Urinary Incontinence Naturopathic Treatment

Reclaim Bladder Control

Urinary Incontinence affects people world wide, and can cause people to avoid social contact and not want to deal with others. This ebook by Alice Benton gives you the best way to avoid the embarrassment and discomfort that is associated with urinary incontinence. Why would you want to deal with annoyance of being unable to control your own bladder when you could find a far better way to help heal yourself? This ebook gives you natural methods of taking back control of your bladder, without having to worry about the dangers associated with surgery or medications that can cause harm to your kidneys. You can learn the best natural way to heal yourself from urinary incontinence and give yourself the life that you deserve; start living the way that you deserve to live, without all of the problems that come with urinary incontinence. Take your life back now!

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Medications for Stress Urinary Incontinence

Pharmacologic therapy of stress urinary incontinence (SUI) is directed toward enhancing urethral sphincteric function, especially during times of increased intraabdominal pressure such as coughing or lifting. Appropriate function of the intrinsic and extrinsic urethral sphincteric musculature, along with appropriate urethral support, as well as integrity of the urethral mucosa and submucosal vascular plexus are the key components of the delicate female continence mechanism. The extrinsic muscular support of the urethra is dependent on intact pelvic floor musculature and its innervation. Physiotherapeutic approaches to SUI are discussed in Chapter 12-2. The urethral mucosal and vascular factors are dependent on estrogen availability. In menopausal women, there is a prompt reduction in blood flow to the urethral submucosa and thinning of the urethral mucosa. Usage of local estrogen cream is discussed in Chapter 11-1. Imipramine (Tofranil) is a drug with combined properties as an...

Other Therapies for Stress Urinary Incontinence

Whereas simple and definitive sling, retropubic, or injectable therapy will suffice for the overwhelming majority of incontinent patients, it is often extremely difficult to manage stress urinary incontinence that is of a refractory nature. Accordingly, less often used modalities may be required to cure the condition, including the use of obstructing or circumferential slings, artificial urinary sphincters (AUS), or even transvaginal closure of the bladder neck.1 These methods are certainly retained for a last resort of therapy, yet still maintain a prominent position in care, because all patients will not be successfully managed with standard therapies.

Overactive Bladder Pharmacologic Therapy

The term overactive bladder (OAB) encompasses a wide range of irritative bladder filling and storage symptoms including the symptoms of urinary frequency, urgency,and urge incontinence, alone or in combination. Overactive bladder represents a health condition of increasing public and medical recognition, and because of the wide variation in reported symptoms of OAB, accurate estimates of prevalence and incidence are difficult to calculate.

Surgical Management of the Overactive Bladder Evacuation Disorders

Overactive bladder (OAB) is a term describing the complex symptoms and conditions of urinary frequency and urgency, with or without urge incontinence and may affect more than 17 million Americans. Although OAB may be successfully managed in a variety of ways, the majority of cases (50 -80 ) presenting to the physicians respond to the triad of measures integrating the individual merits of behavior modification, pelvic muscle physiotherapy, and pharmacotherapy. Awareness by patients and primary care physicians of new advances in this trivium of OAB management has resulted in an increasing number of referred cases to the pelvic health specialist for this condition in which the prevalence is not only much higher than previously expected, but also increasing with the aging of our population. The growing awareness and increasing prevalence of this manageable condition not only increases the absolute number of referred cases, but also the number of cases that will be refractory to the...

Urinary Incontinence

Multiple tools have been evaluated and validated for the assessment of urinary incontinence impact on QOL. Among all of the aspects of pelvic floor dysfunction, this has been the most widely assessed, using QOL assessment tools. We have therefore chosen to utilize the most commonly accepted QOL questionnaires, which have been utilized in clinical practice as well as research. The short-form Incontinence Impact Questionnaire (IIQ-7) has been extensively evaluated, validated, and is well accepted.1 Its questions include various aspects (domains) of QOL impact, including physical activities, social activities, travel, and emotional health. It is easy to complete, and the questions are readily understandable by most patients (Figure 14-3.1). Because many patients' QOL impact from their incontinence is primarily related to one particular activity, we modified the IIQ by adding a question in which the patient identifies the particular activity that is most impacted by her urinary...

Bladder problems

People with MS, 33 suffered urinary incontinence.280 In the Oxfordshire audit6 bladder problems were the most common presenting problem affecting 39 226 patients on 78 occasions over ten months, and they were the fifth most common problem in terms of prevalence. While it is likely that disturbed bladder control is the commonest general cause of bladder symptoms, some bladder symptoms may be indicative of infection, and infection not only causes pyrexia (high temperature) and malaise but can also cause general exacerbation of all impairments, especially spasticity. Urinary tract infection (UTI) may also, rarely, cause pyelonephritis and septicaemia. The frequency of actual UTI is unknown and so, although the potential importance of urinary tract infection is great, its actual medical importance is unknown. This section will first cover the assessment and management of disturbed bladder control leading to urinary frequency, nocturia, urgency of micturition, and incontinence. Then the...

Bladder Control

Three channels for bilateral sacral root stimulation (S2-4) for bladder control (bowel control and erection, if possible) were provided. Sacral root stimulation was achieved by three pairs of LPR electrodes (10-mm long, solid platinum tubing of 1.0-mm diameter) inserted into the external sacral foramina in a lateral direction to follow and to stimulate the nerve roots epidurally. One further channel was connected to an epidural spinal cord stimulating electrode (Pisces Quad Medtronic Inc., Minneapolis, Minnesota) for conus medullaris modulation of spastic bladder and bowel reflexes.

Coexistence of Pelvic Floor Dysfunction Symptoms

Various surveys have been performed to obtain a better understanding of the coexistence of symptoms of urinary, genital, and fecal dysfunction. Not surprisingly, there is a high incidence of coexistence of incontinence and support defects (Table 1-1.1). It has been reported that in patients seen with fecal incontinence, 24 to 53 also complained of urinary incontinence, and 7 to 22 complained of genital prolapse. Of patients who presented with rectal prolapse, 66 also complained of urinary incontinence and 34 complained of genital prolapse.6-8 In a survey of patients who had undergone surgery for rectal prolapse and fecal incontinence at our institution, with an included control group of clinic patients, the incidence of urinary incontinence was 53 in those who had previous surgery for fecal incontinence and 65 in those who had previous surgery for rectal prolapse. Genital prolapse was found in 18 of patients with fecal incontinence and 34 of patients with rectal prolapse. The control...

Epidemiology of Non Neurogenic Urinary Dysfunction

Millions of the general population,particularly women and the elderly, have bladder dysfunction. Although most studies have mainly focused on incontinence, more recently, attention has also included overactive bladder (OAB). Therefore, this chapter will be focused on urinary incontinence (UI) and OAB, because both of them constitute the most common causes of urinary dysfunction. In 1988, the International Continence Society (ICS) defined UI as the involuntary loss of urine that is objectively demonstrable and is a social or hygienic problem. Recently, the ICS redefined it as the complaint of any involuntary leakage of urine.1 The impact of the new definition is that more cases of UI will be discovered and hopefully treated. Urinary incontinence symptoms mainly are stress (SUI), which is leakage with physical exertion, urge (UUI), which is leakage with a strong desire to void, and mixed, which is a combination of SUI and UUI. When SUI is uro-dynamically proven, it is also called...

S Sensitive but thorough problem assessment

The great variety of possible problems that people with MS may have can make it difficult for health care professionals to detect all relevant changes. We have recommended that health service professionals in regular contact with people with MS, should consider in a systematic way whether the person with MS has a 'hidden' problem contributing to their clinical situation, such as fatigue, depression, cognitive impairment, impaired sexual function or reduced bladder control. The main text of the guideline details the various problems that a person with MS may have and appropriate ways of treating these problems.

Urogynecology History

Urinary incontinence and pelvic organ prolapse are problems that cause social embarrassment and inconvenience. It is, therefore, critical to fully understand the patient's chief complaint and its effect on quality of life. Detailed questions should be asked regarding the degree to which the problem has impacted social functioning and living situations. Specific questions will often help clarify the type of incontinence distressing the patient. Women with stress urinary incontinence (SUI), or urine loss associated with exertion, report urine loss with coughing, sneezing, or laughing. Urine loss during physical activity that increases intraabdominal pressure, such as running and sit-ups, also occurs frequently. Women with urge urinary incontinence (UUI), or urine loss associated with uninhibited detrusor muscle contractions,will typically also complain of urinary urgency, nocturia, and symptoms of frequency. These patients often report an urgency to void that occurs with little warning...

Implications For Drug Development

Development of a hepato-renal syndrome associated with the use of benoxaprofen (Hamdy et al., 1982) and problems with other NSAIDs (Castle-den and Pickles, 1988). The need for dose modification for agents such as triazolam (Green-blatt et al., 1991) was identified, as was the need for attention to labelling and modification of package inserts. However, by the time that a new medicine has been marketed, experience with its use remains confined to a relatively small number of people, of whom only a proportion will be elderly. There is, therefore, a need for careful pharmacovigilance to identify unexpected adverse effects such as those produced by terodiline. This agent, which was introduced for use in urinary incontinence due to detrusor muscle instability, was subject to prescription event monitoring by the Drug Safety Research Unit in Southampton (Freemantle et al., 1997). The latter system relies on reporting of significant events ''such as a broken leg'' which may be due to...

Device Therapy for Stress Incontinence

The majority of patients with stress urinary incontinence are successfully managed with surgery however, not all patients desire surgery, nor are all patients operative candidates. Nonsurgical treatment options include pelvic floor muscle exercises, biofeedback, electrical stimulation, and pharmacologic agents. Anti-incontinence devices serve as another alternative to treat these patients, and include both vaginal and urethral prosthesis (Table 6-1.1 Figure 6-1.1).

Sling TensionFree Vaginal Tape

Over the past decade, suburethral slings have emerged as the procedure of choice for the surgical correction of most types of female stress urinary incontinence (SUI). In 1997, the Female Stress Urinary Incontinence Clinical Guidelines Panel of the American Urological Association analyzed the literature regarding surgical procedures for treating SUI and established that retropubic suspension and sling procedures were the most durable procedures with the longest outcome for dryness.1 In recent years, slings have become more common, because needle suspension procedures have failed the test of time, and suburethral sling procedures have proved to be less morbid than retropubic suspensions.

Evaluation and Patient Selection

As with any patient undergoing evaluation for urinary incontinence, the patient's general medical history should be reviewed, especially the incontinence history, previous incontinence therapies, and current incontinence symptoms. In addition to a pelvic examination, urinalysis and or urine culture should be used to check for infection to ensure that an injectable agent will not be implanted in the setting of an active infection. Urodynamics or a supine stress test may be used to confirm the diagnosis of SUI and significant ISD. Cystoscopy may be performed before and certainly at the time of the injection procedure to inspect the urethra for pathologic conditions such as stricture, ure-thral diverticulum, or poor mucosal closure and tissue integrity. Detrusor overactivity may be present or unrecognized in many patients with confirmed SUI. Although injectable bulking agents are indicated primarily for SUI, many patients with mixed signs and symptoms of SUI and overactive bladder notice...

Retropubic Therapy for Stress Incontinence

Since 1949, when Marshall et al.1 first described retropubic urethrovesical suspension for the treatment of stress urinary incontinence, and since Burch's landmark article in 1961,2 retropubic procedures have emerged as consistently curative. Although numerous terminologies and variations of retropubic repairs have been described, the basic goal remains the same to suspend and stabilize the anterior vaginal wall, and thus the bladder neck and proximal urethra, in a retropubic position. This prevents their descent and allows for urethral compression against a stable suburethral layer. We select a retropubic approach (versus a vaginal approach) depending on many factors, including the need for laparotomy for other pelvic disease, the amount of pelvic organ relaxation, and whether a vaginal or abdominal procedure will be used to suspend the vagina. Additionally, the age and health status of the patient, and the preferences of the patient and surgeon are also determining factors. We...

Artificial Bowel Sphincter

Augmentation of the sphincter with a prosthetic device was first reported for fecal incontinence in 1992 after the idea was borrowed from urology, where artificial sphincters are used for urinary incontinence.8 The current device used for fecal incontinence, the ActiconTM NeoSphincter (American Medical Systems, Minnetonka, MN), consists of three silas-tic components an inflatable cuff, a pressure-regulating

History and Physical Examination

The patient is a 40-year-old G2P1 woman with a 4-year history of stress urinary incontinence (SUI) and fecal incontinence (FI) that began with the vaginal delivery of her now 4-year-old daughter complicated by a fourth degree laceration. Since that time, she has had progressively worsening FI to both liquid and solid stools, as well as an inability to control flatus. Her urinary incontinence is stress related with no significant urgency, frequency, enuresis, or nocturia. She voids with a normal flow. In addition, she complains of dyspareunia and vaginal dryness. Her symptoms have caused significant quality-of-life impairment.

Sacral Nerve Stimulation

Sacral nerve stimulation (SNS) is a useful tool to have in the armamentarium for the treatment of voiding dysfunction. Since Food and Drug Administration approval, SNS has evolved to attain a major role in treating refractory overactive bladder (OAB) and patients with difficult pelvic floor dysfunction. It has become a viable option in those patients who failed conservative therapy, but who desire alternative therapy before more invasive procedures are performed. The technique and the technology have been improved, increasing the safety and efficacy whereas decreasing patient morbidity.

Anterior Vaginal Prolapse

The successful management of anterior vaginal wall prolapse remains one of the greatest challenges in female pelvic reconstructive surgery. Prolapse of the anterior vaginal wall is the most common presentation of pelvic organ prolapse. Recent studies suggest that, of the various segments of the vagina that may be involved in prolapse (anterior, posterior, or apical), the anterior vaginal wall is the segment most likely to demonstrate recurrent prolapse after reconstructive surgery. Additionally, normal anterior vaginal support has an important role in supporting the urethra, and loss of this support can contribute to the development of stress urinary incontinence. It is, therefore, important that the pelvic reconstructive surgeon understand the normal support mechanisms of the anterior vaginal wall and the full spectrum of techniques for correction of anterior vaginal prolapse and cystoceles.

Normal Pressure Hydrocephalus

This condition, most commonly seen in adulthood, is characterized by a clinical picture of gait deterioration, dementia and urinary incontinence in the context of enlarged ventricles on neuroimaging, but relatively normal intracranial pressures. Although in some cases there is a history of subarachnoid hemorrhage, intracranial infection or head trauma, in approximately 60 of cases the etiology remains unknown. The differential diagnosis is wide and the identification of patients that will

Spinal cord and root compression neurological effects

The lower sacral roots are involved early, producing loss of motor and sensory bladder control with detrusor paralysis. Overflow incontinence ensues. Impotence and faecal incontinence may be noted. A l.m.n. weakness is found in the muscles supplied by the sacral roots (foot plantarflexors and evertors), the ankle jerks are absent or impaired and a sensory deficit occurs over the 'saddle' area.

Surgical Management of Urinary Retention

Clean intermittent catheterization (CIC) is one of the major advances in the history of urologie practice. Developed in 1972 by Jack Lapides and colleagues,1 this nonsterile technique has been adopted worldwide and few advances in urology have had the same impact on clinical practice and patient management as CIC for bladder evacuation or emptying dysfunction. It has implications for overactive bladder caused by elevated postvoid residuals (PVR), bladder outlet obstruction resulting in high voiding pressures or various degrees of urinary retention, as well as infectious urinary tract conditions because it actually results in improved urologic care and fewer complications than previously considered management options. Clean intermittent catheterization has improved the quality of life for countless people with transient or permanent voiding dysfunction who might otherwise have been treated with chronic indwelling catheters or surgery for urinary diversion such as an ileal conduit. This...

Bladder Outlet Obstruction after Anti Incontinence Surgery Urethrolysis

Surgical correction of female stress urinary incontinence (SUI) generally results in success rates between 80 to 95 , depending on the procedure used.1 Bladder outlet obstruction (BOO) after surgical correction of SUI is not infrequent. Reported rates of urethral obstruction range from 5 to 20 after Marshall-Marchetti-Krantz procedure,2,3 5 to 7 after needle suspension and retropubic urethropexy,4 and 4 to 10 after pubovaginal sling.5 Obstruction after these procedures may result from excessive suture tension, periurethral suture placement, or excessive sling tension. Placing a supportive rather than obstructive sling is the best strategy for prevention of BOO.

Pathogenesis Of Voiding Dysfunction In Pd

This combination of effects would result in a Dj effect during bladder filling and a D2 effect during bladder emptying. We would expect a salutary effect of Dj agonists on bladder control in Parkinson's disease. Studies comparing the effects of currently available pure D2 versus mixed Dj D2 receptor agonists on the voiding dysfunction of PD patients would be of interest. We are only aware of one study (reported in abstract form) where patients with Parkinson's disease affected with urinary urgency and frequency while on bromocriptine experienced an improvement in their symptoms when switched to per-golide.16

Effect on Continence and Urethral Function

Our knowledge regarding the effect of local estrogen on urethral function and continence is limited and somewhat unclear. It is assumed that urethral mucosal changes mimic those occurring in the vagina during local estrogen therapy. Atrophic women with urinary urgency, frequency, and particularly nocturia - in the absence of cystitis or detrusor instability - will typically benefit from local estrogen therapy. Presumably, this is attributable to thickening of the urethral mucosa with resultant improved mucosal coaptation and thus improved sphincteric function. It has been demonstrated in vivo and in vitro that there is increased contraction of the periurethral smooth muscles with estrogen therapy. This is thought to be mediated through alpha-2-adrenoceptors. Both of these effects should positively impact continence. Some studies have shown improvement in urethral function on dynamic ure-thral profilometry during multichannel urodynamics, whereas others have not.6,7 The overall...

Pelvic Muscle Exercise Kegel Exercises

Mental in developing a standardized program for treating urinary stress incontinence and recommended structured home practice with the perineometer along with symptom diaries. His clinical use of these techniques showed that muscle reeducation and resistive exercises guided by sight sense is a simple and practical means of restoring tone and function of the pelvic musculature and improves urinary incontinence. Unfortunately, clinicians taught Kegel exercises without the use of instrumentation. It has been shown that verbal or written instructions alone are often inadequate and that up to 50 of patients perform Kegel exercises incorrectly. There is a strong tendency to substitute abdominal and gluteal contractions for weak pelvic floor muscles (PFMs). For patients with fecal or urinary incontinence, abdominal contractions increase intraabdominal pressure, thus increasing the probability of an accident or even further worsening pelvic floor weakness. For patients to begin performing...

Patient Education and Behavior Modification

Frequently observed behavioral pattern, common among elderly women with symptoms of urinary incontinence, is the restriction of fluid intake to avoid leakage in fact, this may worsen symptoms of constipation as well as symptoms of urinary incontinence. A bowel and bladder diary can be used to accurately document fluid intake and voiding habits along with any symptoms of urgency, incontinence, or constipation.

Physical examination

Observation of urine loss while the patient has a full bladder can be performed by having the patient cough vigorously in the standing position. If instantaneous leakage occurs with cough, stress urinary incontinence is likely while detrusor instability (urge incontinence) is suggested by delayed or sustained leakage.

Other forms of cns tuberculous infection

Infection of the leptomeninges results in an exudate that encases the spinal cord and nerve roots. This produces back pain, paraesthesia, lower limb weakness and loss of bowel and bladder control. Imaging may be normal while CSF shows high protein, lymphocytes and rarely acid fast bacilli. This disorder is now more frequent in AIDS patients. Differential diagnosis includes cytomegalovirus, cryptococcus, syphilis and lymphoma. Laminectomy and meningeal biopsy may be required to establish diagnosis. When suspected, empirical theory with antituberculous drugs is appropriate.

Voiding Diaries and the Patients History

Several attempts have been made to use an analysis of the patient's history to help predict the type of incontinence most have revealed that patient history is a poor predictor of the underlying cause of incontinence.9,10 Sand et al.11 reported that the history has a good sensitivity for genuine stress urinary incontinence but not for urge. McCormack et al.12 revealed poor agreement between subjectively estimated urinary frequency and urinary frequency shown on a chart.

Using Voiding Diaries in Incontinent Patients

The primary use of voiding diaries in incontinent patients is documentation of incontinence episodes. Diaries may provide clues to the underlying cause of incontinence, particularly if the diary includes patient comments about the reason(s) or condition(s) associated with the incontinence episodes. Voiding diaries can be used in evaluation of the severity of urinary incontinence because the patient can report the number of pad used and the amount of leakage. stress urinary incontinence to a normal group, and surprisingly showed that total voided volume, frequency of micturition, and largest single voided volume were all significantly higher in the genuine stress urinary incontinence group than in the normal group.14 Therefore, the diagnostic role of the diary is limited. It is reasonable to evaluate incontinent patients with a voiding diary before other more invasive tests such as uro-dynamic investigation because it is a simple, noninvasive, and inexpensive tool. It evaluates the...

Application of Voiding Diaries in the Assessment of Voiding Dysfunction Treatment

Tions for treatment of LUTS, including overactive bladder, have been developed in clinical trials. All of these medications are directed at symptom improvement therefore, patient-completed voiding diaries are often used in evaluation of the effectiveness of these drugs.17,18 This application also explains the recent increase in number of published studies making use of the voiding diary (Figure 14-1.6).

Qualityof Life Assessment Tools

The nature of pelvic floor dysfunction as multifactorial with involvement of multiorgan systems makes severity and impact assessment an exceedingly challenging aspect of the evaluation of a symptomatic patient. Various factors such as organ system function, anatomic alterations, lifestyle impact, and psychological well-being may be impacted differently by the disease process, and more importantly, by the therapy received by a patient with pelvic floor dysfunction. Historically, outcome assessment was limited to continence and normal anatomy restoration. As recently as 10 years ago, outcome assessment was focused solely on objective parameters such as urodynam-ics. Aspects of day-to-day living of great importance to the patient, such as lifestyle alterations, work capability, and interpersonal intimacy, were not addressed by clinicians. It is inappropriate to assess outcomes of a multiorgan system dysfunction by assessing only one-dimensional factors. This is particularly true in the...

Initial Regulatory Deliberations

There is little doubt that urinary incontinence, although relatively benign in terms of morbidity, is a highly prevalent condition that has a serious adverse effect on the quality of life. No other drug with a comparably satisfactory and favourable risk-benefit ratio was available at the time of the approval of terodiline in 1986. Clinical trials had shown terodiline to be effective and, by all accounts, relatively safe. The efficacy of terodiline had been demonstrated in a number of studies (Yoshihara et al., 1992 Anon, 1993 Norton et al., 1994). The majority of the reactions reported were mild and anticholinergic. The safety of terodiline 50 mg daily was evaluated in a 6-month study in 100 women with urgency urge incontinence by recording of adverse reactions and measurements of haematol-ogy, liver function, creatinine, ESR, heart rate and blood pressure (Fischer-Rasmussen, 1984). Mean levels of all variables on clinical chemistry were well within the normal range. Ninety-one...

Neurologic Evaluation of the Pelvic Floor

Urinary incontinence reflexic bladder, manifesting as an overactive bladder with frequency and urgency incontinence. Pudendal nerve latencies will be normal in this setting, but lower limb somatosensory evoked potential recording may show delayed conduction along the central somatosensory afferent pathways.

Clinical manifestations of hyponatremia

The signs and symptoms of hyponatremia are directly related to the development of cerebral edema, increased intracranial pressure, and cerebral hypoxia. The early symptoms of hyponatremia (from any cause) may include apathy, weakness, muscular cramps, nausea, vomiting, and headache. More advanced clinical manifestations include impaired response to stimuli, myoclonus, urinary incontinence, and hallucinations. More severe clinical manifestations of hyponatremia may include decorticate posturing, seizures, and respiratory arrest.

Magnetic Resonance Imaging

Utites Prolaps

Netic resonance imaging may also be useful for the radiographic evaluation of stress incontinence. Hypermobility of the proximal urethra and bladder neck descent are important pathological features in the diagnosis of genuine stress urinary incontinence.7'8 Measurement data on dynamic MRI for the bladder neck position and the extension of cystocele at maximal pelvic strain are comparable with lateral cystourethrogram data.9

Rebirth Of Terodiline

Terodiline (Figure 11.1) was first marketed in 1965 as an antianginal agent ( Bicor ) in Scandinavia (Wibell, 1968), a relatively small market. This period of original marketing of terodiline is worthy of note for three reasons (a) it antedates any serious regulatory or clinical interest in drug-induced prolongation of the QT interval, (b) it antedates the first description of torsade de pointes, a unique proarrhythmia associated with prolonged QT interval (Dessertenne, 1966) and (c) the drug probably co-existed with prenylamine, also an antianginal agent. Because of its potent antic-holinergic properties, urinary retention proved to be a frequent and troublesome side-effect during its use as an antianginal agent and terodiline was therefore re-developed in early 1980s for clinical use in urinary incontinence due to detrusor instability.

Risk of Failure and Complications

Detrusor overactivity or urge incontinence may coexist in up to 30 of patients with stress incontinence. The term mixed incontinence has been used to describe this condition. In addition, approximately 15 of patients with stress incontinence who have a preoperative stable cystometro-gram, develop de novo overactive bladder after a colpo-suspension. The course of the detrusor overactivity after a retropubic repair in patients with mixed incontinence is unpredictable. Interestingly, as many as 50 to 60 of patients with mixed incontinence are cured of their detru-sor overactivity by surgical support of the bladder neck. A much smaller percentage (approximately 5 -15 ) have worsening of their overactivity with the remainder (20 -30 ) having persistence of their overactivity. Women with high-pressure detrusor overactivity or poor bladder compliance are more likely to have persistent urge incontinence after incontinence surgery. In general,women with mixed incontinence should initially...

Timed Voiding and Fluid Management

Timed voiding (also referred to as bladder retraining training, bladder drill, bladder discipline, and bladder reeducation) is a behavioral exercise used to establish bladder control in adults. Evidence indicating that bladder training is effective in women with urodynamic urge incontinence with or without associated detrusor overactivity, sensory-urgency without incontinence,1 and urodynamic stress incontinence,2 has led to the 1996 Clinical Practice Guideline's recommendation of bladder training as a first-line therapy for urge, stress, and mixed incontinence.3 Urodynamic studies are not required before initiation of behavioral therapy. The three components of timed voiding are education regarding continence and incontinence mechanisms scheduled voiding with systemic delay of voiding by implementing distraction and relaxation techniques and positive reinforcement provided by a caregiver. The specific goals of bladder training include correcting inappropriate habits of frequent...

Effects Of Basal Ganglia Surgery

Abramovicz, M. et al., Tolterodine for Overactive Bladder, Medical Letter, 40 101-103, 1998. 39. Yokoyama, O., Komatsu, K., Ishiura, Y., Akino, H., Kodama, K., Yotsuyanagi, S., Moriyama, N., Nagasaka, Y., Ito, Y., Namiki, M., Overactive bladder Experimental Aspects, Scand. J. Urol. Nephrol., Suppl., 210 59-64, 2002.

Practical Aspects of Biofeedback Therapy for Pelvic Floor Dysfunction

Practical aspects of biofeedback therapy for PFM dysfunction to treat symptoms of urinary incontinence, voiding dysfunction, constipation, and fecal incontinence include the technical, therapeutic, behavioral, and pelvic muscle rehabilitation (PMR) components. The technical component involves the instrumentation used to provide meaningful information or feedback to the user. Devices include surface electromyography (sEMG), water-perfused manometry systems, and the solid-state manometry systems with a latex balloon. Although each system has inherent advantages and disadvantages, most systems provide reproducible and useful measurements. A solidstate system is preferable to a water-perfused system because there is no distraction or embarrassment from leakage of fluid and the patient can be moved to a sitting position without adversely affecting calibration. Surface electromyography instrumentation is widely used and proven effective for biofeedback training. Although not suitable for...

Other Agents Of The Same Pharmacological Class

As it was, the clinical trials database on terodi-line was comparable with those for other drugs intended for urinary incontinence. In retrospect, however, it was not large enough for a drug with its chemical and antianginal pedigree. It had included 8 controlled (n 229) and 6 uncontrolled (n 147) studies with a total patient population of 376 exposed to terodiline. Of these, 241 had received the drug for up to 1 month and a further 39 for 2-3 months. Seventy-five patients had been treated for 4-12 months.

Functional Electrical Stimulation

Stress incontinence, and high frequency (200 Hz) for urinary retention. A review of trials of functional electrical stimulation for stress urinary incontinence showed cure in 18 and improvement in 34 of patients. In the treatment of OAB, maximal electrostimulation cured 20 and improved 37 of women with urodynamic detrusor over-activity incontinence.1 Functional electrical stimulation is of limited value in the treatment of stress incontinence.

Potential Risk Factors

Urinary incontinence in women is often assumed to be attributable to the effects of pregnancy and childbirth. The literature shows that UI is a more common occurrence among pregnant women compared with other groups of women,with reported prevalence rates of 31 and 60 .17,18 Urinary incontinence during pregnancy is a self-limited condition. Viktrup et al.19 found a 28 prevalence rate of SUI during pregnancy, with 16 becoming free of symptoms in the puerperium. It is still questionable whether pregnancy itself is a risk factor for UI in later life or if it is the vaginal delivery that is the main risk factor. The authors also compared continent women having delivered vagi-nally with women who underwent a cesarean delivery and found a difference in favor of cesarean delivery. However, 3 months after delivery, the difference became statistically insignificant.

Sexual Function after Pelvic Surgery

Pelvic surgery to correct prolapse may affect sexual function for a number of reasons including narrowed vaginal canal, poor lubrication, and fear of urinary incontinence. Some studies suggest that sexual dysfunction can occur up to 20 of the time after surgery for prolapse or incontinence. It is thought that the vaginal dissection may lead to pelvic floor neuropathy affecting the pudendal nerve, which subsequently affects vaginal sensation and orgasm. Hysterectomy has been associated with sexual dysfunction. It is thought that removal of the cervix alters the upper portion of the vaginal canal and causes a neuropathy, which is the source for dyspareunia as well as anor-gasmia. However, studies in the literature are conflicting as to the exact cause of sexual dysfunction after hysterec-tomy.22 Another possible cause for dyspareunia is poor estrogenization of the vaginal mucosa in those women who undergo surgical menopause at the time of a hysterectomy. Techniques used to repair the...

S Evidence statements

Ten systematic reviews were identified that assessed the efficacy of a number of different interventions for urinary incontinence, though some of these contained data from the same trials (IIa). Four reviews examined the effectiveness of different behavioural bladder training programmes for urge, mixed and stress incontinence. The first review compared bladder training to no intervention, drug therapy (oxybutynin and flavoxate hydrochloride plus imipramine), pelvic floor muscle training and electrical stimulation. The results showed that there was weak evidence to suggest that bladder training is more effective than no treatment, and that bladder training is better than drug therapy. There was insufficient evidence that electrical stimulation is more effective than sham electrical stimulation.281 The second review assessed the efficacy of prompted voiding either alone or in combination with oxybutynin. The results indicated that prompted voiding was beneficial compared to no...

Anterior Colporrhaphy

Kelly Plication Suture

Anterior vaginal prolapse resulting from a central defect is best corrected through a transvaginal approach. The anterior colporrhaphy was popularized by Howard Kelly in 1912,2 and although no longer an acceptable treatment for stress urinary incontinence, it remains a commonly used technique for transvaginal correction of anterior vaginal prolapse today.Although many variations of this technique have been described in the last century, the basic approach is still similar to that originally described by Kelly.

Treatment Management And Cost

In addition to the primary medications used for symptomatic treatment of the specific motor symptoms of PD, there is also a need for complementary medication to treat the diverse non-motor symptoms (constipation, urinary incontinence, sexual dysfunction, orthostatic hypotension, sleep disorders, psychiatric symptoms such as depression, psychosis and behavioural disorders, and cognitive disturbances) that affect a significant number of patients with PD in the advanced stages.

Spinal Dysraphism in Adults

Adult patients with spinal dysraphism include those with new symptomatic onset of a previously unsuspected occult dysraphic condition and those with a known dysraphic lesion in childhood but with symptom onset only in adulthood. In both groups, unlike in childhood, pain is the most frequent presenting symptom. This may be poorly localized and bilateral, and coupled with weakness in the legs as well as sensory disturbance. Problems with bladder control, as well as erectile dysfunction, also occur frequently. Not infrequently, the problem only comes to light as a result of excessive stretching of the conus, as may occur in childbirth or trauma 25 . In those with a known dysraphic lesion, presentation in adulthood may be with a progressive scoliosis or foot deformity, although these features are generally not seen in an adult with a previously unsuspected dysraphism.

Laparoscopic Augmentation Cystoplasty


All patients consented to participate in a long-term outcome study using preoperative and postoperative validated questionnaires concerning bladder control (BLCS) and bowel control (BWCS). In regard to the quality-of-life For patients with complex comorbid illnesses desiring an improved quality of life associated with traditional augmentation cystoplasty, the reduced morbidity observed in our series of patients undergoing a laparoscopic procedure makes this approach an attractive option to consider. A clinically significant positive impact on their postoperative QOL related to their bladder control compared with their preoperative status will be achieved using a laparoscopic approach. Furthermore, this benefit in their QOL from improvement of their bladder control can be achieved without a negative impact on their bowel control. Our experience suggests that laparoscopic enterocystoplasty has become a viable alternative to open enterocystoplasty and is a surgical option to consider in...

Dysfunction Of Infravesical Mechanisms

* Detrusor hyperreflexia with impaired contractile function was defined as an overactive bladder with uninhibited detrusor contractions associated with low maximum detrusor pressure during the voiding phase of less than 40 cm of water with a slow pressure increase and a large post-void residual volume.6 Stocchi et al.36 studied 30 PD patients irrespective of presence of urological symptoms. They found that 27 (8 30) had an inability to relax the perineal muscles immediately and completely when asked to initiate micturition. This was their only abnormal finding (they had normal cystometrics). Not a single one is described with hesitancy or weak urinary stream. This subgroup of 8 patients had more severity and longer duration of disease than 11 patients with totally normal findings. An additional three patients (10 ) had the same abnormality but associated with detrusor hyperreflexia. One of the three patients had urinary incontinence, diurnal and nocturnal, but the authors do not...

Dissociative conversion disorder

Pseudo-seizures are more difficult to evaluate because they are episodic and often coexist with true epilepsy. An account from a reliable observer is invaluable but it is essential for the clinician to witness an attack before making a firm diagnosis. The clinical features, which simulate epilepsy to a varying degree, have been described in detail.44 During an attack there is marked involvement of the truncal muscles with opisthotonus and lateral rolling or jerking of the head and body. All four limbs may exhibit random thrashing movements which increase in amplitude if restraint is applied. Cyanosis is rare unless there is deliberate breath holding. Corneal and pupillary reflexes are retained although they may be difficult to elicit because the eyelids are kept firmly closed. Tongue biting and urinary incontinence are uncommon unless the patient has some degree of medical knowledge and has learned from experience that they are characteristic features of epilepsy.

Urethral Dilatation Incision or Reconstruction

Weighed against the complication of developing urinary incontinence. Curative therapy ranges from transurethral incision of the urethra to various forms of urethral reconstruction depending on the degree (mucosal vs transmural) and the area involved. For urethral reconstructions without bladder neck involvement, there is usually sufficient tissue of the anterior vaginal wall to use as pedicle flaps for reconstruction. If the vaginal tissue is extensively scarred, ischemic, or atrophied, other potential donor sites should be considered. These may include labial and perineal pedicle flaps, and rarely the use of rectus and gracilis pedicle flaps. We prefer to use buccal mucosa grafts (Figure 10-2.1) for urethral reconstruction in women when the anterior vaginal wall tissue is not applicable for reconstruction or the urethral defect is too large. This obviates the more disfiguring and morbid complications of muscle flaps or anterior bladder flap repairs (Barnes' bladder flap...

Fascia and Ligaments of the Pelvic Floor

Pelvic Floor Ligament Suspension

Posterior to the rectum is the mesorectum, which contains both blood vessels and lymphatics that supply and drain the rectum. This is loosely bound down the front of the sacrum and coccyx by connective tissue known as the fascia propria. The lateral ligaments, which attach the rectum to the pelvic walls, are condensations of the fascia propria and contain loose areolar tissue, nerves, and small blood vessels. Thus, the mesorectum can be mobilized by dissection in the mesorectal plane leaving the mesorec-tum invested in this thin layer of fascia. The sacrum and coccyx are also covered in a thicker fascia, which extends downward and forward, just superficial to the anococ-cygeal ligament known as Waldeyer's fascia. Anteriorly the rectum is covered with a layer of visceral fascia that extends from the anterior peritoneal reflection to the urogenital diaphragm. This is Denonvilliers fascia and lies between the rectum and vagina (or prostate in men). Nerves important to bladder control and...

Denervation Procedures

Because the etiologic mechanisms for the development of the OAB may lie in the neural control of the detrusor muscle, denervation procedures of the overactive bladder muscle has been tried with varying success using both central and peripheral approaches. Surgical or chemical denervation can be used at central or peripheral levels to interrupt motor and or sensory reflex pathways.

Symptomatology of Urogenital Atrophy

It is estimated that the urethral submucosal vascular plexus is responsible for up to 30 of urethral closure pressure. As a consequence, devascularization will lead to decreased urethral tone. This frequently presents with urinary urgency and frequency, presumably because of wetting of the proximal urethra during bladder filling. Nocturia is an exceedingly common symptom of urethral atrophy, and one that is promptly reversible with local estrogen in a more efficient manner than with an anti-cholinergic medication. Although hypoestrogenism leads to devascularization of the urethral submucosa, stress incontinence typically does not develop in an isolated manner secondary to menopausal urethral atrophy. Local estrogen is thus an important cofactor in the treatment of overactive bladder and stress incontinence symptoms. When used in combination with alpha-agonist medications, stress urinary incontinence symptoms may be reduced (Chapter 6-2).


The full document gives specific advice to clinical staff on a huge range of issues such as the management of bladder problems, the treatment of spasticity, therapy for reduced walking ability and the identification and management of difficulties in swallowing. One strong message


The goal of physical examination and subsequent investigation is to explain the symptoms, identify the causative mechanism and its risk factors, and finally propose treatment. Using sophisticated testing, it may be possible to even predict outcomes. For example, a patient with impaired bladder contractility on preoperative urodynamics, who is undergoing a sling procedure for stress urinary incontinence, may need to be taught clean self-catheterization after surgery. Preoperative counseling to predict such specific outcomes can help to avoid unsatisfied patients. Because pelvic floor disorders are mainly quality-of-life issues, it is imperative that physicians discuss with their patients their goals and expectations for the treatments offered to them.

Perineal Pad Tests

Perineal pad testing can be helpful in evaluating a patient complaining of urinary incontinence, when objective urine loss has not been demonstrated on routine office testing. The patient should be observed over a long enough period of time to witness their symptoms, with most common time intervals of either 1 hour or 24 hours.


Patients with bladder problems will have a variety of symptoms including frequency, urgency, incontinence, hesitancy, retention, and nocturia. In detrusor muscle hyper-reflexia, impaired bladder storage is pres The estimated prevalence of bowel problems varies, but figures of 46 to 68 for bowel symptoms in general, and 43 for constipation in particular, have been documented. Constipation is clearly not unique to MS, but commonly is seen in disabling neurologic disorders. It results from a variety of factors, including spinal cord involvement with slowed passage of the stool through the bowel, increased water absorption, and desiccation. There are also present the negative effects of weakness of abdominal muscles, reduced activity, poor diet, drugs, and an understandable but counterproductive desire to limit fluid intake because of concurrent bladder problems. As with the bladder, frequency and urgency may occur, but the most distressing problem is that of faecal incontinence. This may...


Dementia in the elderly roughly doubles the risk of urinary incontinence. (35* To minimize incontinence, toilets should be easily identifiable and readily accessible. Clothing may need attention to ensure that it is easy to remove. If urinary incontinence is present then reversible causes, such as urinary tract infection, constipation, and medication (such as diuretics or drugs with anticholinergic side-effects causing urinary retention and overflow) should be excluded.


The neurovascular anatomy of the perineum is illustrated in Figure 4-2.6. The motor and sensory innervation of the perineum is via the pudendal nerve. The pudendal nerve originates from S2-S4 and exits the pelvis through the greater sciatic foramen, hooks around the ischial spine, then reenters the pelvis through the lesser sciatic foramen. It then travels along the medial surface of the obturator internus, through the ischiorectal fossa in a thickening of fascia called Alcock's canal. It emerges posterior and medial to the ischial tuberosity where it pierces the perineal membrane and divides into three branches to supply the perineum clitoral, perineal, and inferior rectal (inferior hemorrhoidal). Damage to the pudendal nerve (i.e., birth trauma) can result in denervation of the periurethral muscles involved in reflex contraction during increased intraabdominal pressure resulting in stress urinary incontinence.

Chemical Structure

Apart from the study by Thomas et al. (1995), other studies have shown that adequate ECG monitoring of the patients during clinical trials ought to have identified the proarrhythmic risk. In the study by Yoshihara et al. (1992) in 109 Japanese patients receiving 24 mg daily of terodi-line for 4 weeks, side-effects such as orthostatic hypotension and arrhythmia were observed but these symptoms disappeared following discontinuation of the treatment. Of note is the prospective study of Stewart et al. (1992) in 8 elderly in-patients treated with terodiline for urinary incontinence. They found a significant increase in the QT interval by a mean of 29 ms, the QTc interval by 15 ms and a decrease in the resting heart rate by a mean of 6.7 beats per minute after 7 days treatment with terodiline 12.5 mg twice daily.

Pubovaginal Sling

In 1907, Von Girodano introduced the sling concept for treatment of urinary incontinence when he wrapped a gra-cilis graft around the urethra. However, credit for the first pubovaginal sling went to Goebell in 1910 when he rotated the pyramidalis muscles beneath the urethra and joined them in the midline. In 1914, Frangenheim used rectus abdominis muscle and fascia for slings. Stoeckel argued that the material used for the slings was not important in the outcome, and the success depends on a high urethral position and attachment of the sling to the abdominal muscles. Price described the first fascial sling in 1933. Millin used strips of rectus fascia, looped them under the urethra, and tied them over the top of the urethra. In 1942, Aldridge used fascial slings in conjunction with vaginal plastic operations. He mobilized strips of abdominal fascia, leaving the edges attached to the recti muscles medially, and tunneled the strips through the recti 4 cm above the pubis. The two ends...

Bulking Agents

For the past several decades, injectable bulking agents have been used for a growing number of people with varying degrees of stress urinary incontinence (SUI). The goal of this therapy for incontinence is to create coaptation and a better mucosal seal for the incompetent urethra. These agents improve intrinsic sphincter function as evidenced by an increase in posttreatment abdominal leak pressure measurements.


As with most anti-incontinence procedures, it is difficult to analyze the outcome of Contigen injection therapy for urinary incontinence because of varying definitions of reported cure. Early results have reported subjective cure rates of 85 to 95 . In a multicenter trial reported by O'Connell et al.1 in 1995 on periurethral Contigen injection for 160 females with ISD, 93.8 had significant improvement and 78.1 were completely dry after the injection. That same year, Monga et al.2 reported on 60 women with genuine stress incontinence using periurethral collagen injections. Subjective success rates were 86 at 3 months, 77 at 12 months, and 68 at 24 months. The long-term ( 2 years) success rates are not as favorable (26 -65 ), but some long-term cures are noted in this and other trials.

Clinical Results

Many studies have reported clinical experiences with retropubic urethral suspension procedures for stress urinary incontinence. Although most of these studies are methodologically flawed, increasing numbers of quality studies, including prospective randomized trials, have been or are being conducted. Currently, however, few prospec


Uroflowmetry Patterns

The curve is flat and unbroken, with a large part of the volume voided at a constant Qmax.4 Urinary flow rate provides useful information about whether there is outflow obstruction, especially in males. A flow rate greater than 40 mL s is considered superflow. It may be attributable to decreased outlet resistance,5 and is common in women, particularly those with genuine stress urinary incontinence (SUI) in which outlet resistance is reduced and in those with marked bladder activity. Although low Qmax may indicate urinary outlet obstruction, measurement of the flow rate alone has limited value when determining whether obstruction is present in a particular patient. To provide detailed information, uroflowmetry can be combined with a measurement of the postvoid residual volume (PVR). Postvoid residual volume is the bladder volume immediately after voiding. It reflects bladder contractility, and is an excellent assessment of bladder emptying. One method for measuring PVR is by...


Chronically, side effects, such as dementia, ataxia and urinary incontinence, occur in at least 5 of patients who survive longer than 1 year 10 . In one study, 50 of patients surviving for more than 2 years after surgical resection and WBRT developed leukoencephalopathy or atrophy-induced hydrocephalus ex vacuo. More prolonged fractionation schemes and more focal treatment are strategies designed to decrease the risk of dementia. Patients expected to survive longer than 6-12 months are often treated with 40 Gy in 2 -Gy fractions over 4 weeks. In an attempt to spare normal brain, fractionated local radiotherapy has been used for single metastases, but the relative effectiveness of focal and whole-brain therapy has not been studied. Additional local dose can also be administered as a boost to the lesion following WBRT.

Intravesical Therapy

Success of intravesical administration of anticholinergics for overactive bladder and detrusor hyperreflexia has been documented in many studies.15 However, secondary to the cumbersome nature of administration and the relatively short duration of action requiring repeated catheterization, intravesical anticholinergic drug therapy is not widely accepted. Intravesical administration of local anesthetics such as lidocaine has been shown to be effective for suppressing overactive bladder, but secondary to its short-term effectiveness, the use of intravesical lidocaine is limited to its diagnostic use for differentiating detrusor hyperactivity caused by lesions of the spinal cord versus lesions of the brain.

Vaginal Devices

Urethral Insertion Tampon

Pessaries have long been used to treat stress urinary incontinence. Standard-shaped pessaries, or those that have been modified with a ball or a protuberance, may successfully treat incontinence. These pessaries stabilize the bladder neck and increase urethral resistance. stress incontinence.5 Complications from pessary use are uncommon and include vaginal abrasions, ulcerations, urinary tract infections, and vaginal infection. These problems are rare if the pessary is cared for properly, removed and cleaned at least every 3 months, and if the patients concomitantly use estrogen locally in the vagina. We have not found any particular type of pessary to be superior in treating stress urinary incontinence. If the Smith-Hodge remains in place, it has theoretical advantages in providing bladder neck support. Table 6-1.1. Devices for the treatment of stress urinary incontinence Vaginal Devices Standard pessaries Figure 6-1.1. Devices for stress urinary incontinence include intravaginal...

Bladder Dysfunction

The treatment must fit the situation. Working up bladder problems begins with checking for infection. Obviously, infection can influence urinary function and must be treated with appropriate antibiotics. That being remedied, a residual urine (either by catheterization or by ultrasound) helps determine a large from a small bladder.

Vaginal Pessaries

Pessaries have long been used for the treatment of pelvic floor dysfunction in women. Initial descriptions of a vaginal device entailed intravaginal placement of objects to support genital prolapse and or administer therapeutic chemicals. Pessaries were originally designed to treat genital prolapse. Application of pessaries for women with stress urinary incontinence (SUI) are rather recent and will be discussed elsewhere. With the high coexistence of genital prolapse and urinary incontinence, it is likely that many women who were fit with a pessary for genital prolapse noted an improvement in their urinary incontinence. In addition, women with exteriorized prolapse may have occult stress incontinence, which is uncovered upon being fit with a vaginal pessary for reduction of the prolapse.


As with all patients with symptomatic pelvic floor dysfunction, a detailed history of bladder, bowel, and sexual function should be elicited. Patients with anterior vaginal prolapse often complain of symptoms directly related to the prolapse as well as symptoms of bladder dysfunction. Patients with prolapse at or beyond the level of the hymen often complain of pelvic pressure and bulging. Stress urinary incontinence often occurs in association with anterior vaginal prolapse and approximately one-third of women with stage II or greater prolapse will complain of symptoms of urinary urgency, frequency, and or urge incontinence. Symptoms of voiding dysfunction such as a feeling of incomplete emptying, intermittent or reduced urine flow, or the need to splint to complete urination are common in women with prolapse beyond the hymen. Sexual difficulty is also a common complaint of women with advanced prolapse. In addition to this functional assessment, a detailed history of previous prolapse...

Diagnostic Tests

Symptoms of urinary incontinence and voiding dysfunction are common in women with advanced vaginal prolapse. Additionally, because significant anterior vaginal prolapse often results in urethral kinking that may mask underlying stress incontinence it is our practice to obtain preoperative urodynamics with vaginal packing or pessary placement to evaluate the lower urinary tract in these patients.


Postoperative complications from the repair of advanced anterior vaginal prolapse are not unlike those of other vaginal reconstructive procedures. These may include prolonged urinary retention, de novo urinary urge or stress incontinence, recurrent prolapse, or vaginal shortening. Urinary retention is usually a transient phenomenon and often resolves on its own. Rarely, one may require a prolonged course of suprapubic catheter drainage or intermittent catheterization until satisfactory spontaneous voiding occurs. De novo urinary incontinence (urge or stress) may occur in a small portion of patients, quite


Although this patient did not demonstrate paradoxical contraction of the puborectalis muscle during defecogra-phy, she did demonstrate significant levator hypertonicity on vaginal and rectal examination. This likely contributed to her rectal prolapse because of the need to perform intense Valsalva efforts for bowel evacuation. Providing further evidence of increased pelvic floor tone is the rather elevated urethral closure pressure at 195 cm H2O. This may have provided her protection from developing stress urinary incontinence.


The reverse of this extension can be similarly achieved using this stimulating and sensing system to bring the grasped object, for example, to the mouth. Similar closed-loop controls of stimulation could be used in the lower extremities for standing and ambulation. For partially paralyzed extremities, sensing of the muscle activities using BPBs would act as triggers to other BPBs to stimulate the motor-points of these muscles, thus augmenting the total action. Goniometry sensors would add the closed-loop controls to reduce or stop the actions. This approach could be used to augment swallowing, bladder control, and respiration.

Botulinum A

Botulinum A toxin inhibits the release of acetylcholine from the presynaptic neuromuscular junction that leads to muscle relaxation. The actions are temporary because axonal regeneration occurs in approximately 3 to 6 months. Botulinum A toxin has been used in patients with detrusor sphincter dyssynergia and refractory overactive bladder. Two studies have reported the use of botulinum A in patients with voiding dysfunction. Phelan et al.13 performed a prospective evaluation of the injection of 80 to 100U of botulinum A into the external urethral sphincter in 8 men and 13 women with voiding dysfunction secondary to neurogenic detrusor sphincter dyssynergia, pelvic floor spasticity, or an acontractile bladder. All patients except one were able to void spontaneously, and all but two were able to discontinue the use of catheterization. Larger randomized controlled trials are needed to determine long-term safety, efficacy, and durability of treatment. Potential side effects include...


Withdrawal of estradiol during menopause results in thinning of the mucosal layer. The vaginal and urethral mucosa appear pale, dry, and flattened. These changes are associated with vaginal dryness, dyspareunia, atrophic vaginitis, urethritis, and urinary incontinence. Use of systemic estrogen replacement or local estrogen creams and urethral suppositories can reverse these changes.

Habit Training

A voiding diary is the starting point for bladder training by allowing the patient to see how often voiding and incontinence actually occur. This is then used to set a voiding interval. Patients who are infrequent voiders are instructed to do timed voiding every 2 to 2-1 2 hours during waking hours. Regular bladder emptying should result in less incontinent episodes. Patients are then instructed to increase the voiding interval by 15 to 30 minutes per week in order to achieve voiding every 3 to 4 hours while awake with less urgency and less incontinence. Timed voiding has been proven effective in patients with urgency, frequency, and urge and stress incontinence. The goal of retraining is increased functional bladder capacity. The initial prescribed voiding interval may be as little as every 30 minutes in patients whose baseline diaries show voiding occurs more often than every 30 minutes. Urge suppression strategies assist with maintaining bowel and bladder control by educating...


Pharmacotherapy is used for detrusor instability (urge incontinence) and stress urinary incontinence. 6. Estrogen replacement, either oral or vaginal, should be used as an adjunctive agent for postmenopausal women with stress urinary incontinence. The combination of an alpha-agonist and estrogen have a synergistic effect. Progestin should be added in patients who have a uterus.

Primary parasomnias

Nocturnal enuresis(48) is very common, affecting about 5 per cent of 7-year-olds at least once a week. Delayed maturation often seems to be the explanation, but physical or psychological factors may be involved especially where previous bladder control is lost. Behavioural treatment can be very effective. The term nightmare is sometimes used misleadingly for any form of dramatic parasomnia. True nightmares (frightening dreams) are common.(49) If frequent and associated with intense bedtime fears, they may indicate an anxiety disorder and their content may suggest the cause.

Sexual Function

At the current time, we are using two sexual function questionnaires, the Pelvic Organ Prolapse - Urinary Incontinence Sexual Function Questionnaire (PISQ-12) (Figure 14-3.4) in its short 12-item form, and the McCoy Female Sexuality Questionnaire (MFSQ) (Figure 14-3.5). These instruments were selected with the help of the sexual function member of our Pelvic Floor Center.

Multiple Sclerosis

Fibers causing nerve electrical transmissions to become dysfunctional. The cause is not known but the two most prominent theories are a virus or autoimmunity in which the immune system mistakenly attacks the sheaths. Stress, environmental toxins, and food sensitivities can exacerbate the condition. Symptoms vary and include muscle weakness, loss of coordination, loss of vision and bowel and bladder control, and paralysis. The illness can stabilize or go into remission. In studies, a low-fat diet has been shown to improve symptoms significantly. The Swank diet is recommended. Regular exercise is beneficial. Some individuals have experienced benefits from apithery, a treatment involving bee venom which has anti-inflammatory properties.

Back Pain

Cation of cancer somewhere in the body. If back pain is accompanied by numbness or tingling in the legs, pain shooting down a leg to the knee or foot, inability to move legs and feet, urinary incontinence or stomach cramps, chest pain or fever, see a physician immediately. Otherwise, most back pain will subside in a matter of days, weeks, or possibly several months with proper rest and care.

Bone metastases

Surgical intervention for metastatic breast cancer to the bone is usually reserved for either the fixation of pathologic fractures, stabilization of weight-bearing bones with impending fractures, or for acute spinal cord compressions which may result in life-threatening or significant functional neurologic compromise that can lead to bowel or urinary incontinence (31, 32). It is estimated that 5 of all cancer patients will develop metastatic spinal cord compression during the course of their disease, with urgent


Various clinical studies have demonstrated the effectiveness of oxybutynin in controlling OAB. In a randomized study that compared the immediate- and extended-release formulations of oral oxybutynin, the mean number of weekly urinary incontinence episodes was reduced by 88 and 84 , respectively. Although effectiveness was high, so was the incidence of dry mouth - 68 for extended-release oxybutynin and 87 for immediate-release oxybutynin.7