Urinary incontinence

Overactive bladder and Urge Incontinence

The "Overactive bladder" syndrome consists of any 2 of these 3 symptoms:

Urinary urgency: Difficulty in controlling the bladder when struck by the urge to "go"

Urinary frequency: Going too many times a day. This is usually defined as more than 8 times a day. But one also needs to take account of the type and amount of fluid drunk, amount passed each time and level of urgency to decide if there really is a problem.

Urge incontinence: Urinary leakage presaged by a sudden desire to void.

Sometimes, these same symptoms are caused by stones, infections or even some medical conditions . Sometimes there is no known cause (idiopathic). A few tests and xrays are usually done to make sure one's symptoms are not due to a treatable condition before it is deemed "idiopathic".

We treat our patients with overactive bladders with a combined bladder training regime. Under the purview of a urologist, a continence nurse will train, supervise and monitor patients on behavioral techniques that include education, dietary changes, bladder training and Pelvic floor muscle training, biofeedback or functional electrical stimulation.

We also use medications to relax the bladder. Sometimes, a few different medications may be tried before the best one is found for a specific individual. Unfortunately, many of these medications do create undesirable side effects; therefore, frequent communication between doctor and patient is essential to get the best results with the least side effects.

More invasive therapy or complex surgical treatments are available for patients with overactive bladder who do not respond to medical therapy. Such patients should undertake urodynamic testing before alternative or surgical therapy is considered

Dr Quek is a pioneer in using Botox for urge incontinence and lower urinary tract dysfunction and has conducted several clinical trials using Botox in the lower urinary tract .The off label use of Botox may be considered in selected cases after failure of medical therapy.

Stress incontinence

Stress incontinence

After pregnancy or childbirth, one in three women experience urinary leak when they exert themselves.It can happen while coughing, sneezing or during exercise, running after a bus, laughing loudly with friends or carrying your child. This is due to a weakened bladder support and urinary sphincter. It is the most common type of incontinence affecting younger and middle-aged women.

Stress incontinence

Patients with mild symptoms are often taught pelvic floor muscle training as a first option. Pelvic muscle exercises (also known as Kegel exercises) are designed to help strengthen weak pelvic muscles around the bladder. Patients are personally supervised to ensure that the exercises are performed properly and are advised to do the exercises consistently for a minimum period of 2 months before results are seen. Performed consistently, significant improvement is experienced by up to 70% of patients.

Patients unable to learn how to do their exercises properly are usually taught using biofeedback and/or electrical stimulation of their pelvic muscles.

Stress incontinence Stress incontinence

There are more than 200 types of surgery to correct stress incontinence. Some were industry driven fads that did not work and others have not withstood the test of time. Currently, the 3 main forms of surgery that have proven long term success are the Burch coloposuspension, the pubovaginal sling and the subrethral slings. All 3 operations seek to resuspend the loosened pelvic floor and provide a firm backing against which the urethra is squeezed during a cough, laugh or sneeze. Of these, the most commonly performed currently is the suburethral sling as they are minimally invasive, can be performed as a day procedure and have the least down time. Suburethral slings like the tension free vaginal tape (TVT) offers excellent cure rates.

Stress incontinence

These diagrams show how the “hammock” or “backing” afforded by the pelvic floor tissue under the urethra has lost its tone or integrity. So when one coughs, laughs or strains in any way, the transmitted pressure is not contained and urine is allowed to leak. If the sphincter area is especially weak, the leak is even worse.

  TVT Burch PVSling
Mean Op time 22-42min 72min -
Resume voiding 6-24H 70-115H -
Mean Hosp Stayd 0.3-3d 5-8 16d
Resume work 10-21d 42d 42d

A comparison of downtime between the various continence procedures:

  TVT Burch PVSling
Short term cure 80-100% 84-100% 64-100%
Medium term cure 80-95% 84(77-89)% 82(73-89)%
Long term cure 80-95% 84(79-88)% 83(75-88)%

A comparison of cure rates between the various procedures

Continence issues in the elderly

Urinary incontinence is quite common in the elderly. It can be embarrassing and socially crippling for the patient and leads to hygiene issues at home. Incontinence is the commonest reason for institutionalising the elderly. There are many forms of incontinence but one of the commonest in the elderly is the inability to control their bladder at night or on the way to the washroom. Cure or significant improvement can be achieved with a combination of medication and bladder training. Another common cause is the onset of senile dementia. In such cases, there are simple aids to help caregivers cope.

Post prostatectomy Incontinence

One of the side effects of a radical prostatectomy is urinary incontinence. This takes many forms and patients need to be fully assessed before a treatment plan can be formulated. Post prostatectomy incontinence is worst immediately after the operation and takes up to a year to get better and stabilize. A combination of treatments is available to help patients achieve continence earlier. Continence aids are also available to help patients cope in the meantime. A urodynamic testing is usually required to determine the best treatment option as post prostatectomy incontinence can be quite complex. The best results are also obtained if treatment is started earlier. In severe cases where the urinary sphincter complex is damaged, surgical options are available to augment or replace the damaged sphincter.

Young men with bladder control and voiding problems (Lower urinary tract symptoms)

Some men between 20 to 50 experience symptoms like urinary frequency, a sense of incomplete emptying, urgency and poor bladder control, weak or staccato urinary flow or initial difficulty when trying to empty their bladders. These symptoms are known as lower urinary tract symptoms (LUTS) and are often misdiagnosed as prostatitis and overactive bladders. Patients are often times given repeated courses of antibiotics without much relief. The actual causes can be as varied as bladder neck dysfunction, weak bladder muscles, dysfunctional voiding or overactive bladders. In rare cases, some patients are found to have hitherto undiagnosed spinal abnormalities.

This is one of Dr Quek's areas of interest and we have a wealth of experience in treating young men with the above symptoms. By assessing one's voiding habits, urinary flow and performing a video urodynamic study a more accurate diagnosis and treatment plan can usually be reached.

Continence aids and appliances

For people who are currently participating in a treatment programme or whose urinary incontinence cannot be cured, there are many absorbent products and devices that are available to help patients and caregivers cope:

  • Containment Devices: Pants, pads or pouches with absorbent lining that can contain 150 to 2300 ml of urine.
  • Collection Device : For those with mobility problems who cannot get to the washroom in time
  • Bed Protection : For bed wetters and those who "overflow" at night
  • Catheters : For those unable to empty their bladders completely
  • Others eg night alarms, female urinals

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