Editor’s note: This is the second of a two-part series on female incontinence with Lehigh Valley Health Network urologist Dr. Shawn Mendonca.

By Kristine Porter

kporter@tnonline.com

When natural methods for incontinence in women stop working, there are medication and surgical treatments.

Dr. Shawn Mendonca, a urologist with Lehigh Valley Health Network, explained that there are three main types of incontinence: stress incontinence, urge incontinence and overflow incontinence. Urge incontinence is also known as overactive bladder.

Stress incontinence occurs when a person coughs, sneezes or exerts themselves. Urge incontinence occurs when the bladder contracts sooner than expected. This creates a sudden urge to run to the bathroom.

Overflow incontinence is when a person’s bladder doesn’t function at all. This occurs most often in people with spinal cord injuries, advanced stages of multiple sclerosis or spinal surgery.

A woman can have one or both, but rarely all three.

Treatments for stress incontinence

There are two surgical options for stress incontinence. The most minimally invasive procedure uses a bulking agent.

Mendonca explained that a camera is slid through the urethra and a substance is injected to narrow the lumen of the urethra.

“With a narrowed lumen, patients are less likely to leak,” he said.

It’s an outpatient procedure, and recovery is quick.

The second surgical option is a sling. It supports the urethra and offers some type of resistance to prevent the leakage of urine.

The procedure is also an outpatient surgery, and takes about 30 minutes. Patients are told to not lift anything over 15 pounds for six to eight weeks.

Mendonca said he likes to use a mesh-based sling, because it is durable and has a long-lasting result.

“This is not the mesh that has been banned by the FDA,” he said. “The downside of using mesh is that it is a foreign object. There is always a risk of erosion into the urethra and vagina.”

There is also a non-mesh sling that takes a piece of tissue from either the leg or the abdominal wall.

With any surgery, there are risks of complications. It’s rare, but it does happen.

“The sling surgery is more invasive than the bulking agent,” Mendonca said. “The bulking agent lasts three years. The sling is supposed to be once and done.”

If the sling does need to be replaced, it can.

Treatments for urge incontinence

Behavioral modifications and physical therapy can be combined with medication for a patient with urge incontinence.

Mendonca said there are two classes of medications. One is called anticholinergics and the other is called mirabegron. The down side of medication is that it has to be taken every day.

“The way both of these medications work is by relaxing the bladder and prevent it from contracting sooner than we want it to,” he said.

The difference between the two medications is that they work on different receptors.

Anticholinergics are inexpensive and covered by most insurance companies and Medicare, he said. Another positive is that the dose can easily be titrated up or down.

The down side is that there are possible side effects, such as dry eyes, dry mouth, constipation, and it can increase the risk of dementia in elderly patients.

“The mirabegron (Myrbetriq), in my experience, works way better than the anticholinergics, and the side effect profile is great. It’s very, very rare you have a side effect,” he said. “I love the medication.”

The problem is the price tag. It can cost about $500 a month and isn’t covered by most insurances.

It isn’t side effect free. Some people have complained about a slight increase in blood pressure.

Another option for urge incontinence is a third line therapy - Botox injection. Mendonca said a camera is slid through the urethra into the bladder, and a needle is used to inject Botox into the bladder.

“It’s a very potent medication to help relax the bladder and works really, really well,” he said. “Each poke feels like a mosquito bite.”

The downside is that it only lasts six to nine months. Complications are very rare, but if there is one, the upside is that it wears off.

When a complication occurs, it is usually an infection or a little bleeding, and is treated easily.

One risk Mendonca said is that sometimes it relaxes the bladder so much that the patient’s bladder is unable to squeeze. If that happens, then the patient has to catheterize herself in order to empty the urine until the medication wears off. It could be a few weeks or a few months.

The last option is sacral nerve stimulation, which Mendonca compares to a pacemaker for the bladder. He explained that the device is implanted in the patient and is connected to the nerves that are connected to the bladder. It stimulates these nerves to suppress the urge to urinate by suppressing the contraction of the bladder.

The device is about 2 inches long. The leads are attached to a battery that is strapped around her. If symptoms improve, then the battery is implanted just under the skin on the patient’s buttocks.

“It sounds a little scary, but every patient I’ve done this on has been extremely thankful, extremely grateful,” he said. “They’re very happy, especially when they’re really miserable with their urinary symptoms.”

If it doesn’t work, then the device is removed and the patient goes back to the way life was beforehand.

“Of all the treatments I’ve talked about, its very efficacious,” he said.

overflow incontinence treatments

Recently, the sacral nerve stimulator has been used to treat women with overflow incontinence, Mendonca said. A woman with this condition cannot empty her bladder and it is always full.

As long as she can urinate and there are no obstructions, this device can stimulate the bladder to contract, he said. It’s a different effect than it has for people with urge incontinence.

The only other treatments for women with overflow incontinence is to catheterize themselves every few hours to empty the bladder or to get a super pubic tube. This tube goes in through the belly to the bladder and drains the bladder. It is changed once a month.