Urinary incontinence and pelvic prolapse are problems that are rarely talked but are very common, especially with women.
We’ve all seen the euphemistic commercials for products that let you dance, jog and hug someone “safely” and for medications that help your “inner pipes” work better.
There are also surgical procedures that can correct continence problems.
TODAY medical contributor and gynecologist Dr. Judith Reichman explains the different types of bladder control problems and what you can do to control your bladder better.
How common are bladder control problems?
The estimate is that at least twenty-five million Americans suffer from urinary incontinence or loss of bladder control. Eighty percent of these individuals are women. Incontinence is a major cause for need of nursing care and decision to enter a nursing home facility. The types of incontinence, their causes and symptoms are, of course, put into categories: (We do this all the time in medicine.)
- Stress incontinence (SUI) — Leakage of urine when coughing, sneezing, laughing, straining or lifting (think of the phrase “I laughed so hard I wet myself”). This type of incontinence often occurs as a result of stretching and weakening of the pelvic floor. This is the most common form of bladder control problem experienced by women. SUI is often accompanied by pelvic prolapse.
- Urge incontinence — An urgent need to go with little or no warning so that there may not be time to get to the toilet. The bladder muscles, called the detrussor muscles are over-stimulated and overactive. One in five adults over age forty are affected by an overactive bladder and have recurrent symptoms of urgency, frequency, and on occasion, accidents... with loss of urine.
- Overflow incontinence — This occurs when the bladder doesn’t properly empty and becomes over distended. The bladder simply can’t hold the urine and some spills out. Overflow incontinence can occur as a result of an obstruction (one of the things that causes this obstruction is a prolapse of the uterus or a large uterine tumor) or can be caused by nerve damage, especially in spinal injuries.
- Mixed incontinence — This signifies a combination of urge and stress incontinence symptoms.
What exactly is pelvic prolapse?
The definition of pelvic prolapse is a stretching and weakening of the ligaments, muscles and tissues that act as a hammock for the pelvic organs. As a result, the bladder, uterus, cervix, rectum and the vaginal walls themselves may descend from their normal position. When prolapse is significant, these organs “balloon” below the opening of the vagina especially after coughing, pushing down (which you do when you have a bowel movement) or simply from gravity when standing. About 50% of women over the age of fifty have some degree of pelvic prolapse in addition to continence problems. Symptoms from prolapse include feeling of pressure and discomfort from the bulge of the protruding organs. Obviously this can cause sexual dysfunction. Eleven percent of women who suffer from pelvic prolapse will end up having surgery to correct this problem.
What causes urinary incontinence?
The primary cause of SUI is pelvic prolapse. Indeed, 50% of women are likely to develop this. The most common risk factors are:
- Vaginal delivery —This is more likely to occur with vaginal delivery of large babies.
- Hysterectomy — This increases risk by 40 to 80% for women sixty years or older. If the cervix is not removed (subtotal hysterectomy) risk of prolapse may be lower.
- Family history of pelvic prolapse
- Age — Getting old puts us at risk for both SUI and urge incontinence.
- Medications, smoking, alcohol and caffeine- Medications include tranquilizers, antidepressants, laxatives, antibiotics and estrogen ( although local vaginal estrogen is sometimes prescribed to help women with atrophy subsequent to menopause with bladder control)
- Other diseases — Diabetes, stroke, dementia and Parkinson’s (all these can cause damage to the nerves that are needed for bladder control).
- Excess weight — Abdominal weight pushes down on the pelvic organs and weakens their support.
Are there fail-proof (or leak-proof) therapies for urinary incontinence?
Therapies vary from special exercises to medications and finally to surgeries. Obviously surgery will be the last resort. So what can we do to make sure we stay dry? Let’s start with self-help measures:
- Limit your fluid intake — especially carbonated and caffeinated beverages; too much fluid may be causing you to overfill and stretch your bladder. Caffeinated substances increase bladder muscle activity.
- Weight reduction
- Quit smoking (just one more reason to do this)
- Pelvic floor — muscle exercises (Kegel exercises). You need to identify the pelvic floor muscles. To do this you may have to put your finger in the vagina, squeeze around the finger and see what muscles you need to contract. Do this without using your buttock or abdominal muscles. You may need to see your health practitioner to learn how to isolate these muscles (thirty to fifty percent of women perform Kegel exercises incorrectly). You should learn to do both fast and slow contractions. Start with ten contractions of each in the morning and gradually increase the number repetitions to twenty two or three times a day. Bio feedback and electrical stimulation can help women gain awareness of which muscles to contract.
- Medications — There are a number of prescription drugs generically called anticholinergic medications which inhibit involuntary contractions of the bladder muscles and help control overactive bladder and stress urinary incontinence.
- Mechanical Support — The bladder and uterus can be pushed up with various support devices called pessaries. These usually have to be removed and cleaned periodically. There are also urethral devices that can be inserted to plug the bladder opening, they are then removed before voiding.
- Surgery —There have traditionally been scores of surgeries developed to treat stress incontinence all of which attempt to support the lower part of the bladder and strengthen urethral closure. Some procedures are combined with abdominal hysterectomy and are done through an abdominal incision. Since the 1990’s less invasive procedures have been developed and are done through a laparoscope. If SUI occurs together with prolapse of the uterus a vaginal hysterectomy is usually performed. If the vagina and bladder have ballooned down (a cystocoele) they are then pushed upwards and repaired during the vaginal surgery.
In the past, recurrence rates of bladder prolapse have been as high as fifty percent. New procedures have now been developed in which a special graft material, human fascia lata (if you want to know this is sterilized cadaver support tissue) is used to close the defect and add support between the bladder and the vagina. To make sure that this does not push the urethra downward or in cases where the urethra opening is already displaced, synthetic vaginal tape is attached under the vaginal tissue to support the urethra. This approach appears, at least in the last five years, to work well and last longer. Before I get into very complicated details about surgery (which I guess I did just now) let me state that if you have prolapse and SUI you should consult a gynecologic or urologic surgeon who has specific expertise in performing these procedures.
Incontinence and pelvic prolapse may be uncomfortable topics but they are problems that ultimately affect the majority of women. We have to get the subject out of the (water) closet so that we can get the best and most appropriate treatment.
For more information on incontinence go to www.nafc.org.
Dr. Judith Reichman, the TODAY show's medical contributor on women's health, has practiced obstetrics and gynecology for more than 20 years. You will find many answers to your questions in her latest book, "Slow Your Clock Down: The Complete Guide to a Healthy, Younger You," which is now available in paperback. It is published by William Morrow, a division of .
PLEASE NOTE: The information in this column should not be construed as providing specific medical advice, but rather to offer readers information to better understand their lives and health. It is not intended to provide an alternative to professional treatment or to replace the services of a physician.