A new use for Botox: incontinence in women

06/24/2014 4:22 PM

06/24/2014 4:22 PM

It’s a nuisance that can drag a woman back to her potty-training days: accidentally peeing in her pants. Urinary incontinence rears its ugly head in two basic forms. If urine leaks out when you cough, sneeze, laugh or jog, that’s stress incontinence. If you have to go so badly or frequently that you often don’t make to the bathroom, that is urge incontinence.

And it’s the kind of dirty laundry most women don’t like to air in a doctor’s office.

“There is a component of embarrassment. There is a component of social acceptance that it is OK to pee on yourself as you get older. It’s not something you normally bring up in conversation,” said Dr. Carlos Medina, associate professor of obstetrics and gynecology and director of the Division of Female Pelvic Medicine and Reconstructive Surgery at UHealth, University of Miami Health System.

Though women in their late 40s to 60s typically seek medical help for incontinence, Medina said he is seeing a trend toward younger women.

“You have women saying ‘I want to go to the gym. I want to enjoy life. I want to wear normal clothes again. I don’t want to be embarrassed,’” he said.

To diagnose the problem, patients are asked to keep a three-day voiding diary to document how much they drink, how many times they use the bathroom, and if they leaked urine at any point, said Dr. Yvonne Koch, a urologist and assistant professor of urology at the Columbia University Division of Urology at Mount Sinai Medical Center. A thorough history is taken, and typically a urodynamics test, an interactive test which tells how the bladder is working, or a cystoscopy, which uses a camera to make sure there is not an anatomic problem, she said.

Treatment depends on the type of incontinence.

Stress incontinence

For stress incontinence, women can try pelvic floor muscle training, also known as Kegel exercises, at home, Medina said. If a patient is overweight, then losing weight also may help. “Those are the two home remedies,” he said.

“I would avoid buying all sorts of gadgets that promise to improve the pelvic floor because they don’t really work,” Medina said. “The exercises are what have been proven to work.”

Another option is a pessary, a ring that a woman can insert in the vagina. The ring presses at the level of the bladder neck to help avoid incontinence episodes, he said.

Some women find improvement by wearing a tampon, depending on the degree of leakage. Every woman has a different degree, Medina said.

Surgery, considered the most effective treatment for stress incontinence, is an option for those who have not found relief from Kegels or physiotherapy to help identify pelvic floor muscles and proper exercise techniques, he said.

Many surgeries for incontinence provide support for a sagging urethra with a sling of strong material that acts as a “hammock.” Though there are various options for sling material, the position of the sling, its purpose and how it is placed, “the gold standard worldwide is mid-urethral slings,” Medina said. Placed at the middle portion of the urethra, they “provide a backstop,” he said.

Other procedures include urethra bulking, which use injections to build up the urethra to help stop urine leakage.

Medina said the most common surgical treatment in his practice is the mid-urethral sling. He performs about a dozen a month. Risks include urinary obstruction, difficulty urinating or recurring urinary tract infections. The success rate is about 81 percent.

“It is like being born again. Some of these women have never been able to wear white pants. Some have never been able to jump or cough without worrying if they were going to pee on themselves,” he said. “I’ve had marathon runners who could run again. I’ve had very athletic people who could go to the gym again. It is totally life changing.”

Urge incontinence

Women who suffer from urge incontinence sometimes have trouble working or shy away from socializing because they often can’t make it to the bathroom on time.

The American Urologic Association sets the protocol for treatment for urge incontinence. Anticholinergic medicines in tablet form, which help relax the bladder, are generally tried first, Koch said. There are seven or eight on the market, and patients should try at least two for a four-week period, she said.

If the tablets don’t help, or you can’t tolerate them, Botox is one mode of treatment. Just as it relaxes facial muscles, it can relax bladder muscles, Koch said.

She typically treats four to five patients a month with Botox. In the 15-minute procedure, a tiny camera called a cystoscope is inserted into the bladder through the urethra. A small needle on the cystoscope injects the Botox into the bladder wall, calming it down and increasing its storage capacity.

“It relaxes the bladder muscles, which gives people time to get to the bathroom,” Koch said. “We’re not making the body retain fluid…you’re going to pee. We just want you to have time to get to the bathroom so you don’t have an accident.”

On average, Botox is administered every six to nine months. Complications are rare, but can include urinary tract infection. Patients are screened for infection prior to the procedure and are given antibiotics as a precautionary measure.

There is a 92 percent success rate, Koch said. About eight percent will experience retention of fluid, where the bladder is relaxed so much that the patient is unable to urinate, and must temporarily use a catheter.

“Most people are so desperate to get relief, that they have no problem doing the procedure,” she said. “Most people do fine.”

Another mode of treatment is sacral neuromodulation, which uses a device similar to a pacemaker for the bladder. “We’re trying to change the impulses to the bladder, so you can control when you go to the bathroom,” Dr. Koch said.

In the procedure, a small wire and a device the size of two quarters is implanted in the buttock area, right underneath the skin. It is performed under a local anesthetic.

The procedure is done in two phases. In the trial phase a small wire is inserted through the back. The wire is connected to a programmable unit the size of a cigarette box. Settings are adjusted over one to two weeks, and if the patient feels relief, the next phase – implantation - takes place, Koch said. The risks are bleeding and infection, so preventative antibiotics are given, and patients on blood thinners have to be off of them for two weeks prior to the procedure.

Patients need to follow-up annually with their doctor. The device’s battery needs to be changed about every five years in a minor procedure, she said.

About 90 percent of patients who go through the trial phase get the implantation, and about 90 percent of patients are happy with the device, Koch said. She does about four procedures a month.

“This is something that really affects their quality of life. Some people go to the bathroom every 15 minutes. They can’t work. They can’t sleep. They’re exhausted. They can’t sit through a movie. They don’t want to go on trips,” she said. “The benefits outweigh the risks.”

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