More than 25 percent of women over the age of 40 are suffering from urinary incontinence and or pelvic organ prolapse.

Beyond 65, more than half of all women suffer from these problems. Most women are reluctant to talk about these problems, choosing instead to suffer in silence.

Urinary incontinence is the involuntary loss of urine. This can be very embarrassing – so embarrassing that many women would rather wear disposable panty liners or pads than seek help from a medical specialist.

With rare exception, a Urogynecologist can treat these problems without surgery. When surgery is required, most can be completed in less than 20 minutes in an outpatient procedure and require no abdominal incisions.

A Urogynecologist is a surgeon who specializes in the treatment of frequency of urination, incontinence, and prolapse. Unfortunately, there are very few full-time Urogynecologists throughout the country.

When you live in a communitiy that does not have a Urogynecologist, a General Gynecologist or Urologist may be able to assist you. You will need to be actively involved in the decision-making-processes. To be prepared for this, it's critical that you understand the disorder and treatment options.

Overactive Bladder
Frequency of urination and loss of urine associated with the feeling of urgency may be associated with a urinary tract infection. However, in the absence of infection, these symptoms are most commonly secondary to an overactive bladder.

As children, we are taught to suppress the bladder reflex and hold our urine. Young children are taught to fight the urge to urinate. This soon becomes a subconscious process and the child becomes potty-trained.

As a woman ages, this subconscious suppression of the bladder reflex is often lost. All of a sudden, a woman may start to have frequency of urination, urgency, and may not be able to get to the bathroom quickly enough.

Occasionally, this loss of control may be associated with a serious health disorder such as Multiple Sclerosis, Parkinson's Disease, back or disc disease, diabetes or stroke. For the vast majority of women, however, there will be no identifiable cause for this disorder, medically known as “Detrussor Instability” or “Hyperreflexia.”

A Urogynecologist will perform a comprehensive assessment to determine a necessary treatment plan. This evaluation should include a pelvic examination to measure pelvic organ prolapse, movement of the urethra and how well the bladder is being emptied. The doctor may also perform a Cystoscopy to look in the bladder; and Urodynamic testing, which involves placing water in the bladder to record pressure measurements and nerve-muscle function.

Overactive Bladder Treatment Options

• Drug Therapy can be very effective at suppressing the overactive bladder. Unfortunately, overactive bladder medications are often associated with common side effects such as dry mouth and constipation, and in some cases may even cause memory impairment. There is evidence, however, that the drugs Enablex® and Sanctura® may cause less of these side effects.

• Tibial Nerve Stimulation, a cross between acupuncture and electrical stimulation therapy, has provided considerable relief for many women and has proved especially helpful in reducing nighttime urination. After a tiny acupuncture-like needle is placed just above the ankle, a small computer is used to send an impulse up the nerves of the leg to the nerves of the bladder.

• Sacral Nerve Stimulation utilizes an implantable device and wire to give full-time stimulation to the nerves of the bladder and pelvis. We hold this as a last resort option.

• Botox® Injections. Although not approved by the Food and Drug Administration for this use, thousands of women have successfully been treated with Botox® injections to the bladder without any complications. Greater than 75 percent of women who do not respond to other treatments will respond to Botox®. Repeat injections are typically performed every four to six months.

• Bladder Retraining and Physiotherapy involves behavioral exercises that help women regain subconscious control over the bladder reflex.

Stress Incontinence
In this disorder, movement of the urethra or weakness of the urethra leads to the loss of urine. Dripping can occur with coughing, laughing, sneezing, straining, jumping and exercising. However, these same activities also may excite an overactive bladder imitating Stress Incontinence. This is why it is very important to have a complete assessment before considering surgery to treat Stress Incontinence.

Without such assessment, a surgeon may incorrectly operate on a patient with an overactive bladder. This often makes the problem worse. A Urogynecologist will be able to help distinguish between the two disorders.

The assessment of Stress Incontinence is identical to that utilized for Overactive Bladder symptoms.

Stress Incontinence Treatment Options

• Surgery. The standard of care in the surgical treatment of Stress Incontinence is the “Sling.” This outpatient surgery involves placing a small sling of synthetic material underneath the urethra. The procedure usually can be completed in less than 20 minutes. Success rates vary among surgeons, but generally approach 90 percent.

  When considering surgery, it is important to make sure your surgeon has ample experience. It is reasonable to chose a surgeon who performs at least 50 sling procedures each year.

• Injection Procedures. When weakness of the urethra – rather than movement of the urethra – causes Stress Incontinence, as many as 90 percent of women can achieve dryness with a simple injection of collagen. Most surgeons can perform this procedure in their office in about five minutes or less. The result may last as long as two years.

• Physiotherapy. This method utilizes a physical therapist or similar expert to coach the patient in strengthening the muscles around the urethra.

• Pessary. Small rings, similar in shape to a diaphragm, may be worn inside the vagina to help support the urethra. This method is generally successful in only about 40 to 60 percent of women. When beneficial, a pessary may be left in place for up to three months.

• Drug Therapy. This only works for cases of mild Stress Incontinence. Drugs for treating Stress Incontinence are similar to those used for the common cold. One example is Pseudophed®.

Pelvic Organ Prolapse
Pelvic Organ Prolapse is the loss of pelvic organ support leading to bulging of the bladder, uterus, rectum or vagina. This condition often requires surgery. If possible, seek the care of a Urogynecologist with extensive experience. To achieve a long lasting cure, this reconstructive surgery often requires the insertion of synthetic materials, referred to as Meshes. Most of these surgeries can be performed without an abdominal incision.

Speak Up
It's time to discuss your problem. If there is a full-time Urogynecologist in your community, arrange for a meeting to discuss your concerns and learn about treatment options. If one is not available, try to find a Gynecologist or Urologist with ample experience.

Speak Out
Overactive Bladder and Stress Incontinence often travel together. Don't let anyone operate on you, even if you have Stress Incontinence symptoms, until you have tried all reasonable treatments for Overactive Bladder symptoms.

Ralph Zipper, M.D., is the Director of Urogynecology and Pelvic Reconstructive Surgery at Urogynecology Associates in Melbourne. For more information, call (321) 674-2114.