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Continence Center

Middlesex Continence Center and Institute for Pelvic Health


Welcome!

Here at the Middlesex Continence Center and Institute for Pelvic Health our mission is to use cutting edge research and state-of-the-art technology to manage troublesome and sometimes embarrassing conditions.  We will help you navigate your pelvic health needs with compassion and sensitivity. We have a network of providers who are ready to help.


Common conditions we treat include:

-Urinary incontinence
-Voiding dysfunction
-Benign prostatic hyperplasia (BPH)
-Vaginal prolapse
-Sexual dysfunction
-Neurogenic bladder
-Fecal incontinence

Our director is a board-certified Urologist who has specialized training in pelvic medicine and reconstructive surgery. She manages both men and woman and has created this center to meet all your pelvic health needs

DANA KIVLIN, DO

Urinary Incontinence

Urinary incontinence occurs when a person leaks urine involuntarily and unexpectedly. It is a troubling condition that can affect both men and women but is nearly twice as common in woman. Although the incidence goes up with age, younger people can experience incontinence as well. For men with incontinence issues please click here for more information.

The incidence of incontinence increases as you age: as many as 1 in 4 women between the ages of 20 and 39 are affected and nearly 40% of all woman over the age of 80 experience urinary incontinence. You are not alone, and it is not something you have to live with. Many things can be done to treat your symptoms and stop the unwanted leakage. There are two main causes of urinary incontinence and many patients may experience both:
– STRESS URINARY INCONTINENCE (SUI)
– Urine leaks with activities
– Coughing, sneezing, laughing, lifting, exercising
– OVERACTIVE BLADDER AND URINARY INCONTINENCE
– “Gotta go now” (urgency)
– “Gotta go now” with leakage (urge incontinence)
– “Gotta go often” (frequency)
– Going often during the night (nocturia)
– OTHER TYPES
– Mixed incontinence (stress and urge)
– Continuous (unpredictable) incontinence
– Neurogenic bladder

Overactive Bladder Syndrome and Urge Urinary Incontinence

Overactive bladder, or OAB, is a condition in which the bladder muscle, called the detrusor, becomes hyperactive and contracts intermittently and suddenly resulting in the sensation significant urge to urinate more frequently than is normal.

An estimated 30 million people in the United States alone suffer from this condition. Urge urinary incontinence or UUI, is a severe form of overactive bladder where the intermittent contractions are strong enough that you start to urinate before making it to the bathroom. This is different from stress incontinence (SUI) in which leakage occurs with sudden increases in abdominal pressure like coughing because of weakening of muscles surrounding the bladder. However, many people experience both stress and urge incontinence, termed mixed urinary incontinence.
There are many causes of OAB and UUI, but there are also many treatment options. Some of the common symptoms of OAB including:
– Frequency — having to urinate more than 8 times over 24 hours, often including 2 or more times a night.
– Urgency — frequent, sudden, strong urges to urinate with little or no chance to postpone urination.
About 60% of patient with OAB experience only urinary frequency and urgency whereas the other 40% have incontinence in addition to these symptoms. Common triggers for symptoms include hearing running water, standing up after sitting for extended period of time, and arriving home/to a pre-meditated destination (“garage door syndrome” or “key in door syndrome”)
What are treatment options?
There are many things that can be done to improve symptoms. Simple changes such as limiting acidic fluids such as coffees, teas and sodas can make a big impact on symptoms. Physical therapy for pelvic floor muscles with a program called Biofeedback can also control symptoms. There are also many medications that can help. If one medication doesn’t work, oftentimes another medication will.
If these measures fail to control symptoms there are additional treatment options. One such option includes injecting Botox into the bladder. This is a simple procedure performed in the office and the effects can last 6-9 months at a time. Another option is the Interstim in which a small pacemaker for the bladder is implanted under the skin in your lower back. It sends a continuous signal to your bladder to decrease the hyperactivity. This is a permanent treatment solution. Lastly, another option is called percutaneous tibial nerve stimulation where a small needle, the size of a needle used for acupuncture, is temporarily placed above your ankle. This is connected to a battery that sends a signal to your bladder to relax. There is no pain and the treatment session lasts for 20 minutes and is repeated on a weekly basis until symptoms are controlled.

Overactive bladder/Urge Incontinence versus Stress Incontinence

Sometimes it can be hard to differentiate between overactive bladder (OAB) with or without urge urinary incontinence (UUI) and stress urinary incontinence (SUI). The chart below can to distinguish the two. It is important to make this distinction because they are treated differently.

Stress Urinary Incontinence

in women
Stress urinary incontinence (SUI) affects 1 in 3 women over the age of 45 but can affect younger woman as well. Women most commonly develop SUI after changes that happen in pregnancy or childbirth which weaken the normal bladder support to the urethra,

but chronic coughing, constipation, obesity, aging, smoking, or extreme weight lifting can also cause SUI. Genetics may also play a role.
Stress urinary incontinence (SUI) is the involuntary loss of urine when there is an increase in abdominal pressure, or stress, that is transmitted onto the bladder. For example, increases in pressure happen when you cough, sneeze, laugh or lift something heavy. Normally, there are muscles and tissues that make-up the pelvic floor that help support the bladder and the urethra (the short tube that carries urine out of the body when you are ready to urinate). Specifically, there are muscles within the urethra itself that act as a valve to regulate the release of urine (urinary sphincter). When these weaken, the valve can open at times it should be closed and result is the loss of urine when you are not expecting it. This condition is more common in women, but can also effect man especially after prostate surgery for prostate cancer.

What are risk factors for SUI?
Childbirth, higher number of pregnancies
Excess weight
Chronic cough
Previous pelvic surgery (hysterectomy, prolapse surgery, prostatectomy)
Smoking
What are treatment options?
There are many treatment options. For both men and women we recommend weight loss if you are overweight. This can lessen the severity of incontinence and in some people, cure it completely. Pelvic floor physical therapy and biofeedback is recommended for anyone with incontinence to retrain and strengthen the pelvic floor muscles which is the foundation for your pelvis organs. Biofeedback therapy uses computer graphs, visual feedback and audible tones to show you the muscles you are exercising. Over 70% of patients have significant improvement with this program alone.
Another option to treat SUI is with the use of a urethral bulking agent that is injected in the tissue alongside your urethra where your sphincter is. This injection help to “bulk” up the sphincter and stimulates your body to deposit new collagen there allowing to make your valve muscle work better to prevent leakage. You may notice improvement right away, but often it takes 2-3 weeks for the full effect to be achieved. This is usually not permanent and another injection may be needed.

The “gold standard” for treating SUI is through surgery. A sling is placed underneath the urethra to help support the tissue. A sling is most commonly a small piece of mesh, but can also be fashioned out of your own tissue called fascia that is then positioned underneath the urethra to act as a hammock or backboard to support the urethra and prevent leakage with increases in pressure. If a mesh sling is used, it is an outpatient procedure and takes about 30-45 minutes. You will go home the same day with minimal discomfort. The mesh that is used is very small, safe and effective and FDA approved. Talk to you doctor today to learn more about which option may be best for you.

Urinary Incontinence

in Males
Men can experience overactive bladder, urge urinary incontinence and stress urinary incontinence just as females can but there are some important distinctions that are related to differences in male and female anatomy. In a male, the prostate gland sits beneath the

bladder and the urethra, or tube that carries urine out of the body, travels directly through the prostate. The prostate gland continues to grow throughout a man’s life and as it grows, sometimes is can obstruct, or pinch off, the urethra slowing or blocking the flow of urine. This can result in an irritated, overactive bladder with similar symptoms of urinary urgency, frequency and nighttime urination that woman can experience. The treatment options are the same (see Overactive bladder) but oftentimes the prostate requires treatment to improve flow of urine first or concomitantly. See BPH for more information.
Stress urinary incontinence (SUI) occurs when there is weakening of the sphincter muscle. This allows for leakage of urine with increases in abdominal pressures. For example, increases in pressure happen when you cough, sneeze, laugh or lift something heavy. In men, the cause of this is often related to prostate surgery, specifically after radical prostatectomy for prostate cancer but occasionally after prostate surgery for benign growth unrelated to cancer. During surgery, the nerves that control your sphincter muscle can be affected and the sphincter muscle can become weakened.
When conservative measures fail, such as pelvic floor physical therapy and biofeedback, surgery is the next step, either with a synthetic sling but often with placement of an artificial urinary sphincter. There are 3 components to the device and include a pressure-regulated balloon (sometimes referred to as a reservoir), a urethral cuff and a pump to control it. The balloon is placed in the lower abdominal wall under your muscle and stores fluid when the cuff is deflated and you want to urinate. The cuff is placed around your urethra and, at rest, is filled with fluid to support the urethra and prevent leakage of urine. The pump is placed in your scrotum. When you want to urinate, you will squeeze the pump and the fluid from the cuff moves into the balloon (or reservoir) and allows the passage of urine. Over the next 90 seconds to 3 minutes, the cuff automatically fills back up and again prevents the leakage of urine.

The operation takes about 1-1.5 hours. There is a small incision in the perineum (skin underneath the scrotum) and usually a small incision in the lower abdomen (3cm). Patients spend one night in the hospital. The goal of this surgery is to significantly improve your quality of life. Achieving complete continence requiring no pads is often difficult, however a realistic goal for surgery is to cut down on your pad use significantly. Most men require 1 thin pad after surgery for minimal drips here and there and most men are extremely satisfied after surgery.

Neurologic Disease and Urinary Issues

Welcome to our center for continence and pelvic health! Normal voiding requires a complex coordination between multiple neurological circuits. There are a lot of signals that go back and forth from the bladder and pelvic organs to the spinal cord and brain to allow for normal storage of

urine and intermittent evacuation of urine at normal intervals. Conditions that affect the nervous system can also often affect the urinary tract and disrupt or impair these signals. Some of these conditions include Multiple Sclerosis (MS), Parkinson’s Disease, strokes, spinal cord injuries, traumatic brain injury and much more.
As many as 75% patients with MS have urinary issues and more than 80% of patients with spinal cord injuries will have some urinary complaint. It is also very common to have new onset or worsening urinary symptoms including overactive bladder, incontinence or difficulty voiding after having a stroke. A stroke happens every 40 seconds and is the leading cause of adult disability in the U.S. and incontinence is a main contributor.
Neurologic conditions can affect the urinary system in multiple ways. Below are some common ways the urinary tract can be affected:
– Overactive bladder syndrome and urge urinary incontinence
– Underactive bladder or incomplete emptying
– Areflexic bladder with complete urinary retention
– Detrusor sphincter dyssynergia or impaired coordination between the bladder and the sphincter muscles
All of the above conditions can severely affect one’s quality of life, but what most people don’t know is that they can also result in dangerous voiding patterns that can put at risk for kidney failure, urinary tract infections, and other health conditions. Any patient with a chronic neurologic condition should see a Urologist regularly to monitor for any emerging dangerous patterns. This usually involves annual kidney ultrasound, bladder function tests and urine tests.
Goals of the Continence Center:
(1) Identify, correct and monitor for any dangerous voiding patterns to preserve kidney function
(2) Control of urinary tract infections
(3) Maximize quality of life
Once you establish care at our continence center, an individualized treatment plan will be created for you and you will have a network of providers who communicate regularly to give you the best care possible! Join our center today! Call for a consultation.