Gary Lemack, M.D. Answers Questions On: Incontinence and Pelvic Prolapse

For incontinence, especially in women, we offer a variety of treatments, depending on the type and the severity of the condition.

Typically, when we talk about urinary incontinence, we talk about stress incontinence and urge incontinence.

Stress incontinence is urinary leakage associated with activities like coughing, straining, moving, walking, bending, hitting a tennis ball, or picking up a grocery bag.

Treatments for stress incontinence range from something as non-invasive as pelvic floor muscle training to various types of transurethral injections, to surgical procedures such as slings. Slings can be very effective and are more durable than even five or 10 years ago.

Urge incontinence – leakage associated with the sudden and compelling desire to urinate, which can’t be postponed – is a different type of problem. It’s generally related to the bladder rather than the outlet not being strong enough.

We can help that with conservative strategies such as dietary modifications. When those don’t work, we offer other treatments, such as oral medications and transdermal medications. The next step is to go to additional strategies, including botulinum toxin injections into the bladder or other forms of neuromodulation.

Some patients who have refractory urge incontinence don’t respond to medications. For example, a patient with multiple sclerosis may have severe urgency and can’t control leakage, and medications don’t help.

Botulinum toxin injections in the bladder greatly improve the bladder capacity and decrease bladder spasms. They decrease the urge episodes and leakage, and profoundly improve quality of life for many patients.

In the office, after instilling a numbing agent, we place a cystoscope into the bladder.  We then inject Botox throughout the bladder in about 20 different spots. It generally needs to be repeated at six-month intervals. The vast majority of our patients who may not have been helped by other therapies note a significant and sustained improvement in their urinary symptoms.

The FDA approved the treatment last year for use in neurogenic patients who have overactive bladder, and it’s also been approved for patients who have refractory urgency incontinence but don’t have a neurogenic condition.

Prolapse can be a variety of conditions: the bladder can prolapse, or fall, through the pelvic floor and cause a vaginal bulge; the rectum can prolapse up and into vagina; the uterus can drop down, or, if the uterus has been removed, the vaginal vault can drop down.

It’s commonly associated with aging and women who’ve had a hysterectomy, but it doesn’t always have to occur in that situation.

When prolapse gets severe enough or affects quality of life, we can offer several treatments.

Occasionally, we’ll do something like placing a pessary, which is a removable device inserted nonsurgically into the vagina for support. If that fails, there are a variety of surgical procedures that can either be performed vaginally or abdominally to repair the problem.

Urodynamics is a test of the bladder function that is helpful in evaluating a variety of bladder conditions, particularly when patients don’t respond to typical treatments.  

For example, in neurological patients, it gives you some sense whether their bladder function may be dangerous to their overall health and put their kidneys at risk over time.

The results give a better idea what’s behind the problem and might give a better idea of what the possible solutions are.

People can do little things for themselves to prevent or reduce irritation, such as watch what they eat and drink. Caffeine, spicy food, citrusy fruits, acidic foods, alcohol, and tobacco are the common ones that can irritate the bladder. Keeping those in check in their diet may help reduce the amount of irritation or urgency they have.

Another thing that helps is what we call urge suppression. This helps with urge leakage, when people have a sudden urgency to urinate. If you have urgency, rather than running to the bathroom – which can often lead to leakage – we instruct people to contract their pelvic floor muscles or do a Kegel exercise. This activity helps physiologically stop the bladder contraction that may be underlying the urge episode but also increases the outlet resistance to make it less likely that they will leak.