The economic, social, and emotional burden of urinary incontinence (UI) profoundly impacts patients' lives, heavily contributes to healthcare spending, and results in millions of office visits, diagnostic studies, and therapeutic interventions each year. UI is the symptomatic complaint regarding the involuntary loss of urine. When assessing UI, it is essential to establish the nature (type), severity, impact on quality of life, duration, and frequency with which the incontinence occurs. Stress urinary incontinence (SUI) is the complaint of involuntary loss of urine with physical exertion (i.e., walking, straining, exercise) or with sneezing/coughing or other activities that cause a rise in intra-abdominal pressure. Urgency urinary incontinence (UUI) is the complaint of involuntary urine loss associated with urgency. Mixed urinary incontinence (MUI) is the complaint of involuntary urine loss associated with urgency and is also associated with effort, physical exertion, sneezing, or coughing.
Prevalence rates for UI in women vary considerably depending on the study, but typically range between 20% and 40%.
Overall, about 50% of reported UI in women is in the form of SUI, with slightly less in the form of MUI, and somewhat less as UUI.
Younger populations tend to have a greater prevalence of SUI overall, and the differences in prevalence of the different forms of UI tend to be less apparent with older populations.
Approximately 10% of women experience UI episodes at least weekly.
Risk Factors for Incontinence
- Age: Aging is clearly demonstrated as a potent risk factor for the development of UI in women. Advancing age is clearly linked with a greater likelihood of incontinence and a shift away from SUI to MUI or UUI.
- Long-term care facilities: Distinct from aging, maintaining residence in a long-term care facility is an independent risk factor for UI. Similarly, severe impairment in activities of daily living has a particularly strong association with UI.
- Pregnancy and postpartum: Prevalence of SUI, in particular, increases during pregnancy and increases with gestational age during pregnancy. Prevalence decreases considerably within 3 months postpartum. Properly performed PFMT has been shown to decrease the likelihood of developing SUI.
- Aspects of delivery: Cesarean section, when compared to vaginal delivery, appears to confer an advantage with regard to the later development of UI. This advantage may be lost with even one vaginal delivery in addition to the cesarean section. Birth weight of the largest child also appears to be positively correlated with an increased risk of later UI. Other factors, such as forceps use and length of delivery, have been proposed as risk factors for UI, although overall the association is less clear.
- Parity: Whereas a single vaginal delivery increases the risk of UI (and SUI in particular), subsequent deliveries further increase this risk. Age at time of delivery also appears to augment this risk, and those women who are younger when first exposed to pregnancy and delivery appear to be at greatest risk.
- Race/ethnicity: An increased prevalence of UI and SUI is noted in Caucasian women when compared to African-American and Asian women. Differences compared to Hispanic populations are less clear. Rates of seeking treatment for UI are similar between African-American and Caucasian women.
- Hormonal therapy: Oral estrogen use with or without progestogen is associated with the development of SUI in middle-aged and older women. Topical estrogen has not been clearly associated with this finding, and it can be used for the treatment of vaginal atrophy and, frequently, associated urinary tract infections.
- Obesity: The presence and severity of UI is positively correlated with obesity. SUI and MUI are most strongly linked to BMI overall. UI related to weight gain may be reversible in most instances, with either surgical treatment or regimented weight-loss programs providing evidence of substantial improvements in UI.
- Smoking: Several compelling studies suggest that symptoms of urinary urgency/frequency, as well as SUI severity (in a surgical cohort), are associated with active smoking. Heavy smokers may be at greatest risk. Data on the impact of smoking cessation are scant.
- Diet: The most convincing data with regard to diet and incontinence concern the link between caffeine (coffee in particular) and urgency incontinence/OAB. No clear association exists with SUI. Carbonated beverages and artificial sweeteners have also been associated with UUI, although less clearly so.
- Medical conditions: Diabetes and depression are the two most common medical conditions frequently associated with UI. For diabetes, the risk appears to be present in both insulin- and noninsulin-dependent forms, although these are more heavily studied in type 2. Depression in the early years or midlife appears to increase the risk of developing UI later in life.
Initial evaluation involves a detailed voiding history, physical exam, and possibly adjunctive studies such as Urodynamics and cystoscopy.
Treatment depends on the specific type of incontinence and may involve physical therapy, behavioral therapy, oral medications, stimulators, or surgical correction. All of these options are available from our experienced Providers.
Eastern urological continence center
At Eastern Urological, we have established an innovative therapeutic environment, state-of-the-art facilities, and urological therapies that are proven highly effective in relief of bladder control problems including urinary urgency and frequency, urinary incontinence (accidental urine leakage) and increased nighttime frequency. We provide the most comprehensive diagnostic and treatment modalities for female and male voiding disorders. Our highly trained continence nurses partner with our physicians to provide our patients customized programs and treatment plans. We have a modern urodynamics suite with the latest technologies, along with a pelvic floor and continence center. Our services include:
- Urodynamics testing
- Pelvic floor therapy/biofeedback and Urgent PC percutaneous nerve stimulation (PTNS)
We provide expertise in both medical and surgical management of problems that both men and women may have with their bladder, and that women may have with their pelvic organs, with a specific focus on the following types of conditions:
- Overactive bladder
- Problems with urination
- Urinary Incontinence
- Vaginal/Pelvic prolapse (cystocele, rectocele, enterocele)
- Recurrent urinary infection (UTI)
- Pelvic Floor Dysfunction
- Vesicovaginal Fistula
- Complications from prior pelvic surgery – mesh erosions
- Bowel dysfunction/fecal incontinence
- Interstitial Cystitis
- Abnormalities of the urethra
- Bladder outlet obstruction
Eastern Urological has been Eastern North Carolina’s premier urology provider for the past 50 years since 1967, when Dr. Walsh began Greenville Urology. In addition to treatments for urinary incontinence, the practice provides comprehensive male, female and pediatric urological care including stone disease, pediatric voiding dysfunction, urological cancer, and sexual dysfunction.
When surgery is an option, your best chances for long term success and recovery is with your initial procedure. It is so important to seek expert evaluation from the start.
A Urodynamics study tells us how your lower urinary tract (bladder and urethra) are performing their job of storing and releasing urine. We are proud to provide comprehensive Urodynamics testing that utilizes state-of-the-art technologies. Our highly skilled nurses and clinicians can administer the testing which will help your doctor determine the best form of treatment for the conditions that present with some of the following conditions:
- Recurrent urinary tract infections
- Painful urination
- Frequent urination
- Sudden, strong urges to urinate
- Problems with emptying your bladder completely
- Urinary incontinence
- Voiding dysfunction
Urodynamics testing focuses on the bladder’s inability to empty steadily and completely. It can also show whether the bladder is having abnormal contractions that cause leakage. Your doctor will want to know whether you have difficulty starting a urine stream, if you have to strain to maintain the stream, whether the stream in interrupted and whether any urine is left in your bladder when you are done voiding. The remaining urine is called the post-void residual.
You will be asked to empty your bladder with some small catheters (pediatric sized) placed in your bladder while you are sitting on a special chair that has a flow device beneath the chair. There is minimal discomfort, and our staff will make every effort to make you comfortable. The nurse will guide you through the entire test answering any questions you may have. The Urodynamics test takes anywhere from 45 min to one hour.
Please read the following instructions so you can prepare for your appointment and allow your doctor to get the best possible information for your care:
Preparing for your urodynamics test
- Please complete the bladder diary you were given when appointment was made. It is more ideal to complete this on two consecutive days prior to your appointment, if possible. If you have an indwelling foley catheter, you are not required to do the bladder diary. If you self-catheterize, please record these volumes, in addition to the voided volumes (if you are able to void).
- Avoid using powders, creams, lotions or ointments on the day of the test.
- Please arrive with a COMFORTABLY FULL BLADDER. We recommend drinking some water on the way to your appointment to fill the bladder. Please try not to empty your bladder while you are in our waiting areas.
- Wear comfortable, easy-to-remove clothing to the test.
- Eat and drink normally, do not skip a meal prior to the test.
- Take your regularly scheduled medications unless your doctor tells you otherwise. No pain medication is necessary for the test.
- Please take your antibiotic pill after the testing is complete and drink plenty of fluids.
We will do a urinalysis at the time of your Urodynamics test; if you have a bladder infection, the testing will have to be rescheduled.
Following the test, you should be able to drive yourself home or to work and continue your day normally.
Pelvic Floor Physical Therapy/Biofeedback
At Eastern Urological, we help you regain confidence and reduce pain from pelvic floor issues. We have established an innovative therapeutic environment, ultra-modern facilities, and urological therapies proven highly effective in relieving bladder control problems including urinary leakage, frequency, and increased nighttime frequency. We also offer successful treatment plans for pelvic pain, interstitial cystitis, sexual discomfort, testicular pain and other conditions. Our nurses are specially trained in pelvic floor dysfunction treatments and certified by the Biofeedback International Alliance. We partner with our physicians to provide customized programs and treatment plans.
Patients are often referred to Eastern Urological Associates with complex pelvic pain and bladder dysfunction. Pediatric patients are often referred for nighttime bedwetting and constipation. We have successfully treated these patients with targeted approaches that may include muscle re-education and measurements, electromyography (EMG), gentle trigger point massage, electrical stimulation, exercise, patient education and PTNS (Percutaneous Tibial Nerve Stimulation)
Common therapies include:
- Home exercise and therapy
- Manual therapy for pelvic floor muscles and surrounding tissues
- Musculoskeletal exam for posture, breathing, flexibility and strength
- Extensive patient education
- Electrical stimulation to desensitize nerves or to contract and relax pelvic floor muscles
- Biofeedback to help you learn to relax and strengthen muscles
- Percutaneous Tibial Nerve Stimulation (PTNS)
Our nurses are highly trained and understand the sensitive nature of these types of medical problems. Our treatments are in private rooms with low lighting. Our goals are to make our practice comfortable and to provide gentle, effective treatment.
Pelvic Organ Prolapse
Pelvic organ prolapse, or POP, refers to “downward descent of the female pelvic organs, including the bladder, uterus, or posthysterectomy vaginal cuff, and the small or large bowel, resulting in protrusion of the vagina, uterus, or both.” Anterior compartment prolapse refers to a weakness of the anterior vaginal wall, often associated with the descent of the bladder (cystocele). Posterior compartment prolapse is a weakness of the posterior vaginal segment often associated with bulging of the rectum into the vagina (rectocele) but can also include the small intestine (enterocele). Rectoceles are usually associated with perineal descent, or weakening of the perineal body. Apical prolapse entails descent of the uterus, or, in the post-hysterectomy patient, the vaginal cuff. Enterocele is a true hernia of the intestines into the vaginal wall; it may be an asymptomatic consequence of apical vaginal prolapse, but can also be associated with significant defecatory dysfunction when they are located between the posterior vagina and rectum, even when the apex is well supported. Uterine procidentia refers to total vaginal eversion with stage IV uterine prolapse. The sensation of a vaginal bulge remains the only symptom that is strongly associated with prolapse at or below the hymenal ring.
The prevalence of symptomatic prolapse ranges from 4% to 12%, although asymptomatic prolapse is present in the majority of adult women.
Both the incidence and prevalence of POP increase with age, as do rates of surgery for POP.
Parity is associated with an increased risk for POP later in life. Current evidence also suggests that an increasing number of childbirths increases the risk of POP, although the rate of increase slows after the first two deliveries.
Obesity is not only a risk factor for the development of POP, but it is associated with early recurrence of anterior vaginal wall prolapse after anterior colporrhaphy.
Hysterectomy and other pelvic surgery may increase the risk for POP, and hysterectomy for POP is a strong predictor of secondary pelvic floor surgery.
Cesarean delivery is associated with a decreased risk for subsequent pelvic floor morbidity in comparison to giving vaginal birth, but whether cesarean delivery prevents the development of POP remains uncertain.
POP is more common in Caucasian and Hispanic women when compared with African-Americans
More than 40% of women with SUI will have a significant cystocele.
Occult SUI is urethral sphincteric incompetence masked by the presence of high-stage anterior POP. Failure to address occult SUI at the time of surgery for POP may lead to more severely symptomatic SUI postoperatively.
POP may be associated with defecatory dysfunction and fecal incontinence. Disorders of defecation, including fecal incontinence and urgency, should be carefully evaluated before considering POP surgery.
Sexual dysfunction is often associated with both POP and UI. Treatment of these conditions may ameliorate symptoms of sexual dysfunction. Still, dyspareunia has been associated with some types of POP repair, and, as such, changes in sexual function are an important aspect of preoperative counseling.
The hallmark is evaluation. Every prolapse condition and its severity can be accurately diagnosed by a thorough pelvic exam. Cystoscopy may be employed.
Treatment can involve physical therapy, pessary support, or surgical correction.
The urine is normally free of bacteria. Bacteriuria indicates the presence of bacteria in the urine. Bacteriuria can be symptomatic or asymptomatic. Pyuria is the presence of white blood cells in the urine and, when seen in conjunction with bacteriuria, is indicative of a true urinary tract infection. Asymptomatic bacteriuria (ASB) is the isolation of bacteria from the urine in significant quantities consistent with infection, but without the local or systemic genitourinary signs or symptoms. The presence of ASB in the absence of symptoms or pyuria is often referred to as colonization. Cystitis refers to the symptoms of dysuria, urgency, frequency, and/or suprapubic pain. Infection (bacterial cystitis is only one of many causes of this symptomatology, but one which is generally easy to prove or disprove with a simple urine culture.
Urinary tract infections (UTIs) can be classified as to their site of origin. Cystitis refers to the nonspecific clinical syndrome of dysuria, urinary frequency, urgency, and suprapubic pressure. Fever, chills, and flank pain can indicate the presence of pyelonephritis, an interstitial inflammation caused by bacterial infection of the renal parenchyma. Surprisingly, based on symptoms, it can be remarkably difficult to differentiate infection involving the upper tracts from bacteriuria confined to the bladder.
UTIs can also be classified in terms of the anatomic or functional status of the urinary tract and the overall health of the patient. An uncomplicated infection indicates it is occurring in an otherwise normal urinary tract in a healthy individual. A complicated infection is one occurring in a functionally or structurally abnormal urinary tract, in a host with a compromised immune system, or an infection with bacteria of increased virulence or antimicrobial resistance
UTIs are considered to be the most common bacterial infection. They are generally associated with minimal morbidity except among specific subpopulations. 11% of women report having had a UTI during any given year, and more than half of all women have had at least one UTI in their lifetime. One in three women have a UTI before the age of 24 years. This contrasts with men, in whom infection is uncommon until after the age of 50, when the problem of an enlarged prostate and outlet obstruction may occur. Between 3.5 and 7 million office visits a year are the result of UTI, and direct costs exceed $1.6 billion. It is difficult to assess the true incidence of UTI, because urine cultures are not often done in the outpatient setting, and symptoms are variable.
Initial evaluation involves a detailed voiding and medical history to assess for the presence of true bacterial infections and risk factors for recurring infections. Further workup would include a thorough pelvic exam, imaging, and cystoscopy.
The majority of women with recurrent UTIs are anatomically normal and are not found on workup to have a source for recurring infections. These women may have hormonal disturbances, abnormal hygiene, or be genetically predisposed to more infections. Most women require conservative treatment such as frequent voiding, increased hydration, probiotic use, and estrogen supplementation if necessary. Some women require post-intercourse or chronic antibiotics.
Diminished sexual function is associated with impaired quality of life and well-being (Laumann et al, 1999; Davison et al, 2009). Many urologists underestimate the prevalence of female sexual concerns and do not routinely make the assessment of sexual wellness a part of their practice (Bekker et al, 2009), despite evidence that many women in urologic clinics have sexual issues (Elsamra et al, 2010).
Relatively few women discuss sexual issues with their provider.
Estrogens are the primary “female” sex steroids, and estradiol (E) is the most significant of these. Estrogens maintain female genital tissue integrity and thickness. With menopause, there is a marked decline in genital sensitivity, vaginal thickness, collagen content, baseline moisture, and acidity. Menopausal women who start E hormone replacement (vaginal or systemic) typically report increased sexual interest and enjoyment, less sexual pain, and greater orgasmic potential.
A complete history (medical, sexual, partner, etc.) and thorough physical examination (particularly of the genitals) is fundamental to evaluation of sexual wellness in women. Many patients are reticent to ask questions about sex; providers should initiate conversations about sexuality. Questionnaires and adjunctive testing are of benefit in some cases but do not replace history and physical examination.
A woman's sexuality may be affected by medical, sociocultural, and life factors.
Sensitivity to the sexual wellness needs of minority populations and/or women who have suffered trauma is an essential component of professionalism.
Female sexual dysfunction (FSD) is an umbrella term that encompasses distressing situations that interfere with a woman's ability to enjoy a satisfying sexual life. FSD is not truly a diagnosis, but rather an umbrella term that may encompass one or more distressing situations that interfere with a woman's ability to enjoy a satisfying sexual life. FSD is a controversial topic, but one of great importance to many women. A variety of medical and psychosocial issues have been clearly linked to risk of sexual concerns in women. Classification of female sexual disorders remains controversial; however, most classification schemes recognize disorders of sexual desire/interest, arousal, orgasm, and sexual pain.
The etiology of sexual concerns in women is often multifactorial. There is substantial overlap between sexual concerns in women. There are few approved pharmacotherapies for female sexual concerns; there are a number of treatments, but many of these are off-label. A multidisciplinary approach to sexual concerns with sensitivity to the woman's unique situation is most likely to be effective. Psychosocial support is critical in the management of any sexual concern.