| 
YITZHAK BERGER, M.D.
Attending Urologist, Saint Barnabas Medical Center and Associates
in Urology
 Recent epidemiological investigation into the incidence
of bladder dysfunction, urinary incontinence and recurrent
urinary tract infections (UTI), surprisingly, revealed a higher
than expected incidence of these conditions.
According to different estimates, there are roughly 33 million
adult Americans who are affected by the symptoms of urinary
frequency and urgency, with or without additional urge urinary
incontinence. This condition, called overactive bladder (OAB),
has an overall prevalence of 16 percent in women and 17 percent
in men. The incidence of OAB increases with age and approximately
one-third of men and women who are 75 years of age or older
suffer from this condition.
If one is to consider the total incidence of urinary incontinence,
including the involuntary loss of urine with coughing, sneezing,
laughing, or physical activity (stress urinary incontinence),
the prevalence increases to roughly 40 percent of the adult
American population. And finally, if one adds the incidence
of urinary tract infections, which again, significantly increases
with age, then the impact of these conditions on the aging
American and non-American population is substantial.
These conditions (bladder dysfunction, urinary incontinence
and recurrent UTI), are associated with a significant burden
from a medical, social and economic
aspect of life.
The medical complications are associated with hospital admission,
deterioration of preexisting conditions, skin breakdowns and
increased incidence of injuries secondary to a fall when one
hurries in an attempt to get to the bathroom (especially at
night). The social impact of urinary incontinence on the individual's
quality of life, the eventual need for the elderly person
to enter into a nursing home and/or their disengagement from
socializing may lead to subsequent depression and can be extremely
detrimental. And finally, it is estimated that the entire
management of urinary incontinence in the U.S. has an economical
cost of approximately $15-$20 billion dollars a year.
The normal urinary bladder has two functions. The first
is to store the urine and the second is to release it when
it is socially and physically acceptable. Any involuntary
loss of urine is considered to be urinary incontinence. The
bladder maintains these functions through a complex neurological
system that is controlled by the brain via the spinal cord.
During the storage phase, neurological receptors throughout
the urinary bladder inhibit bladder contraction on one hand
and contract the continence mechanism at the neck of the bladder.
The reverse occurs through a command from the brain via the
spinal cord that releases the inhibition on bladder contractility
and leads to stimulations of various neurogenic receptors.
This results in a contraction of the bladder on one hand and
relaxation of the bladder neck and the sphincter mechanism
on the other hand, and subsequent evacuation of urine.
In the aging population, many bladder and non-bladder abnormalities
occur, resulting in the lack of urinary control. The causes
that are not directly associated with the bladder are neurological
conditions, such as stroke, Parkinson's disease and dementia.
In women, relaxation of the muscle structures in the pelvis
result in decreased muscle tone and subsequently diminished
support for the bladder and the urethra. This results in increased
incidence of stress urinary incontinence (SUI).
Other medical conditions have a negative impact on bladder
function. These include pelvic surgery, hysterectomies in
woman and prostate surgery in men (for both benign and malignant
conditions), certain types of medications that affect bladder
function and various conditions such as diabetes, hypothyroidism,
etc.
The direct aging effect on the bladder, especially in women,
seems to be related to three causes:
In the aging and estrogen-deficient bladder, there are
fewer neurological receptors. This results in diminished bladder
inhibition during the storage of urine and the subsequent
development of overactive bladder.
Reduced elasticity and coaptability
(the sealing properties) of the urethra results in the symptoms
of stress urinary incontinence (SUI). with pathogenic types
of bacteria and subsequently increased incidence of UTIs.
Studies have clearly shown the benefit of restoring the
normal blood supply within the vaginal cavity following estrogen
replacement therapy and subsequently reversal of the recurrent
UTIs. There is also evidence that estrogen replacement increases
urethral circulation, thickening of the lining of the urethra,
and that improves the symptoms of stress urinary incontinence
as well.
The treatment of the various types of urinary incontinence
include pelvic muscle exercises (Kegel exercises), biofeedback
rehabilitation of the structure of the pelvic musculature,
various medications and surgery. We will briefly discuss each
modality of urinary incontinence and the recommended treatment
for each specific condition.
The patients experience urinary frequency with an immediate
need to urinate (urgency), with or without additional symptoms
of urge incontinence, and at times the need to urinate at
night. These symptoms are caused by involuntary bladder contractions
and the patients are instructed to use their pelvic floor
muscles in an attempt to interrupt these uncontrolled bladder
contractions. Many patients, especially the ones who are relatively
medically and mentally fit, are capable of controlling most
of their OAB symptoms with such approach. The others, however,
need to be treated with various pharmacological agents. These
include oral medications such as Ditropan XL or Detrol LA
and other older medications.
Of Note: We at Associates in Urology, who are members of
the Division of Urology at Saint Barnabas, are involved in
ongoing clinical research that investigates the efficacy of
each of those medications. Our experience based on these studies
has been that these medications (Ditropan XL and Detrol LA)
are both excellent, highly tolerable and have no substantial
difference between the two of them. Recently a patch (oxytrol)
was introduced and time will tell whether its efficacy with
regard to the control of bladder dysfunction and safety with
regard to side effects will be comparable to the oral medications.
We recently completed another study for a new medication
for OAB. This medication is expected to target the bladder
more specifically with fewer systemic side effects such as
dryness of the mouth and eyes and constipation. The results
will be published soon. And finally, a more aggressive treatment
for symptoms of OAB is indicated for patients who did not
benefit from other treatment. These include the percutaneous
placement of a pacemaker-like system. We use this device,
called sacral neuromodulation (Interstim), only when all other
conservative modes of treatment have failed.
In this condition patients leak urine during different physical
activities such as exercising, dancing, coughing, laughing
or sneezing. Again, the initial management should consist
of Kegel exercises. So far, pharmacological treatment for
this condition has only limited therapeutic efficacy, most
notably with medication such as imipramine.
Most recently, duloxetine, a new class of medication, was
introduced and is currently being tested but it is not FDA
approved. Recent preliminary studies showed an approximately
50 percent reduction in the episodes of SUI in these patients.
We at Associates in Urology are currently involved with an
ongoing multicenter clinical trial that studies the efficacy
of duloxetine.
A subclass of SUI is associated with weakness of the urethral
closing (leaky urethra). In this condition, called Intrinsic
Sphincteric Deficiency (ISD), the patients have the typical
symptoms of SUI but the cause is diminished sealing properties
of the urethra. Patients with ISD can be treated with Kegel
exercises and subsequent injections of bulking agents, such
as Collagen, into the urethra. In postmenopausal women with
physical findings of urethral and vaginal thinning (atrophy),
estrogen replacement therapy plays a very important role.
For women with SUI in whom the cause is weakness of the
supporting muscles around the urethra, surgical management
may be the best therapy. As a representative of Saint Barnabas
Medical Center, I was one of the original investigators for
a new and revolutionary minimally invasive surgical procedure
to correct SUI in women. This procedure, called tension-free
vaginal tape (TVT) involves the placement of a porous synthetic
tape around the midurethra.
Of Note: The first case of a TVT in North America was performed
at Saint Barnabas Medical Center. Our data showed a success
rate of approximately 92 percent and these data were presented
in meetings both in the U.S. and abroad. We are currently
collecting data from our first 450 cases to be presented next
year and eventually will be the subject of an upcoming publication.
This condition can be classified into complicated and uncomplicated
UTIs. In complicated UTIs, the patient has either recurrent
episodes of infection, suffers from neurogenic bladder dysfunction,
immunosupression, diabetes, or experiences symptoms such as
fever and chills, back and flank pain and blood in the urine.
Those patients should be treated based on the specific findings
of bacteria in the urine (urine culture) and the specific
sensitivity of the bacteria to various antibiotics. Following
the treatment of UTIs, the urine culture should be repeated
to assure complete sterility of the urine.
It is advised that patients with complicated urinary tract
infections should be referred for further urological investigations
such as kidney ultrasound, intravenous pyelogram (IVP) and
cystoscopic examination of the bladder and the urethra. Some
elderly and postmenopausal women with recurrent episodes of
UTIs can benefit from estrogen replacement therapy, but these
issues should be discussed with their gynecologists.
To find a Saint Barnabas urologist call 1-888-SBMC.
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