinence are either referred by their primary care doctor or have scheduled a visit directly with my office staff. I first have them them fill out a basic questionnaire about their incontinence. After gathering a good history and exam and determining which type of leakage they may have (one or both), I usually do some basic studies to make sure they don’t have a urinary tract infection or trouble emptying their bladder, for example. If they do, I treat these conditions first.
For those with persistent SUI or OAB/urge incontinence, I recommend starting with conservative measures such as avoiding bladder irritants (excess coffee, sodas, etc.), emptying their bladder often, and trying pelvic floor or “Kegel” exercises. Many of my patients have already adapted these “coping” strategies on their own and have not found them to be very effective. In those cases, I go over treatment options depending on which type of leakage they have.
Non-surgical treatment of SUI
For those who’ve been through the initial evaluation and have failed conservative measures (and are still seeking treatment, which includes most patients in my office), I then go over the various surgical and non-surgical treatment options outlined in our guidelines.
Up until just a few months ago, the treatment repertoire for SUI in my office consisted basically of either surgery or more ineffective Kegels. I am excited to announce that I can now offer a new, non-surgical option called the EmsellaTM chair. This chair uses electromagnetic energy to stimulate stronger and more-effective contractions of the pelvic floor muscles in a way and number that no person can possibly do on their own. Just imagine doing 11,000 supraphysiologic Kegels in 28 minutes! The standard treatment course involves 6 sessions (2 per week x 3 weeks) with success rates of up to 95% in one study.
We also now have the MonaLisa TouchTM vaginal laser for the in-office treatment of symptoms related to “vaginal atrophy” or the loss of estrogen in the vaginal tissues (such as burning, itching, painful intercourse, and recurrent infections). This laser can also help treat stress urinary incontinence and would ideally be used in combination with the EmsellaTM in patients who suffer from both conditions. I personally believe these new treatment options are game-changers. Many women would prefer to try these before considering surgery.
The EmsellaTM treatment is also ideal for men with mild post-radical prostatectomy incontinence (requiring pads or liners after surgery). Studies have shown that Kegel exercises and pelvic floor rehabilitation may help men both recover more quickly and potentially avoid surgical intervention.
Both new treatments are, unfortunately, not covered by insurance. That said, I encourage all my patients with stress incontinence to sit on the EmsellaTM chair, experience the pelvic floor contractions, and decide if they think the cost is worth it for them. For those women who also have symptoms of atrophic vaginitis (see above), I speak to them about the MonaLisa Touch with or without the Emsella treatment for added benefit. To learn more about both of these options, please visit our website.
Surgical Options for SUI
For those women contemplating surgery, I go over with them the pros and cons of injection of urethral bulking agents versus insertion of a mid-urethral “sling”. Both can be done under general anesthesia as an outpatient surgery. We usually have a long discussion outlining the differences between these options in terms of efficacy, recurrence rates, and possible complications. (Men with mild to moderate stress incontinence after surgery may be a candidate for a similar “male sling” procedure in outpatient surgery. Again, I would highly recommend considering the EmsellaTM treatment before going through another surgery.) For more information, you may again refer to the guidelines or this website.
In addition to conservative measures (including voiding at regular intervals and avoiding bladder irritants), I recommend a trial of medications designed to decrease the urge and leakage episodes. My favorite drug is called Myrbetriq (mirabegron). (You may have seen the commercials with the little bladder pulling the person’s arm, telling them to go the bathroom). This drug is usually well covered by insurance plans, has fewer side effects than any of the prior OAB meds, and begins to work within 2-3 wks of starting. I have seen quite a few patients who are delighted with the results and happy to continue.
For those not responding to medications + conservative measures, I explain to them that there are several options that we can offer and that I have seen successes with each one of them.
These options include injection of Botox in the bladder (yes, the same Botox doctors use in the aesthetic industry), something else called the “PTNS” treatment (think of acupuncture with electrical stimulation of the tibial nerve just above the ankle), and, finally, stimulation of the sacral nerves in the lower back via the InterstimTM device made by MedtronicTM. Each has its own set of advantages and disadvantages that must be weighed and tailored to the patient.
Studies show that most urologists are not making enough use of these potentially life-changing options. In my office, I am happy to say that we can and do offer all of them. Most of my patients this year are choosing the PTNS option because it is the least invasive and has the fewest side effects. Many of them are also choosing to combine this with the EmsellaTM chair for potential additional efficacy.
Urinary incontinence is a common problem that affects millions of Americans. I regularly see patients who tell me stories about how their leakage is negatively impacting their lifestyle. Many of them had no idea about the available treatment options.
I am very excited about what my staff and I now have to offer. We are one of the few urology clinics in Houston that offers many non-surgical treatment options, including the EmsellaTM chair and the MonaLisa TouchTM vaginal laser. If you are having problems with urinary incontinence and would like learn more, tell your primary doctor or give us a call to make an appointment directly.
Know that treatment is available and that my staff and I would be happy to work with you on a plan to give you back your best quality of life!
Written by Omar Durrani MD, 7/1/18