Important information for the millions of women who suffer from incontinence. Millions of women experience difficulties controlling their bladders but suffer in silence, reluctant to speak to their doctorsâor even to their best friendsâabout the problem. Here, at last, women will find the most up-to-date medical explanations and state-of-the-art solutions.
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Incontinence is the uncontrollable loss of enough urine to cause social or sanitary difficulties. When we study the body and look at how we control urination, we know that an infant does not have the proper connections between its brain and bladder to be able to control the bladder. We also know that as the brain develops, young children can be taught to control when and where they empty their bladders. This learned control is then maintained, usually without much thought, throughout adulthood. To a child or an adult, any loss of bladder control feels like a return to infancy and can be an embarrassment and a source of terrible discomfort.
Incontinence can be a significant problem for young, middle-aged, and older women. Life with incontinence, even mild incontinence, can become very stressful as it threatens self-image, body image, and self-esteem. Concerns about having to deal with incontinence may hinder career opportunities for women in the workforce. The embarrassing loss of self-control makes a woman feel old and helpless. Outings for shopping and recreation may be planned around the availability of bathrooms. Travel to new places becomes difficult. Having a change of clothes handy and worrying about odor are constant concerns. Worst of all, women suffering from incontinence may stop some of the activities they enjoy altogether; they may avoid getting together with friends or family and having sexual contact altogether. Understandably, they may feel depressed.
Many people consider adult incontinence a natural part of aging. It is not! The vast majority of older women do not have incontinence. Most people are not aware that young women can also have incontinence. Since incontinence is so frequently associated with aging, younger women are even less likely to talk about it or seek treatment. The good news is that there are now many ways to treat women of all ages who have incontinence.
IS ALL INCONTINENCE THE SAME?
Incontinence is a symptomâthe loss of urine. The two most common types of incontinence are loss of urine with laughing, coughing, or sneezing, called stress incontinence, and loss of urine preceded by a strong urge to go, called urge incontinence or overactive bladder. Sometimes a woman has both types of incontinence at the same time. This combination of types of incontinence is called mixed incontinence. Different types of incontinence have different causes, and different treatments solve each type. The first step toward ending incontinence is for your doctor to determine which type of incontinence you have. This begins with your answering questions about your symptoms. Following that, a number of simple tests are performed to help pinpoint the nature of the problem, which we will discuss in Chapter 3. But first, it will be helpful to understand what the possible types of incontinence are. The chart below gives brief definitions of the types of incontinence. More detailed explanations follow.
TYPES OF INCONTINENCE
WHAT HAPPENS WHEN A LAUGH, COUGH, OR SNEEZE CAUSES LEAKING?
You may have noticed that sometimes a loss of urine occurs as a result of a cough, sneeze, laugh, or vigorous exercise. Many women with this problem, known as stress incontinence, may begin limiting their own activities for just this reason. However, coughing, sneezing, and even laughing are often unavoidable. We need to laugh and exercise (and cough and sneeze) to live life to its fullest. Understanding stress incontinence is the first step toward finding a solution.
Stress incontinence got its name because the pressure or strain from a laugh or cough results in a loss of urine. The bladder and urethra are normally held firmly in place by muscles and connecting tissue in the pelvis (Figure 1-1). When you cough, the pressure inside your abdomen increases, and the pressure pushes on your bladder and urethra. If the supporting pelvic muscles or connecting tissues have been damaged or weakened, they may not be able to withstand the force of the cough. The pressure then forces the urethra to open, and urine leaks out (Figure 1-2). Many activities that you ordinarily wouldnât even think about can cause increased pressure in the abdomen and the bladder. Coughing, straining to lift a heavy piece of luggage, aerobic exercise, or even a hiccup can challenge a woman with this problem.
Figure 1-1: NORMAL PELVIC ORGANS AND MUSCLES
WHAT CAUSES STRESS INCONTINENCE?
As we discuss in Chapter 4, pregnancy and childbirth can damage the pelvic ligaments that anchor the uterus and bladder to the bones of the pelvis. The muscles that support the bladder work differently from most other muscles. Other muscles in your body usually relax until you ask them to do something for you, such as lifting a fork or bending at the waist. However, the pelvic muscles are always contracted so that they can continually hold up the bladder, uterus, and intestines. If these muscles, and the connecting tissue that attaches the muscles to the pelvic bones, are stretched or damaged, as may happen during childbirth, they become less effective at holding things up. The urethra may then be pushed out of position by a cough, sneeze, or strenuous activity because the muscle support cannot withstand the extra pressure.
Figure 1-2: STRESS INCONTINENCE
The nerves sending messages from the brain to the pelvic muscles may also be altered due to childbirth. In the birth canal, the babyâs head puts pressure on these nerves. Prolonged pressure, or undue pressure because of the size of the babyâs head, may damage these nerves so they cannot send proper signals to the supporting muscles. As a result, the muscles may not be able to hold the bladder up.
Other factors may also cause increased pressure on the pelvic organs that probably contributes to incontinence. A family history of incontinence may be an important factor since the amount and strength of the collagen that makes up the supporting tissue is inherited. Smoking can decrease the amount of oxygen the muscles and ligaments get and thereby lead to weakened tissues. In addition, smokers often cough, and every cough pushes against the bladder and pelvic ligaments and, over time, may weaken them. If a woman is overweight, extra pressure is added to an already weakened system and may aggravate the problem of leakage. Chronic constipation, which causes straining to pass a bowel movement, also increases the abdominal pressure and can weaken the support of the bladder and pelvic organs.
In some women, the hormonal changes that occur with menopause can cause thinning of the tissues and blood vessels of the urethra. Try to visualize the urethra as a tubeâif you were to cut across it, the cross section would look like a doughnut. With declining estrogen levels, the walls of this tube shrink, resulting in a larger hole. The larger the opening, the more difficult it is for the muscles to seal. If the urethra is not closed, urine can leak out (Figure 1-3).
Any one or more of these factorsâstretched pelvic muscles, excess body weight, damaged nerves, or thinning of the urethraâmay lead to stress incontinence. As you will see in later chapters, treatment for this type of incontinence involves strengthening the pelvic muscles or repairing the supporting tissues to the bladder and urethra.
WHAT IF YOU HAVE THE URGE TO URINATE FREQUENTLY?
Urgency is the sense that you have to urinate right now. When you gotta go, you gotta go. The constant urge to empty the bladder and all those trips to the bathroom can be disabling to many women. They do not necessarily leak urine, but their lives are nevertheless taken over by their bladder problems. Urgency is basically the result of the bladder misbehaving, of the bladder being overactive. In fact, the term overactive bladder is now frequently used instead of urgency. Instead of quietly collecting urine, the bladder is constantly making a nuisance of itself. This is perceived as everpresent bladder pressure. The bladder feels as if it is always full, but in fact most trips to the toilet produce no more than a few ounces of urine. Some women may note urgency during the night that wakes them repeatedly.
Figure 1-3: BLADDER AND URETHRA
Urgency and frequency are frustrating problems. Many women suffer in silence because they do not realize that, thankfully, there are many solutions to their problem. These include taking prescription medication, learning to urinate on a schedule, and doing muscle exercises that can help reduce spasms. Simple dietary changes may also help reduce frequency and urgency. These nonsurgical treatments and others are fully discussed in Chapter 5.
HOW COMMON IS URGENCY?
Urgency is one area where age does seem to make a difference. About 6 percent of women under forty have symptoms of urgency, and about 10 percent of women have this symptom prior to menopause. By the time women reach their late fifties and early sixties, about 40 percent will have urgency. And by the time women reach their eighties, nearly 80 percent have this problem. About 40 percent of women who develop urgency also have urge incontinence, meaning urgency to the degree that they may actually lose urine.
WHAT CAUSES A STRONG URGE TO URINATE?
The most common temporary cause of having a strong urge to urinate is a bladder infection. The infection causes an irritation of the bladder lining that leads to spasms of the bladder muscle. However, the bladder irritation and urgency go away once the infection is treated with antibiotics. Only rarely does a bladder infection lead to such severe urgency that incontinence results. If treated, these infections have no permanent effect on your bladder.
Unlike with stress incontinence, childbirth does not appear to play any role in the development of urgency. Most womenâs urgency problems are not easily explained. A number of theories suggest what the causes might be, but none have been proven. Some researchers focus on the nerve signals to the bladder. They suggest that some women may have a mild, probably age-related, change in the nerves or the chemical signals between the nerves that leads to overactivity of the bladder. Some propose that the problem is rooted in the muscle cells of the bladder itself, which may be overactive. This theory is supported by the fact that about 50 percent of women with urge incontinence also have a similar problem with their intestines called irritable bowel syndrome. The overactivity of the muscle cells in the intestines that occurs with irritable bowel syndrome leads to abdominal cramping.
Some women have overactivity of the bladder from causes that are easier to establish. Women who have had multiple surgeries to correct incontinence are at a slightly higher risk of developing urgency and urge incontinence. In these women, the bladder nerves may be injured after being pulled, stretched, or even cut at the time of surgery. In others, previous surgery may have caused scar tissue to block the flow of urine out of the bladder. The bladder then needs to work harder to get the urine out past the scar tissue, and the overworked bladder muscle may function poorly.
Another condition associated with bothersome frequency and urgency is called interstitial cystitis, or IC. IC may also be associated with recurrent discomfort or pain in both the bladder and the nearby pelvic area. Interstitial cystitis is fully discussed in Chapter 7.
Conditions affecting the nervous system, such as Parkinsonâs disease, multiple sclerosis, Alzheimerâs disease, or stroke, may also cause urge incontinence. Other rare conditions such as benign polyps or stone formation in the bladder can also lead to urgency and incontinence. These problems can easily be evaluated with a cystoscope, a small telescope that allows the doctor to look into the bladder. This office procedure, called a cystoscopy, takes only a few minutes. Prior to insertion of the cystoscope, a topical anesthetic in a gel form is inserted into the urethra in order to relieve discomfort. With the cystoscope, we can see irritation from interstitial cystitis or the presence of a bladder stone, bladder cancer, or overgrown bladder lining cells that form polyps.
WHAT IF THEREâS A STRONG URGE TO URINATE AND THEN YOU LOSE CONTROL?
Normally you make a conscious decision about when to empty your bladder. When you get the feeling that your bladder is full, you control the urge to urinate and make it to the bathroom in time. However, some women have an overactive bladder that tries to empty on its own, often without much warning. If you feel a bladder contraction that causes such a strong sense of urgency that you cannot control it, you may lose urine before you can get to the bathroom. This is called urge incontinence. The causes of this problem are similar to those described for urgency.
Some women may have urge incontinence when they put their hands in running water or hear water running. Some note urge incontinence when they change position rapidly, such as when they get up quickly from a chair. Others get urge incontinence when they return home with a full bladder, park the car, rush to the front door, and put the key in the door. The anticipation of relief triggers a bladder spasm. This is so common it has a name, âkey-in-the-door incontinence.â Women with urge incontinence report that it affects the quality of their lives more than do women who have stress incontinence, depression, or even diab...
