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Stress incontinence with cough
Losing urine with cough or abdominal straining is called stress urinary incontinence. If it only happens enough to wear a pad for when you have a bad cold, probably not much treatment is needed. If it persists after your current illness, you may want to tell your gynecologist about it and see if the changes are mild or severe.
There are several different non-surgical treatments for stress incontinence and they are most successful if you are premenopausal and the urine loss only happens with severe coughing or straining.
Urine loss with extensive running
As I understand, you don't lose urine from increasing intraabdominal pressure (stress) but you do have urgency when running and that is the time when you leak urine? Do you have any leakage with any other activities other than running? Can you tell when you have the leaking if there is a large or normal amount of urine in the bladder or just a very small amount? A small amount would be against drinking too much fluid. Electrolytes don't seem to make that much of a difference for this problem. On the surface this sounds like urge incontinence or overactive/uninhibited bladder contractions but it still could be stress incontinence.
Now I'm would be more sure , but not certain that it's stress incontinence. If you were our a patient, we would do an exam with a full bladder and have you cough and strain lying down and look to see if there was any urine loss. If none, this would be repeated standing up and holding a brown paper towel over the vaginal and urethra area. If there is a fluid stain on the towel, that is proportional to the amount of urine lost. Either of these would diagnose stress incontinence. You can do the paper towel test at home. This wouldn't mean that there wasn't also urge incontinence also. Actually a mixed incontinence is more common than either alone.
Next we would check to see if the bladder neck descends with straining. A Q-tip lubricated with xylocaine gel is placed in the urethra and as you strain down, the change in angle of the Q-tip is measured to see if the bladder neck drops more than 30 degrees. This would be confirmatory of stress incontinence and mean that surgical repair would more likely be successful than if there wasn't any movement.
The next study is a cystometrogram which may be part of urodynamic studies. In this, a catheter with a pressure measuring device is placed thru the urethra into the bladder and the bladder filled. Measurements are then taken to see if the bladder muscle is contracting on its own, uninhibited bladder contractions. If it is, you have an urge component. That is treated thru bladder retraining and medical therapy.
In your case (loss with vigorous exercise) it is possible that you might not have leakage with just coughing but with extremely high intraabdominal pressure still have stress. That degree of pressure needs to be simulated with cough or you may need to have a stress urethral pressure profile test done as part of the urodynamics.
Incontinence after blow to abdomen
I have not had a patient with prolapse directly attributable to a motor vehicle accident or blows to the abdomen but similar rapid increases in intraabdominal pressure can cause prolapse. It has been reported in military trainees making jumps from platforms for paratrooper training and we have seen it in patients who have had sudden falls or who have strained to lift heavy weights. So it would not surprise me that what you describe could happen.
I would also be concerned that you may have had some bladder trauma and the urine loss is more urge incontinence than stress. If so, it should get better over 3 months.
Fear of chronic cough and need for a 2nd incontinence surgery
What you describe is stress urinary incontinence. It might be important to have urodynamic studies since you are probably taking medicines for the allergies that may affect urethral constriction. There may be uninhibited bladder contractions also present or a change in total bladder capacity that can worsen stress urinary incontinence. While those things, if treated, may not remove the need for surgical correction, knowing all the components of the diagnosis can make the surgery more likely to be successful.
If the first surgery was vaginal, that may explain partially why it failed. Vaginal procedures to correct urinary incontinence have recently been mostly replaced by abdominal procedures which have a higher success rate.
The chronic cough problem is certainly reason to worry about the long term success of surgery for incontinence. It's not a reason not to do another surgical procedure since it is unlikely an allergy problem will get better in the short run. When we do surgery under these circumstances, the best that can be done is to make sure there are not additional causes of incontinence going on, get the respiratory system in the best shape possible, perform the surgical procedure most likely to result in the best long term cure rate, correct all the associated pelvic support defects (in addition to the bladder neck dropping) with permanent suture or even mesh and finally, to minimize as much abdominal straining as possible in the first 3 months following surgery. That's a lot, but the alternative is to continue on as it is. Non-surgical treatments can be used but in my experience are not very successful when there is a chronic cough.
Finally, I would suggest that you learn to cough by using the diaphragm to expel air and not let the pressure transmit to your abdomen. Some women relax their abdominal and perineal muscles when coughing and that makes stress incontinence worse. If you tighten the abdominal muscles and at the same time tighten your perineal muscles and then cough, that may help.
Newer incontinence treatments
There are some devices that try to plug up the urethra but they do not seem to work well for active women.
Vaginal probe electrical stimulation can help to strengthen muscles and helps urge incontinence if that is part of the problem, as well as stress incontinence.
There are chairs with electromagnetic fields that stimulate pelvic muscle contraction. Their efficacy has not yet been studied. Essentially they induce Kegel contractions just like pelvic floor stimulation therapy.
Certain pessaries which have been designed especially for incontinence do not totally get rid of incontinence although they can reduce some urine loss.
There are some weighted vaginal cones that serve as a type of continuous Kegel exercise. These seem to work better in premenopausal women who have genuine stress urinary incontinence.
Detrol® and Ditropan XL® are recent medications for urge incontinence which seem to work well and has less side effects than some of the traditional medications.
These are all I know of. Surgery is still the mainstay for stress urinary incontinence and bladder retraining and medical therapy the mainstay for urge incontinence. Most of the surgery is shifting to abdominal approach rather than vaginal procedures. The abdominal procedures seem to be more successful in the long run and there are almost always other pelvic support defects that have to be fixed to enhance success rates.
What is the best surgery for bladder dropping?
A dropped bladder can represent several different conditions such as a cystocele, descent of the bladder neck (urethrocele) or vaginal vault prolapse. You may have any one, two or three of the above conditions so without an exam it is difficult to give a precise answer to your question.
In general the non-surgical treatments are muscle strengthening exercises such as Kegel's, use of vaginal weighted cones, pelvic floor muscle stimulation (microelectrical or magnetic), and artificial support devices such as a pessary. After age 50 and especially if you have had previous bladder support surgery at the time of your hysterectomy, the non surgical treatments are less likely to be successful in the long term. While the exercises may not be curative, they are always beneficial even if you end up having surgery so I would encourage those.
Since you have symptoms of stress urinary incontinence, it is very likely that you have a dropping of the bladder neck. There are several procedures that are very effective to repair this and it depends upon the skill of your doctor with what procedure works best for him or her. The vaginal procedures would include transvaginal tape, a sling with bone anchors, a fascial sling procedure and abdominal procedures would include a bladder suspension such as a Burch or MMK procedure. These can be done open incision or some physicians can do these laparoscopically.
If the bladder is also falling down and causing pressure and difficulty starting to void and to completely empty the urine, surgical repair can be performed vaginally or abdominally with a paravaginal repair.
The biggest risk with this surgery for future failure is if the physician does not recognize whether or not the end of the vagina is also prolapsing again like the uterus did. If it is moving more than an inch with intraabdominal straining (vaginal vault prolapse), then it needs to be fixed as well along with the other support defects. If it is not, you will have recurrence of relaxation problems within a few years. This vault support is done the easiest by an abdominal incision although some surgeons are skilled in a vaginal vault suspension that does not significantly shorten the vagina.
I think your best course is to have the physician who did the original surgery refer you to someone whom they know is skilled in this type of secondary repair. Members of the Society of Gynecologic Surgeons (http://www.sgsonline.org) specialize in these problems.
Night time incontinence and urgency
What you describe sounds like urge incontinence with a hyperreflexic bladder or possibly overflow incontinence. The tests to diagnose this are catheterization for the amount of urine left in your bladder after voiding and a cystometrogram (involves a catheter and filling of the bladder). While it is never comfortable, these tests aren't that bad especially when diagnosis and treatment can significantly help you. The mainstays of treatment are bladder retraining and medical therapy.
Bladder retraining you can do yourself at home. It involves keeping the bladder empty before you get the urge to void. To do this, we start women out at voiding every hour during daytime hours for a week. You void whether or not you have the urge to void. You need a timer to do this such as a kitchen timer from Radio Shack that you can carry around or a watch that you can set to "beep" every 60 minutes. If you get an urge at 55 minutes to void, try to suppress if you can until time is up. The next week you go to 1.5 hours (90 min), the following weeks to 2.0 hr, then 2.5 hr, then 3 hours. Don't go longer than 3 hours in the daytime without voiding. It takes 5 weeks or sometimes longer of this bladder retraining to get better. If you can do this, I guarantee your symptoms will improve.
Medical therapy for urge incontinence is usually Ditropan®, imipramine or Detrol®. The Detrol® has less dry mouth side effects than Ditropan®. All of the meds are only about 40-50% effective and must be combined with bladder retraining. You may be able to talk your doctor into treatment without testing. I'm not sure that's best but I understand why.
What is a cystometrogram?
A cystometrogram involves putting a special, pressure-measuring catheter in the urethra and slowly filling the bladder with fluid and measuring the pressure inside the bladder. Pressure spikes represent uninhibited bladder contractions (bladder detrusor muscle). You are awake while it is done and the main pain or discomfort is from having a catheterization and an over full bladder. I would say the cost is about $200 although the entire battery of urodynamics, including uroflow and urethral pressure profile, probably runs about $800.
MRI is not useful for diagnosing a hyperactive bladder problem which is a functional, not an anatomic problem. An MRI could pick up a spinal problem that was causing nerve irritation and sometimes an MRI is used to diagnose coexistent prolapse problems.
What is a urethrogram?
A urethrogram is a test in which dye is injected into the bladder via a catheter and then the woman voids while xrays are taken. It may be a voiding cystourethrogram to look at the bladder and urethra for dropping of the bladder neck, or it may be a pressure urethrogram to look for a urethral diverticula.
I hardly ever use it because bladder neck descensus can be diagnosed from a physical exam and a urethral diverticula can usually (but not always) be seen with cystourethroscopy and felt on palpation of the urethra.
What kind of tests are needed to diagnose stress urinary incontinence?
The only test needed to diagnose stress urinary incontinence is to cough and see urine leak from the urethra, Your doctor usually does this during a pelvic exam. If urine does not leak while checking you when laying flat on a table, the doctor may ask you to stand up and put one leg on a stool and then have you cough while checking for leakage.
You can check yourself by holding a paper towel over the vagina and urethra with one leg up on a stool or chair. Then a strong cough and see how wet the paper towel is. If the paper towel is not wet at all, then you may have a different type of urinary incontinence.
The doctor may use a cotton-tipped applicator in the urethra lubricated with xylocaine gel ( a local anesthetic) but that does not diagnose stress incontinence, it just diagnoses bladder neck hypermobility and tells the doctor what type of treatment may be needed. Other urodynamic studies are often used to rule out other types of incontinence and urinary problems but not to diagnose stress incontinence. A cystometrogram may be ordered if you have urinary urgency or frequency symptoms and a urethral pressure profile will be ordered if you are over 65, have had previous continence surgeries or urethral trauma, of if you lose urine with just minimal stress such as going from sitting to standing. An electromyography study (EMG) is ordered if you have difficulty voiding or pain with voiding. This looks for urethral sphincter dyssynergia,
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