What Every Woman Should Know

What Every Woman Should Know

Urinary Incontinence is a condition affecting millions of adults of all ages in the United States. The majority suffers in silence, believing there's no remedy for this medical condition and that there's no remedy for this medical condition and that there's nothing for them to do except put up with it and adapt their lifestyles around their limitations. Among women, there are many who resign themselves to the idea that incontinence is an untreatable consequence of having had children or as a result of aging. Those suffering from this condition not only have to bear the physical symptoms; they have to bear a great deal of emotional suffering as well. Often they isolate themselves, they feel ashamed and they stop participating in many social activities because they feel embarrassed, which results in a loss of self-esteem.

If you or a loved one is affected by urinary incontinence, you should know that you are not alone. Approximately 25 million people nationwide are affected. It is estimated that between 75-80% are women.

Women are between four to five times more likely than men to have urinary incontinence problems, in great part because of the trauma the body experiences during pregnancy and child birth. Indeed, decisions made during pregnancy and childbirth can impact bladder and pelvic function for years to come.

A few areas of a female's body are particularly important:

  • The perineum lies between the vaginal and anal openings, the area cut with an episiotomy. Injuries, including from the episiotomy itself, may create muscle weakness or bowel problems.
  • The Levator (pelvic floor) muscles provide key support for the pelvic organs, helping to maintain control over bladder and bowels. After childbirth, muscle strength is usually reduced.
  • The pelvic nerves maintain strong and healthy levator (pelvic) muscles. Nerve injuries, especially common after a long or difficult delivery, are associated with incontinence.
  • The Connective tissues help to secure the pelvic organs in place. During childbirth they routinely stretch, tear and weaken.

Female Pelvic Floor

Women can also experience spasms of the bladder due to unknown causes, what is known as an overactive bladder (OAB). This affects approximately 33-34 million adults in the U.S. (men as well as women). Among them, about nine million have accidents because they cannot reach the toilet before losing bladder control, the large majority of whom are women.

Women also have a greater probability of experiencing fecal incontinence, or bowel control problems. There is a variety of causes for these different types of incontinence, and it is possible to have multiple problems at the same time.
You should seek treatment when you are not able to control your bladder or bowel as you once did or when the frequency or urgency to urinate is interfering with the quality of your life. In the great majority of cases symptoms can be controlled or at least significantly improved with an accurate diagnosis and the appropriate treatment. These are medical problems and NOT something to accept as part of having had children or growing older.

Problems with control of the bladder and the bowels are not in themselves a disease; they are symptoms that can have many causes. It is important to understand that there is no reason to accept incontinence as if it were something that had no remedy. The first step is to become educated, in order to be able to understand your condition and decide with your healthcare provider the best way to treat and manage it.

For Women in Their Childbearing Years: Preparing Your Pelvic Floor for Delivery

It's easy to overlook as your due date approaches, but one of the most important issues is your body.

Start early. Prevention should begin with your first baby, since this one appears to carry the greatest risk of injury.
Kegel Exercises can decrease incontinence, and your first pregnancy is one of the best times to learn about them. Not only because the need is so great - up to 70% of women have some leakage during or after pregnancy - but also because the muscles are still at their greatest potential.
Perineal Massage involves gently stretching of the vaginal opening and may decrease the risk of birth injury and pain afterwards.

How the Bladder Works

In order to understand the causes of urinary incontinence, it is necessary to learn a little bit about how the bladder works.
The bladder has two functions:

  1. To store urine produced by kidneys.
  2. To contract and push out the urine when it is convenient and socially acceptable to empty the bladder.

There is a sphincter muscle surrounding the exit to the bladder, or bladder neck, at its connection with the urethra (this is the tube that carries the urine to the outside of the body). The urethra extends from the neck of the bladder to the outlet located near the cervix in the vagina. There are many conditions, such as menopause or obesity, which can interfere with the normal function of the bladder and sphincter.  There can also be neurological causes of incontinence. When the normal bladder is full, it sends the brain signals alerting it that it needs to be emptied. Nerve damage caused by diseases such as diabetes, Parkinson's disease, multiple sclerosis, or strokes due to high blood pressure, can cause interruptions of the signals between the bladder and the brain.

Female Urinary System

The condition of the pelvic floor muscles, located at the base of the pelvis, has much to do with urinary incontinence. The pelvic organs (the bladder, the vagina, the uterus and the rectum) are supported by a complex "hammock" that includes different types of muscles and tissues. The pelvic floor muscles help to support the sphincter muscle that keeps the bladder closed while it fills with urine.

Types of Bladder and Bowel Control Problems

  • Stress Incontinence: Leakage that occurs when laughing, sneezing, coughing, lifting heavy objects, or exerting other pressure on the bladder. Often the result of pregnancy and child birth.
  • Urgency Incontinence(OAB): Loss of urine due to the inability to reach the toilet after the sudden or frequent urge to urinate. Most often caused by overactive bladder (OAB). Frequent bladder spasms resulting in urinary frequency, sudden urges to go to the bathroom and having to get up at night to go to the bathroom are symptoms of OAB
  • Mixed Incontinence: A combination of stress and urge incontinence.
  • Fecal Incontinence: The inability to control liquid or solid feces resulting in seepage or staining of underwear. More likely to occur in women who have suffered physical trauma and nerve damage during childbirth, have stress incontinence, or prolapsed of the   rectum.
  • Pelvic Organ Prolapse: Refers to a weakening or rupture of the structural support of the pelvic organs allowing one or more organs to drop into the vaginal canal. Weakened muscles can allow the bladder or uterus to drop or the rectum to bulge or protrude. Prolapse can cause urinary incontinence from its early stages and interfere with sexual relations.Sometimes women with a "dropped" (prolapsed) bladder have difficulty emptying their bladder due to blockage of the pathway. This can cause them to feel the sensation that they need to go to the bathroom often, but the problem is prolapsed, not an overactive bladder. They may also feel pressure in the perineum, the area between the vagina and the anus. They may even experience back pain. Especially after having given birth, part of the rectum may collapses and starts protruding from the anal opening. Having given birth vaginally to three or more babies greatly increases the risk of prolapsed. In this case, age is not a contributing factor.
  • Constipation: Can worsen an overactive bladder because the brain could be sending signals to cause a more frequent urge to urinate; ironically, medications for overactive bladder could have the effect of causing constipation. Prolapsed of the pelvic organs is also worsened by constipation because pelvic muscles can be further weakened by straining or pushing to have a bowel movement.

Treatment and Management Options

Non-surgical management and treatment options:

  • Weight loss: Can greatly reduce the severity of stress incontinence, as obesity contributes significantly to stress incontinence and the wakening of muscle support.
  • Dietary Changes: Aimed at eliminating caffeine, alcohol, and artificial sweeteners may decrease irritation of the bladder wall and symptoms of OAB. A high fiber diet, regular physical exerts, and hydration helps, especially with constipation.
  • With the professional instructions of a specialized nurse of physical therapist, bladder retraining can help control OAB.
  • Routine pelvic muscle exercises (PMEs), also known as Kegels, are considered essential for strengthening the support of the pelvic organs, controlling leakage from stress incontinence, and managing sudden urges. PMEs are also important in maintaining sexual vitality. Women who have difficulty performing PMEs on their own may find that biofeedback therapy or electrical stimulation can help them rehabilitate their pelvic floor muscles.
  • Biofeedback therapy: Uses small sensors close to the muscles of the pelvic floor to detect and record pelvic floor muscle activity. The goal of biofeedback is to ensure proper practice of PMEs and to establish and exercise routine.
  • Pelvic floor stimulation: Involves the controlled delivery of small amounts of stimulation to the nerves and muscles of the pelvic floor and bladder. This stimulation helps the muscles contract, thereby strengthening the pelvic floor and support of the bladder. Over time, it is believed that electrical stimulation helps relax the bladder muscle, so it also can be helpful for women with overactive bladder or urge incontinence. Biffed back and electrical stimulation are available from a physical therapist or nurse specialist.
  • Topical (vaginal) estrogen, low-dose vaginal estrogen tablets (Vagifem) and vaginal estrogen devices, such as Estring: Not to be confused with hormone replacement therapy, can help menopausal women who experience stress incontinence due to the inability to effectively close their urethral sphincter. This is because a woman's estrogen level declining during menopause and can contribute to weakening and dryness of the vagina.
  • Pessary: Is a small device placed in the vagina that supports the muscles and help to hold the pelvic organs in place. Pessaries can be acceptable in cases of mild prolapsed in women who wish to postpone or avoid surgery. It does not contain any medication.
  • Medications that work to relax the bladder muscle can be prescribed for overactive bladder. Currently, there are no medications for treating leakage from stress incontinence. When medication is not satisfactory or effective for treating urgency incontinence, women may consider an in- office produce that involves electrical stimulation of nerves in their legs.
  • Bulking agents can improve closure of the urethra and are used in a technique called injection therapy for teat in stress incontinence. Over the past decade, several different biocompatible materials have revived FDA approval to serve as bulking agents. Also for treating stress incontinence, a recently developed technique administers thermal energy to the neck of the bladder in order to increase tissue thickness.
  • While seeking treatment, you may opt for controlling leakage by means of absorbent products or other management devices. Look for the appropriate size and fit. Change the product at least once a day for good hygiene and protection against fungus and skin irritations. Call NAFC for mail-order sources of absorbent products.

Surgical Treatment Options:

  • In more severe cases of urgency incontinence, a minimally invasive procedure can be performed to implant a device that delivers mild electric pulses to lower back, much like a heart pacemaker. This same system is being researched as a promising option for fecal incontinence.
  • In less severe cases of stress incontinence, a synthetic mesh can be vaginally entered in same-day surgery at the hospital. In more severe cases of stress incontinence or in cases of multiple problems, surgery could be of a reconstructive nature, requiring graft material to strengthen and rebuild the tissues for support.
  • In more severe cases of fecal incontinence, surgery could be necessary when there is no improvement through biofeedback or electrical stimulation applied by a therapist.

Types of Healthcare Providers

Start with your primary care provider (PCP) when seeking treatment of problems with bladder or bowel control. This may be a physician, nurse practitioner, or physician's assistant. If a PCP does not have a special interest in diagnosing and treating incontinence or symptoms persist, you may ask to be referred to a urologist or urogynecologist. An urologist is a surgeon who specialized in the urinary conditions of men and women. A gynecologist is a doctor specializing in the reproductive health of women. Some have special interest and training in urinary incontinence and pelvic organ prolapsed. If they have advanced training in this area, they may become urogynecologists and no longer deliver babies. A geriatrician is a doctor who specializes in treating older people. A gastroenterologist is a doctor to who specializes in problems of the intestinal system. If you have diarrhea, constipation, or fecal incontinence, you may be referred to a gastroenterologist. Some specialize in surgery and are known as colorectal surgeons. Nurse specialists, physical therapists, and occupatational therapists may have training that qualifies them to offer electrical stimulation and biofeedback therapy as a means of treatment.

What to Expect During an Appointment

When first seeking treatment: expect your healthcare provider to be concerned about your complaint and be attentive to the information you bring. Be prepared to give a complete history, have a physical examination, and give a urine specimen with testing afterwards to see if there is still urine in the bladder. Sometimes this is done by passing a small thin tube (Catheter) into the bladder. Other times it is done with a small sensor that is rubbed over the lower abdomen. This is called an ultrasound. Your healthcare provider may begin treatment immediately or do some other tests called urodynamics. These tests show how well the bladder fills and empties. The reason for all tests should be explained. Ash when and how you will get the results.

Once your provider has made a diagnosis of the bladder or bowel problem, make sure you understand your diagnosis. Have the treatment choices explained, with the risks, benefits, and estimated cost of each option.

Finally, expect to participate in your own care to get the best results. Treatment will be most successful when you help to choose the solution and are engaged. Of course, report any side effects of medicines or treatments and discuss any concerns with your healthcare provider.