Urinary Incontinence

How does incontinence occur?

As incontinence or bladder weakness, we define an involuntary discharge of urine from the bladder. There are two main types of urinary incontinence: stress incontinence in which urine loss occurs during exercise, coughing, sneezing, or sports, and urge incontinence, in which, because of an over activity of the bladder muscle, urine is discharged involuntarily. The causes of incontinence are diverse. In women, it is often caused by a weakening of the pelvic floor muscles due to pregnancy or obesity. A hormone deficiency caused by the menopause or an age-related sphincter weakness may favor a stress incontinence. Inflammation of the bladder and spinal cord or nerve disorders can cause the so-called urge incontinence, which might also occur as a result of accidents or operations.

How many women are affected?

A major problem with the urinary incontinence that it is not still not talked today and that it remains a taboo.  This is extremely stressful for the affected person. The disease occurs more frequently in the Western world than do for example cardiovascular diseases. According to the Society for Help of Incontinence (GIH), in Germany about 4 to 5 million persons need to be treated for urinary or fecal incontinence. The real figure is probably much higher because many people do not go to the doctor, not least because of shame.

Are only older women affected?

Incontinence can affect people at all ages, ranging from children with bedwetting to the elderly with age-related sphincter weakness. With the increasing life expectancy in developed countries, the problem of urinary incontinence in old age increases tremendously. While only 3% of men under the age of 65 suffer from incontinence, in persons over 65, every tenths person suffers from incontinence. In persons above the age of 80, it is one-third of the population.

What can we do about it?

The treatments of incontinence are as varied as are their causes. The first step is to see an urologist or gynecologist to clarify the cause.  Especially in the case of urge incontinence the tangible causes ((e.g., bladder infection) must first be eliminated.  If the urge symptoms persist despite of the treatment or the cause cannot be determined, bladder training or drug treatment will become an option. These methods calm the bladder sphincter and eliminate the urge. Through targeted pelvic floor training, supported by electrical stimulation and biofeedback, an amazing success can be achieved. Incontinence can furthermore be reduced by locally administered estrogen.

In many cases, especially in the case of severe stress incontinence, surgical measures are the only remedy. The interplay between bladder and sphincter muscle is optimized to make the patient permanently "dry" again through a variety of surgical techniques. Examples to be mentioned are the operative lifting of the bladder with collagen injections or raising the urethra using urethral tapes.

Do pelvic floor exercises help in all cases?

Pelvic floor exercises help especially in low to moderate stress incontinence. If performed consistently, they can achieve a success rate of up to 30%. The pelvic floor exercises can be extended by an electrical stimulation or biofeedback exercises.

What are good exercises and how often you have to do them?

At the start of a pelvic floor muscle training a professional trained physical therapist (e.g. VHS) should provide appropriate instructions. Once the patient has developed an understanding and a routine, the exercises should be continued at home consistently several times a day. This is the only way to successfully apply the pelvic floor exercises.

Can specific medications or herbal teas etc. really help with an irritable bladder?

Symptoms of an irritable bladder can be relieved with herbal medicines (e.g., pumpkin seed oil) after exclusion of a physical cause. In the case of more severe urge incontinence, pharmaceutical drugs reducing the bladder muscle activity are considered to be more reliably. These medicines may only be used after medical evaluation and by prescription.

Do you have to take such medication permanently or only for a certain period?

In some women, the symptoms are temporary urge complaints that can be treated well with periodically taking medication. However, there are also many cases in which the drug treatment must be continued permanently to achieve freedom from symptoms.

Are there new surgical methods can control the problem?

There are a number of new approaches in the surgical treatment of urinary incontinence. Especially the urethral tapes have been developed within a very short time as a standard therapy. Their advantage is the lack of an abdominal incision since the urethral tapes can be inserted minimally invasive via three small incisions. Furthermore, this procedure can usually be carried out with only minor outpatient surgical risks such as the insertion of a bladder catheter. Finally, the long-term success of this method (urethral tape) is very encouraging: the majority of treated patients are permanently free from incontinence after surgery.

For how long is this surgical procedure successful?

In approximately 85-90% of the women, urethral tapes are able to permanently eliminate the incontinence. These patients then require no further treatment. For the remaining 10-15% of the women, a surgical bladder boost will later become necessary.  

 Which therapies are paid for by the health insurance?

Treatment options mentioned so far are all paid either as an outpatient or inpatient treatment by health insurances in Germany.

If control no longer works, are diapers or catheters the only alternatives?

After exhausting the previously mentioned conservative and surgical treatment options, a last resort is the implantation of an artificial. Especially after radical surgery on the prostate, men can be permanently “dry” again.  However, this complex procedure should only be performed in experienced clinics. An artificial sphincter will be implanted around the urethra, which allows for controlling without urine loss by means of a drain valve from the outside.

Is there hope for people who had their bladder removed, due to a tumor?

In all cases in which the bladder needs to be removed due to a tumor or other disease, a replacement bladder for urine drainage is necessary. This is usually modeled by a section taken from the intestine. Types of replacement bladders are here wet bladders that relieve the urine through an opening in the skin (Stoma) into a urine bag. Younger patients that are more active prefer the dry replacement bladder (e.g. continent bladder). For these dry bladders, a section of the intestine is modeled according to a real bladder The dry (i.e. continents) blowing straight replacement in young and active patients have prevailed in recent years. In this case, a bubble is formed from a spare portion of the intestine that is connected either to the urethra or to a dry skin stoma. In both cases, the patient has the possibility to control the emptying of the bladder and is therefore “dry”. Further developments in that area are on the way. In 2001 for the first time an artificial bladder was introduced that consists of so-called biocompatible materials (material from the body rather than foreign materials), which can also controlled by electric control outside.

Are there data about the reliability?

This development is still in a very early state. However, there is data on the mechanical reliability.

How complicated is the surgery and how long can you live with an artificial bladder until it needs to be replaced?

Again, at this time very little can be reported.  However, the cost of the operation should not be higher than an intestinal bladder substitute.

When can patients in Germany expect the approval of this device?

Until patients can actually benefit from this device, some years will pass. It is hoped that application in humans will be realized in 2006.

How are patients cared for after surgery?

Currently the available intestinal replacement bladders offer an excellent opportunity to provide adequately for patients after a bladder removal.  The majority of the surveyed patients are very satisfied with the results after such a surgery. It is however crucial, to discuss the implantation of the bladder before surgery with the treating physician and to decide about what replacement bladder to be selected to achieve the most satisfactory results.