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Regaining Control
Incontinence is not just our grandmother’s ailment
by Roberta Greenwood

Ellen has worked in the medical field for years, but nothing prepared her for the early onset of urinary incontinence. An active 43-year-old mother of four, she realized her life was beginning to shrink as she planned her daily activities around the nearest restroom.

“I began to wear pads, select certain routes for my runs, and eventually had a horrible experience in a department store as I was trying on clothes. My incontinence was getting in the way of my life.”

Ellen (name changed to protect her privacy) isn’t alone. According to the National Institutes of Health, nearly 13 million Americans suffer from some type of urinary incontinence. It is second only to arthritis as the most common chronic condition in America. Contrary to common belief, this isn’t a disease of only the old: An estimated 15 to 20 percent of women between the ages of 15 and 64 will suffer some symptoms of urinary incontinence. It’s not uncommon for younger women to experience symptoms early in their childbearing years. In fact, stresses from pregnancy are a contributing cause of pelvic floor disorders that can lead to urinary incontinence.

Jeanette Shurr, RN and lead practitioner at the Evergreen Center of Continence and Pelvic Health, says most women don’t understand this isn’t just their grandmother’s problem. “The common types of incontinence that we treat — stress and urge incontinence — can be caused by straining and childbirth. In fact, 50 percent of all women will have some type of pelvic disorder in their lifetime.”

Many women don’t talk about the problem, even with their primary care providers or intimate partners. They choose instead to curtail daily activities, opt to wear pads, or never venture too far from a public restroom. Shurr says it’s simple: Women are embarrassed and believe it’s only happening to them. “Nothing could be further from the truth! Women need to become their own best advocate; they have to stop dismissing symptoms or thinking there’s nothing they can do. Women need to realize they’re not alone in this.”

Kathleen Kobashi, MD, is co-director of the Continence Center at Virginia Mason and president-elect of the Washington State Urology Society. She believes patient education is a key element to successful treatment of incontinence. “Many misconceptions keep patients from seeking treatment. We have a responsibility to educate our patients. Incontinence is treatable.”

Types and Symptoms of UI

Although there are five types of UI — stress, urge, mixed, overflow and functional — all share the same symptom: the inability to urinate normally. According to the American College of Obstetricians and Gynecologists, normal urination, also referred to as voiding, occurs when a woman can empty her bladder when she has a natural need to do so. “It’s important to discern the type of urinary incontinence a patient may experience,” explains Dr. Allen South, clinical assistant professor of obstetrics and gynecology at the UW Medical School and a member of the teaching panel at Swedish Medical Center. “There’s a very different approach to urge and stress incontinence; patients need to understand their symptoms.”

Stress incontinence is the most common type of problem in younger women; when the muscles that support the bladder get weak, a loss of urine can occur if the woman laughs, coughs, or participates in activities such as running or even walking. Urge incontinence is signaled by the strong urge to void and is sometimes referred to as an overactive bladder. Again, leakage can occur if the woman can’t locate a restroom quickly enough. Mixed incontinence is a combination of both stress and urge incontinence and often results in more leakage than either type alone would. Overflow incontinence occurs when the bladder doesn’t empty all the way, while functional incontinence is caused by additional health problems such as stroke or arthritis which limit a woman’s ability to get to a bathroom on time. Some diseases increase the risk for UI; women with diabetes have a 70 percent greater risk of incontinence than non-diabetics.

While the leakage of urine is perhaps the most distressing symptom, other problems also can be present with urinary incontinence. Often, the bladder feels uncomfortably full, which can cause complaints of pelvic pressure. Frequency of voiding is a common complaint and nocturia (frequent night urination) is a problem for many women. Dysuria refers to painful urination and enuresis is leakage that occurs while sleeping. Symptoms can also affect a women’s feeling of sexuality. “With extreme cases of prolapse, the vagina may be stretched and weakened over time,” explains South. “With corrective surgery, we can reconstruct the vagina, strengthen the pelvic floor and this can increase a woman’s sexual experience.”

All the practitioners agree that urinary incontinence can be successfully treated, especially with the recent improvements in medications and surgical interventions. “The technology we have today is so improved,” says Shurr. “It’s not perfect, but it’s progressed. We have new diagnostic tests, new surgeries that are less painful, less invasive — and we’ve learned so much about how physical therapy can help women control incontinence.”

Treatments

Physical therapist Alexandria Wells, MPT, says her practice empowers women to work at improving their pelvic floor strength so they can mitigate many of the symptoms of UI. “At any age, we can help make muscles better. Most pelvic floor improvements can be measured within eight weeks; we provide biofeedback to ensure women are doing their strengthening exercises (commonly referred to as Kegels) correctly and we can assist with correcting breathing techniques.”

Wells offers these tips to help women retain pelvic health throughout their lives: Understand the stresses of labor and delivery and learn how to protect your pelvic floor before giving birth; limit straining while lifting or having a bowel movement; and make effective Kegels a regular part of your exercise regime. “Seek out help,” Wells says. “Don’t suffer with this; there are so many modalities out there that can help women with this problem.”

Ellen agrees. “Physical therapy was very successful for me,” she explains. “In my biofeedback sessions, they placed electrodes on my stomach and thighs so I could see my contractions and work on my breathing. I learned to make mental notes to myself to void before certain activities. I saw results in four weeks.”

Several continence clinics throughout the Seattle area provide a comprehensive approach to treating UI. Primary care physicians commonly make referrals — and most continence procedures are fully covered by insurance. Shurr thinks the idea of a women-centered clinic improves the chances a patient will come in for treatment. “We work in a welcoming and accepting environment; women can feel comfortable coming here and discussing their problems. We do a comprehensive work-up at the first visit, obtaining a complete medical history. We team with a fantastic group of doctors who provide a full spectrum of treatments. If surgery is required, we can make referrals and often, a less invasive surgery is successful for many of our patients. I just can’t emphasize strongly enough that no woman has to suffer these embarrassing symptoms any longer.”

Miriam Jaffee, a nurse practitioner, says that many times conservative options such as bladder retraining can have huge impacts on a woman’s symptoms. “In bladder retraining, we teach patients to use their pelvic muscles for ‘timed voiding.’ Normal voiding urges are between six to eight times per day; anything over that is considered frequent urination and can be problematic for some women.” Jaffee adds that urge incontinence can often be managed with medication or the use of a pessary to strengthen pelvic muscles. “The important thing for women to realize,” she stresses, “is that surgery is often unnecessary. Up to 75 percent of our patients see significant improvements with other forms of treatment.”

While South agrees that medication, bladder retraining and physical therapy can be successful in some cases, when stress incontinence is severe, he feels surgical procedures are the most effective treatment. “Often the severity of prolapse is such that the vaginal tissues are weakened significantly,” he explains. “In those cases, I believe that surgery will provide a patient with her best chance of improvement.” The first option is commonly referred to as a “sling” procedure: A piece of synthetic tape is placed under the urethra to increase tension, thereby limiting leakage. “This requires about a five-hour hospital stay,” says South. “Recovery is fairly rapid in otherwise healthy women, although we caution that patients should limit heavy lifting for eight weeks.” If a woman has more severe symptoms, vaginal reconstructive surgery or full bladder augmentation may be required; these procedures require a longer hospital stay (three to five days) and a six-week recovery period.

According to the Continence Center at Virginia Mason, surgical interventions have increased their overall success rate to nearly 90 percent. In addition, lifestyle changes have been shown to significantly reduce stress incontinence — Kobashi recommends losing weight, eliminating caffeinated drinks and stopping smoking.

“I just want women to realize that incontinence isn’t normal,” concludes Jaffee. “We can significantly impact a woman’s lifestyle — we can assist her in taking back the freedom to live her life fully. No one should feel embarrassed by this problem — and no one should feel like there’s no hope.”

Roberta Greenwood writes frequently about women’s health issues for Seattle Woman.

©2007 Caliope Publishing Company