China Medical University Hospital-Department of Urology

Division of Female Urology Director Chieh-Lung Chou

Ms. Lin (anonym), 50-year-old female, is the mother of three children. She has been troubled by frequent urination and urge after giving birth and experiencing urine leakage when coughing and sneezing. She initially considered these symptoms as natural phenomena after giving birth but the symptoms have become more aggravated in recent years, as she encounters urine leakage if she does not go to the bathroom immediately. The incontinence from coughing also becomes more apparent; sometimes she experiences urine leakage when jogging. These symptoms prevent her from taking exercise, causing her weight to increase and she does not want to leave the house. Then she faces with the problem and goes to see the doctor.

Ms. Lin received different explanations after seeking medical treatment. Some doctors told her that this was caused by overactive bladder and recommended medical treatment. The symptoms of urge were improved after medication but the urine leakage during coughing were still serious. She went to another doctor and the doctor told her that she had stress urinary incontinence and recommended surgery. However, the patient may still suffer from frequency, urgency and even urge incontinence after the surgery.

Finally, Ms. Lin came to clinic office of Division of female Urology Director Chieh-Lung Chou, Department of Urology-China Medical University Hospital. Director Chou told her that she suffered from “mixed incontinence,” which combines two different incontinences. Director Chou performed the minimally invasive surgery of “Midurethral Intra-vaginal Sling” and “Urethral injections of botulinum toxin” on her. Ms. Lin was discharged from the hospital the next day after the surgery, while her previous urine leakage by coughing, urgency and urge incontinence all improved.

Director Chieh-Lung Chou stated that due to the shorter urethra of women, usually 2~4 cm, many elderly women are frequently troubled by incontinence due to giving birth, aging, menopause and other factors.

There are many types of women’s incontinence and the most common types are stress urinary incontinence and urge incontinence. The cause of these two types of incontinence are different, resulting in different treatments. In other words, the clinical conditions may both be urine leakage, the cause are different while the treatments also vary.

A.“Stress Urinary Incontinence”: Adding stress on the abdomen. For example, urine leakage during sneezing and coughing, which is related to the dysfunction of external urethral sphincter muscle. Similarly, when the cap of a plastic bottle is loose, the liquid inside the bottle will leak out when compressing.

For treatment, start with Kegel exercises and if that fails, the patient may consider surgery treatment. Currently, the “Midurethral Intra-vaginal Sling” places a synthetic mesh sling in mid-urethral. The surgery hour is short with fast recovery while the success rate is considerably high.

B.“Urge incontinence”: Typical symptoms include sudden urge and usually too late when intended to go to the bathroom. The cause is related to the dysfunction of nervous system and usually accompanied by frequency and nocturia.

Such incontinence is mostly treated by medicine, i.e. anticholinergic agent or β3- adrenergic receptor agonists. If the oral administration is not effective or comes with major side effect, the patient can consider “Urethral injections of botulinum toxin” to control the incontinence caused by the excessive contraction of detrusor muscle.

What should women do if they suffer two or more incontinences? Director Chieh-Lung Chou suggested that such “mixed incontinence” is actually very common. Statistics reveal that about one third of women with incontinence are mixed incontinence. Conventionally, the doctor will put priority in treating more severe symptoms. For example, patients with significant incontinence due to coughing or sneezing will choose surgery. Patients with more severe symptoms of urge incontinence will be controlled by medication.

Director Chieh-Lung Chou stated that the treatment for mixed incontinence is one great challenge because patient will still suffer from another type of incontinence even if the other type of incontinence is cured.

Director Chieh-Lung Chou also implements the “Midurethral Intra-vaginal Sling” and “Urethral injections of botulinum toxin” to treat patients of mixed incontinence. Namely, two surgeries are implemented under one anesthesia. The post-operative incontinence significantly improves, compared with patients receiving only Midurethral Intra-vaginal Sling. The post-operative success rates are 88％ and 71％, respectively. This research outcome was published on the international journal – Toxin, in 2020.

Director Chieh-Lung Chou stated that the “urge incontinence” in mixed incontinence is related to the nervous system of bladder and there is no ultimate cure. The effect of botulinum toxin injection swill stay for about four to six months while the continuous oral administration and tracing after the surgery will maintain the optimal treatment effect.