Shamed to silence
Urine is supposed to stay put, right in the bladder until the brain gives the order to vacate the premises, preferably into a toilet. But bodies don’t always co-operate. The uncontrolled loss of urine is a medical disorder called incontinence, which the World Health Organization claims is “a widespread global disease and one of the last medical taboos for many people.” Its most common forms are urge, stress and overflow incontinence.
People with urinary incontinence may spend $1,000 to $1,500 on products to manage the disorder, and some end up in nursing homes when caregivers just can’t cope with the level of hygiene needed. The Canadian Continence Foundation estimates incontinence costs Canadians about $2.6 billion annually.
For controlled urination, the bladder wall muscles and the sphincter muscle that regulates the urethra (the tube conducting urine from the bladder) must function normally. Urge incontinence occurs when bladder muscles squeeze spontaneously and urination can’t be delayed. It can have a neurological basis or may result from infections or bladder disorders including cancer, or by obstruction of the bladder’s outlet by an enlarged prostate. In many cas, the cause is unknown or “idiopathic.”
With overflow incontinence, there’s no dash for the washroom because there’s no sense of a need to urinate. Instead, urine can dribble out day and night, though the bladder doesn’t empty completely. The condition can be caused by diabetes or other diseases that affect nerves or by spinal cord injury. It can also occur when the urethra is obstructed. The problem is more common in older men with kidney stones or an enlarged prostate. Tumours in the uterus or ovaries can similarly affect women.
A woman’s worry
Stress urinary incontinence (SUI) is the term used for the involuntary leakage of urine that occurs when there’s an increase in pressure on the bladder caused by physical exertion, such as sneezing, laughing, coughing or vigorous movement. Men who have had prostate surgery can be affected, but it is the most common form of incontinence in women.
Dr. Lesley Carr heads up the Women’s Pelvic Health Centre at Toronto’s Sunnybrook and Women’s College Health Sciences Centre. She points out that risk factors for SUI include “anything that damages the control muscles of the pelvic floor or the nerves that control the muscle function, most commonly vaginal delivery. Other things like pelvic surgery, hysterectomy or vaginal surgery can do the same thing.” Carr also notes smoking-induced coughing, bearing down caused by constipation, and obesity can increase pressure on the bladder.Causes can be genetic in origin or include muscular anomalies, damage from radiation treatment, or vaginal or uterine prolapse (in severe cases, pelvic organs fall through the vagina).
Carr is concerned that women don’t know SUI is a medical condition with solutions and not a function of normal aging. The impact on a woman’s lifestyle and health can be significant, especially if she thinks there is nothing to be done. Cutting back on exercise to avoid leakage can affect a woman’s overall health, Carr says. “There’s other things,” she adds. “Social isolation, fear of intimacy because of commencing urinating during intercourse — would obviously be of concern. Women who are career-oriented, who have the severe forms and have to wear bulky pads may in time lose the ability to work because they are afraid of odour or that they will leak so much that it will not be contained in the pads.”
Women are remarkably uncomfortable discussing symptoms of SUI with a health professional. Almost two-thirds of those with the disorder had not talked to a doctor about it.
Cope – but see a doctor
The Canadian Continence Foundation notes these women sometimes cope by mapping out toilet locations for emergency access, drinking less fluid and using absorbent pads for leakages. (Carr’s advice on the Women’s Health Matters website is to use pads specifically for urinary, not menstrual absorption and to ask a pharmacist for creams or wipes that will minimize urinary odour.)
Most cases are in the mild to moderate stage, suggests Carr, and can probably be managed through behavioral therapies (cutting back on caffeine, quitting smoking, avoiding constipation and voiding regularly rather than waiting too long to go) and specific exercises. Some women don’t talk to a physician, afraid of being sent to a specialist and undergoing cystoscopic and catheter tests, she notes. What they need is “a simple urine test to make sure there’s no infection; a vaginal exam, which a woman should be having once a year to make sure the bladder hasn’t dropped; and to be taught the Kegel exercises.”
Kegel exercises strengthen the pelvic floor and must be done correctly and regularly to be effective. To learn to activate the correct muscles may need a therapist’s coaching. There’s also a special electrical device that strengthens pelvic muscles by causing them to contract involuntarily. Active women can talk to their physician about using devices such as tampons or pessaries that are inserted in the vagina before exercise and support the urethra. Disposable barrier devices designed to close off the urethral opening must be removed before urination.
Surgical interventions work mainly on two mechanisms, Carr says. The first elevates and supports the bladder neck, although the trend is toward a technique that “seals the urethra by putting a mesh or netting – like a hammock – around the urethra to support it, which also seals it during a cough or when doing jumping jacks and other exercises. Those have led to the new vaginal tape procedures in which minimally invasive incisions can be done under sedation or local anesthetic as an outpatient,” Carr says. “This means faster return to work and to activities of living.”