New research suggest surgical operations to correct urinary incontinence in women are socially viable
Urinary incontinence in women affects 15% of women of adult age, but only one in four requests health assistance and when the disorder is serious. In his PhD thesis, Manuel Montesino Semper, Head of the urology section of the Virgen del Camino Hospital in Pamplona, analysed the financial cost which would be required for surgical operations to be carried out under the local public health service in order to combat the problem. “When costs include the enhancement in the quality of life of the patients” he explained, “one comes to the conclusion that, from a perspective of the economics of health standards, such operations are cost-effective or, stated in another way, they are socially profitable, given that, with relatively low costs, benefits in the quality of life for the patients are obtained”.
Urinary incontinence is the involuntary loss of urine. In the case of adult women it means an important deterioration in their quality of life and a challenge for the urologist and gynaecologist who have to attend to them. According to doctor Montesino, “this problem, at times hidden and even taboo, gives rise to important financial costs for the health services and for the patients themselves, besides the intangible costs involved in the personal insecurity and anxiety that can arise”.
The research undertaken by Doctor Montesino Semper showed that surgical operations for urinary incontinence are effective and provide a clear enhancement in the quality of life of the women affected. “In patients who have been operated on, improvements are manifest in aspects involving anxiety and depression, with mobility and undertaking everyday activities, family activities or free time ones, as well as household chores”, pointed out the author of the research.
Apart from the financial cost this type of surgical operation involves, this thesis also evaluated the enhancement in the quality of life of the women undergoing surgery and, finally, the two parameters were linked. “The conclusion is, from the perspective of the economics of health standards, such operations are cost-effective or, stated in another way, they are “socially profitable”, given that, with relatively low costs, benefits in the quality of life for the patients are obtained”.
The costs computed for this PhD thesis included the health care from the first medical check-up carried out after one year after the operation, the sum coming to 1,250 euros per patient. Most operations are outpatient ones, without any need for patients to spend the night in hospital. Moreover, the operation is relatively simple, being carried out with local anaesthetic.
The research analysed the results from 69 patients through a questionnaire, one specific to urinary incontinence and the other about general health, both internationally recognised and validated.
Factors such as being younger and the type of urinary incontinence (associated only with physical effort, without urgency) are associated with better results in surgical operation, while overweight and obesity are associated with poorer results.
New guidelines to help family doctors identify and treat incontinence
Millions of women experience a loss of bladder control, or urinary incontinence, in their lifetime. It’s a common and often embarrassing problem that many patients don’t bring up with their doctors – and when they do, it may be mentioned as a casual side note during a visit for more pressing medical issues. New guidelines from doctors at the University of Michigan Health System offer family doctors a step-by-step guide for the evaluation of urinary leakage, to prevent this quality-of-life issue from being ignored.
“I think a lot of physicians don’t realize that this problem can be successfully treated without surgery or other major interventions and there are some pretty simple things they can do in the office to make a big difference for a lot of women,” says lead author Abigail Lowther, M.D., clinical lecturer in the Department of Family Medicine. “We hope to give primary care providers a framework for how to evaluate and treat different many forms of incontinence without the need for referral to a specialist.”
The article was published in the Journal of Family Practice this month (Reference: “Managing incontinence: A 2-visit approach,” Journal of Family Practice, September 2012, Vol. 61, No.9.)
Studies have found that 10 to 40 percent of women older than 18 years old – and as many as 53 percent of those over 50 – are affected by urinary incontinence. Among the long list of culprits are childbirth, aging and obesity. Despite the prevalence of female incontinence, however, busy family doctors may not hear about the problem until well into a visit focused on separate health issues – and some doctors may not feel like they can help.
But the paper suggests three simple, immediate steps a doctor can take to address the problem while keeping the appointment on track: Collecting a urine sample, asking the patient to keep a diary that charts fluid intake and urination and scheduling a follow-up visit. By the second visit, the physician will have more information for further evaluation and a management plan. High-yield questions will also classify the type of incontinence being experienced. Questions may include asking how worried patients are that coughing will lead to a leak, how quickly patients need to find a bathroom when their bladder is full and whether washing hands – or the sound of running water – leads to leakage.
Urinary incontinence of all types can be a great disruption to daily activities, ranging from occasionally leaking urine after a cough or sneeze to having an urge so sudden that patients may not make it to the bathroom in time. For some, bladder leakage may be a symptom of another underlying medical condition.
Lowther says some women don’t broach the subject with doctors because they think loss of bladder control is a normal part of aging. But left untreated, it may get worse with time and lead to more restrictions, she says.
“We want to emphasize to women that this is not something they have to live with, that they should tell their primary care physicians about their symptoms,” Lowther says. “We also want to remind physicians that simple interventions can go a long way towards improving this problem for patients.”
New video about Incontinence types and causes
We’ve just added a new video to our “About Incontinence” website page. The video talks through incontinence and bladder issues and talks about the common types and what causes them including Stress Incontinence, Urge Incontinence, Overflow (or Drip), Mixed Incontinence, Reflex Incontinence and Faecal Incontinence.
The video can also be seen below.
Julie Goodyear talks about continence issues
Julie Goodyear has been causing havoc in the Celebrity Big Brother house.
“I sneeze, I pee,” she announced to fellow housemates, flicking away any embarrassment at suffering from urinary incontinence as if it were ash at the end of her trademark cigarette holder. In doing so she highlighted the millions of Britons who have poor bladder control.
It is estimated 14 million people in the UK have urinary incontinence and although it can occur at any time of life problems are most likely in middle age. One in five women over the age of 40 experience problems although men can also be affected, particularly if they have undergone prostate surgery.
However, as Julie, 70, has shown, there is no need to suffer in silence and there are many ways to deal with the problem.
Professor Linda Cardozo, an expert in urogynaecology at King’s College Hospital in London, says: “There is not one solution for everyone but there is help for absolutely everybody.”
There are four types of incontinence: stress, which causes leaks when you cough, sneeze or laugh; urgency, which is characterised by a sudden compelling need to pass urine; mixed, which is a combination of the two; and overflow, which occurs when the bladder overfills but there is no corresponding urge to urinate.
Childbirth increases the risk of problems. A Norwegian study published in the New England Journal Of Medicine found 10 per cent of childless women experience problems compared to 16 per cent of those who had children via caesarean and 21 per cent who had a vaginal delivery.
Other factors include loss of muscle tone as we age, obesity and lifestyle. Smokers like Julie are more likely to suffer because of their chronic cough. Constipation can also increase pressure on the bladder. White wine, champagne and caffeine-based drinks are the most irritating for the bladder but the fashion for downing copious amounts of water doesn’t help either.“Women often drink far more than they ought to. There is absolutely no need to drink all that sippy mineral water,” Professor Cardozo says.
“In a temperate climate the fluid intake recommended by renal physicians is 24mls per kilogram of body weight. For the average woman that would equate to 1,200 to 1,500mls a day.”
Diet versions of popular carbonated drinks are also more likely to cause problems than standard sugary ones. “The diet drinks are better for teeth and weight but they are not better for your bladder,” Professor Cardozo says.
Some forms of exercise are bad news. “Trampolining is about the worst, 70 per cent of women will leak when they are on a trampoline.” High-impact aerobics and weight training can also cause leaks but exercises to strengthen the pelvic floor, the sling of muscles which holds the bladder in place, will help reduce symptoms if you do them regularly. Professor Cardozo says pelvic toning devices may help, if only to identify the right muscles to flex and relax.
If in doubt ask your GP for a referral to a member of the Association of Chartered Physiotherapists in Women’s Health or search their website for a local one.
Incontinence specialists can offer distraction techniques such as sitting on the edge of a hard chair and other tips to minimise the risk of accidents.
If the problem is more troublesome you may be prescribed antimuscarinic drugs that suppress involuntary bladder contractions. A new class of drug which regulates nerve signals to the bladder will be available within a year or two.
Botox and other forms of botulinum A toxins are another option: injected into the wall of the bladder they can prevent for up to a year the muscle spasms which trigger leaks.
Surgical solutions involve slings to support the bladder, procedures to lift the neck of the bladder or placing a tape under the urethra which blocks urine if the pelvic floor drops. “It works like a hosepipe when kinked,” Professor Cardozo explains.
“The most important thing to remember is there is help available. Urinary incontinence is no longer such a taboo because there are so many high profile people who have now admitted to having problems.”
Urge Incontinence linked to sleep apnea in women
Breathing difficulties in women while sleeping are linked to an urge incontinence (over active bladder), according to a new study.
Researchers from the Hospital del Mar in Barcelona, Spain, analysed 72 female patients referred to a sleep disorders clinic with suspected sleep apnea.
All patients completed a questionnaire asking them about four symptoms associated with their bladder control; urgency and frequency of urination, incontinence and nocturia. They were also asked to rate their discomfort with each of these symptoms.
Urge incontinence (or Overactive bladder) is characterised by an increased frequency to urinate along with incontinence and frequent awakening periods during night time to use the toilet (nocturia).
The need to urinate during the night is also a common symptom of sleep apnea, but little research has been carried out to investigate any links between the two conditions.
The new study analysed the questionnaires and 62 of the women were diagnosed with sleep apnea. The people within this group showed significantly higher scores for the prevalence of symptoms associated with bladder control and their discomfort with these symptoms.
Within the group diagnosed with sleep apnea, the symptoms were rated a median average score of 5, out of a possible total of 12, compared to a score of 3 in the group not diagnosed with the condition.
The median average score for discomfort with bladder control symptoms was 4 out of 12, compared with a score of 1 in the group of women who weren’t diagnosed with sleep apnea.
“Overactive bladder has a prevalence of 16 per cent among people over 40 years in Europe and it is a difficult condition to live with, affecting a person’s quality of life. The findings of this study provide evidence that bladder control could be linked to sleep apnea, although we do not know whether one of the conditions causes the other,” lead author, Nuria Grau from the Hospital del Mar in Spain, said in a statement.
The research was presented at the European Respiratory Society’s Annual Congress in Vienna.
Gestational diabetes raises risk of long-term urinary incontinence
Women with gestational diabetes mellitus (GDM) are at increased risk of postpartum urinary incontinence, including stress, urge, and mixed type, according to Taiwanese investigators. And the problems may persist for at least two years after delivery, a finding that goes against the common belief that genitourinary problems subside soon after delivery.
The study also found that quality of life is often compromised in these women, Dr Chi-Mu Chuang from Taipei Veterans General Hospital and National Yang-Ming University said.
“Women with GDM should be provided with timely consultation and support once urinary incontinence occurs,” Dr Chuang and colleagues advise in a report online in the British obstetrics journal BJOG.
The impact of GDM on postpartum urinary incontinence was studied in 6,653 pregnant women who delivered a single term infant between 2002 and 2007 at a single hospital in Taiwan. A total of 580 of the women had GDM.
At six weeks postpartum, the percentage of women with urinary incontinence was higher in the GDM group than the non-GDM group: stress urinary incontinence, 11.9% vs 5.6%; urge urinary incontinence, 4.4% vs 1.6%; mixed urinary incontinence, 2.7% vs 0.3%.
After adjusting for multiple confounding factors, GDM was a significant independent risk factor for all types of urinary incontinence, with odds ratios of 1.97 for stress urinary incontinence, 3.11 for urge incontinence and 2.73 for the mixed type.
The authors say, “Compared with women without GDM, women with GDM tended to exhibit more severe symptoms of stress incontinence for up to two years postpartum, whereas for urge or mixed incontinence, more severe symptoms were found only at six months postpartum.”
Quality of life was “generally poorer” among women with GDM, the researchers say. In particular, based on the Incontinence Impact Questionnaire 7, women with GDM who required insulin had a higher likelihood of functional impairment than women with GDM who required conservative treatment only or women without GDM (p<0.05, by the chi-square test for trend).
In their paper, Dr Chuang and colleagues say the “epidemiological value” of the study lies in the establishment of a positive relationship between GDM and urinary incontinence, “in addition to the established positive relationships between diabetes mellitus and urinary incontinence, and between gestation/delivery and urinary incontinence.”
“This finding,” they say, “suggests that diabetes and gestation/delivery may have additive or synergistic effects on postpartum urinary incontinence. However, the underlying biological pathway was not investigated in the current research, and merits further in-depth study.”
Drug reduces urge incontinence in Overactive Bladder trial patients
Fesoterodine fumarate (Toviaz) appears to reduce urge incontinence in patients with overactive bladder who had a suboptimal response to tolterodine tartrate extended release (Detrol LA), according to a phase IV study.
The 14-week randomized, placebo-controlled, double-blind multicenter study assessed fesoterodine, 8 mg, in patients with OAB who had been taking tolterodine, 4 mg, for 2 weeks and had less than 50% reduction in urge urinary incontinence episodes. After open-label treatment with tolterodine, 4 mg, treatment with fesoterodine, 4 mg, was started for 1 week, followed by treatment with fesoterodine, 8 mg.
The study results demonstrated that fesoterodine, 4 mg, for 1 week followed by fesoterodine, 8 mg, statistically significantly reduced the average number of urge urinary incontinence episodes (-2.37 episodes from baseline) per 24 hours (p<.0001) in OAB patients who had a suboptimal response to tolterodine, 4 mg. The safety and tolerability profiles of fesoterodine and tolterodine were consistent with previous studies. The most common treatment-emergent adverse events for both fesoterodine and tolterodine were dry mouth and constipation.
“This study adds to the body of evidence supporting fesoterodine as an effective treatment for patients with overactive bladder, including patients who may not have responded to tolterodine,” said principal investigator Steven A. Kaplan, MD, of New York-Presbyterian Hospital/Weill Cornell Medical Center, New York. “Health care professionals often question how to treat patients who have had a suboptimal response to tolterodine, which is commonly used but does not have a dose higher than 4 mg, and these data may help to guide treatment decisions.”
Drug treatments for urge incontinence are used alongside bladder re-training.
Some information to help solve incontinence worries
Urinary incontinence is more common than reported. Regrettably, many people suffer in silence and restrict their daily activities. Yet incontinence is often easily managed and treated, indeed, experts have shown that nearly 80% of people with poor bladder control can be cured or improve.
Bladder control is a problem for women and men, and some young people. Experts estimate that four out of five incontinence patients are women — especially those who have had pregnancies or who are elderly.
Urine leakage is the symptom of a medical problem. Diabetes, strokes or Parkinson’s can damage nerves. A bladder infection or irritation (like a kidney stone) can scar the urethra (the tube that moves urine from the bladder). Childbirth can weaken muscles, stretch tendons, or damage nerves. Drugs like diuretics can increase bladder activity. It can be hard to get to a toilet if severe arthritis slows walking, or if medication makes a person confused or sleepy. Lower estrogen during menopause can weaken the vaginal canal.
There are several types of incontinence. Stress incontinence occurs when pressure on the bladder causes a loss of control and leakage. This often occurs when a person sneezes, laughs, falls, runs, exercises or lifts a heavy object. Urge incontinence is different; the bladder becomes overactive, perhaps from a spasm. The sudden urge to go makes a person rush to the toilet. Overflow incontinence can occur when the bladder will not empty and urine builds. Something might prevent the bladder from emptying, such as constipation, an enlarged prostate, or scar tissue.
Pelvic surgery and trauma can affect the nerves, muscles, and structure of the pelvic area.
For women, the trauma of childbirth and carrying a baby can reduce support of pelvic organs, affect the bladder, and injure nerves. After a pregnancy, weak muscles can also cause the bladder or uterus to drop out of place and bulge into the vaginal canal or press down on the rectum.
For men, especially older men, an enlarged prostate or prostate surgery can weaken muscles or cause nerve damage. The surgeon might widen a passage for urine or use techniques to shrink an enlarged prostate gland. Men can need surgery for prostate cancer. At times, surgery results in complications such as impotence or incontinence
There are many urological tests that can help specialists learn the specific problem or problems causing leakage. Urodynamics tests are helpful to see how efficiently a bladder fills and empties.
However, don’t assume that incontinence is a problem that you must just accept.
Don’t be embarrassed to get help. Specialists (urologists for men and women, or urogynecologists for women) can do tests to pinpoint medical problems. Finfing the right solution depends on identifying the real problem.
Don’t be afraid to be honest with your doctor or nurse, give a complete history so they have all the information to make a correct diagnosis. Don’t be surpised to be asked for a physical examination and to provide a urine sample.
Look for habits that you can change to manage leakage. Some people improve by avoiding caffeine, alcohol and certain drugs, and by limiting fluids at night before bedtime. A diet of fruits, vegetables and whole grains can reduce constipation. Drink enough fluids in the daytime to avoid urinary tract infections and constipation.
If you weigh too much, lose weight. A large belly puts pressure on the pelvic muscles. Excess weight can cause both stress and urge incontinence.
For urge incontinence, create a regular schedule to empty your bladder, starting at every two hours. Over time, you can increase the time between trips to the bathroom. This schedule can retrain your bladder to control urges.
Regardless of your age or sex, force yourself to do Pelvic Floor (Kegel) exercises. They can strengthen muscles to support the bladder and control leakage. Don’t just blame old age or being out of shape for your poor bladder control.
If you are a young woman, start doing Kegel exercises before getting pregnant. Strong pelvic muscles will serve you throughout your life and could make the effects of childbirth less difficult.
If a treatment does not work well for you, don’t be afraid to ask for another option and remember that there are many ways to manage incontinence alongside incontinence pads and incontinence pants.
Implant used to treat urinary incontinence
The Urodynamics unit at the Hamad Medical Corporation’s Urology Department six months ago introduced the Intersim advanced sacral neuro-modulation Implant featured a few weeks ago.
The surgical device acts like bladder pacemaker to treat those suffering from urinary incontinence. “We have introduced the new treatment to help our patients who are suffering from bladder or urinary incontinence and it has been found to improve the quality of life in men and women who primarily suffer with severe bladder problems,” urology consultant Dr Adralan Ghafouri said. So far, six patients, men and women aged 23 to above 70 years have received the implant from the unit.
“Our first patient is female aged 23 years, who is diabetic, also had weak bladder muscles and she had difficulty emptying her bladder. She could only pass stools three-four times a month due to chronic constipation,” he recalled.He mentioned that after the neuro-stimulator implant was inserted in the patient, she began to pass stools spontaneously and can now empty her bladder normally. He explained that the device, which has a lifespan of between five-eight years, is implanted through a procedure known as the sacral nerve stimulation – a minimally invasive procedure to treat urge incontinence, overactive bladder, urinary retention or interstitial cystitis.
Overactive bladder, which is one of the leading causes of urinary incontinence, is a condition recognised by symptoms such as urinary urgency, frequent urination, waking up at least twice a night to urinate or urge incontinence (leakage of urine).
“The InterStim implant is a tiny device, which is surgically implanted near the tailbone through a small incision near the tailbone. This pacemaker sends mild electrical impulses to stimulate the sacral nerves, which controls bladder function,” he explained.
Similar to a cardiac pacemaker, the implant is programmed to stimulate the bladder nerves located in the lower back (sacrum), to relax or tense as urine fills the bladder or as elimination of urine is required, Dr Gahfouri said. He explained that during the procedure, the surgeon will insert an electrical pulse generator, like a pacemaker, under the skin in the upper, outer quadrant of the buttock and the generator is attached to a thin lead wire with a small electrode tip, which is anchored near the sacral nerve. ”The device is found to work flawlessly in about 50% of the patients who are tested and determined to be good candidates for the device with the testing phase taking about a week.The patient simply wear an external device on the belt to see if his bladder will respond to stimulation,” he explained.
Some answers to common questions about Incontinence
Do women have incontinence more often than men?
Unfortunately for women, yes. Urinary incontinence often occurs because of problems or weaknesses in muscles, support mechanisms and nerves that help to hold or release urine. Pregnancy and delivery, body changes associated with menopause and the way a woman’s female urinary tract is structured are among factors that contribute to twice as many women having incontinence problems. What’s important to know is that you don’t have to live your life wearing pads or being embarrassed by leakage. Incontinence is treatable at all ages.
Do symptoms differ for women?
The most common type of Urinary Incontinence for women is stress incontinence where coughing, laughing, sneezing, or other movements put pressure on the weakened bladder structure or surrounding muscles, resulting in urine leaks. With urge incontinence, women suddenly feel an uncontrollable urge to urinate and leak without control. Something as simple as hearing the sound of running water may be enough to prompt the release of urine. Mixed incontinence, a combination of stress and urge incontinence, also occurs much more frequently in women.
How is incontinence treated?
Significant progress has been made in treating incontinence effectively. Make an appointment with your Healthcare professional for an exam that will identify what type of incontinence you have. The doctor also will determine if you have underlying medical conditions that can cause incontinence.
Common medical reasons include pelvic growths, blockages and vaginal or bladder prolapses. Some medications also can contribute to the problem, so bring a list of all meds you take when you go to your appointment.
Depending on the type and extent of your problem, you may be referred for a course of treatment. This may include behavioral therapies such as fluid management, pelvic floor strengthening, bladder retraining, bulking agent injections, biofeedback or nerve stimulation (neuromodulation).
Finding the right combination for your needs may take some time and you will need to work with your Healthcare Professional to determine a treatment that works best for you. Sometimes surgery may be necessary; for instance, the bladder or urethra may have moved out of its normal position following childbirth.
What can I do to lessen my symptoms?
Some women find success by restricting certain liquids, such as coffee, tea, and alcohol. Severe constipation can worsen symptoms so try to keep your bowel movements regular. While absorbent undergarments such as adult diapers make the problem less visible, it’s important to use appropriate skincare products at the same time to avoid skin irritation and sores.