Mixed Incontinence in Women

Signs & symptoms

Women with mixed incontinence experience symptoms of both urge incontinence and stress incontinence. Usually, one type is more bothersome than the other. For example, a woman may mostly suffer from stress incontinence and only rarely be unable to reach the toilet in time.

Symptoms of urge incontinence include:

• Loss of urine associated with sudden, strong urge to urinate

Symptoms of stress incontinence include:

• Leakage of urine when performing activities such as coughing, sneezing, laughing or exercise

Diagnosis

If you have incontinence, keeping a urinary diary — a record of your daily urination, urine accidents and fluid intake — can help us make the proper diagnosis and decide on the appropriate treatment.

At your first visit to UCSF, your provider will ask questions about your general health, your history of incontinence, past surgeries, illnesses and medications you are taking. The provider will also perform a physical examination, including a pelvic exam. In addition, a urine sample will be tested. If your problem is complex, additional tests may be done at a later visit.

Physical Exam Assessment

Depending on the particular details of your medical history, your doctor may proceed to any or all of the following physical evaluations.

• Neurologic examination to evaluate strength, sensation and reflexes in your legs.
• Pelvic exam to assess whether you have any pelvic relaxation or prolapse.
• Pelvic floor assessment, in which your provider will evaluate the strength of your pelvic floor muscles, particularly your ability to contract and relax the appropriate muscle group.
• Postvoid residual urine assessment to measure how much urine remains in your bladder within 15 minutes of voiding. This test offers an estimation of your bladder's ability to efficiently "empty the tank." The same urine sample may be analyzed for other factors, such as blood, sugar, crystals or signs of infection. Such an evaluation can be accomplished with an office urine dipstick or the hospital laboratory's microscopic urinalysis.
• Urine culture if a urine dipstick or urinalysis suggests signs of acute infection. The culture is sent to the microbiology lab and, in approximately 24 to 48 hours, bacterial growth can be detected and the specific strain identified.
• Cough stress test, in which your bladder is filled with water, and you are asked to cough or strain in the same manner that would cause you to leak urine. This test can be performed in the office or incorporated into more elaborate urodynamics testing.
• A urinary diary provides details about your fluid intake and urine output, which can be crucial to making the right diagnosis. Because this is not typically the sort of information we take notice of in our daily lives, your provider will give you a urinary diary and a measuring receptacle. You may be asked to carefully record the time and amount of any fluids you drink and the urine you void over a complete 24-hour period. You may be asked to repeat this 24-hour diary for three to five days. This allows us to notice patterns that might be important to planning your treatment.

Additional Diagnostic Tests

In some cases, the doctor may decide to pursue further diagnostic testing. Below is a list of some scenarios that are more complex and merit further testing:

• Uncertain diagnosis for bladder problems
• Inability to develop successful treatment plan
• Unimproved symptoms or failed treatment
• Patient is considering surgery
• Failed surgical procedure
• Prescence of other conditions, such as hematuria (blood in urine) without infection, recurrent urinary tract infections, elevated postvoid residual urine volume, neurologic condition

Urodynamic Studies

The purpose of these studies is to evaluate the anatomy and function of the bladder and urethra, reproducing your symptoms.

• Cystometrogram During this test, catheters are placed in your bladder and vagina or rectum, and your bladder is filled with fluid via the catheter. The test is used to determine your perception of water filling the bladder, any urgency to urinate, uncontrollable bladder contractions, the volume at which your bladder cannot comfortably hold any more, and the pressures within your bladder during the fluid storage process.
• Stress testing You may be asked to perform a number of maneuvers such as coughing, changing positions, or bouncing on your heel with a catheter in place in an effort to reproduce any symptoms of incontinence.
• Urethral pressure profile A catheter in your urethra is manipulated to measure urethral function.
• Uroflometry During urination, a specially devised receptacle will measure the varying rate of urine flow, as well as duration of urination.
• Pressure voiding study This test identifies abnormal voiding patterns or urine obstruction.

Cystoscopy

In cystoscopy, a slender camera is inserted via the urethra into the bladder, enabling the doctor to view the interior anatomy of your bladder and urethra in great detail. It is typically an outpatient procedure performed for the following symptoms or situations:

• Blood or pus in urine with no bacteria present
• Bladder infections that are unusually difficult to treat
• New onset voiding irritation
• New onset bladder pain
• Suspected foreign body in the bladder
• Urodynamics tests fail to duplicate incontinence symptoms

Radiologic tests

• Intravenous pyelogram (IVP) This test involves administering intravenous (IV) dye to your bloodstream and taking X-rays of the entire urinary tract while the kidneys are processing the injected dye. This test cannot be performed if you have an allergy to IV contrast dye or abnormal kidney function.
• CT scan A CT scan of the abdomen and pelvis may be performed, in which an X-ray machine takes a rapid sequence of two-dimensional, thin cross-sections of the body in the area of interest. This exam can be performed with or without contrast dye; mostly, this depends on what your doctor is looking for. The X-rays pictures provide great anatomic detail of most of the internal organs.
• Ultrasound Unlike the previous two tests, an ultrasound does not involve X-rays. It utilizes a skin probe that directs sound waves to bounce off the body's internal organs, producing an anatomic picture. It can be a very useful screening tool for a number of the above indications.

Treatments

Treatment for mixed incontinence can include combinations of therapies prescribed for either stress or urge related incontinence. These treatments are described below.

Behavioral Treatments

Behavioral treatments are simple, self-directed, have no side effects and are often used in conjunction with other treatment options. They have proven effective for many women and work well for certain types of incontinence. They include:

• Bladder Training The goals of bladder training are to increase the intervals between emptying your bladder and the amount of fluid your bladder can hold. This training can help diminish the sense of urgency and leakage. Bladder training requires adhering to a fixed voiding schedule, whether or not you feel an urge to urinate. If you feel the urge to urinate before the assigned interval, you should use urge suppression techniques, such as relaxation and Kegel exercises. As success is achieved, the interval is lengthened in 15- to 30-minute increments until you can remain comfortable for three or four hours. This goal can be adjusted to suit each woman's needs and desires.
• Pelvic muscle exercises Pelvic muscle exercises, also known as Kegels, are an essential part of improving incontinence and preventing it from worsening. They can also help you suppress the urge to urinate. The exercises strengthen and tone the muscles that support the pelvic organs. These muscles contract and relax under your command to control the opening and closing of the bladder. Achieving results requires commitment and regular exercise. Correct technique is also very important.
• Biofeedback Biofeedback has been proven effective in numerous research studies for the treatment of urinary incontinence. It can help you learn to control and strengthen your pelvic floor muscles, which play an important role in bladder control. Because you cannot see the pelvic floor muscles, you may find it difficult to locate them or to determine if you're doing pelvic muscle exercises correctly. Biofeedback therapy uses computer graphs and audible tones to show you the muscles you are exercising. It also allows the therapist to measure your muscle strength and individualize your exercise program.
• Urge Suppression Urge suppression is a way to help control the sudden urge to urinate, so that going to the bathroom is not an emergency. Running to the bathroom is the worst thing you can do, as it increases bladder irritability and interferes with your ability to concentrate on controlling your bladder.

Electrical Stimulation

Pelvic floor electrical stimulation uses low-grade electrical current to stimulate weak or inactive pelvic muscles to contract. A tampon-like sensor that connects to a handheld adjustable device is inserted in the vagina. The patient then increases the current to the level of a comfortable tingle. Regular electrical stimulation sessions can supplement or augment your pelvic muscle exercise regime. Units are available for home use and may be covered by medicare or insurers.

Percutaneous Tibial Nerve Stimulation (PTNS)

Normal voiding depends not only on the normal function of organs and muscles, but also on nerves that deliver appropriate signals regarding urination. In urge incontinence, the nerves regulating the bladder can become hyper-reactive, sending strong signals to empty before the bladder is full. Nerve stimulation therapies "jam" the pathways that transmit these abnormal messages.

In PTNS, a small acupuncture needle is placed in the ankle along the tibial nerve. A handheld device connects to the needle to deliver mild electrical impulses to the nerve. These travel up the tibial nerve to the sacral nerve plexus, which regulates the bladder. PTNS sessions are painless, last 30 minutes and are repeated weekly for 12 weeks. All sessions take place in a medical office.

Sacral Neuromodulation Therapy (Interstim)

Sacral neuromodulation therapy also uses electrical impulses applied directly to the sacral nerves. Wires are threaded through openings in the pelvic bones along the sacral nerves. This is done in an operating room using local anesthesia. The wires are attached to a small external generator. If a two week test using the external device shows improvement in symptoms, a permanent device, called Interstim, is implanted under the skin. This procedure requires general anesthesia.

Botox Bladder Injections

Botulinum toxin A, better known as botox, is used to treat patients with urge incontinence that does not improve with medications or other conservative therapies. It works by paralyzing bladder muscle, which helps decrease unwanted bladder contractions. Maximum relief is usually seen seven days after injection and normally lasts six to 12 months. Repeat injections are often needed.

Vaginal Inserts

Vaginal inserts and pessaries are frequently used to treat bladder and pelvic support problems. These devices are placed into the vagina to provide support for the uterus, bladder, urethra and rectum. A number of types are available, and the inserts are fit to meet your needs and anatomy.

Surgery

Surgery is performed to restore the normal position of the bladder neck and urethra. There are two main types of operations for incontinence: bladder neck suspension procedures and sling procedures. Within the medical community, the comparative effectiveness of these procedures is still being debated, and it is important that your decision is based on your individual circumstances.

Medications

There are currently no medications marketed specifically for the treatment of stress urinary incontinence. However, there are several experimental medications in development. Medications for this condition should be available in the near future.

In urge incontinence or overactive bladder, medications can help relax the bladder. These medications do not cure incontinence, but they can be very useful in reducing or eliminating problems of bladder control. They can be used alone or in combination with behavioral treatments.

Estrogen replacement therapy taken in pill or skin patch form has not been shown to be an effective treatment for female urinary incontinence. Vaginal estrogen (creams, vaginal rings or vaginal pellets) have helped reduce recurrent urinary tract infections in postmenopausal women, but their effectiveness for incontinence is unknown.