My Doctor Online The Permanente Medical Group

Symptoms

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There are 2 main types of incontinence that typically affect women. The type of incontinence you have will determine the pattern of symptoms you experience. Based on your symptoms, you can determine if you have 1 or both types of incontinence. The 2 types and their symptoms are:

Stress incontinence

• The most common type.
• Caused by the urethra not squeezing well enough.
• You lose urine during activities when you strain or put pressure on your bladder, like exercising, coughing, laughing, or sneezing.

Urge incontinence or overactive bladder

• Caused by the bladder squeezing when you don’t want it to.
• May occur if your bladder is irritated. 
• Having to urinate suddenly without the ability to delay urination.
• Loss of warning signal that you need to urinate, with sudden involuntary leaking of urine.

There are other types of urinary incontinence that both women and men may experience. Some of these types may happen because of short-term conditions like a urinary tract infection or constipation. When we treat the underlying condition, the urinary incontinence goes away. Other types of urinary incontinence can result from neurological conditions such as stroke, multiple sclerosis, Parkinson's disease, nerve damage, or dementia. Surgery, trauma, or radiation treatment to the pelvic area may also cause urinary incontinence.

Diagnosis

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If you find yourself leaking urine, you can begin home treatment immediately to try to control or eliminate your symptoms. Bladder training (establishing routines to prevent incontinence), pelvic muscle control exercises (Kegel exercises), changes in the types of fluids you drink, and other modifications work for many women.

If we discuss incontinence during an office visit, we will review your symptoms and the conditions that cause you to leak urine. It's helpful if you keep a record of your symptoms in a urinary diary. We can use this to talk about the cause of your symptoms and choose between your treatment options. We will discuss the situations that may improve or worsen your symptoms. We will usually do a physical examination and urinalysis. These tests look for urinary tract infections, which commonly cause urinary incontinence.

Causes and Risk Factors

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Risk factors that increase your chance of developing female urinary incontinence include:

Aging. As women age, lower estrogen levels cause changes in the lining of the bladder and urethra. This can decrease the ability of the urethra to tightly seal, resulting in leaking urine. Bladder muscles may weaken or become hyperactive, and tissues supporting the urethra also weaken.

During Pregnancy. When you are pregnant, the developing baby pushes on your bladder, increasing the chance of urinary incontinence. This condition usually returns to normal after pregnancy. If you give birth several times, the structures that support your pelvic organs may permanently weaken and increase your chance of developing urinary incontinence.

Post Pregnancy. Pregnancy and childbirth can cause changes in the body's support structure for the bladder and urethra. Weak muscles and ligaments in the pelvis may lead to urinary incontinence.

Obesity. Extra weight creates more pressure on the bladder and the support structures of the pelvis. This increases your risk of having both stress and urge incontinence. The good news is that losing weight can significantly improve both types of incontinence.

Smoking. Smoking can lead to coughing, which then puts more pressure on your bladder, increasing your risk of stress incontinence. Smoking also irritates the bladder and may lead to urge incontinence.

A bladder infection. New leaking or loss of control of your urination may be caused by a bacterial infection in your bladder. If this is the case, we can easily treat the infection with antibiotics.

Why Treatment Is Important

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If you have symptoms of urinary incontinence, we want to help you find the best treatment. Urinary incontinence can affect the quality of your life and lead to other health problems. Feeling embarrassed by urinary incontinence causes some women to avoid social activities or sex. Some women experience loss of confidence or depression as a result of incontinence. Leaked urine may also cause skin irritation and infections. Some women have difficulty sleeping because of the frequent urge to urinate, which sometimes leads to bedwetting. Slipping and falling on leaked urine when rushing to the bathroom can result in injury.

Our first treatment recommendation will be to experiment with treatment strategies you can try at home that have helped many women relieve incontinence. If these don't help, we can discuss medications, pessaries (devices that help support the urethra), or surgical options.

Home Treatments

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We recommend small, effective changes to your lifestyle or behavior as the first treatment for urinary incontinence. For many women, these treatments effectively control or cure the incontinence completely.

Kegel exercises

Kegel exercises strengthen your pelvic floor muscles. This allows better control of your urine flow and prevents leaking. Stronger pelvic muscles can also improve your sexual function. We recommend all women do Kegels as one of the best ways to prevent urinary incontinence. Learning to properly do Kegels takes a bit of practice and patience. It may take a few weeks to feel an improvement in your symptoms.

Here is how to do Kegel exercises correctly:

• Practice finding the proper muscles by repeatedly stopping your urine in midstream and starting again. Focus on the muscles that you feel squeezing around your urethra and anus. (After you find which muscles to squeeze, don’t do this exercise again on the toilet because you can develop difficulty urinating.)
  
• Practice squeezing these muscles while you are not urinating. If your stomach or buttocks move, focus on keeping them relaxed.
  
• Squeeze the muscles and hold for 3 seconds, then relax for 3 seconds.
  
• Repeat the exercise 10 times per session.
  
• Complete at least 3 sets (30 squeezes) per day. The wonderful thing about Kegels is that you can do them anywhere and anytime. No one will know what you are doing except you.
  

Bladder training

Urinary incontinence is sometimes caused by contractions (sudden squeezing) of the bladder. Bladder training is a technique to teach the bladder to stay relaxed when you want it to.

Double voiding. Relax and empty your bladder sitting on the toilet, then stand and count to 10, and finally sit and relax again. This helps completely empty your bladder. Double voiding is helpful for people who find that they have a small amount of urine leakage after they get up from the toilet, or “postvoid dribbling.” 

Watch for foods or drinks that irritate or stimulate the bladder. Everything that you eat or drink can be broken down during your body’s digestion and eventually end up in your bladder as liquid waste. If these foods or drinks irritate your bladder, this can feel like an urge to go to the bathroom, even if your bladder isn’t full. Sometimes if the bladder is very irritated, it will spontaneously squeeze, resulting in urine leakage or urinary incontinence.

To prevent this kind of irritation, it can be useful to identify any foods and drinks that bother you and avoid them. People are sensitive to different foods, so you’ll likely need to experiment to see which ones cause irritation, make you to go to the bathroom frequently, or cause you to leak urine.

Lose weight. If you carry extra weight, losing weight can reduce the pressure on your bladder. Studies show that a loss of less than 10 percent of total body weight improves incontinence problems for many women.

Quit smoking. If you smoke, consider quitting. This can decrease coughing, which may in turn decrease incontinence.

Wear absorbent pads or briefs. Some women choose to wear absorbent pads or briefs for certain activities that tend to cause urinary incontinence. While this does not cure the incontinence, it is a way to manage the condition while trying other treatments.

Don’t force fluids. Drink if you are thirsty but remember that most of the fluid that you need comes from the food that you eat. You need about 2 to 3 glasses of fluid each day in addition to regular meals.

Treatments and Medications

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If changes in your lifestyle or behavior do not relieve your urinary incontinence, we will discuss other interventions, like the use of medication or a pessary. It’s important to remember that stress urinary incontinence and overactive bladder are different problems (although they both lead to urine incontinence) and therefore have different treatments.

Medications

Medications will not help with stress incontinence, but they can be effective for an overactive bladder. Medications include:

• Anticholinergic medications, which relax the bladder muscle so it does not contract as much.
• Estrogen cream, rings, or tablets can be inserted into the vagina to improve the mucous membranes of the vagina and urethra and decrease incontinence.

Talk with us about medications that you take on a routine basis. Some prescription and over-the-counter drugs may affect urination. We may decide to make some adjustments.

Pessaries

An incontinence ring, or pessary, is a thin, flexible ring or disk that you wear inside your vagina to support the pelvic area. It is fitted by a specialist. An incontinence ring reduces incontinence by improving the sealing of the urethra so you do not leak urine. It is often most effective when used together with lifestyle changes. Most women cannot feel a pessary when it is in place. We can teach you how to take it out and put it in so you can wear it only when you want to wear it.

Neuromodulation

For urge incontinence that is not responding to home treatments or medication, stimulation of bladder nerves or injections of Botox into the bladder muscles can help some patients. Although these treatments can be effective, they are not for everyone. The treatments may involve frequent visits to your doctor’s office.

Biofeedback

Biofeedback is a treatment technique that measures and tracks your bladder function. Tracking when your bladder and urethral muscles contract, for example, can help you gain control over these muscles. Biofeedback is often used in addition to pelvic muscle exercises and neuromodulation to help treat incontinence.

Injections

A variety of bulking agents, such as collagen, can be injected near the urinary sphincter to help treat urinary incontinence. This helps make the tissues around the urethra and the narrow part of the bladder thicker, which can reduce stress incontinence. This procedure is done under local anesthesia or sedation. Repeat injections are necessary, because your body slowly eliminates the bulking agent over time. We can discuss which type of bulking agent might work best for you.

Catheterization

If you have overflow incontinence or weak muscles due to past surgery or injury, you might use a catheter to empty your bladder. A catheter is a tube inserted through the urethra into the bladder to drain urine. It’s possible to learn to insert this tube yourself, so you may either use a catheter once in a while or on a constant basis. If you use a catheter all the time, the tube connects to a bag that you can attach to your leg.

Surgery

If other treatments do not reduce your symptoms of stress incontinence, there are surgical procedures that may help.

One type of procedure that we offer on an outpatient basis involves supporting the urethra with a device known as a midurethral sling. There are several types of midurethral slings, but both use synthetic mesh materials that a surgeon places midway along the urethra. To perform the surgery, a surgeon makes small incisions behind the pubic bone and inside the vagina, and places a synthetic tape under the urethra. The ends of the tape are pulled through the incisions and adjusted to provide the right amount of support to the urethra.

We can discuss whether surgical treatment is a good option for you.

Your Care with Me

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Urinary incontinence can usually be treated with self-care at home. If your symptoms concern you or are not improving with home treatment, please contact me.

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You can connect with me in a variety of ways, depending on the situation and what is most convenient for you at the time. I am available online, by telephone, or in person.

• For nonurgent questions or concerns, you can e-mail me using this site. You can also book an appointment online to see me in person.
• If your concerns are immediate, or you simply prefer to use the telephone, please call our Appointment and Advice line, which is available 24 hours a day, 7 days a week. Our advice nurses can give you immediate advice, and our telephone staff can send me a message or book an appointment for you. 

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Coordinating Your Care

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Having all of our Kaiser Permanente departments located together or nearby, including pharmacy, laboratory, radiology, and health education, makes getting your care easier for you.

Another major benefit is our comprehensive electronic medical record system, which allows all of the doctors and clinicians involved in your care to stay connected on your health status and collaborate with each other as appropriate.

When every member of the health care team is aware of all aspects of your condition, care is safer and more effective.

If you call the Appointment and Advice line

• Our call centers are open every day of the year around the clock. If you need advice, we will transfer you to one of our skilled advice nurses (RNs). They can help you determine when you need to be seen and in what location.
• The advice nurse can often start your treatment by telephone depending on the situation and has access to your electronic medical record.

If you come to an office visit

• At the beginning of your visit, you will receive information about when you are due for your next test, screening or immunization. We can discuss and schedule any preventive tests that you need.  
• At the end of your visit, you may receive a document called the “After Visit Summary” that will summarize the issues we discussed during your visit. You can refer to it if you forget what we discussed, or if you just want to recheck your vital signs and weight. You can also view it online under Past Visits. 
• To help you prepare for your visit, please see additional details under Office Visit. 

If I prescribe medications

We will work together to monitor and assess how your medications are working and make adjustments over time. Prescriptions can be filled at any Kaiser Permanente pharmacy. Just let me know which pharmacy works best for you and I will send the prescription electronically in advance of your arrival at the pharmacy.

If refills are needed in the future, you can:

• Order them online or by phone. Order future refills from my home page or by phone using the pharmacy refill number on your prescription label. 
• Have them delivered to you by mail at no extra cost. Or you can pick up your medications at the pharmacy. If no refills remain when you place your order, the pharmacy will contact me regarding your prescription.

If lab testing or imaging is needed

For lab tests, I will use our electronic medical record system to send the requisition to the Kaiser Permanente laboratory of your choice. For imaging procedures, we will schedule an appointment with the Radiology department. When the results are ready I will contact you with your results by letter, secure e-mail message, or phone. In addition, you can view most of your laboratory results online, along with any comments that I have attached to explain them.

If I refer you to another specialty colleague

If we decide together that your condition would also benefit from the care of other types of specialists, our staff will help arrange the appointment(s) with one or more of my specialty colleagues.

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Convenient Resources for You

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My goal is to provide high-quality care and to offer you choices that make your health care convenient. I recommend that you become familiar with the many resources we offer so that you can choose the services that work best for you.

My Doctor Online is available 24/7 so that you can access and manage your care where and when it is most convenient. From my home page you can:

Manage your care securely

• View and compose secure e-mail messages.
• Manage your prescriptions and schedule appointments.
• View your past visits and test results.
• View your preventive services to see whether you are due for a routine screening or updated immunization.

Learn more about your condition

• Read about causes, symptoms, treatments, and procedures.
• Find interactive health tools, videos, and podcasts to help you manage your condition.
• View programs to help you decide on or prepare for a surgery or procedure.

Stay healthy

• Locate health education classes and support groups offered at our medical center.
• Explore interactive programs, videos, and podcasts that focus on helping you stay healthy.
• View your Preventive Services to see whether you are due for a routine screening or updated immunization.

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If Surgery or a Procedure is a Treatment Option

I will recommend that you review educational information and tools to help you prepare for your procedure or surgery. The information will often help you decide whether surgery is right for you. If you decide to have a surgery or procedure, the information will provide details about how to prepare and what to expect.

If we proceed with surgery, I will have my Surgery Scheduler contact you to determine a surgery date and provide you with additional instructions regarding your procedure. Once your surgery is scheduled, a medical colleague of mine will contact you to conduct a preoperative medical evaluation that will assure that you are properly prepared for your surgery.

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