Voiding Disorders PracticeHome > Patient Care > Voiding Disorders Practice
With an emphasis on voiding dysfunction in female urology patients, the practice established by Jason Gilleran, MD, offers a complete range of diagnostic and therapeutic capabilities. Dr. Gilleran’s emphasis in this area has been of great clinical and educational value to the department.
We hope that the following information is helpful to women and men with this bothersome and common condition, and answers several questions you may have with regard to why this problem occurs in some people and the services we at The Ohio State University Medical Center can offer.
URINARY INCONTINENCE
Urinary incontinence is a common and bothersome condition that affects millions of women and men. There are two major types of incontinence. Stress urinary incontinence is defined as involuntary loss of urinary control during exertion, such as with sneezing, coughing, laughing, or lifting a heavy object. Urge urinary incontinence is defined as involuntary urinary leakage accompanied or immediately followed by a strong urge to void. Patients with this problem will often report an inability to “make it to the bathroom on time.” Mixed urinary incontinence means both types are present. These distinctions must be made during clinical evaluation, since treatment for each type of urinary incontinence can be quite different.
Many will shy away from long car rides, public places, or athletic activities to avoid an embarrassing leakage. Others will urinate frequently to avoid overfilling the bladder and increasing the chance of accidents.
Stress urinary incontinence occurs because of either a loss of bladder support, weakness of the urinary sphincter (the muscles around the urethra that keep it closed), or a combination of both. Treatment depends on the type and degree of stress incontinence. To date, there is no medicine strictly aimed to correct stress incontinence that has been approved by the US Food and Drug Administration (FDA).
Urge urinary incontinence may occur secondary to other causes, including infection, neurologic disease, foreign body or even early malignancy (bladder cancer). Once these have been excluded, therapy relies upon a combination of behavioral therapy and pharmacologic intervention with good, fairly reliable results.
EVALUATION
A thorough and complete evaluation is essential and will include a history of the duration of incontinence, degree of incontinence – often measured by number of pads or diapers used – and degree of bother or impact the incontinence has on one’s “quality of life.” Your doctor will likely ask for a urine sample to rule out infection or blood in the urine. After you urinate, you may be asked to undergo a bladder scan, which is painless and can measure if the bladder is not emptying entirely. An examination will be done to look for any anatomic abnormalities that could explain symptoms. Your doctor will often ask you to do maneuvers that may provoke loss of urine; it is important not to be embarrassed by this, as it is a normal part of the exam and will help your doctor to determine the reason for the leakage and how to correct it.
In some cases, your doctor will ask for a fluid intake and voiding diary, which involves recording the amount of fluid you drank, episodes of incontinence, and volume of each urination over a 2 day period. You may be asked in addition to complete some simple questionnaires about your condition. A bladder x-ray or cystogram may be done at a separate visit. Lastly, you may be advised to return for a urine function study, or urodynamics, which involves filling the bladder and measuring pressures to assess for type of leakage, and abnormalities with storage and emptying of the bladder.
TREATMENT OF URGE URINARY INCONTINENCE
Since the bladder is designed to store urine and empty to completion, it is important to remember that fluid intake – both the amount and type of fluid – can have a large impact on urinary symptoms. In general, most adults need no more than 64 fluid ounces per day (eight 8 ounce glasses) to maintain good hydration. Beverages such as coffee, tea, and soda pop (diet or regular) can also affect urinary symptoms by acting as a diuretic (creating more urine in a shorter period of time), or as a bladder irritant or stimulant. Minimizing caffeine intake can result in a dramatic improvement in urinary symptoms.
Your doctor may also counsel you on specific urgency control techniques, such as Kegel exercises, and/or to maintain a regular voiding schedule (also known as “timed voiding”) to minimize overfilling of the bladder.
It is also important to remember that other parts of the pelvis can affect how the bladder behaves. Severe constipation can indirectly affect how the bladder behaves. Bowel regulation with diet modification, stool softeners (docusate or Metamucil), or even gentle laxatives (such as Milk of Magnesia) can improve bladder function. Also, in cases of severe vaginitis after menopause, topical estrogen therapy (Premarin or Estrace cream) may be prescribed 3 times weekly at bedtime to help strengthen tissues and in turn help with bladder symptoms.
If these efforts have not made a significant impact on symptoms, you may be prescribed a medication to relieve bladder symptoms. Examples include oxybutynin (Ditropan, Oxytrol), tolterodine (Detrol), darifenacin (Enablex), solifenacin (Vesicare), or trospium (Sanctura). All of these medications can have the side effects of dry mouth or constipation, so it’s important to let your doctor know if these occur, and to avoid drinking more fluids as this can “negate” any beneficial effects the medicine may have.
More advanced and sophisticated treatments for this condition are available if the above measures have failed. These include sacral neuromodulation therapy (InterStim), percutaneous tibial nerve stimulation (Urgent PC), and botulinum toxin (BoTox).
The InterStim device (see figure) is an FDA-approved implant for the treatment of chronic urgency/frequency, urge incontinence and some forms of urinary retention (the inability to empty the bladder). Placement of a small electrical lead in the sacrum, or tail-bone, is done as a minor, outpatient surgical procedure and takes between 30-90 minutes. The lead, once in place, is brought out through a small opening in the skin and connected to a temporary generator that provides constant, low-level electrical stimulation to a particular nerve that helps control the bladder and pelvic floor. If after the “test phase”, which lasts between 10-21 days, we see significant improvement in symptoms, we proceed to a second stage. This is also a minor surgical procedure that takes less than 30 minutes and involves placement of a permanent generator, similar to a pacemaker, underneath the skin that can operate uninterrupted and continue to provide relief of urinary complaints. More on this device can be found at the manufacturer, Medtronic, web site: www.medtronic.com/hic/bladder.html.
The Urgent PC works similarly to address chronic urgency/frequency and urge urinary incontinence via placement of a small needle (so small that most patients can not even feel it) just above the ankle to locate a nerve that can provide feedback to the tail-bone and in turn the bladder. Treatment involves about 12 thirty-minute sessions, either once weekly or every other week, or until bladder symptoms improve. More information can be found at www.uroplasty.com/UPC_US.asp.
BoTox is a medicine that is best known for its use in cosmetic surgery, but has new applications in the treatment of urinary incontinence. Although it is not yet FDA-approved, there has been substantial evidence on its efficacy, and is currently available either as part of an approved research study at Ohio State (see Dignity Study below) or as an out-of-pocket expense, since most insurances do not yet cover this treatment.
TREATMENT OF STRESS URINARY INCONTINENCE
As there is no FDA-approved oral medication for stress incontinence, the treatment options focus on correcting the anatomy. Non-invasive treatment options include vaginal electrical stimulation, also known as “e-stim” (see figure), which is designed to strengthen the muscles around the urethra. This in turn can improve bladder and urethral support, improve sphincter strength, and in turn improve or correct incontinence.
The most common and popular surgical procedure for stress incontinence is the urethral sling procedure (see figure). This is a minor surgical procedure that is usually done under an anesthetic with a one-night hospital stay. Your doctor will discuss the types of slings, risks of the procedure and expected outcome with regard to either significant reduction of “cure” of incontinence, if he feels this is the best option. Newer slings that have recently entered the market may offer even faster recovery and can often be done as an outpatient.
In cases of mild incontinence or if your doctor feels you are not a candidate for a sling, he may discuss ‘bulking agent’ therapy, which involves bulking or “puffing up” the urethra to increase resistance and lessen urinary leakage. This is done in the office as an outpatient procedure under a light sedative and carries minimal risk.
There are currently two approved studies enrolling patients in the field of Incontinence and Female Pelvic Medicine at The Ohio State University Medical Center. Please feel free to read and see if you potentially qualify as a candidate for either study; further contact information is provided.
1. The Dignity Study: We are currently enrolling patients with urinary incontinence due to a “neurogenic bladder,” which due to a neurologic condition, such as multiple sclerosis (MS) or spinal cord injury (SCI). This is an industry-sponsored study to test the effects of botulinum toxin (BoTox) on treating this type of incontinence. Candidates can find out more about the study at www.dignitystudy.com, or by contacting our office at 293-8155, or contacting Study Coordinator Lisa Hafer at 293-7877.
2. Interstitial Cystitis Spectroscopy Study: We are enrolling patients who suffer from interstitial cystitis (IC), also known as painful bladder syndrome (PBS), which is a chronic condition associated with urinary frequency, urgency and suprapubic or pelvic pain. Currently there is no available urine or blood test to diagnose IC/PBS, but we are investigating a potential method of differentiating patients who have this condition compared to patients who do not (controls). Enrolled subjects will be asked to fill out questionnaires, provide a urine sample, and small blood sample that can be obtained by finger-stick only. Please contact Dr. Gilleran’s office at (614) 293-8155 to set up an appointment and find out if you qualify for this study. About Dr. Gilleran...
Jason P. Gilleran, M.D. is currently Assistant Professor at the Department of Urology at The Ohio State University Medical Center in Columbus, Ohio. He is Director of Female Pelvic Medicine and Reconstructive Surgery and joined the faculty in September 2005. Dr. Gilleran is a board-certified member of the American Board of Urology (ABU) since 2007, and is a member of the American Urologic Association (AUA), Society of Female Urology and Urodynamics (SUFU), and the North Central Section of the AUA. He also serves on the Board of Directors currently for the Ohio Urologic Society (OUS). He received his M.D. degree from Wayne State University School of Medicine in his hometown of Detroit, Michigan. He completed his residency training in Urology at the University of Illinois in Chicago and finished a fellowship under the training of Dr. Philippe Zimmern and Dr. Gary Lemack in Female Urology, Incontinence and Urodynamics at the University of Texas Southwestern Medical Center in Dallas, Texas in 2005. Dr. Gilleran’s clinical interests lie in complex urinary incontinence and voiding dysfunction cases, as well as pelvic organ prolapse, benign prostatic hyperplasia, and painful bladder syndrome/interstitial cystitis. He also specializes in reconstructive cases, such as urinary fistulae, recurrent prolapse, and urethral stricture disease. His academic interests include neurogenic bladder, voiding dysfunction, and a multidisciplinary approach to PBS and other chronic pain conditions. He has authored many peer-reviewed journal articles, several book chapters, and review articles, as well as serving as a reviewer for Journal of Urology, Urology, and British Journal of Urology International. Dr. Gilleran is currently accepting new patients and appointments can be scheduled through (614) 293-3648 or (614) 293-8155. |
