Seeking the Best Way to Stay Dry
Adult diapers may be a $16-billion industry, but there are signs that aging baby boomers are looking for far better ways to address the very common problem of incontinence.
And medicine isn’t letting them down. With the help of simple exercises, medication and surgery, many people are overcoming incontinence and finding their way back to nice cotton underpants (or even sexy lingerie).
More than 15 million Americans have incontinence, and 85% of them are women--and not just elderly women. In younger women, incontinence can be a problem after childbirth. While men tend to have incontinence associated with prostate problems, female incontinence tends to be more insidious.
Many women are embarrassed to tell their doctors about it, and many doctors still hesitate to ask.
“It’s a significant problem. But most of the effort goes into diapers and so forth, and not enough goes into proper treatment,” says Dr. Michael Tahery, a Beverly Hills urogynecologist who has pioneered one of the many new surgical treatments used to address incontinence. “Everyone deserves an explanation for the cause of their problems and treatment options to help them enjoy life more.”
More than half of all women in the U.S. will suffer from incontinence at some point in their lives, but only one in five will seek help, according to the American Urological Assn. On average, a woman with incontinence will wait eight years before seeking medical help.
Diapers aren’t the only consequence of living with incontinence. The disorder contributes to depression, social isolation and inactivity. And half of all nursing home admissions are due to incontinence, according to the urological association.
But the old idea that people have to live with incontinence is changing, experts say.
It’s never too late to address the problem, experts say. Lucile Toole, 86, had been struggling with incontinence for several years. In 1997, she almost backed out of a cruise to Norway because of her incontinence. She decided to go and survived the trip without any embarrassing accidents. But her worries over incontinence clouded the experience, and upon returning home, Toole decided to do something about her problem.
After discussing her incontinence with Tahery, Toole made weekly visits to his clinic to learn exercises, along with biofeedback, to retrain her pelvic muscles. Her problems abated.
“I’m so excited about this change in my life,” the Echo Park woman says. “I take classes and go to lectures. I’m not completely cured. But last week I was in a crowd, and I knew I couldn’t get to a bathroom for at least an hour. And I could wait. It was a big win.”
Recent Developments Offer More Answers
Toole sought treatment for her incontinence on her own initiative. Others may be encouraged to do so thanks to several recent developments:
* The American Urological Assn. last month launched a public service campaign called “You Are Not Alone” to educate Americans that incontinence is not an inevitable part of aging and can be treated.
“Most women who feel that they are the only ones with this problem don’t realize that millions of others have the same problem,” says association President Dr. William R. Turner Jr., of the Medical University of South Carolina.
* A study last month in the Journal of the American Medical Assn. suggested that many women could be helped by simple, noninvasive exercises and biofeedback. An accompanying editorial called on doctors to redouble their efforts at diagnosis and treatment.
* Two new alternatives in drug therapy have become available within the last year.
* A major research effort is underway to explore various surgical techniques to cure female urinary incontinence.
“In the last few years, we’ve really seen this come out of the closet,” says Kathryn L. Burgio, a researcher at the University of Alabama at Birmingham who wrote the recent JAMA study. “Manufacturers of drugs and devices are doing direct-to-consumer advertising. The consumer is getting the message that they are not alone and there is treatment out there.”
“It is clear that diapers and institutionalization will be inadequate responses to the incontinence epidemic as baby boomers age,” says Dr. Lauri J. Romanzi, a Cornell gynecologist, writing in the new issue of the Journal of Gender-Specific Medicine.
What’s still unclear, though, is whether women are aware of the new options and whether doctors are getting that message to them. Part of the effort to help women involves bringing doctors up to speed on new and emerging treatments, says Dr. Neil M. Resnick, chief of geriatrics at Brigham and Women’s Hospital in Boston, the author of the editorial in JAMA.
“Unfortunately, most physicians have received little education about incontinence, fail to screen for it, and view the likelihood of successful treatment as low,” Resnick said in the JAMA editorial.
A Dec. 16 study in JAMA illustrates that point. Researchers showed that a technique called biofeedback-assisted behavioral therapy was very effective in helping women ages 55 to 92 with urge incontinence, a type of incontinence in which there is a sudden, pressing urge to urinate.
The patients receiving biofeedback-assisted therapy were taught how to control the responses of their bladder and pelvic muscles. More than 80% of the women in this group improved, compared with 68.5% of women who were treated with a standard medication (oxybutynin chloride).
Since behavioral therapy is safe, inexpensive and--the new study shows--effective, the technique should be offered to more women, Burgio says.
“This is a treatment that is not widely available. It’s our hope it will be more widely utilized now,” she says. “Most doctors don’t really learn how to treat incontinence with behavioral therapy. That’s a big reason why the treatment is underutilized.”
Behavioral therapy is becoming more popular in the Southern California area, experts say.
“Biofeedback is a hot new area,” Tahery says. “It increases the capacity of the bladder, and it increases the patient’s control.”
Least Invasive Approach Advised for Females
Guidelines from the Agency for Health Care Policy and Research and the National Institutes of Health have also advised doctors to try the least invasive treatments first for female urinary incontinence. And medications have been the most common treatment. The advantages of drug treatments are that they work quickly and involve less of the doctor’s and patient’s time and effort.
Last spring, a new medication called Detrol received federal approval. It is an improvement over older drugs because it is less likely to cause side effects, such as dry mouth and constipation. And, last month, the popular medication oxybutynin chloride (the brand name is Ditropan) was released in a new formulation (called Ditropan XL), which allows for a once-a-day dose instead of taking the medication every few hours.
Surgery is also very successful at treating stress incontinence, in which urine is leaked when the abdomen is under physical stress. But it is often difficult for women to know when they should opt for surgery and which surgical technique to have.
There are more than 100 different surgical procedures for incontinence, Burgio says.
“Surgery has been an area of controversy,” she says. “Some people think the least invasive options should be exhausted first. Other people think you ought to go straight to surgery. But we are getting better at selecting appropriate patients for surgery.”
Before treatment decisions are made, patients should have a complete physical and medical history, and the doctor should rule out other disorders, such as diabetes or infections, that might be causing the incontinence. Most women also undergo several types of tests to help doctors pinpoint the problem.
“It’s very important to find out what kind of problem a woman has because the treatment varies depending on the cause,” Tahery says. He notes that some women suffer damage to the pelvic floor after childbirth, while older women may become incontinent because of the loss of hormones during menopause.
“We’ve been trying to phase out the [poor] treatments from the good ones. We need a lot more studies and improvements. But treatment has gotten significantly better.”
Consumers need to learn about the full range of options, Burgio says.
“I think there is an increasing awareness that for many types of incontinence there is more than one type of treatment that can be chosen. There is a push to give patients more choice.”
She advises women to first consult their primary care doctor, who can treat some types of incontinence. That doctor can also provide an appropriate referral to a specialist. Many specialists treat incontinence, including gynecologists, urologists, urogynecologists, nurse-practitioners, geriatricians and physical therapists.
Women might be wise to select a multidisciplinary clinic. Geriatric clinics often are staffed with a variety of specialists, for example.
“The multidisciplinary approach is being recognized as an appropriate way to address this,” Burgio says. “The more integrated, the more treatment options available to the patient. I think that is better than just having one perspective, because each specialty will approach it from their point of view and training.”
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That Matter of the Bladder
Urinary incontinence affects half of all women at some time during their lives. Many women do not seek treatment, even though there are numerous successful approaches to curing it.
Most of a woman’s bladder control system is located inside the pelvis, and incontinence problems often occur when the muscles in this system are too weak or too active.
The urinary system
Urine stays within the body when the pelvic floor and sphincter muscles are tight and the bladder is relaxed.
When the bladder is full, nerves located in the bladder signal the brain to create the urge to urinate. The brain signals the sphincter and pelvic floor muscles to relax and for the bladder to contract.
Types of incontinence
Stress: Loss of urine caused by physical stress to the abdomen, usually due to weak muscles in the bladder control system.
Stress can be caused by coughing, sneezing, laughing and exercise.
Urge: A sudden, strong urge to urinate and uncontrollable leakage of urine.
Mixed: A combination of stress and urge.
Overflow: A frequent or constant dribble of urine because the bladder does not empty completely.
Contributing factors
* Pregnancy and childbirth
* Urinary or vaginal infection
* Weakness of sphincter muscles
* Bladder or other pelvic organs slipping out of place
* Radiation therapy
* Pelvic injury or surgery
* Hormonal deficiency
* Neurological diseases
Resources
* As part of its “Incontinence: You Are Not Alone” campaign, free information is available from the American Urological Assn. Call toll-free (877) DRY-LIFE (379-5433) or access its Web site: https://www.drylife.org.
* The National Assn. for Continence offers referrals to providers around the nation. Call (800) BLADDER (252-3337).
Source: American Urological Assn.