Anatomy of female pelvis
Urinary Incontinence (Loss of urinary controll)
Types of Loss of Bladder Control (Incontinence)
Test For Loss Of Bladder Control
TREATMENT Of Incontinence Or How To Restore Bladder Control
The Female Pelvis contains 4 important organs. Urinary bladder is located just behind a pubic bone (Symphysis). Above the urinary bladder is uterus. Behind the urinary bladder is Vagina; behind the vagina is rectum which opens at the Anus.
All these structures are supported by the pelvic sheet of muscle called levator Ani.
On each sidewall of the pelvis is ovary suspended by ovarian ligament and surrounded by uterine tube (Fallopian tube). It is important to appreciate the location of these organs. Bladder is a storage bag for the urine, which is produced by the kidneys. The size of the bladder is variable, 350ML - 800ML (12 -25 oz).
The Urinary Bladder is a muscular organ (Detrusor muscle). The Bladder cavity leads into neck of the bladder which leads into the pipe (Urethera). These bladder muscles are controlled by two types of nerves. The nerves which contract the bladder muscles and cause urination are called Parasymphathetic nerves. The nerves which help in relaxing the bladder are called Sympathetic nerves. These sympathetic nerves also control the bladder neck muscles and muscles in the Urehra.
Please note that pelvic organs are supported by pelvic floor muscle which forms a hammock suspended between pubic bone in front and sacrum behind. When these muscles become weak as in childbirth the pelvic organs drop down, similar to a hammock getting torn in the middle and person falling through it! The pelvic floor muscles are important for female sexual response. The pelvic floor muscles are wrapped around the lower 1/3 of vagina. The contraction of this muscle is felt by the male partner. The vagina can grip the penis firmly. This enhances the sexual sensations in both partners. The superficial part of pelvic muscles consists of smaller muscles (bulbo-spongiosis and ischio-cavernosus). These muscles surround the clitoris in females and base of the penis in males. This is responsible for pumping action of the clitoris in women and pumping action of penis in men, experienced during ejaculation. It is evident that a strong pelvic floor muscle will result in stronger orgasms in both partners. It is particularly important in women after childbirth when pelvic floor muscles become stretched and vagina becomes very wide and loose. She looses most of the sensation in her vagina and can hardly feel the female partner. Similarly a male partner does not get any sensation from vaginal penetration. The quality of sexual intercourse is seriously affected. However this condition is fully reversible by means of pelvic floor exercises. (see below)
Loss of Bladder Control is common, one in every 10 women has a bladder control problem. It may be just few drops or total lack of control. 12 Million Americans suffer from lack of bladder control.
There is no more distressing lesion than urinary incontinence - a constant dribbling of the repulsive urine soaking the cloths which cling wet and cold to the thighs making the patient offensive to herself and her family and ostracizing her from society.
(Howard A Kelly, 1928)
Urinary incontinence is present in 25% general female population. It increases with age, childbirth and any neurological disease. Urinary incontinence is the most common reason for committing our elderly parents to nursing homes
Loss of urine during coughing, sneezing, running, exercising and lifting. During these actions the bladder neck opens up due to lack of posterior support and urine leeks down the urethra. It is usually experienced during standing position. It does not happen while lying down. Main reason is the weak pelvic floor muscles which do not give adequate support to the bladder. During childbirth pelvic floor muscles are overstretched and become weak. Weakness of the pelvic floor also takes place with advancing age.
When sudden urge to urinate cannot be stopped and urine leaks out despite the best effort on part of the patient. This usually happens upon arriving at the front door and as soon as once put the key in the door, there is not enough time to reach the bathroom and urine leaks out (Key in the door syndrome). Individuals who have a long commute home are forced to have a container in the car to urinate (Jar in the Car). This condition is due to sudden spasms in the bladder muscles (Over active Bladder) which cannot be controlled.
In this condition bladder is generally full even after urinating. The urine spills out of the full bladder. This can closely resemble the stress incontinence or urge incontinence. This generally occurs in elderly diabetic patients. The neurological disorders e.g. Lumbar Disc disease multiple sclerosis can cause loss of bladder function which leads to incomplete emptying which is not sense by the patient.
The tests commonly used to distinguish between various types of incontinence are as follows.
This test measures the capacity of the bladder, sensation in the bladder and strength of the bladder muscles. This part of urodynamics is called Cystometry. The pressure can also be measured in this urethra which is the tube through which urine comes out(Urethral pressure measurement). The speed at which the urine comes out can also be measured. this is called Uroflometry. A small tube is inserted into the bladder and connected to a computer for recording of various measurements. it is a simple test done in the office. It generally takes 20 minutes to perform. it is painless and one can return to work if need be.
The bladder is filled with special liquid which can be seen on the X-Ray (Contrast medium). The X- Ray pictures are taken. This test gives information regarding the shape of the bladder.
When urodynamics tests and X-ray test are done together so that function of the bladder and the shape of the bladder can be tested simultaneously, this test is called Video Urodynamics.
This test examines the inside of the bladder by means of a telescope called Cystoscope. Bladder conditions like Tumor, Polyps, Stones or other abnormalities can be seen.
For over active bladder (Urge Incontinence) medications are very helpful. These medications relax the over active bladder. therefore frequent urination and sudden urge to urinate is controlled. Most commonly used medications are; Oxybutanine, Detrol, Ditropan & Levbid.
These exercises to strengthen the Pelvic floor muscles in order to improve bladder control were popularized by Dr. Arnold Kegel in California.
You can identify and strengthen your muscles in the following way:
How to identify the bladder control muscle; while urinating try to stop the flow of urine. Remember the muscle you pulled to stop the flow. This is the muscle which needs to be exercised by pulling and relaxing repeatedly. This should not be done during urination. The exercise itself should start by pulling the muscle tight and holding it tight for 10 seconds. Than relax for 10 seconds. It should be repeated 10 times preferably 4 times a day. It takes approximately 3 months to make the pelvic floor muscles really strong. A strong pelvic floor not only gives better urinary control it helps in greater sexual enjoyment by increasing the intensity of orgasms.
The pelvic floor muscles can be exercised by means of a computer. these muscles become strong and provide support to the bladder neck and Urethra. A small probe is inserted into the vagina and connected to the computer. The computer sends signals to the pelvic floor muscles to make them strong. the regimen consists of 24 sessions of half an hour each. A very high success rate has been reported in women with mild stress incontinence. This method has also been used for urge incontinence with reasonable success.
This is the latest addition to strengthen the pelvic floor muscles. It helps Urge as well as Stress incontinence. In this system patient sits in a chair (No need to undress). The magnetic waves are generated below the seat. these magnetic waves when passing through the pelvic muscles make them contract. The repeated contractions, exercise the pelvic muscles and improve the muscle strength. The net result is improved bladder control.
It is estimated that approximately 50% of the patients with overactive bladder or not help by medications or other treatments. The continue to urinate very frequently and leak urine, with the help of interstim many of these individuals can control their urine. A very thin wire (lead) is placed over the nerve which controls the bladder functions. this lead is connected to a small Pacemaker, which can restore the normal functioning of the Bladder. The first stage of the procedure is called trial interstim. under local anaesthesia lead is inserted in the area between the buttocks and connected to a temporary device called external pacemaker. It is generally done in the office. the patient will wear it for four days, during which if the symptoms are completely controlled, it will indicate that this patient will benefit from this technique. At that time a permanent pacemaker is placed under the skin of the buttock, so that it is not visible. it is an ambulatory procedure.
Many surgical procedures have been designed to improve the urinary control due to stress incontinence. Only the most popular and effective one will be mentioned here.
In this procedure a small fascia (covering of the muscle) is taken from the abdominal muscles or outerside of the thigh and placed under the bladder neck to provide support. Therefore upon coughing and sneezing the bladder neck will not open and urine will not leak out. The new modifications of this procedure do not use patient's own facia, instead tissues from cedavers are used as a graft. no side effects have ever been reported.
A revolutionary method for treating the stress incontinence. A synthetic tape is placed under the urethra to provide support. It is an extremely simple procedure, done on ambulatory basis. it has a very high success rate and rapid recovery.
It has been found that in some patients the urethral muscles are very week and under slightest pressure on the bladder, urine leaks out. In order to improve the closing mechanism this simple system was devised. Collagen is a natural compound in the skin. This is purified from the animal source. It is injected under the lining (Mucosa) of the urethra near the bladder neck. It raises a cushion and helps in improving the closure of the urethra. It is a simple procedure done on ambulatory basis.
For more references visit the following site: www.womenswaterworks.com
Bladder stones are generally formed when bladder will not empty completely due to some sort of obstruction e.g. enlarged prostate, bladder neck contraction. The bladder stones may originate in the kidneys and come down to rest in the bladder where the grow by sedimentation in the form of layers. The center called nucleus may be different in chemical composition than the layers which deposit around it. The common types of bladder stones are Calcium, Oxalate, Phosphates or uric acid. Most of the time its is a mixture of these chemicals. The size of the stones can vary from a small grape to the size of an egg.
The prevention of the stones is similar to kidney stones i.e. to drink plenty of liquids, avoid diet containing above-mentioned ingredients and removing the cause of obstruction.
The treatment is generally surgical. Modern method consists of removing the stone without any incision. A small telescope is inserted into the bladder through the urinary canal and stones are broken up by laser or shock waves. The broken pieces are washed out.
Cancer of the bladder is common in the industrial zone. The chemicals in the environment are considered important factors in the development of bladder cancer. Smoking is the greatest risk factor, doubling the chance of developing this cancer. The Cancer arising from the lining of the bladder is called Transitional Cell carcinoma. This is the most common kind of bladder Cancer. In the early stages the only symptom is presence of blood in the urine without pain. Sometimes repeated urinary tract infections may be the only sign of underlying bladder cancer.
The diagnosis is generally made by telescopic examination of the bladder. This simple painless test is performed in the office (Cystoscopy).
The urine can also be tested for cancer cells (Cytology). In the early stages the bladder cancer can be easily burnt out through the telescope called Fulguration. Bladder cancer has a tendency to comeback, therefore regular cystoscopic examination at 3-6 months interval is necessary. To prevent the recurrence of cancer BCG Vaccine has been used. The bladder is washed with this vaccine once a week for six weeks, after that once a month for six months.
If the cancer is extensive and penetrates the muscles of the wall of the bladder, that part of the bladder may be cutout (partial cystectomy). However a large, penetrating, extensive cancer requires total removal of the bladder to avoid the danger of spreading of the cancer to other organs (Total Cystectomy). A new bladder can be constructed from the intestine to replace the original bladder (Neo-Bladder).
The Urinary Tract Infections are common in females at various ages. In young girls before puberty, young adult female at the commencement of sexual intercourse (Honeymoon Cystitis), post menopausal female.
In young adult females urinary tract infections are due to sexual intercourse. The common form of bacteria is E.Coli. The source of these bacteria is rectum. These Bacteria are present around the opening of the Vagina. During sexual intercourse these are milked into the urethra and bladder. Once they reach the bladder, these bacteria grow and cause symptoms of infection
You may have Urinary infection if:
- You have pain or burning when you urinate
- You have to urinate frequently & small amounts.
- There is blood in the urine.
- Pain in the lower part of abdomen (Pubic area)
- There are chills & fever associated with urinary symptoms.
The important causes of repeated infections in a female can be as follows:
- Lack of local surface immunity around the vagina.
- Incomplete bladder emptying.
- Presence of stones or tumor in the bladder.
- To drink plenty of water. So that more urine is made and bladder is flushed out.
- Do not force yourself to hold urine for a long time.
- Urinate immediately after sexual intercourse.
- Female with dry vagina must use lot of lubricants. e.g. KY Jelly to avoid friction and break down of lining of urethra.
- After going to bathroom always wipe from front to back with toilet paper.
- Allow free air circulation around the genital area, avoid tight synthetic garments, always use cotton under pants.
These conditions must be ruled out by cystoscopic Examination.
It is important to take the specimen of the infected urine and grow these bacteria in the laboratory, in order to accurately identify the type of bacteria for treatment purposes (Culture and Sensitivity)
Urodynamics tests are done when dysfunction of the bladder is suspected. Sonogram of the kidneys or special X-rays of the kidneys called IVP (Intravenous Pyelogram) is also done when the source of infection may reside in the kidneys.
It is important to drink more liquids so that more urine is made and it can wash the bladder. Many individuals drink cranberry juice. Please note that it is the water in the juice, which is important. The first line of treatment is the use of simple drugs which can kill the bacteria. Such as Macrobid 100 mg twice a day for five days. The other popular medications are:
- Septra/ Bactrim 1 tablet twice a day for five days.
- Cipro 250 mg 1 tablet twice a day for five days.
- Levaquin 250 mg 1 tablet once a day for five days.
- If the pain is very severe, Pyridium 100 mg three times a day for five days can be added.
Please note that these antibiotics must be taken under the supervision of a physician.