Bladder control problems are a source of anxiety and embarrassment for 17 million women in this country. Some women may leak a few drops when they cough, sneeze, or strain; others will have an overwhelming urge to void which cannot be controlled on the way to the bathroom. Often, women restrict their activities to avoid embarrassing accidents: They may avoid long car trips or exercise, or sometimes even sexual activity if it makes them leak. Other women will settle for pads or panty-liners, even though they frequently cause rash, irritation, and vaginal infections. Constantly concerned about odor and accidents, many women feel that their lack of bladder control dominates their life.
Unfortunately, most women hesitate to discuss this problem with their doctor because they are embarrassed about their symptoms: It is estimated that 50-70% of women with incontinence never seek treatment. Even when they do initiate a discussion, an entire generation of women has too often been told that “it’s no big deal” or “it’s normal for your age.” As a result, there are now more diapers sold in this country for adults than for babies! Anyone who has ever walked through a hospital ward or a retirement facility is greeted with the unmistakable and unpleasant odor of urine. Loss of bladder control is not normal for adults. If loss of bladder control is a source of anxiety, shame or embarrassment, or causes you to limit your activities or frequently wear protection, you should definitely discuss the problem with a doctor experienced in the diagnosis and treatment of incontinence.
Bladder control problems are a source of anxiety and embarrassment for 17 million women in this country.
What Causes Incontinence?
Urinary incontinence is much more common in women than in men, primarily because of the effect of pregnancy and childbirth on the pelvic floor in women. Among women, there are multiple possible causes of incontinence. Temporary incontinence can be caused by a urinary tract infection, or by use of certain medications (for example, some medications used for high blood pressure or depression). More intractable cases of incontinence can be caused by neurologic conditions like stroke, multiple sclerosis, or Parkinson’s disease.
The most common types of incontinence in women are stress incontinence and urge incontinence (or overactive bladder). Stress incontinence consists of leakage when the bladder is stressed by coughing, sneezing, yelling, laughing, lifting, exercise, etc. Most women are familiar with the sensation of having to cross their legs once in a while when they enjoy a good laugh with a full bladder. When such episodes actually result in frequent leakage—frequent enough that women feel the need to wear protection—it’s time to talk about treatment.
Stress incontinence is caused by weakness in the muscles which support the bladder and control the release of urine. Most commonly, these muscles lose tone because of muscle and/or nerve damage occurring during childbirth. Carrying and/or delivering a child, especially if there are many hours of pushing, a large baby, or a complicated delivery (e.g., forceps) can result in pelvic floor muscles which are permanently damaged. The result is a diminished ability to hold urine when pressure is applied to the bladder by a cough, a sneeze, or a laugh.
In many cases, the pelvic floor muscles are congenitally weak: Women leak because they inherited poor pelvic floor muscle support from their mother. I have treated many daughters who subsequently referred their mothers for treatment, and vice-versa!
Stress incontinence is often seen in association with visible signs of pelvic floor weakening and loss of support: The bladder may be dropped, and bulge into the vagina (a cystocele); the rectum may similarly bulge into the vagina (a rectocele); or the uterus may descend into the vagina (uterine prolapse). In some cases, these conditions may result in pelvic pressure, back pain, a sensation of something resting in the vagina or getting in the way of sexual intercourse. In advanced cases, women may actually see or feel a bulge coming out of the vagina. In other cases, stress incontinence is an isolated finding, with no other perceptible signs of pelvic floor damage.
While women with stress incontinence typically present with urinary leakage associated with coughing, sneezing, laughing, or exercise, women with urge incontinence complain of a strong urge to void, with some leakage of urine before they can reach the bathroom. Urge incontinence is generally a symptom of an overactive bladder: In women who have an overactive bladder, the muscular supports of the bladder may be intact, but the bladder does not wait for instructions from the brain; an urge to void is rapidly followed by an OVERWHELMING urge, and then by leakage. Women with urge incontinence typically say, “When I go somewhere new, the first thing I do is find out where all the bathrooms are,” or “When I get home at night, I put my key in the door and I have to race to get to the bathroom in time.”
Most women’s symptoms fall somewhere along a continuum, with a mix of stress and urge symptoms.
While stress and urge incontinence represent two distinct conditions, most women do not suffer from pure symptoms of only one or the other. Rather, most women’s symptoms fall somewhere along a continuum, with a mix of stress and urge symptoms:
Because stress and urge symptoms are each associated with a different underlying condition—with each requiring different treatment—evaluation of urinary leakage begins with a diagnostic evaluation to determine the fundamental cause(s) of the problem
How Is Incontinence Evaluated?
Usually, the evaluation of a woman with loss of bladder control begins with just talking. We strive to understand exactly what type of symptoms women find bothersome. Is leakage mostly associated with activity, straining, or exercise? Or does leakage occur while on the way to the facilities? Is leakage a problem during intercourse? Does it occur at night? Is their actual leakage, or just a sense of urgency? Is it necessary to wear protection?
This last question is particularly informative: Most women have experienced a slight leak at some point in their lives (e.g., a good joke and a full bladder), but when women feel the need to wear protection, it signifies an ongoing, regularly occurring problem. Wearing protection indicates that women are starting to tailor their lives around their symptoms. Moreover, since incontinence generally worsens with age, a woman in her 40’s who wears a panty-liner is likely to mature into a woman in her 50’s wearing a full pad, and subsequently to other incontinence products (Poise, Serenity, Depends, and others). Women don’t just wake up one day and need Depends; most older women have had gradually worsening symptoms for decades. Thus, when a woman starts to wear protection because of urinary leakage, it’s an indication of a worsening problem which probably requires attention.
Assessment of the woman with urinary leakage includes laboratory urinalysis and culture, followed by urodynamic evaluation, a study performed in the office to assess the function of the bladder. During urodynamic evaluation, the bladder is filled using a catheter, and pressures inside the bladder are recorded. Women are asked to perform various “provocative maneuvers” like coughing or bouncing on their heels. Measurement of various pressures permits us to determine whether the bladder is functioning normally, or whether it is overactive. Urodynamic evaluation is particularly useful in distinguishing between stress incontinence and an overactive bladder, which is vital to guide treatment. Urodynamic evaluation takes about 30 minutes, and is not painful. Women can return to work right after the evaluation.
Treatment of Incontinence
For women who have primarily “urge” symptoms, behavioral interventions can reduce the frequency and severity of leaking. Some dietary changes are usually recommended, since many foods can exacerbate urgency. Foods which exacerbate symptoms of an overactive bladder include:
- Spicy foods
- Acidic foods like citrus fruits and juices
- Carbonated drinks
In addition to dietary modification, Kegel exercises are often recommended to improve bladder control. Kegel exercises strengthen the muscles of the pelvic floor, and thus improve urinary control. Other behavioral interventions include timed voiding (e.g., void every 2 hours whether you feel you need to or not) which can prevent overfilling and reduce accidents.
When behavioral modification fails to control symptoms of an overactive bladder, there are at least 6 different medications approved by the FDA for this purpose. The medications are safe, and provide meaningful relief for many women with an overactive bladder. No single medication has been proven to be definitively superior to the rest, and all of the medications have similar types of side effects, the two most common being dry mouth and constipation. The medications however are safe and effective, and for some women provide a meaningful improvement in their quality of life.
For women in whom urodynamic evaluation indicates stress incontinence, and for women with mixed causes of incontinence who are not helped by conservative measures, minimally invasive procedures are available which provide excellent, durable results. The current state of the art is the obturator sling procedure. This procedure is performed through a tiny incision inside the vagina. The obturator sling requires only about 15 minutes under anesthesia. During the procedure a short strip of material is placed under the neck of the bladder to create a permanent support. Your own body’s tissues engulf the material so that it creates a natural support, fused to surrounding connective tissue. This material is strong and lasts effectively forever; it’s the same material used to “patch” a hernia.
If you have noticed worsening leakage, especially if you are concerned about odor or embarrassing accidents, or have resorted to using a pad for protection, you owe it to yourself to investigate your options. You are not alone, and treatment is available. If you would like to discuss your option, we would welcome the opportunity to meet with you.
May We Help You?
Would you like to find out more about our treatments and services? Are you looking for a second opinion on a diagnosis or treatment recommendation you received at another practice? The experienced team at The Woman’s Health Pavilion is happy to help. Just let us know how and when you’d like to hear from us.