Urinary Incontinence

Emmanuel K. Essel, M.D.
Obstetrician Gynecologist
5040 Oberlin Avenue
Lorain, OH 44053
Tel:216 960-0644

URINARY INCONTINENCE IN WOMEN, A TREATABLE EPIDEMIC

When I was growing up, I didn't understand why my grandma Mary shunned public gatherings or travelling long distances by car. She had to change her clothes many times a day so that she wouldn't smell of urine. She was suffering from Urinary Incontinence. Grandma Mary is typical of many women who suffer from this disease. They limit their social activities and keep to themselves. Many become depressed.

According to the International Continence Society(the society that sets standards for Urinary Incontinence), the criteria that should be satisfied before a woman can be diagnosed as having Urinary Incontinence are as follows:

With a comfortably full bladder, the patient should be able to demonstrate the urine loss to the physician during physical examination.
The urine leakage should be severe enough to cause a hygienic problem such as daily use of pads.
The leakage of urine must affect the patient socially such as avoiding certain activities because of the embarrassment of her condition.

In 1988 a Consensus Development Conference on Urinary Incontinence organized by the National Institute of Health said that at least 10 million American adults suffer from Urinary Incontinence. It affects 50% of Nursing Home residents and 15 to 30% of community dwelling adults. Most of the people affected are women and yet few seek help. Studies have also shown that only a few physicians address this issue. Even when the patient complains about the problem to their physicians only a few of them treat the condition or refer them to a physician who is interested in this disease. It is no wonder that Mrs Smith exclaimed when I told her I can help her: "I can't believe you can help me. Most of my friends have this problem. Everyone wants to see how I come out of this before they come for treatment. Since my mother and her sisters had it I thought it was part of old age."

The effect of Urinary Incontinence on the affected women is tremendous. Most patients are ashamed and embarrassed by the condition. They withdraw from social activities and become depressed. The regular pad use by these women and constant contact of urine with the vulva cause unbearable skin conditions that sometimes prevent sexual interaction.

How do I maintain dryness?

The normal mechanism involved in normal urination involves the nervous system, the bladder, the urethra(the tube leading from the bladder to the outside) and the muscles in the pelvis holding the bladder, the urethra, the vagina and rectum in place. As the bladder fills with urine, it expands to hold the urine without increasing its pressure. There is usually no sensation that the bladder is filling. When the bladder reaches its maximum volume, it sends information to the central nervous system to notify it that it is full. If it is not convenient for voiding, the woman may suppress the sensation to empty the bladder. The bladder will relax and the bladder neck will close down to prevent urination. When it is convenient, she will contract her bladder and relax the bladder neck so she can urinate.

Why do some women leak urine?

When this normal function becomes abnormal, the patient can't suppress the sensation to urinate. She may have to rush to the bathroom or else the bladder contracts on its own and the bladder neck opens to expel the urine. Such a patient is like a baby whose bladder contracts to empty itself whenever it is full. The baby has no control over the bladder.

In some patients the bladder neck opens without the bladder itself contracting whenever they cough, exercise or walk. This also causes leakage of urine and usually occurs in patients who have weakness of the muscles in the pelvic floor. The bladder neck in such patients has moved from its typical position in the pelvis.

What are the different types of Urinary Incontinence?

Urinary incontinence comes in different forms. There is the patient who may not get to the bathroom fast enough and have an "accident." Some patients may leak urine only when they laugh, cough, sneeze or exercise. Others can't empty their bladder completely. The urine in the bladder thus overflows to cause leakage.

What should I do if I have symptoms of Urinary Incontinence?

A patient who leaks urine when she doesn't want to, must see her physician to find out the type of Urinary Incontinence she has. This diagnosis depends on what the patient tells her physician, the physical findings and the results of investigations. These are necessary to distinguish between the various types of Urinary Incontinence so they can receive the appropriate treatment.

Certain medical conditions may predispose to Urinary Incontinence. Patients with Multiple Sclerosis, Diabetes Mellitus, prolapse of the Bladder, Vagina or Uterus and constipation may have Urinary Incontinence. Patients who wet the bed into later childhood tend to have Urinary Incontinence later in life. Other conditions that may lead to Urinary Incontinence are Dementia, physical limitation (inability to move to the bathroom quickly), urinary tract infections and medications. The clinician would ask questions to exclude any of these conditions and to figure out the severity of the Urinary Incontinence.

Most physicians will give their patients pre-printed questionnaires to complete. This is to ensure that the woman would answer most of the questions in privacy. It also saves time. The physical examination that follows would aim to confirm leakage of urine. It is also to exclude neurological conditions and relaxation of the pelvic floor muscles that may cause the bladder, uterus vagina or the rectum to drop.

What tests do I need?

After the physical examination certain tests have to be done. Urine is obtained to examine for infection. Urinary tract infection can mimic Urinary Incontinence. It is also important for the patient to complete a Urine Voiding Diary. This will record how much she urinates each time she empties her bladder and the number of times she urinates during the day and night. The patient will also record episodes of urine leakages as well as the amounts and types of fluid intake. The Diary will show the patient who urinates frequently during the day and night. It also will show the patient who is drinking too much fluids.

A method called cystometry tests the ability of the bladder to hold urine without contractions until the patient is ready to urinate. The simplest form involves inserting a catheter into the bladder and filling it serially with about 50 cc of water at a time until the patient cannot hold the water in the bladder anymore. The volume at which the patient has a sensation to urinate is noted. The largest volume at which the patient cannot hold the fluid in the bladder anymore is also recorded. The patient then coughs to prove the leakage of urine. If no leakage is evident with the patient lying down, the patient stands and coughs. After the patient urinates the amount of urine left in the bladder is measured by passing a catheter or using an ultrasound. Patients who cannot empty their bladder completely would have large volume of urine in their bladder.

Some patients may need more complex studies. These include patients who have had previous surgery for urinary incontinence, older patients and patients with complex history. Patients with blood in their urine, symptoms of frequency and urgency may need their bladder and their urethra examined to exclude any local diseases.

Do I need surgery to treat my disease?

Every patient with urinary incontinence does not need surgery. Patients with bladder neck weakness can be treated with pelvic floor exercises if their condition is mild. In these patients the bladder neck has moved from its normal position in the pelvis. When this is severe or when exercises fail, the patient may be treated with surgery. The aim of the surgery is to restore the bladder neck to its natural position in the pelvis. There are different types of surgical treatment for displaced bladder neck. If we make the right diagnosis and choose the right surgical method the cure rate is about 85 to 95%.

On the other hand when the patient is found to have a weak bladder such that she cannot get to the bathroom early enough, I do not recommend surgery. Most patients improve with bladder training and medications. Bladder training comprises of re- educating the bladder function. One method involves the patient urinating, say, every thirty minutes for two days and increasing the interval between urination by thirty minutes every two days.During this training period the patient should not use the bathroom before the scheduled time even if she has the urge to urinate. In well motivated patients bladder retraining in combination with medications that prevent the bladder from contracting have good outcome.

Similarly, patients who have overflow Urinary Incontinence do not need surgery. I usually teach them to catheterize themselves intermittently to prevent leakage of urine.

Urinary Incontinence is a complex problem which physicians need to fully evaluate before treatment, especially if the intended treatment is surgery. Without the proper preoperative testing, the wrong diagnosis could lead to treatment failure.

Treatment is available for most patients with urinary incontinence. Women who have Urinary Incontinence should seek help from their physicians. Even Grandma Mary is dry now after her treatment.

Manny Essel