Suffering in silence - urinary incontinence
Do you wet yourself when you sneeze? Many women find,
after having a baby, that childbirth has brought with it an
unpleasant side effect - leakage of urine due to weak pelvic floor
muscles or an overactive bladder. Urinary incontinence is an
embarrassing problem, but, as Dr Anil Sharma explains, it is very
treatable.
The accidental leakage of urine in adults is a terribly
debilitating condition, causing not only major stigma and
isolation, but very significant social and hygiene problems. It
causes considerable physical and psychological ill health and huge
damage to the economy of nations, both in terms of days of work
lost and costs of treatment. In the UK, the cost to the National
Health Service (NHS) is around £424 million (almost NZ$1.1 billion)
per annum.
In a survey of over 10,000 women in
England over the age of 40, over 20% or one in five women had
urinary incontinence. In New Zealand, it has been reported that one
in three women experience the problem. Although many women also
have prolapse (downward movement) of the womb or vaginal walls,
this is not always the case, and prolapse will be discussed in a
later article.
Types of urinary incontinence
There are two types of urinary incontinence that women experience:
Stress incontinence and overactive bladder.
Stress incontinence
Stress incontinence is loss of control of the "valve" (or "tap
mechanism") that prevents urine from constantly leaking out of the
bladder. It is due to injury to the supporting structures of the
pelvic floor during pregnancy, childbirth, and, later,
menopause. It is known as stress incontinence because it
usually happens after "stresses" like coughing, sneezing, laughing,
exercise, or even standing up from a seated position.
Overactive bladder
An overactive bladder often causes frequency (the need to go to the
toilet many times) during the day and/or night. It also causes the
sudden urge to "go", with leakage happening if the individual
doesn't make it to the toilet in time.
The bladder starts to behave independently
of the woman's "control", squeezing whenever it wants to. This can
happen very unpredictably and at awkward times. Sometimes it
happens during certain evocative circumstances, like opening the
front door or hearing a tap running. Overactive bladder can be due
to a number of causes, including bladder nerve damage secondary to
childbirth, but, sometimes, it is "idiopathic" (a word that doctors
use when they don't know the cause of something!).
Bladder symptoms can be very misleading to
medical professionals, not least because of learned behaviour - for
example, many women deliberately and frequently empty their
bladders to avoid leakage that might happen otherwise. Many women
also know where all the most convenient public toilets are located
when they go out on the town or or on a shopping trip, to ensure
that they can maintain dryness.
In most cases, the type of symptoms a
woman has doesn't always tell us which main type of incontinence
she has, or, indeed, if she has both types. This is obviously
important to be able to plan the best treatment. Almost
predictably, the treatment of one type can make the other type
worse!
The diagnosis and planning of treatment, either surgical or
medical/behavioural, often requires further tests. These tests are
called urodynamics and are generally used when non-surgical
treatment has failed, when surgery is planned, or where there are
complex symptoms.
General treatment points
Although women with urinary incontinence can benefit from
incontinence pads, these can become very expensive and are nothing
more than a control rather than a specific treatment of the
problem. Also, many women believe that there is nothing that can be
done, so they just end up putting up with problem. This issue is
made worse by the fact that the embarrassing nature of the problem
means that women don't discuss their situation even with close
friends or relatives.
Your family doctor can start by ruling out a urine infection with
a mid-stream urine test. Although the ideas around fluid intake are
controversial, it would be reasonable to limit fluid intake (all
drinks in total) to two litres a day for women with urinary
incontinence. For the same reasons, smokers should try to quit,
since chronic chest problems make urinary incontinence worse (see
www.quit.org.nz).
Constipation needs to be treated to
prevent excessive bearing down, and caffeine junkies should be
advised to reduce their intake, although it remains controversial
whether long-term caffeine excess is a significant cause of urinary
incontinence.
Pelvic-floor exercises can be very helpful
throughout life, both after having a baby and for the long-term
(see "Pay attention
to your pelvic floor" for suggestions on
how to do these exercises properly, and information about their
benefits). Sometimes oestrogen creams given as vaginal insertions
are said to be beneficial in postmenopausal women with
incontinence, although contradicting evidence about this
exists.
Your family doctor will also be able to
advise whether any medications that you may be taking are making
the problem worse. For example, some medicines that are for high
blood pressure work by making the patient urinate more often and in
greater amounts.
Similarly, cutting down on alcohol intake
can relieve symptoms, as can weight loss (by reducing pressure on
the bladder and pelvic floor). Control of asthma and chest problems
can also help.
Subsequently, a review by a gynaecologist trained in pelvic floor
problems and urinary incontinence is advisable, as the field is
developing and changing rapidly.
Treatment of stress incontinence
There are three treatment options commonly suggested for women
suffering from stress incontinence: Conservative treatment,
devices, and surgical treatment.
Conservative treatment
Kegel or pelvic-floor exercises (PFE) have been successful for many
women since 1948. The aim is to "body-build" the pelvic floor
muscles by contracting them.
Devices
Although not widely used, electrical or magnetic stimulation of
the pelvic foor muscles can be used to contract the pelvic muscles
as well. Other types of devices that are inserted into the vagina
to "hitch-up" the bladder neck can temporarily improve the problem,
although side effects include urinary tract infections and
soreness. These devices are not useful for women who are sexually
active.
Surgical treatment
The latest widely used surgical treatment involves, under
anaesthesia, the placement of a small tape or sling. This sits
under the urethra (the short tube that women urinate from), and,
when the bladder gets pushed down (such as during a sneeze), the
urethra kinks on the tape. Therefore, urine is prevented from
leaking out. This is effective around 90% of the time and most
women have been delighted by the results. This operation is short
and quite safe, having replaced much bigger procedures.
Newer forms of tapes or slings are being
developed to make the procedure safer still, with promising
preliminary results. Sometimes, a semi-fluid bulking agent can be
injected around the entrance to the bladder to give the valve
mechanism a bit more substance (like squeezing a hose), and this
may be useful for women who cannot tolerate an operation because of
other medical problems.
If a woman needs surgery, prolapse
(downward movement of the pelvic structures such as the womb) can
be corrected at the same time.
Treatment of overactive bladder
This is the second most common cause of urinary incontinence in
women and affects 30% of incontinent women, getting worse with
increasing age.
Conservative treatment
Bladder retraining therapy aims to re-educate the bladder about
exactly who is the boss. This is a good form of treatment, but
requires a lot of hard work and patience. Therefore, the results
can be variable. The final aim is to reduce the frequency of
bladder emptying to every three to four hours by gradually
increasing the interval between each trip by 10 minutes, every week
or so.
Another way of doing this is to go every
hour on the hour, whether you want to or not, and then increase
this time by 10 minutes every few days. Most patients worry about
this approach because their mothers always taught them to not hold
on! Initial success rates can be as high as 88%, but tend to
decline again with time to half this figure.
Medical treatment
Despite the success that can be achieved with bladder retraining,
medicines are commonly used as treatment for overactive bladder.
They work by reducing bladder contractions. Unfortunately, most
also produce unwanted side effects, especially dry mouth and
blurred vision, which must be balanced against the benefits. They
can also cause drowsiness and patients should be advised against
driving or operating dangerous machinery. Newer tablets have fewer
side effects, but are currently expensive (around $5 a
tablet).
Another treatment involves low-grade
electrical therapy to a nerve behind the ankle via an acupuncture
needle. It is thought that the nerves that get stimulated
"backwards" also lead to a controlling influence on the nerves that
supply the bladder, because all the nerves arise from the same part
of the spinal cord.
Almost everyone knows about the use of
Botox to paralyse the muscles that cause facial wrinkles. Botox is
now also used for severe cases of overactive bladder, with
injections into the bladder muscle under anaesthetic, and this is
showing some very promising results that last for around six
months.
Don't just put up with it
Urinary incontinence causes significant ill health, severe
embarrassment, and damage to the economy. Many women suffer in
silence as they are from the era that "quietly coped". It is
only by discussing this topic widely that the extent of the problem
and its treatment can be publicised to empower sufferers to seek
help. While it is true that not everyone with this problem can be
helped, the majority can, so don't just put up with it!
Dr Anil Sharma is a specialist doctor in Gynaecology
and Maternity. He is very involved in lectures and updates for
family doctors and frequently takes part in debate regarding
women's health and maternity for print media and radio. He believes
that anxiety and fear can be conquered by knowledge. Anil emigrated
to New Zealand from the UK in 2001 with his wife, Rachel, and he
tries hard to be a hands-on and fun father (putting golf and cars
on hold for the time being) to their three daughters, who were all
born here. For further information about Anil's practice,
visit www.dranilsharma.co.nz
.
As seen in OHbaby!
magazine Issue 2: 2008
Subscribe to OHbaby!
magazine
Purchase Issue 2