Urinary incontinence is one of those subjects that most women would rather not think about. Your own potty training is long in the past and you have escorted several children of your own into dry pants. Now you are back to thinking about diapers and wet pants again. It raises all sort of unpleasant thoughts about nursing homes and being dependent. No matter who they get to do the advertising on TV, incontinence pads are never going to be sexy. Unfortunately, urinary incontinence is very common. Many studies have been done over the years and the numbers vary somewhat but it is clear that urinary incontinence is very, very common. At least 40 % of women will be incontinent for six months after delivering their first child. Most will improve with time but the incontinence gets worse with each subsequent delivery. By age 60 around 30% of all women are incontinent.  This is a serious problem both to individual and to the population as a whole.

                For the individual, urinary incontinence is a chronic burden. She has to constantly be aware of where the nearest toilet is, and she can’t be fussy about how clean a restroom is when she needs it.  She is always worried about whether she can sit down without soiling the upholstery or whether her clothes are wet. She is always afraid that she smells like urine. Diaper rash is as common in the elderly as it is in children.  Nationally the expense, both personal and through insurance is enormous. Sanitary pads don’t come cheap. The national expenditure for pads is many millions of dollars.  It is common for elderly people with incontinence to get skin ulcers, abscesses and urinary tract infections.  In spite of good care these can lead to hospitalization or even death. 

                So what about incontinence? Is there more than one type? Can anything be done about it? Once your bladder starts leaking, is that the beginning of the end? What is the doctor going to do if I have this problem?

                Urinary incontinence has two basic types: Stress incontinence and Urge incontinence.

Stress incontinence is when one coughs or laughs or sneezes and wets her pants. It is very common. As many as 14% of normal young women will occasionally have stress incontinence when the bladder is full and they stress their bladders. This becomes more of a problem when the supporting structures of the bladder and vagina are weakened by childbirth or other injury. After menopause it again worsens when the tissues lose some of their elasticity and strength from estrogen deprivation. Stress incontinence is often associated with prolapse-a feeling that the bladder and uterus are falling out. Sometimes the tissues do protrude through the vaginal opening and may cause pain as well as incontinence. If the protrusion is bad enough it can make it impossible to empty the bladder completely unless it is pushed back in before voiding. Some people have to stand up after voiding and then sit back down to finish emptying.

In early cases stress incontinence can be treated by physical therapy or exercises that strengthen the muscles of the pelvis. Most women remember being told to do the “Kegel Exercises” by their obstetrician. Some even find time to do them.  These exercises may also be helpful later on. Physiotherapists can use electrodes to help people isolate and identify the muscles that need to be strengthened. Sometimes electrical or magnetic stimulation can help to passively exercise these muscles. When the situation is too bad for physiotherapy, surgery may be the best choice. A number of operations are available that support the vagina and bladder. Almost always these can be done by minimally invasive means: laparoscopically or through small incisions. If the problem is attacked from above, from the abdominal side,  the person can have a support operation called a Burch Procedure. This fastens the bladder neck and sometimes the vagina as well,  to the tissues around the pubic bone. Some physicians do this operation through a larger incision in the abdomen, but often it can be done laparoscopically. From the vaginal side, the bladder can be supported by a vaginal paravaginal repair. This is something like the old “bladder tack” operation but instead of just taking a tuck in the already worn support tissues, the tissues are re-suspended to the pelvic sidewalls. Sometimes it is useful to supplement the tissues with a patch, usually of a porcine membrane like that used to replace heart valves. When only the bladder stem, or urethra is loose an operation called a “sling” can be performed. This is frequently done as a “Tension Free Tape” or similar operation. In this operation an instrument like a curved knitting needle is used to pull a ribbon under the urethra in a “U” shaped path. This ribbon sticks to the tissues and supports the bladder stem when a cough or other stress occurs. Over all, around 80 to 95% of women with stress incontinence can be made significantly dryer by one of these operations.

Urge incontinence is a different process. It is sometimes called bladder spasms or over-active bladder. This is when someone has an urge to go and can’t hold it. Often someone will say that she is coming home from the store and just as she gets her keys in the lock on the door, her bladder lets go. This is sometimes a result of aging or menopause. It may be as a result of injury or childbirth. It may be related to prolapse or it may be due to chronic obstruction or voiding difficulty. There are several  types of treatment that may be recommended. If there is a significant prolapse, surgery may help, but this isn’t the usual case. Between 30 and 60 % of people will improve with medicine, usually Detrol or Ditropan. Physical therapy, magnetic or electrical stimulation and biofeedback will help some people. For people who have failed everything else there is a new treatment available called Interstim. An electrode is implanted a natural opening in the bone in the lower part of the back. This  is attached to an impulse generator that looks and acts very much like a cardiac pacemaker only for the bladder. This treatment is somewhat involved and rather new but is a salvation for people who haven’t responded to anything else.

If you go to your doctor and tell him that you have incontinence, you should expect that he will take a history about the various things that affect your bladder and either help or worsen your leaking. He will want to know about problems that you have had with your female organs and bladder conditions you may have had in the past. He will want to know about what medicines you take and what foods or liquids may affect your problem. When he examines you he will want to evaluate the support of your bladder, rectum and uterus. He should check the nerves to the pelvis and vagina. He will want to examine the strength of your pelvic muscles and the muscles of the legs. We often do a pad test  to measure the amount of urine lost in a day, a voiding diary to identify the frequency and amount of voiding. We also ask for the patient to fill out a questionnaire about her problems.

 If there is any question about the cause of the incontinence or if surgery is planned a cystometrogram may be done. This is a test done with tiny catheters and a computer to measure the pressures in the bladder during leaking and voiding. It will help to confirm if surgery will likely be successful and what complications may occur. Cystoscopy is occasionally recommended. This is when the doctor looks into the bladder with a small telescope inserted in the urethra. Sometimes he uses a video camera and you can see your own insides too. This is to look for bladder stones or tumors or inflammations that may affect your voiding.

There are many conditions other than those I have discussed here that may cause voiding problems or incontinence. Damage to the nerves that control the bladder can cause problems. This can be from an illness such as diabetes or stroke or can be from an injury to the head or the spine. Nerve diseases like Multiple sclerosis or Lou Gerhig’s disease can be a cause. Even a bladder infection or menopause can make a bladder leak. A good history and examination from a doctor who is interested in bladder problems can usually get to the cause and find a solution.

 It is important to find a doctor that is interested in bladder problems. Traditionally urologists and gynecologists have mainly been responsible for ladies bladder problems. Recently many medical school gynecology departments have developed programs in Urogynecology for doctors specially interested in incontinence and pelvic floor problems. This has often been in collaboration with their urology departments. A number of professional associations have been formed to encourage study and understanding in this field. One of the oldest is the Interational Continence Society.The main association for gynecologists is the American Urogynecology Society and the International Urogynecology Association as well as the Society of Pelvic Reconstructive Surgeons. Most physicians who are really interested in incontinence will belong to one or more of these associations, but as yet there is no certification for Urogynecologists and very few of the older doctors had an opportunity to attend a regular program.

It is important to remember that incontinence can be helped. With treatment nine out of every ten women can be much dryer and more comfortable. New medicines, physical treatments and operations are developed every day.  Do not let a false sense of shame or embarrassment stop you from getting help. Tell your doctor about it and get help. It is not just “something that everyone has to put up with.”  Talk to your doctor.  Talk to your friends. Join the National Association for Continence (1-800-Bladder). Get help.