• Treatments for Urge Incontinence

    Dietary Modification

    Certain foods and beverages have been shown to contribute to urgency, frequency or urge incontinence. Caffeine is a big offender! Many people are unaware of how much caffeine they ingest in a single day. They often just remember the one or two cups of coffee that they drink in the morning. What they forget is the cola drink with lunch, the cup of tea in the afternoon, and the coffee after dinner. Caffeine is found in varying degrees in all of these products, and because it is a bladder irritant, it causes more urgency to void. In addition, caffeine is also a diuretic, meaning that for every cup of caffeinated beverage you drink, you will void more than that amount. Many people find that reducing or eliminating their caffeine intake alleviates their symptoms of urgency and frequency.

    An example of an appropriate fluid regiment is drinking 16 ounces of fluid with each meal and eight ounces of fluid between meals, but nothing after dinner. Half of the fluid intake should be water.

    Timed Voiding

    This method involves urinating on a set schedule during the day, regardless of the need or urge to void, in an attempt to preempt urge incontinence episodes before they occur. This form of behavioral therapy is useful in older adults or other individuals for whom bladder retraining is not a option, and does not involve attempting to increase the time interval between urinations.

    Bladder Retraining

    Many people with urgency, frequency and urge incontinence can be helped through the use of bladder retraining. Bladder retraining involves urinating on a set schedule during the day. You are going to the bathroom by the clock only, not your urge to void. For example, if you normally go to the bathroom every hour or less during the day, you should start this technique by voiding every hour. Use the timer from your kitchen, or a pillbox timer that you can buy at the local pharmacy. You will need to do this for a week or so. Once this becomes easier, slowly increase the interval of time by 15 or 20 minutes each week or two until you are up to the normal interval of 3 to 4 hours during the day. The trick to bladder retraining is going into the bathroom to void according to the set interval even when you do not feel the need to void.

    Urge Suppression

    You get the urge to urinate as your bladder signals your brain by sending a message through your spinal cord. This is just a message about the filling status of your bladder. It is not a direct order to urinate. Believe it or not, you can, and in fact should, wait to void. The worst possible time to try to get to the bathroom "in time" is when you really have to go. A lot of people will leak, especially the closer that they get to the bathroom. So what do you do? First of all sit down and take a few slow deep breaths. If you know how to tighten your pelvic floor (Kegels) do this. Tighten and relax your pelvic floor muscle in rapid succession until the urge subsides. This will help to kick in a natural reflex that quiets down your bladder. If you can, distract yourself from the urge by doing some mental task to get your brain onto some other activity. If you are reading an interesting novel, finish the next chapter. Think of what gifts you are going to get all of your relatives for their birthdays or the winter holidays. Pick a very high number and start counting backwards by sevens. 

    Biofeedback

    Biofeedback, or EMG (electromyographic study of muscle and nerves), is a method of displaying information about what is going on in the body.

    An example of this is what happens when a person steps on a scale. The number displayed tells the person the weight of his or her body. Another example of biofeedback is when a person uses a thermometer to check his or her temperature. The reading on the thermometer gives feedback to the person about whether or not he or she has a fever.

    Certain people can utilize biofeedback to rehabilitate their pelvic floor muscle. People with a diagnosis of urinary incontinence or voiding dysfunction can benefit from this treatment.

    The pelvic floor muscle is a type of hammock that supports the bladder, rectum and uterus. When it is not exercised, the muscle weakens and is not effective in holding urine back in the bladder. On the other hand, if the muscle has too much tone and is unable to relax, the person may have a difficult time urinating. After exercising this muscle using proper technique, the muscle regains its strength and ability to relax so the person's symptoms should lessen.

    Computerized equipment is used with pelvic floor muscle biofeedback therapy. It provides visual and auditory cues as to what the pelvic floor muscles are doing at various stages of therapy. Muscles give off electric signals that the computer monitor displays. A special sensor is used to pick up these signals. This sensor is either a small vaginal or rectal probe. There is no discomfort in having this sensor used for any part of the therapy session. Another sensor, a small surface electrode or sticker, is placed on the abdomen to pick up accessory muscle use during the therapy. It is very common for people beginning to learn how to contract their pelvic floor muscle to actually bear down with their abdominal muscles by mistake. The biofeedback helps the person see what he or she is doing while exercising, which helps reinforce learning and ensure the correct technique is being used.

    Biofeedback Therapy

    If, in conjunction with your physician, you decide to proceed with this therapy, an initial appointment will be scheduled for you.

    During this first appointment, your bladder history will be completed and reviewed, a care plan will be developed and any questions you may have will be answered. You will also be given a lot of written information about what is discussed during the visit.

    Biofeedback appointments are usually scheduled on a weekly basis, especially for the first few weeks. After this, sessions are scheduled based on the progress of the patient for the remainder of the treatment. The length of a session is typically forty-five minutes to one hour. Patient motivation is very important to the success of this therapy. Together with the nurse therapist, you will work to achieve goals you have set forth.

    It is critical to your progress and success that you practice the exercises four times a day at home, according to your prescribed program. These exercises take only a few minutes per session.

    Pretty soon you will be able to incorporate the exercises into your daily routine and do them anywhere. When done correctly, no one will be able to tell you are doing the exercises. Like any exercise though, you have to keep doing it to maintain the strength of the muscle. Otherwise, it weakens again and your symptoms may reoccur.

    During the course of the treatment, you will be asked to complete voiding diaries for a few days between each appointment. These provide valuable information about your urinary status, including dietary intake and frequency of voiding and incontinence episodes. People usually start to see progress after the first three sessions. The number of sessions varies with each person. Typically, you should plan on at least six to eight sessions.

    Cost of Therapy

    While some insurance plans cover the cost of biofeedback completely, some may only cover part of the charge. You should contact your insurer for information about your coverage. If you have any questions regarding the cost of the therapy, please contact the Financial Office at Lahey Clinic at 781-744-8770.

    Pelvic Floor Stimulation

    Pelvic floor stimulation (PFS) is often done in conjunction with biofeedback therapy. PFS may be used for stress urinary incontinence, urge incontinence and/or urinary frequency. The principle behind PFS for stress incontinence is to strengthen the pelvic floor muscles to help the urethra (or tube that transports urine out of the body) stay closed during certain activities. With urgency or urge incontinence, the stimulation helps relax the muscles of the bladder and pelvic floor to help lessen unwanted bladder contractions and resulting leakage.

    For PFS, a small vaginal or rectal probe is inserted. The probe is connected to a small battery operated PFS unit that delivers electrical stimulation to the muscles of the pelvic floor for 15 minutes. This stimulation is painless and barely noticeable to patients. Patients with urgency or frequency of urination may notice a marked decrease in their symptoms during the day following therapy. In this case, the patient may obtain a PFS unit for home use.

    For the home setting, the patient uses the stimulator unit twice daily for 15 minutes, over a period of several weeks, until overall symptoms decrease. Then, they may proceed to use the stimulator only once daily or once every other day, and so forth. The patient is the best judge of how often to use the PFS unit based on his or her symptoms. Some insurance plans will cover the cost of a PFS unit with an approximate retail price of $600. If you have any questions about coverage, please check with your insurance carrier.

    Medications

    There are a variety of medications available to treat both urge incontinence and overflow incontinence. Patients with urge incontinence may be treated with medications that help decrease unwanted bladder contractions and the amount of leakage, while increasing the warning time for the patient to get to the bathroom. Common medications are Imipramine, Levbid, Probanthine, Ditropan XL and Detrol.

    Common side effects with these medications are varying degrees of dry mouth and constipation. Work with your physician to determine which medication is best for you. These medications are not suitable for individuals with narrow angle glaucoma.

    Estrogen may also be used in a vaginal cream or insert. Estrogen works to increase blood supply to the vaginal and urethral tissue, thereby making the urethra more watertight. This medication also helps to decrease the incidence of bladder infections and vaginal dryness and discomfort. Women who have had breast cancer usually cannot take estrogen.

    Sacral Nerve Stimulation

    Sacral nerve stimulation (SNS) is a relatively new surgical procedure for men and women used to treat urge incontinence that is unresponsive to other treatments. SNS is a two-phase treatment therapy. Lahey Clinic is the first site in New England to offer surgical implantation of this therapy.

    By stimulating the sacral nerve, the signals that regulate the bladder are better in control, which leads to decreased urgency. This procedure involves two visits to the operating room. On the first visit, a lead is placed under the skin and attached to the third sacral nerve. The lead exits out through the skin and attaches to a control box the size of a pager. The patient is then instructed to keep track of his or her voiding for two weeks. If there is 50 percent or greater improvement in the patient's urinary symptoms, during his or her second visit to the operating room, a small, implantable pulse generator (slightly larger than a nine-volt battery) is placed in one of the buttocks cheeks. If, on the other hand, the patient's urinary symptoms did not improve by 50 percent or greater, the lead is removed during the second visit.

    For the testing portion, a small wire is passed into the lower back to the area of the sacral nerve. Once in place, the wire is taped to the person's back and connected to a small portable stimulator unit that is about the size of a pager or small Walkman. The person then keeps a log of their urinary symptoms and voiding episodes to determine if the treatment is effective. After discussion with the physician, the decision to implant the device is agreed upon.

    The surgical procedure for implant of the Interstim® SNS therapy takes two to four hours and requires two or three incisions. One incision is in the lower back, and the other one or two are located where the implantable pulse generator (IPG) is placed. The patient stays overnight in the hospital following surgery, and the device is programmed one week later. The patients use a handheld programmer to increase or decrease the level of stimulation. The stimulation feels like a pulsing or tingling in the rectum or vagina. The patient also has the ability to turn the device on or off, depending on the situation (i.e., operating heavy machinery). This procedure is totally reversible, should the patient choose to have the device removed at a later date.

    Patient recovery from surgery takes one to two weeks. Patients are encouraged to stay home from work for a week to 10 days and to avoid lifting heavy objects (greater than 10 pounds). This allows the lead wires to heal in place without inadvertently moving. To check the status of the stimulator, patients must follow-up with the Continence Center and their physician(s).