The treatment recommended will depend on the type of incontinence as well as the severity of the problem. Treatments may include behavioral therapy, medications or estrogen, minimally invasive surgery, or traditional surgery.

Regardless of your type of incontinence, the initial treatment will likely involve behavioral therapy.

Behavioral therapy is safe, easy to learn, and has no side effects.

Up to 80 percent of patients who regularly adhere to behavioral therapy will see improvement in their bladder control. The results may take several months to achieve and results will differ from person to person. It is important to be compliant with the therapy and have realistic expectations.

Behavioral therapy includes:

• Pelvic muscle rehabilitation (based on Kegel exercises)
• Bladder training programs
• Fluid and dietary modification

Pelvic Muscle Rehabilitation

The pelvic floor muscles are the most important tool that women have to improve their bladder control. Many women with incontinence are unable to isolate nor contract their pelvic floor muscles and so have no defense mechanisms when stress or urgency threaten to cause incontinence.

Your pelvic floor muscle function will be assessed during your vaginal examination and you will be taught how to strengthen and how to use these muscles when incontinence threatens.

Duke also offers focused Pelvic Floor Rehabilitation clinics for those who need biofeedback techniques.

Instructions for Pelvic Muscle (Kegel) Exercises

1. The pelvic floor muscles are the muscles you use to stop urine flow during voiding, and you can identify them by practicing stopping the flow during voiding. Many patients mistakenly contract their buttock and/or abdominal muscles, believing that they are doing the exercise correctly. You can be taught how to do this exercise correctly so as to make maximal gains.
2. You should feel your vagina tighten.
3. These exercises are best performed lying in bed. As you become better at recognizing the muscles then you can perform the exercises while talking on the phone, watching TV, cooking etc.
4. The exercises should be done in sets of 10, two times a day and each muscle contraction should be held for three to five seconds. Like any muscle in the body, "if you don't use it you will lose it." If during your evaluation, your doctors identify extremely weak muscles or that you can not identify the muscles well, they will have you see a physical therapist, who will be your "personal trainer." The physical therapist may use visual aids called "biofeedback" techniques. These are techniques that help you locate and isolate the pelvic floor muscles for maximal benefit.
5. The initial consultation with the physical therapist is usually one hour. Based on the progress made with home exercises, further biofeedback sessions may be needed.
6. Other aids for pelvic floor exercises include the use of vaginal cones and other appliances.

Bladder Training

A number of different techniques may be recommended to you, depending on the nature of your problem and a variety of other factors. These include:

Timed/prompted voiding. This technique is usually advised in the elderly population, who may have associated problems that preclude the use of bladder retraining. The goal of this simple technique is not to 'cure' the incontinence, but simply to deal with it! The patient voids “by the clock” at intervals of one, two, or three hours, and often needs a care-giver to prompt them.

Bladder retraining. In the patient with an overactive bladder, the sudden urge to void is usually met with a sudden rush to the restroom, and often with urinary leakage along the way. Bladder retraining attempts to give the patient back control of this situation by teaching defense mechanisms, and these rely considerably on pelvic floor muscle function.

It is important to recognize that contraction of the pelvic floor muscles not only stops the flow of urine, but also “switches off” the bladder, making the urge go away.

This program of urge control relies upon the patient first gaining control of the pelvic floor muscles, as described earlier.

Once this has been mastered, the bladder retraining program will involve one of two techniques:

1. Challenged voiding. Using this technique the patient challenges the sudden urge to void, does not rush to the restroom, but instead:
   
   • Stops what he/she is doing
   • Rapidly contracts and relaxes the pelvic floor muscles
   • Breathes deep
   • Walks to the restroom in a controlled manner once the urge has gone away
   This progam relies on the fact that the pelvic floor muscles can inhibit the bladder.
2. Timed interval voiding. Using this technique the patient challenges the urge to void using the same methods detailed above, but instead of heading for the restroom once the urge is under control, the patient resumes normal activities and only goes to void once their “time is up.”
   
   The time to void is laid out by the program in intervals that increase by 15 minutes each time the patient graduates to the next level. The initial interval between voids will be determined by examining the bladder diary of normal bladder events, and the program will likely require some adjustment of fluid intake, and certainly will require that the patient’s fluid intake be spread out evenly over the day.
   
   By way of example, the program may commence with voids restricted to every 45 minutes, then graduating to every one hour, then one hour and 15 minutes, then one and a half hours. The progress is continued until four hour intervals are achieved.
   
   This program requires considerable fortitude, as the patient is constantly challenged, and always feels as though he/she needs to void. However once the four hour interval is achieved, any shorter interval feels comfortable. The goal is not to make four hours the expected interval between voids but to challenge the bladder so that acceptable intervals of one to three hours are easy! Ideally the patient should not wear incontinence protection during the program, giving added incentive to be successful.
3. Fluid and dietary modification. Most patients with voiding problems, urinary incontinence and pelvic organ prolapse give very little consideration to their fluid intake and to their bowel habits. The bladder diary will give us considerable insight into factors that can be changed to improve your condition. In general advice will include:
   1. Decrease or eliminate caffeinated and alcoholic beverages. Other foods and beverages are also thought to contribute to bladder leakage, although their affect on the bladder is not always understood. The patient may want to decrease their intake of citrus juices and fruits, highly spiced foods, sugar and artificial sweetener, milk and milk products, and carbonated beverages.
   2. Avoid constipation by adding high fiber foods and by not restricting water intake. (ideal total fluid intake is between six to eight 8-ounce glasses per day) Cranberry, apple and grape juice do not irritate the normal bladder and makes the urine more acid-thus preventing the spread of bacteria.
   3. No smoking.
   4. Drink a total of six to eight 8-ounce glasses of fluid per day. Too little allows for a concentrated urine which can irritate the bladder. Too much only aggravates an urgent bladder.

Medications may include:

• Estrogen therapy
• Anticholinergics
• Antispasmodics
• Tricyclic antidepressants (medication to treat urge incontinence)

These medications do not cure incontinence but may help "relax" the bladder. In particular they may increase the interval between voids but tend not to increase the warning time. There are many medications on the market and all are similarly effective. Some may have fewer side effects.

Estrogens may be very helpful for women with both stress and urge incontinence and those with pelvic organ prolapse symptoms. If the patient does not have a uterus, then estrogens may be taken alone.

There are many brands of oral estrogen therapy and all are similarly effective. Estrogen can also be delivered by a skin patch. To directly treat the vaginal tissue, vaginal estrogen cream is available. A newer way to deliver estrogen is by wearing an device in the vagina. This ring is placed in the vagina by your doctor and changed every three months. Estrogen given orally allows for the systemic benefits of estrogen.

If you have a uterus, a hormone called progesterone must be given along with the estrogen. This hormone is commonly given orally. When a uterus is present, bothersome side effects can include vaginal bleeding. This problem can often be treated by changing the dosage. Estrogen is contraindicated in some patients, such as those with a history of breast cancer.

Minimally Invasive Surgery

Neuromodulation (Interstim) may be beneficial in selected patients with symptoms of urgency, frequency, and urge incontinence who have found behavioral and medical treatments ineffective. The technique electrically stimulates the sacral nerves that influence the behavior of the bladder, urinary sphincter and pelvic floor.

The first stage of this treatment is a test stimulation that involves a minimally invasive procedure performed in the office. A stimulation wire is temporarily placed through the skin near one of the bladder nerves and is secured to stay in place for several days. This allows the patient to temporarily experience stimulation and the effect it has on controlling the incontinence and or frequency/ urgency episodes.

If the test stimulation is deemed successful, the second stage is the actual surgical implantation of the Continence Control System, and this performed in the operating room, as an outpatient procedure. To find out more and read patient testimonials you can visit Medtronics' Interstim Website.

Minimally Invasive Procedures for Stress Incontinence

Urethral bulking using collagen

For some patients with activity related (stress) urinary incontinence, the urethral competence can be improved by the injection of a bulking agent into the wall of the urethra. Currently the most favored product for injection is collagen (Contigen), although others are available and in development. The procedure is performed in the clinic, as an outpatient procedure, under local anesthetic. It is virtually painless, and results are known within weeks. The procedure often needs to be repeated at periodic intervals to maintain the effect.

Traditional Surgery

In some cases of intractable urge incontinence, the behavior of the bladder can be modified by the removal of some of the bladder muscle (Detrusor Myectomy), or by the addition of an intestinal 'patch' to the bladder (Enterocystoplasty).

These techniques can be quite successful in carefully selected cases, but they do require a surgical procedure of moderate magnitude (three to seven days of hospitalization), and may result in urinary elimination problems as the price that is paid for being dry.

There is no consensus regarding which is the best procedure to treat stress incontinence.

Operations may be performed vaginally or through an abdominal incision. At Duke, in more than 95 percent of cases, surgeons prefer the vaginal approach. When one considers the very many variables in the patients who have such surgery, it is evident that the results are not really comparable, and that the better operations performed by the better surgeons in the better hospitals carry similar results.

While some women are “cured” by surgery, this may be an unrealistic expectation for some. At Duke, the goal is to achieve dramatic improvement in bladder control. However, many patients may still expect to wear protection on occasion, and particularly during energetic activity.

At Duke, the pubovaginal sling is the preferred procedure in the majority of cases, and it proves to be quite successful in treating incontinence, regardless of severity.

The procedure takes less than one hour to perform and does not require hospital admission in most cases. Most women will require a week of recuperation at home and will return to most prior activities after one month.

There are many variables in the way in which the sling may be performed. The sling material used varies, and while some have a long history of successful use, others are new, and their long term outcome remains unknown.

The Burch colposuspension is a popular operation that is performed abdominally. It brings good results in selected cases.

Unlike the sling, it does not address all types of stress incontinence. In addition, because it is performed through the abdomen, it requires hospitalization and does not facilitate the repair of vaginal prolapse that commonly accompanies incontinence.