Incontinence: Treatable and curable
Urinary incontinence — the uncontrollable loss of urine — is a problem you don’t hear much about, even though it affects the lives of millions of people. Because it’s rarely discussed, exactly how many are affected isn’t known. According to one estimate, between 1.5 and 5 per cent of men and 10 to 25 per cent of women between ages 15 and 64 are affected; over 60, the rate rises to between 15 and 30 per cent, and up to half of all nursing home residents may suffer urinary incontinence to some degree.
The effects of incontinence are more clearly defined: Patients tell me they can’t go shopping or visit friends-for fear they’ll stain their couches. They’re afraid to visit their grandchildren, because they can’t pick them up; if they do, they lose all their urine. They’ve had to give up sports, they’re often depressed and they suffer severe social embarrassment. They may have problems with hygiene, and their sex lives, in many cases, are only a fond memory.
It’s an economic hardship as well for people on fixed incomes. They could be spending as much as $1,500 a year for pads, deodorants, washing and dry cleaning. There are women, some not so elderly, who wear protecte undergarments for years. There is a place for protective garments — you can’t fix everything — but in many cases it’s simply inappropriate: These people should have definitive management so they’re continent. Adding insult to injury, incontinence may be the deciding factor in institutionalizing an elderly person.
The astonishing thing is, only about one in 12 suffering from incontinence seeks help. Why? Embarrassment mostly, sometimes a sense the problem doesn’t warrant medical attention; many people believe it can’t be helped. The fact is, incontinence is usually treatable and often curable; we can help people to take charge of their bladders, often permanently, so that they feel that life, in all its fullness, has become possible again.
The first step is simple: Talk to your doctor. Anyone, at any age, of either sex, can be affected by urinary incontinence (UI), though women are affected up to eight times more often than men till age 70, when the numbers begin to even out, and older people more often than younger. Age and sex are two of the key risk factors associated with incontinence (estrogen deficiency in women going through menopause can lead to UI).
Obesity is a third. As well, men who have had radical prostate surgery often have trouble. Women who have had big babies or difficult deliveries are at risk, as are people with certain chronic illnesses, such as multiple sclerosis and diabetes. Prior surgery in the pelvic floor area can also lead to incontinence, as can stroke and some nervous-system disorders.
On the bright side, in recent years there have been many research advances. Surgical correction is one; there’s also been excellent research in terms of appliances, especially for women who are not surgical candidates. Research into electrostimulation of the pelvic floor, where the muscles are artificially stimulated to contract, shows great promise, as do new biofeedback techniques. There’s also a great deal of research into bladder pharmacology.
Stress urinary incontinence
The most frequent kinds of UI are stress, overflow and urge incontinence. Stress urinary incontinence (SUI, which mainly affects women) basically means that you lose urine when you put a force on the bladder with a cough or a laugh, exercise, picking up heavy objects — anything that causes a bearing-down sensation. The root of the problem is loss of pelvic floor support: The neck of the bladder (at the bottom, where it joins the urethra) has fallen below the pelvic floor, a sling of muscles that holds the uterus, bladder, bowel and other organs in place. If the bladder falls below that floor, the force vectors that usually operate to close it when you cough or sneeze do the opposite: They kick the door open, and there’s a spurt of urine.
SUI is the most treatable form of incontinence, often with directed pelvic floor exercises that bulk up the muscle and recruit new muscle fibres. With instruction, these exercises can be done at home. There are also medications that can help, but surgery is the gold standard for mild SUI. The bladder neck is properly repositioned inside the abdomen, then supported with a sling made out of the front wall of the vagina, through a tiny incision in the navel. The patient goes home the next day.
Collagen can also be injected around the neck of the bladder to build it up and create an artificial valve. It’s good for elderly people who are not otherwise surgical candidates, but it’s not recommended for young women who may be athletic for the next 20 years.
With urge incontinence, the patient has to go so badly she can’t restrain the urge to void, and the whole bladder empties. She has to void constantly, yet there’s nothing there. She may be running to the bathroom every 15 to 30 minutes and is up six times a night. There’s a wide variety of causes — it can even be poor voiding habits learned at age 3. Urge incontinence is by and large very responsive to medication and training — even diet. (Caffeine is the enemy. Eliminate coffee, tea, Pepsi, Coke, chocolate, and prescribe estrogen vaginal cream, and a lot of women are fine.)
One of the best approaches teaches people to take charge of their bladder, using a schedule: The first week, they go to the bathroom every hour during the day whether they need to or not. Week Two it’s every hour-and-a-half, then every two hours. You take them back to age 2 and retrain the bladder, with the aid of medications. As the training takes over, the patient is weaned off the medication.
Overflow incontinence is more commonly seen in men, because they can’t empty their bladder. It fills to the point that they can’t suppress a contraction, so the bladder starts to squeeze out the excess urine. Women sometimes experience overflow if they have a lot of narrowing at the urethra. Treatment usually consists of relieving an obstruction (in men, through prostate surgery; in women, through dilation of the urethra).
There’s a stigma attached to loss of control of all kinds that keeps people silent. Certainly few people are comfortable talking about their incontinence with friends, although that’s changing-people are learning that there are things that can be done. Incontinence has to be brought up front-in all age groups. We’ve got to get people willing to talk to somebody about it. Then-and only then-can we do something about it.
Dr. William A. Easton is chief, Department of Obstetrics and Gynecology, at the Centenary Health Centre in Scarborough, Ont., and a lecturer in the Department of Obstetrics and Gynecology at the University of Toronto.