For every woman Dr. Scott Owens sees in his urology practice, he suspects five to 10 more don’t want to make that visit.
Incontinence, he says, is “a social disease.” Patients come to him when they can no longer exercise or socialize.
“When it becomes socially embarrassing, that’s the time to get it fixed, or before it gets that bad,” says Owens, urology division chief for PinnacleHealth, Harrisburg (www.pinnaclehealth.org). “It really is a decision made by the patient, and it really is a socially driven decision.”
Here, doctors answer five questions about women’s incontinence.
1. What causes incontinence?
Most incontinence falls into two categories – stress or urge incontinence.
Stress incontinence is familiar to women who feel tears running down their legs when they laugh or cough. Pressure on the belly can cause the urethra—the urine pipeline—to fall. Or, there can be weakness in the muscles supporting the urethra.
Stress incontinence can be inherited, but it can also be triggered by obesity and smoking. Hormone loss from menopause can weaken vaginal tissues, and heavy lifting can put pressure on the pelvis. Childbirth can tear muscles and tissue.
“Having a baby is probably the biggest risk factor that you can see, especially if you have big babies or lots of babies,” says Dr. John Lawrence of the Women’s Healthcare Group, York (www.thewhcg.com). “You can’t change your parentage. You hate to tell someone not to be physically active. I’m not so sure there’s something you can modify that can lessen your risk.”
Urge incontinence comes from an overactive bladder constantly signaling the need to use the bathroom. Leakage can result when the excessively squeezing bladder pushes out urine. Causes aren’t completely known, says Dr. Kenneth Lessans, a partner at Lancaster Urology (www.lancasterurology.com), but hormonal changes and strokes can be factors.
2. Can younger women be incontinent?
Lessans sees women “as young as 18 and as old as 90.” Lawrence agrees that patients include younger women who “want something done because they live a more active life.”
Childbirth and weight gain can cause incontinence among younger women. Childhood bladder problems can reappear as overactive bladder, says Lawrence.
Owens has performed surgeries on mothers as young as 28, but his patients are typically women in their 40s.
“Their kids are old enough, they know this won’t go away, they’re active again physically, and it’s a nuisance,” he says.
3. Do Kegel exercises really help?
The squeezing of Kegel exercises can “tighten up the pelvic muscles,” says Lawrence. “The sooner you start, probably the better off you are.”
The problem is compliance and execution.
“They should be done a lot more often than most women do them,” says Lessans. “A rule of thumb is six to 10 times an hour, 10 seconds per squeeze.” It’s the same sensation as stopping urination.
Trained nurse therapists can provide coaching, “like a personal trainer who helps you to do the right exercise with the right muscles and do the right amount of tension,” says Owens.
More intensive “pelvic floor therapy” involves regular training with a physical therapist, says Lessans.
“Someone who leaks every single time they stand up, every single time they get out of bed in the morning, and every single time they talk or cough is not going to get better with a little bit of Kegel exercises,” says Lessans. “But somebody who’s wearing one or two small pantiliners a day, very likely, is going to get better.”
4. What are my non-surgical options?
Medications for urge incontinence can work, but side effects include dry mouth and constipation. Believe it or not, a sort of acupuncture can stimulate an ankle nerve that interrupts the urination reflex. And—again, believe it or not—Botox injections to the bladder might paralyze nerve endings that relay a false sensation of fullness. An implantable pacemaker can regulate nerves to keep the bladder from contracting.
No medications have been approved for stress incontinence, although an antidepressant might help, says Lawrence. Injections of a bulking agent, repeated every year or two, can help the urethra seal itself.
“The material stays put forever, but the effectiveness of treatment doesn’t last forever because of the problems that caused incontinence in the first place,” says Lessans.
5. is a bladder sling safe?
Bladder slings, one of the primary weapons against stress incontinence, are safe and effective, say urologists. Mesh attached like a hammock to pelvic muscles lifts the urethra to the place of honor it held before childbirth, age and weight gain.
Bladder slings took a PR hit in 2008 when the FDA warned of dangers from surgical mesh implanted through the vagina to correct pelvic organ prolapse and stress incontinence. In 2011, an updated warning stripped out stress incontinence and focused only on prolapse.
Small sheets of mesh had been used for stress incontinence since 1998 with few problems, says Lessans. But because they worked so well around the urethra, larger sheets were used for prolapsed organs, causing serious complications for some women.
Owens agrees that slings “got a bad name” by association. Appropriate use for stress incontinence has only a one to three percent chance of erosion into the vagina or urethra or painful intercourse, he says.
The “four-letter word that people don’t want to hear is ‘mesh,’” says Lawrence. Any surgery can have complications, but in the right hands, under surgeons who specialize in sling procedures, patients can change their lives.
“No one has ever died of incontinence, but it can definitely affect your lifestyle,” he says. “It can definitely affect your routine. I have people who don’t go on vacation because they’re leaking urine. They don’t go to friends’ houses because they’re afraid to have an accident. If this is something that’s affecting their life, it never hurts to see someone, find out what’s going on, and find out what options there are.”
