Pelvic center Nymphenburg in Barmherzige Brüder Hospital - Management: Attending Franz U. Keuler, M.D. and consulting physician Florian Thein, M.D.
The pelvic centre of the Barmherzige Brüder Hospital is an interdisciplinary treatment center where patients with diseases and malfunctions of the pelvic area receive full attention and care. The cooperation of several clinical sectors such as physiotherapy, nutritional medicine, pain therapy and geriatric rehab is an interdisciplinary concept.
Lead by the urological sector, the pelvic centre is responsible for the coordination of several sectors, enabling optimal medical care. In addition to medical expertise in the sectors of urogynecology, urology, proctology and physiotherapy, the treatment concept is completed by dietary consultation and support concerning the sexual condition.
The involuntary release of urine (urinary incontinence)
Summary
The involuntary, spontaneous release of urine is medically referred to as urinary incontinence. The patient is no longer in control of urination. This can be due to several causes such as a disorder of the bladder, urethra, constrictor muscle of the bladder, pelvic muscular system, and the nervous system providing the concerned organs or an enlarged prostate gland of the man. Urinary incontinence is a wide spread complaint experienced by men and women of all age groups.
Due to increasing life expectancy the disease has become more and more socially and medically relevant. The number of people seeking for help has risen partially due to increasing education. Around 6 million people in Germany suffer from urinary incontinence. However, often patients feel embarrassed to mention their suffering to their doctor. Negative side effects such as unpleasant smells and maceration may occur often leading to social withdrawal due to embarrassment. The patient is faced with strong emotional and physical stress.
An early on appointment with your doctor can prevent this. Questioning and examining the patient can help to find the cause of the urinary incontinence and thus engage in an optimal treatment. These may be simple hygienic measures, medication, behaviour therapy etc. as well as a possible surgical procedure. During and after the treatment continuous supervision by the physician is important to ensure the treatment's success and patient content.
The examination of urinary incontinence
The examination begins with a conversation with your doctor. The patient describes his complaints (symptoms), typically involuntary urination. In addition women often complain about a primary feelings in the abdominal region. Further specific questions enable the doctor to proceed with the examination more specifically. The findings of the examination are evaluated and thereafter an appropriate treatment method is suggested and discussed with the patient.
During questions concerning medical history it is important to mention any past surgical procedures e.g. a prostate surgery of the man or an operation of the uterus of the women. A very important question: When and under what conditions does involuntary urination occur?
To conclude the type of urinary incontinence, special attention is given to the organs of the urinary system: these include the kidneys, bladder and urethra with it's external opening, including adjacent internal and external sexual organs. After the physical examination further examinations may follow depending on the findings. Such may include a blood test to determine the blood sugar value or a palpation of the rectum e.g. palpation of the male prostate to determine if an enlarged prostate gland may be causing the uncontrolled urination. Women will receive an additional gynaecological examination. A urine examination, ultra sound, measure of bladder pressure, x-ray and a possible cystoscopy may be necessary to conclude the origin of the urinary incontinence. In the following, several examination procedures are illustrated more precisely:
- The urine examination
The urine examinationA bacterial infection can be responsible for a bladder infection causing urinary incontinence. A urine examination can lead to further conclusions. The examination of cell tissue in the urine can also give crucial information. - The ultra sound examination
Ultra sound is a frequently used universal method. It is an easy pain free method used to determine information about the inner organs of the abdomen and pelvis. The doctor is able to see a picture of the inner organs on a computer screen. - Examination of the bladder pressure (cystometry)
This is one of the most important examinations for the determination of urinary incontinence. The bladder is filled with liquid by a catheter. Whilst filling, the pressure is measured at different levels of fill. At the same time pressure on the rectum is measured to exclude pressure on the bladder from outside. Often the cystometry is combined with an x-ray of the urethra of the liquid filled bladder; the patient is requested to cough during the x-ray. - Cystoscopy
Cystoscopy in done with local anaesthesia or full narcosis. The cystoscope (see picture) is an instrument attached to a light. A cystoscopy is usually done before any further surgical procedures. It is used to examine the urethra and bladder. In addition the prostate of the man can be viewed.
What types of urinary incontinence are there and how are they best treated?
- Stress incontinence
Stress incontinence occurs when urine is involuntarily released during physical activity such as carrying heavy weights, running, climbing stairs, standing up, coughing or sneezing. This is one of the most common features of this type of urinary incontinence.
This is due to the malfunction of the urethra's sphincter muscle. In addition there is also a weakness of the pelvic musculature. The latter is often found in women suffering obesity or after pregnancy. The pelvic organs of are shifted downwards, thus pressing onto the bladder. In more serious cases the rectum and the uterus descend and contract the bladder.
Stress incontinence is less common in men. It usually occurs due to strong disrupter of the urethra's sphincter muscle e.g. after a surgical procedure of the prostate gland or by serious injury.
In both cases stress incontinence is treated individually according to it's underlining condition:
Weak forms of stress incontinence - involuntary urine loss occurs during strong physical activity - can be treated by pelvic physiotherapy and exercise. With help of expertise instruction the patient learns to deliberately control his bladder (biofeedback training) by strengthening his pelvic musculature as well as the sphincter muscle function of the urethra. First results usually take a while before showing. Often it can take up to six months before improvements are visible.
The physiotherapeutic exercises can be accompanied by electric stimulation of the pelvic musculature. Patients suffering from strong stress urinary incontinence i.e. involuntary loss of urine during simple day-to-day engagement, may have to consider a combination of a surgical and non-surgical treatment.
If involuntary urine loss occurs at a state of rest of while lying down, surgery is unavoidable. This usually only occurs in women. Another option is the use of diapers or the permanent drainage of urine by a catheter though the abdominal wall. However these options must consider skin irritations and infections of the urine as a possible side effect. - Urge incontinence (syndrome of the over active bladder; OAB-syndrome)
Whereas in this case the sphincter muscle of the urethra is in tact, the bladder musculature is overactive. The bladder is therefore no longer able to take in and restrain large capacities of urine. Therefore patients experience a frequent need to use the bathroom. However only small amounts of urine are released each time. By frequently going to the bathroom it is possible to suppress the urge to urinate.
In addition to physiotherapeutic training of the bladder the patient can be given a variety of medications. These medications are aimed at the nervous system, effecting the tension exerted on the bladder. However, results and beginning of cure may take 4 up to 6 weeks. For cooperative patients an alternative treatment of electric stimulus to the pelvic musculature can be provided, however, it could take half a year before first results show. - Reflex incontinence
This type of urinary incontinence is caused by damage to the nerves supplying and controlling the controlled urine flow in the bladder. Depending on the place of damage - brain, spinal chord, nerves - involuntary urination can occur due to increased function of the bladder. This partial or full malfunction of the bladder and sphincter muscle enables the patient to control his urine flow. In addition leftover urine in the bladder is prone to bacterial infection. This can be spotted by the doctor during the examination and thus treated appropriately. Diseases such as multiple sclerosis, paralysis, parkinson’s disease and others are examples for such nervous diseases.
To reduce the pressure on the bladder, which will lead to damage in the long-term, urine is regularly drained from the bladder with a catheter. The patient can to do this by himself. In addition the patient is given medication to decrease the overstimulation and tension on the bladder musculature.
New possibilities are the use of electric stimulus on the bladder by placing a small instrument under the skin. - Overflow incontinence
The cause of an overflowing bladder can often be found by a blockage of the urethra e.g. caused by an enhanced prostate gland. The bladder is overstretched by the continuously growing prostate and overflows. This will cause the bladder to continuously loose small amounts of urine. Every drop of urine flowing from the kidney into the bladder will lead to the overflow and loss of a drop of urine from the bladder. The patient often refers to this as a continuous dripping sensation. This type of urinary incontinence is mostly experienced in men.
In these cases it is recommended to proceed with surgery in order to remove the disturbing object e.g. the enhanced prostate gland. In addition to the surgery, the pressure on the bladder is relieved by a catheter - usually inserted through the abdominal wall.
At this point we would like to reinforce the importance of preventive medical examination of an enlarged prostate gland.
Additional information concerning surgical treatment methods
Every type of urinary incontinence is treated individually. It is differentiated between surgical and a non-surgical procedures.
Women suffering from incontinence because of a weakened pelvic musculature and descended inner sexual organs (bladder, uterus, vagina) can be treated by a correction surgery. This procedure can be done from the lower abdomen as well as from the vagina. Newest operation techniques enable outpatient minimally invasive procedures, however, there have been no long-term results so far.
Usually malformation of the urinary system, infectious diseases and previous surgical procedures only lead to partial incontinence. Surgical treatment is used to reduce the disturbing factors.
In seldom cases it is necessary to conduct the urine over the intestinal tract. There are special methods for this surgical procedure. These procedures are done in specialized clinics with surgeons specialized for bladder replacement.
Is urinary incontinence avoidable?
In most cases urinary incontinence can be avoided. Especially women can avoid urinary continence by reducing overweight in time and regularly exercising the pelvic musculature after childbirth. By reducing weight consequently the pressure in the pelvic region is decreased. In the case of a small pelvic musculature with a weak urinary incontinence strong physical work should be avoided. To avoid worsening, an urologist should be consulted. Preventive medical check-ups are recommended for men and women.
Especially nowadays the patient should not feel embarrassed to consult a doctor in order to prevent a urinary incontinence early on.
Urinary incontinence is curable in most cases. However, consultation with an urologist and subsequent treatment are crucial.
In case of emergency you can reach us around the clock : +49 (0)89 1797 2640 (urological emergency ambulance)
Registration at the ward:
+49 (0)89 1797 2010 (urolog. ward G-1)
+49 (0)89 1797 2110 (privat ward G-2)
+49 (0)89 1797 2020 (dayclinik, ward G-3)
Incontinence consultation: Wednesdays 8-12 o'clock. Appointment neccessary:
+49 (0)89 - 1797 2603
Summary of frequently asked questions and according answers 