Female incontinence: Don’t let embarrassment stop you from seeking medical help
AN APPLE A DAY - Tyrone M. Reyes M.D. (The Philippine Star) - August 10, 2015 - 10:00am

According to a recent report from the US Center for Disease Control and Prevention (CDC), 50 percent of older people struggle with urinary incontinence, and women are particularly vulnerable.  Previous research suggests that the problem is so devastating that patients feel its impact is worse on them socially, mentally, and physically than arthritis, diabetes and even cancer.  “Putting up with the problem can cause people to restrict their activities, substantially reducing their quality of life,” confirms Jonathan Vapnek, MD, associate clinical professor of urology at Mount Sinai School of Medicine in New York.  “It can also put older adults at risk of falls if they are rushing to get to the bathroom.”

Many older adults suffer incontinence in silence because they are too embarrassed to seek medical help.  It is estimated that less than half of women who have this problem consult their doctor for it even though doctors can offer effective treatments.  “In the majority of cases, simple lifestyle changes and behavioral methods are highly effective at treating incontinence,” says Dr. Vapnek. “Your individual pattern of urine leakage can help your doctor to diagnose which type you have and which treatment is most likely to work,” he says.

Types of incontinence

Three types of incontinence primarily affect women:

• Urge incontinence.  With this type of incontinence, which can also occur with stress incontinence, the bladder contracts without warning and you can’t get to the bathroom in time.  “Many people with this type of incontinence urinate while asleep, or may do so if they hear the sound of running water,” says Dr. Vapnek.

• Stress incontinence.  This occurs if the sphincter muscle that keeps the bladder closed isn’t strong enough to hold back the flow of urine. So, urine leaks while coughing, sneezing, laughing, during exercise, or any activity that puts pressure on the bladder.

• Mixed incontinence.  A combination of stress and urge incontinence.

During an evaluation, your doctor will determine which type you have by taking a medical history and by asking questions about your general health and when you’re losing urine.  “If I ask careful questions about when your leakage occurs, in 90 percent of cases, I can fit the person into one of these categories,” says Dr. George Flesh, director of urogynecology of Harvard Vanguard Medical Associates.

Your physician will likely also do a physical exam and may recommend tests that measure the following:  the speed and pressure of your urine flow, the amount you urinate, how much urine is left in your bladder after you use the bathroom, and how much your bladder can hold.  If you will be more comfortable with a female physician, there are now female urogynecologists practicing in the Philippines whose expertise includes urinary incontinence in women.

Urge incontinence treatments

Several treatments can relieve the symptoms of urge incontinence.

• Kegel exercises (see illustration). If your incontinence is not too severe, your doctor might start by recommending that you do Kegel exercises.  During these exercises, you squeeze and release the muscles you use to start and stop the flow of urine.  Kegel exercises strengthen the muscles that support your bladder.  Learning how to do these exercises can, in many patients, overcome the overwhelming urgency and allow patients time to get to the bathroom.  If you can’t seem to know how to use the right muscles to squeeze on your own, your doctor may refer you to a physical therapist who can instruct you on how to do these exercises properly.

• Medications.  If your urge incontinence is more severe or it doesn’t respond to Kegel exercises, your doctor can prescribe an anticholinergic drug, such as darifenacin, fesoterodine, oxybutynin, solifenacin, and tolterodine.

These drugs inhibit the inappropriate bladder contractions that trigger incontinence episodes.  In 2013, the US FDA approved a new, over-the-counter patch formulation of oxybutynin, specifically for women.

Which of the anticholinergic drugs is best? “There is no clearly superior product.  All of the medicines work in basically the same way,” Dr. Flesh says.  One review of studies published in the June 2012 Annals of Internal Medicine found that anticholinergic medications completely relieved incontinence in about 85 to 130 out of every 1,000 women treated.  Anticholinergics do have side effects, such as dry eyes and mouth, and constipation.  If one drug doesn’t work or the side effects are too much for you, your doctor might adjust the dose or try another medicine.

• Bladder training and cognitive behavioral therapy. Your doctor may also suggest bladder training, which involves “holding on” for progressively longer periods of time, the ultimate goal being to lengthen the time between trips to the bathroom. Cognitive behavior therapy (CBT) can also be an effective strategy for managing urge incontinence.  “CBT may help because it improves a person’s awareness of the bladder function and sensations,” says Dr. Vapnek.

• Topical estrogen.  Estrogen cream or suppositories, which are often used to treat postmenopausal vaginal dryness, may also be helpful for urge incontinence.  Estrogen works by helping to strengthen muscles that support the bladder and urethra.  Often in menopause, a woman’s body produces less estrogen. Using a topical form of estrogen may help tighten those areas and relieve some symptoms of urge incontinence.

• Electrical stimulation. A few different types of devices are used to electrically stimulate the nerves that affect bladder muscle contraction.  Sacral nerve stimulation involves implanting a thin device about two inches long under the skin in your back.  A wire carries impulses to your sacral nerve, which calms an overactive bladder.  On the other hand, percutaneous posterior tibial nerve stimulation involves inserting a hair-thin needle into the nerve just above the ankle.  A mild current travels through the needle to nerves in your lower back that control bladder function.  Dr. Flesh says this technique is not widely used because its effectiveness is unclear.

• Botox.  One of the new developments in the treatment of an overactive bladder is the use of botulinum toxin A (Botox).  When injected into the bladder, botulinum toxin can reduce the muscle spasms that lead to incontinence episodes.  Says Dr. Flesh, “This is a very big deal because the biggest problem in urogynecology is the thousands of patients out there with severe overactive bladder that doesn’t respond to oral medications…The effectiveness is high.  Roughly 70 percent of patients will have a good response.  Side effects, which can include mild urinary retention, are usually minor.  Because the effects fade with time, you’ll need to return to your doctor in six to 12 months for a repeat injection.

Stress incontinence treatments

• Kegel exercises.  Some women try Kegels for stress incontinence, which can be effective for mild cases.

• Surgery.  Often, women who are severely affected by stress incontinence will need surgery.  Several different procedures are available.  One of the most common is the suburethral sling.  A synthetic material or tissue taken from your own body is attached to your abdominal wall to support the urethra and prevent it from leaking urine.  The procedure is quick to perform, success rates are high, and complications (which can include bleeding and infection) are low, Dr. Flesh says.

• Bulking agents. Another option for stress incontinence is to inject a material such as collagen into the lining of the urethra to enlarge it so that it stays closed and doesn’t leak.  However, Dr. Flesh says the success rates with bulking agents aren’t as good as they are with slings, and the injection procedure is almost as invasive.

What else can you do

In addition to treatments you get from your doctor, you can try a few techniques at home to manage incontinence, such as these:

•  Lose weight if you are overweight or obese — extra pounds increase the pressure on your bladder.

• Quit smoking, particularly if you have developed a chronic cough as a result, since coughing places the bladder under stress.

• Practice Kegel exercises regularly.

•  Limit fluids.  Try not to drink more than 60 ounces of fluid a day. Drink small amounts of fluid every hour, instead of large amounts all at once.  If you can’t make it through the night without using the bathroom, stop drinking three to four hours before bed.  Also avoid highly acidic drinks (such as lemonade) and caffeinated beverages (soda, coffee), which can aggravate an overactive bladder.

Incontinence isn’t an easy problem to discuss openly.  But if you can put aside your embarrassment and have a conversation with your doctor, you can get started on treatments that could dramatically improve your quality of life.

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Sources:  Focus on Healthy Aging, Icahn School of Medicine at Mount Sinai, and www.health.harvard.edu

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