Anamika, 35 years, is a banking professional and mother of two. Over the past few months Anamika is having a difficult time. She is not able to concentrate on her work or her family. In the middle of her work or interaction with customer, she runs out only to return with a forlorn look. Her sleep is disturbed and she is depressed. Anamika is aware of her problem. But how can she tell her husband or her friends? What will they think?
Her mother told her that most women go through this due to labor or delivery suffered.
But is leakage of urine such a simple issue?
Urinary Incontinence is the most common issue among women. But due to the embarrassment, this health problem is kept hidden and not talked about.
Anamika is not alone. She and many women suffer from this problem silently.
In the US, it is estimated that at least 10 million women suffer from distressing urinary incontinence. The Asian Society of Female Urology puts the incidence of urinary incontinence at 12% in India. About 25% post menopausal women suffer from some form of urinary incontinence.
Studies tell that 58% of women perceive urine loss as a normal consequence of aging and less than 40% will actually talk to their doctors about it.
Urinary incontinence often takes over the woman’s social activity and even work. It threatens self confidence and self esteem, inhibits sexual activity and exercise, according to senior Gynaecologist Dr. Ranjit Chakraborti.
Dr. Chakraborti says, It can happen when you cough, laugh, sneeze or jog. This is called Stress Incontinence. Or you may have a sudden need to go to the bathroom but cannot get there in time. This is called Urge Incontinence or overactive bladder.
Urinary Incontinence is not a normal; part of ageing. The ageing process predisposes a woman to incontinence. Weak muscles, childbirth, poor nutrition and fluid intake, urinary tract infections, spinal cord injuries and emotions all play a role in the aetiology of incontinence., as explained by Dr. Chakraborti.
According to Dr. Chakraborti, the two most common causes of incontinence involve bladder instability and anatomic lack of urethral support. Overflow urine loss and lack of tone in the urethra can happen as age advances..
Investigating a woman with urinary incontinence involves a careful history and thorough physical examination. A woman must appreciate the fact that this affects the Quality of Life.
Incontinence can affect women in different ways. A housewife may not be bothered by her incontinence as a working woman. Hence the doctor must prepare the questions in a customized way and then start the treatment.
We would prefer patients to come to us with a 3-4 day diary with details of the frequency of urination, quantity, urgency, stress or related events and the quantity of fluid intake. Simple tests like urine dip, culture, blood sugar and thyroid function tests can be done initially. A bladder scan can also be done to check post-void residual.
Dr. Chakraborti shares, Urogynecology is the firs twomen’s health specialty devoted to the treatment of the following pelvic floor disorders: (1) urinary and fecal incontinence or loss of bladder or bowel control, (2) overactive bladder defined by urinary urgency or difficulty holding back a full bladder, (3) pelvic organ prolapse or the descent of pelvic organs such as a dropped uterus, bladder, vagina or rectum, (4) voiding or defecatory dysfunction or difficulty urinating or moving bowels and (5) pelvic or bladder pain involving discomfort, burning or other uncomfortable pelvic symptoms, including bladder or urethral pain Urodynamic studies are a series of office tests that are useful in observing the function of the lower urinary tract, which consists of the bladder (a muscular organ that stores urine) and the urethra (the tube from which urine is eliminated from the body). These tests can evaluate storage abnormalities of the lower urinary tract. These include overactive bladder and stress urinary incontinence as well as voiding dysfunction or emptying abnormalities, which may be associated with a feeling of incomplete bladder emptying, the need to strain to empty the bladder, hesitancy or weak urinary flow. A urodynamic study usually takes about 30 minutes to perform. The study consists of a combination of different tests which are described below.
This is a simple and noninvasive test in which the patient is asked to empty her bladder in a special commode that records the flow rate and volume of urine. The volume of urine remaining in the bladder is then measured. Uroflowmetry is a useful screening test to evaluate a patient for bladder emptying abnormalities.
During this study a small catheter (soft tube) is placed in the bladder and another in either the vagina or rectum, and the bladder is then filled with sterile water or saline. As the bladder is being filled with water the patient is asked to report her first sensation of having to empty the bladder followed by a strong desire and urinary urgency. The goal is to try to reproduce similar symptoms that the patient has at home. The pressure and volume relationships of the bladder are measured, including bladder capacity and compliance, bladder muscle activity and sensation.
Two tests can be performed to evaluate the severity or type of stress urinary incontinence, a leak point pressure and urethral pressure profilometry. A leak point pressure is performed by having the patient bear down or strain during various times of the subtracted cystometry and measuring the pressure at which urinary leakage occurs. Urethral pressure profilometry is a graphic representation of pressure within the urethra at successive points along its length. Traditionally, these tests have been useful in deciding on the appropriate treatment for patients with stress urinary incontinence.
During this part of the study, the patient is asked to empty her bladder around the catheters that had been placed during the subtracted cystometry. The purpose is to document objectively the mechanism of abnormal bladder emptying. It is very similar to uroflowmetry, except that the bladder is emptied with the pressure catheter in the bladder and vagina or rectum.
The urodynamic study is performed with electrode patches that are placed near the rectum in order to assess the muscles that control urination. Urodynamic studies are important because a patient’s symptoms do not always accurately reflect the physiologic state of the bladder. The goal of urodynamic tests is to reproduce a patient’s symptoms while observing the changing function of the lower urinary tract during that time. It can be very useful in determining the cause of symptoms and in assessing the severity of stress urinary incontinence. Urodynamic studies provide some level of objectivity and should be used in conjunction with a patient’s clinical history in selecting the appropriate therapy. As part of treatment, behavioural modification including regulation of fluid intake and avoiding caffeinated drinks, spicy food, citrus fruits and chocolates help in reducing bladder spasms. Timed voiding reminds the patient to void at frequent intervals and helps in training the bladder.
Appliances like pessaries and bladder neck support prosthesis may offer a temporary solution.
Pelvic floor muscle training (PFMT) forms the mainstay of conservative treatment. Strong pelvic muscles prevent bladder spasms and also strengthen the support to the urethra.
Medications to relax the bladder muscle and to strengthen the urethral tone are available, however, the side effect profiles of these medicines may limit their prolonged use. SURGICAL OPTIONS
Dr. Chakraborti discusses the latest surgical options: Bulking material injections. Some women and men with stress incontinence benefit from urethral injections of bulking agents. This procedure involves injecting bulking materials – which may be cow-derived collagen, carbon particle beads or synthetic sugars – into the tissue surrounding the urethra or the skin next to the urinary sphincter. The injection tightens the seal of the sphincter by bulking up the surrounding tissue. The procedure is done with minimal anesthesia and typically takes about two to three minutes. Sacral nerve stimulator. This small device acts on nerves that control bladder and pelvic floor contractions. The device, which resembles a pacemaker, is implanted under the skin in your abdomen. A wire from the device is connected to a sacral nerve – an important nerve in bladder control that runs from the lower spinal cord to the bladder. Sling procedure. The most popular and common surgery for women with stress incontinence is the sling procedure. During this procedure, the surgeon removes a strip of abdominal tissue and places it under the urethra. Or the surgeon may use a strip of synthetic mesh material or a strip of tissue from a donor (xenograft) or cadaver. The strip acts like a hammock, compressing the urethra to prevent leaks that occur with the activities of daily living. Sling procedures improve or cure incontinence in most cases. Bladder neck suspension. In this procedure, your surgeon makes a 3- to 5-inch incision in the lower abdomen. Through this incision, sutures are placed in the tissue near the bladder neck while securing the sutures the stitches to a ligament near the pubic bone or in the cartilage of the pubic bone itself. This has the effect of bolstering the urethra and bladder neck so that they don’t sag.
As this problem comes out of the closet, it is the responsibility of the doctors to inform patients of the choices available for treatment as rightly concluded by Dr. Chakraborti