Personal Statement from Dr J Ockrim
As a consultant urological surgeon, I believe that the patient-physician relationship is fundamental to providing and receiving excellent care. I feel that it is imperative to create an environment that preserves a patient's dignity whilst developing a common understanding and a building of trust with the patient, when they are physically and emotionally most vulnerable.
The patient-physician relationship is at the very heart of health care delivery. The private, often uncomfortable sharing of information between patient and physician requires approaching sensitive topics with thoughtfulness and compassion.
Medicine can offer multiple solutions to these debilitating and often life limiting urological conditions. Solutions should be tailored to the patient’s specific circumstances and needs. All the alternatives should be discussed and a holistic approach agreed with patients then applied.
It is important to me to be involved in a career where surgical competence, compassion, and sensitivity are paramount to patient care.
Step-by-step approach to treating incontinence
A step-by-step approach is often used for incontinence treatment, offering the most non-invasive incontinence therapies initially and working incrementally through the steps until an effective solution is found.
Bladder incontinence in women is very common. 40 per cent of women experience incontinence, but only five per cent will need surgery. Frequently, patients respond well to more conservative incontinence treatment. However, all forms of advanced surgical techniques are available for those with persistent problems.
Bladder symptoms also occur in men, and 5-10% of men suffer from some degree of urinary leakage. Incontinence can also occur after prostate surgery.
- Step 1: Behavioural therapy
- Step 2: Pelvic floor exercises and Biofeedback
- Step 3: Medication
- Step 4: Acupuncture and percutaneous nerve stimulation (PTENS)
- Step 5: Minimally invasive techniques
- Step 6: Surgery
There is now a wide range of established treatments for incontinence, with many effective, non-invasive options. You should not feel that you simply have to put up with problems which often have a very distressing and limiting impact on lives.
Step 1: Behavioural Therapy for Incontinence
Behavioural changes, such as changing the volume, timing and what you drink throughout the day is often a very effective incontinence treatment without the need for any surgical treatment at this stage.
Step 2: Pelvic Floor Exercises to Treat Incontinence
This involves exercises to strengthen the pelvic floor – these muscles are tightened to help involuntary leakage, and can be trained to stop yourself from passing water. Like behavioural therapy, this incontinence treatment does not require any surgical treatment.
Pelvic Floor Rehabilitation with Biofeedback
This is an effective incontinence treatment which is popular with patients. It involves using a small probe to measure muscle movement and the results are projected onto a computer screen. Patients can see how their muscles work and exactly how much harder they need to work in order to gain full control. Muscles are re-trained, initially using the computer guidance and then without guidance.
Bladder Retraining to Treat Incontinence
Bladder retraining is a method of incontinence treatment which gradually increases the time between your visits to the toilet, so that your bladder is able to hold larger quantities of urine comfortably.
Step 3: Incontinence Treatment Medication
Medication can be an effective incontinence treatment. Different types of drugs are used for specific types of incontinence, with anticholinegic medications used for urgency and a different group of medication for mild to modest stress incontinence.
Step 4: Acupuncture and Percutaneous Nerve Stimulation (PTENS) Incontinence Treatment
Studies show acupuncture can be effective in terms of increasing bladder capacity and reducing discomfort. Percutaneous nerve stimulation is an advanced form of acupuncture where the needle stimulation is augmented with electrical current. It has been shown to be an effective incontinence treatment for patients with frequency and urgency which result in leakage before the patient can access toilet facilities. The electrical stimulation inhibits the nerve impulses that cause unwanted bladder contraction, resulting in urgency.
Step 5: Minimally Invasive Incontinence Treatment Techniques
Sacral nerve stimulation
Sacral nerve stimulation is an advanced technique in which the nerves controlling the bladder are stimulated directly through the lower end of the spine (through the sacrum). The technique is effective for overactive bladder, as well as patients who have difficulty voiding. It has also been used for patients with pain syndromes to reduce the sensations of discomfort. This technique is performed in two stages, and if the test is effective a bladder pacemaker similar to a heart pacemaker is implanted, and lasts for 5 years.
Step 6: Incontinence Treatment Surgery
Surgery is normally only considered for significant stress incontinence. Most people with an overactive bladder are likely to have found a solution in the first five steps of incontinence treatment. People who continue to experience problems with stress incontinence following the first five steps of treatment may have structural problems which need to be addressed by surgery.
Bladder surgery has rapidly developed during the past ten years and while surgical options for incontinence treatment need to be very carefully considered, success rates are over 80 per cent.
The main types of surgery for stress incontinence are:
- Urethral bulking agents or implants
- Tension-free vaginal tapes (suprapubic TVT or obturator TVTO)
- Autologous vaginal sling
- Bladder neck suspension by colposuspension
- Bladder reconstruction
- Mitrofanoff continent urinary diversion
For men who have incontinence after prostate surgery the options include
- Urethral bulking agents or implants
- Male sling
- Artificial urinary sphincter
For those patients with the most severe urge incontinence surgery involves clam cystoplasty where a small segment of your bowel is used to augment your bladder and prevent bladder spasm. This is a more extreme incontinence treatment used only in a small number of cases.