Better Solutions to an Old Problem : Health: Women, who are twice as likely as men to suffer from bladder-control problems, have options other than simple acceptance.
Therese never thought twice about driving the Southern California freeways to visit far-flung friends. But lately the treks have become troublesome.
“In the middle of a trip, I have to get off the freeway and find a Denny’s or a gas station to use the restroom,” complains the 77-year-old retired teacher. “It’s a major nuisance.”
Mary, an active 83-year-old San Fernando Valley nurse, can empathize. While working, she cuts back on fluids so she won’t have an accident. Just to feel safe, she wears an absorbent pad.
The feelings of these women, who asked that their real names not be used, aren’t uncommon.
More than 10 million Americans are incontinent, according to the American Foundation for Urologic Disease, a Baltimore nonprofit educational foundation. Women are twice as likely as men to have the condition. One in six women 45 and older experiences it, the Foundation estimates, although much younger women also report leakage.
Stereotypes about getting older and bad jokes about diapers have made many hesitant to discuss their problem. But the picture is changing.
“Years ago, a woman would go to the doctor and say she leaks, and he’d say, ‘That’s OK, honey, put on a diaper,’ ” says Dr. Anna Fuchs, a Century City Hospital urologist and UCLA assistant clinical professor of urology. These days, diapers should be a last resort because there are many other options, Fuchs says.
The important first step is to find out the cause of the leakage, Fuchs told participants at a recent seminar. That’s not as easy as it might sound, since there are many types of incontinence and some patients have a mixture of types. A physician should perform a thorough physical and obtain a good history, asking about fluid intake and the severity and frequency of incontinence. Tests of bladder function are commonly done.
Based on that information, urologists generally classify incontinence into four types: stress, urge, overflow and total.
“Stress incontinence is the kind women who have had children hear most about,” Fuchs says, although it can also affect men after prostate surgery. Leakage occurs when a person sneezes, coughs or exercises strenuously.
In this type of incontinence, the bladder “droops.” The normal support to the bladder and urethra (urine-carrying tube) given by pelvic floor muscles diminishes after the muscles are weakened by childbirth. Hormonal deficiencies and surgery can do the same.
In urge incontinence, the bladder contracts involuntarily and the person has an uncontrollable urge to urinate and an inability to get to facilities in time. It can be associated with urinary tract infection, strokes, multiple sclerosis or psychological causes, Fuchs says. Stress and urge incontinence can occur together.
With overflow incontinence, the bladder is distended and does not empty completely and overflow occurs. There can be frequent or constant dribbling. It can be caused by an enlarged prostate, bladder stones or other problems, according to the American Foundation for Urologic Disease.
Total incontinence, often associated with birth defects, involves constant leakage of urine.
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Once the test results are in, treatments should be tailored to the cause. “Total incontinence requires fairly intensive surgical repair,” Fuchs told more than 30 people attending the seminar.
But sometimes, treatment is fairly simple. If hormonal deficiencies are to blame, estrogen, even in the form of topical cream, can help. If infection is to blame, antibiotics are prescribed. Restricting fluids, especially in the evening, can also improve the problem.
For stress incontinence, training women to perform Kegel’s exercise--often prescribed after childbirth to strengthen the pelvic floor muscles--can help, advocates say. While many women think they are performing them correctly, they are not, says Renee Brandon, a registered nurse who also spoke at the seminar. She uses biofeedback to teach women to contract the correct muscle groups.
Doing Kegels is a lifetime commitment, she tells women, much like controlling diet or adhering to an exercise program. “The Kegels strengthen the muscle groups that allow you to control your urine,” she says. But some experts say the Kegel approach is oversold and doesn’t work for everyone.
“Biofeedback doesn’t work for a mechanical problem,” says Dr. Mansoor Karamooz, a urologist and chief of staff at Thompson Memorial Medical Center in Burbank, explaining that surgery is usually needed for moderate to severe stress incontinence. Another approach to doing Kegels correctly is to use vaginal cones in a series of graduated weights.
By July, another non-surgical treatment for stress incontinence is due at physicians’ offices. Called the Introl bladder neck support prosthesis, it is inserted vaginally to elevate the bladder neck and restore the normal anatomical relationship between the urethra and bladder. The plastic device is inserted during the day and removed at bedtime, says Marcy Black, a spokeswoman for Johnson & Johnson Medical Inc., in Arlington, Tex., the manufacturer.
In a study, 13 women (average age 56) who used the Introl reported urine loss decreased by 62%, says Dr. Durwood Neal, a urologist at the University of Texas Medical Branch at Galveston, who conducted the study and reported his findings at the American Urological Assn. meeting in April. He says the device will be especially helpful for women who decline surgery or who must postpone it.
If surgery is needed, many physicians now perform a transvaginal bladder neck suspension procedure, in which the bladder neck and urethra are lifted and secured, thus restoring their correct anatomical position.
Traditionally, this surgery was done through the abdomen, but the newer procedure reduces recovery time. Still, many surgeons use the traditional approach.
Yet another surgical approach is called a percutaneous bladder neck suspension, says Dr. Gary Leach, chairman of urology at Kaiser Permanente Los Angeles who has performed about 50 such procedures in the past 18 months.
Leach hopes to have more clear-cut surgery guidelines for stress incontinence by next year. He is chairman of an American Urological Assn. panel charged with tracking 25,000 women who underwent surgery and evaluating the long-term effectiveness of various procedures.
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When the problem is urge incontinence, behavior modification is sometimes helpful. (It can reduce stress incontinence as well.) Patients are put on a voiding schedule, sometimes visiting the toilet every 30 minutes to an hour, and gradually increase the intervals.
Medications to slow down the bladder, such as the antidepressant Tofranil (imipramine) and the antispasmodic Ditropan (oxybutynin) can help urge incontinence too. For overflow incontinence, intermittent self-catheterization, usually done every six hours, is sometimes recommended.
Some treatments are helpful only for specific kinds of incontinence, Fuchs says. Collagen, a widely publicized treatment, is used for a specific kind of stress incontinence in which the urethra does not close properly.
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Help for the Incontinent
Avariety of educational materials is available for people with incontinence problems:
* American Foundation for Urologic Disease, (800) 242-2383.
* Help for Incontinent People (HIP), (800) 579-7900.
* The Simon Foundation for Continence, (800)23-SIMON.
