UI treatment delivers dry season

Two years ago, Marion Boyce, a former nurse from Charlottetown, was asked to speak at a conference on urinary incontinence (UI) in Toronto. Speak she did, taking full advantage of the opportunity to upbraid the medical establishment for its collective inability to correct a condition that had been bedeviling her for 30 years. After numerous interventions, she was still “wet”, and having trouble understanding why nothing could be done about it.

Recently, Boyce, now 72, received an invitation to speak at this year’s UI conference in Montreal. The reason? Since the 1998 conference, something had been done about her condition, and she now had a very different story to tell. Two months before this year’s conference, Boyce is on the phone from Charlottetown, and she’s jubilant: “I’m dry!”

What happened was yet another surgical intervention – something Boyce hadn’t  wanted to consider two years earlier: She’d undergone four previous surgeries, each one sold with a virtual guarantee that her condition would be improved, if not cured. It never was, and Boyce’s faith in surgical solutions hit rock bottom. Moreover, with the passage of time, her condition was getting prressively worse.

Tries surgery again
At which point, last spring, Boyce’s family doctor suggested she reconsider  surgery. Despite her misgivings, Boyce decided to give it one last try.

She had her doctor get in touch with Toronto urologist Dr. Sender Herschorn, who’d approached her at the 1998 UI conference to say he thought he could help if she ever decided to try surgery again.

“We can look at whether a patient’s a candidate in terms of her bladder or urethral function,” Herschorn says now, “as against age or previous surgery or being disappointed many times. It involves discussing reasonable expectations of outcome. Every operation has risks and complications, and no operation is 100 per cent. Sometimes the operation works, but over time it fails, or starts to fail. You have to have this discussion, and the patient makes the decision on her own.”

As far as Herschorn was concerned, Boyce was as good a candidate as anyone -“except she’d been burned too many times, which is why she was so skeptical, and that’s why she didn’t have the treatment for such a long time.”

Types of surgery
After discussing her options, Boyce elected to have “a sling procedure” – an operation that’s been around since the 1920s, though it’s undergone a few refinements in the intervening years.

“The operations that have been done for the last 50 years or so are called ‘retropubic suspensions’,” Herschorn explains. “Basically, that involves putting stitches into the wall of the vagina behind the bladder and the urinary passage. Those stitches suspend that part of the anatomy to the lower part of the pelvis, or the bone, to stabilize the area behind the urinary passage to provide support.

“We use the patient’s own tissue. We take a piece from the lower part of the
tummy called fascia. It’s fairly durable, fairly strong tissue. Then we create a space around the urethra or underneath the urinary passage and suspend that tissue to the lower part of the tummy wall. So, it’s like a sling.

“It’s a fairly straightforward operation. It involves a few days in the hospital, but it’s far less invasive than what we used to do.”

Three months after the procedure, Boyce is just starting to get used to her
new state: “It’s a new lease on life,” she says, “and I’ve got Dr. Herschorn
to thank.”

The silent problem
In Montreal, Malvina Klag, former executive director of the Canadian Continence Foundation, shares Boyce’s excitement. 

“We always say there’s a way to either treat or manage UI. Marion had been through so much over the past 30 years with surgeries and other treatments. In a sense she was lucky. She found the right person to do the right surgery that worked for her. Many people with this problem aren’t getting that help.”

The trouble is, many people refuse to talk about UI, even to their doctors.

And there are a lot of people who could use help: recent estimates suggest 20 million North Americans may suffer from UI, many of whom haven’t discussed the problem with any health professional – even their own family physician – who might have been able to help.

Most can provide general information about UI, teach patients how to deal with specific problems and handle medications. Plus, if necessary, patients can be directed to other resources (such as nurse continence advisers, physiotherapists and other specialists) in the community.

“If UI bothers them – if, for instance, they wear pads, and it interferes with their life – it’s a problem,” Herschorn says, “and they should seek help, because there are treatments that are available and often effective.”

New treatments available
In fact, there’s a whole crop of treatments currently under evaluation. Some, including medications in clinical trials, are new; some – including injectable agents, such as fat, collagen and Teflon – are being re-evaluated.

“There are small balloons that can be implanted, all sorts of things,” Herschorn says – including such synthetic devices as a new silicone-rubber micro-implant that’s designed for both men and women.

“Men have incontinence, too,” Herschorn adds. “It’s a bit different, because women have labour, delivery, childbirth and hormonal problems, so they have incontinence a little more often than men. But there are effects on the bladder with aging, and both gender have bladder incontinence problems because of that.”

Men and UI
Men may have UI associated with aging and changes to their prostate gland, or as a result of a prostate operation – “and incontinence isn’t any more pleasant for them to deal with than it is for women,” Herschorn observes.

Treatment depends on the problem. If it’s a bladder problem, there’s medication; if  it’s a urethral or a muscle-control problem, especially after a prostate operation, the choice may be an artificial sphincter – a control valve that’s implanted under the skin.

 “It’s been around for about 30 years, and it’s often very effective,” Herschorn says.

On the other hand, sling procedures aren’t commonly done in men, because the anatomy’s totally different and doesn’t lend itself to the procedure. 

However, in women, they have as much as an 80 per cent success rate – though that figure must be tempered with reasonable expectations, Herschorn cautions: “It may make people better. They may not be 100 per cent dry, but hopefully they’ll have a tremendous improvement in their quality of life”

Before and after differences
Says Boyce: “I get up and I don’t have any of this padding business to be bothered with.” The difference, she says, “is more than I can explain to anybody.  It’s almost more than I can explain to myself. Just to get out of a chair was a  problem. To raise my arms above my head, to open a window. To do anything: tie my shoelaces, put on my snowboots, cough or sneeze, bring in bags of groceries. Now I can do all of those things, and I’m 100 per cent as far as being dry.”

Whether Boyce’s new condition is permanent remains to be seen – Herschorn admits there are no guarantees. But, says Boyce, “I’m going on the best part of three months, and I’m enjoying every day.”