(Copyright Bonnie Schiedel. Originally published in Canadian Health, September 2010).
Are you one of the 3.3 million Canadians living with incontinence?
For Hilda Dubé, wetting her pants at a family gathering was the last straw. "I was telling a joke in front of everyone and I got completely drenched," remembers the 54-year-old oncology nurse from Ancaster, Ont. She had struggled with stress urinary incontinence (SUI ) - leaking urine when she laughed, sneezed, coughed or exercised - ever since a very long labour with her second child when she was 31. At the time, doctors told her she was too young to have SUI (a common misconception). Hilda diligently did Kegel exercises, designed to strengthen the pelvic muscles that help control urine, but unfortunately had limited success. "SUI was horrible. I was always concerned about odour, I always had to wear a pad and it was just a huge nuisance," she says. "Plus, it felt like a taboo topic. I was uncomfortable bringing it up with other people, even with my doctors."
"Primary health-care providers can be reticent about talking to patients about incontinence," agrees Dr Sender Herschorn, a Toronto urologist who is head of the Urodynamics Laboratory at Sunnybrook Health Sciences Centre and professor and chair of the division of urology at the University of Toronto. "They may think that it's a really complex issue, when it usually isn't. Other myths are that incontinence only affects women, that it's only an issue for older people and that it's just a normal part of aging. But you don't have to live with it: there are lots of good treatments available."
When Hilda first developed SUI, corrective surgery was a fairly major procedure, but when a minimally invasive sling technique (see Surgery section) was developed, Hilda decided it was time to act. She had the surgery in 2004 and was ecstatic with the results. "My life has improved immensely and I can enjoy all my favourite activities again because I'm dry," says Hilda, who now acts as a spokesperson for the Canadian Continence Foundation. "I want to get the word out: there is help and there is nothing to be embarrassed about!" If you're one of the 3.3 million Canadians (including 33 per cent of women over 40, according to the Canadian Urinary Bladder Survey) living with incontinence, read on to discover the causes and remedies.
Little leaks, big gushes
The most common causes of persistent incontinence are bladder muscles that become weakened over time and damaged pelvic-floor muscles. The pelvic floor muscles - picture a hammock of muscle that runs from your pubic bone to the base of your spine, supporting the bladder, bowel and in women, the vagina - and nerves in the pelvis may be damaged during pregnancy and childbirth, as well as by any surgery in the pelvic area. This damage can lead to incontinence shortly afterwards or many years later. Declining levels of estrogen at menopause can also contribute to incontinence because estrogen keeps the tissues of the urethra (the tube through which urine leaves the body) plumped up and better able to contain urine.. Diabetes, stroke, spinal injury or a neurological disease such as multiple sclerosis can interfere with nerve signals between the brain and urinary tract. In men over 40, an enlarged prostate can lead to urge or overflow incontinence (see "Incontinence info" sidebar to learn more about the different kinds of incontinence). Finally, bladder cancer and bladder stones (accompanied by bladder pain and blood in the urine) are occasionally incontinence triggers.
Temporary incontinence can be caused by a urinary tract or bladder infection, pressure on the bladder due to constipation or pregnancy, natural diuretics (substances that increases the amount of urine produced) such as caffeine, alcohol, pop or fruit juice, and medications such as prescription diuretics and certain antidepressants, muscle relaxants and heart medications.
Sidebar: Incontinence info
There are several different types of incontinence.
Stress incontinence refers to leaking urine when you laugh, sneeze, cough, lift something heavy, exercise or otherwise put pressure on your bladder. It's most common in women.
Urge incontinence means you leak urine following a sudden, overwhelming urge to urinate. It may be triggered by the sound of running water.
Mixed incontinence is the combination of stress and urge incontinence.
Functional incontinence is the result of a mental or physical disability, such as Alzheimer's disease, Parkinson's disease or severe arthritis, which prevents you from reaching the bathroom in time.
Overflow incontinence refers to a frequent or constant small leaking of urine, caused by an overly full bladder that is not completely emptied when you go to the bathroom.
Your treatment options
Lifestyle choices can often help bladder health. Maintain a healthy body weight with a balanced diet and exercise, because extra pounds put pressure on the bladder and urinary sphincter. Try avoiding bladder irritants such as citrus, artificial sweeteners and caffeine. And butt out - nicotine may affect the muscle of the bladder wall. Should you be limiting liquids? Don't go overboard, because too little to drink can affect your kidneys. Aim for six to eight glasses of liquid a day.
Behavioural changes can help your bladder, too. Kegel exercises, which help strengthen the pelvic-floor muscles, can be quite effective for stress or mixed incontinence (see below). Here's how to do Kegels: to locate the correct muscles, imagine that you are trying to hold back urine or gas. Squeeze those muscles, without tightening your stomach or buttocks, for five to10 seconds, then release for 10 seconds. Breathe normally. Repeat 15 to 20 times, three to five times a day.
If you have urge incontinence, your health-care provider may suggest bladder retraining (learning how to suppress the urge for frequent urination and keeping to a regular bathroom schedule).
Prescription medications may be used in combination with behavioural changes. These medications work in different ways: blocking the chemicals that tell the bladder muscle to contract (eg oxybutynin), decreasing the amount of urine you produce at night (eg desmopressin), relaxing the prostate (eg tamsulosin or terazosin) or relaxing the bladder wall and strengthening the sphincter (eg imipramine).
Silicon or collagen injections are another option for stress incontinence. "These bulking agents help build up the internal structure of the urinary passage, so it closes a little tighter," explains Dr Herschorn.
Estrogen, as part of menopausal hormone therapy, has often been prescribed because the decrease in natural estrogen at menopause can cause the urethra to thin somewhat, leading to urine leakage, says Dr Herschorn. "However, it's not clear if it works. The suspicion is that there's no benefit." He points to a landmark study of more than 27,000 women, published in the Journal of American Medical Association in 2005, which revealed that taking conjugated equine estrogen therapy, with or without progestin, actually increased the risk of incontinence in continent women, and made symptoms worse for incontinent women. Topical estrogen, such as a cream applied to the vagina, may be of some helpful though.
Mechanical treatments are another option for some forms of incontinence. Women with pelvic-organ prolapse (where the bladder, bowel and/or uterus sag into the vagina) may use a pessary, a device made of rubber or silicon that is placed against the cervix to hold up the organs. Catheters may also be inserted to help the bladder drain properly.
Surgery may be called for if less invasive treatments have been unsatisfactory. The most common surgery is a sling procedure, a minimally invasive, outpatient procedure performed under local anesthetic, in which a synthetic mesh tape is placed under the urethra to support it and prevent leakage, explains Dr Herschorn. Recovery time is only a few days. The sling procedure has a good success rate in women with stress incontinence, and is currently under study for men. Another procedure, called bladder-neck suspension, lifts the sagging bladder. It is minimally invasive but has a six-week recovery time. Surgery for men usually addresses damage due to prostate issues and includes reducing an enlarged prostate and installing an artificial sphincter or inflatable implant near the bladder neck.
Self-care
Disposable pads, liners, belted undergarments and disposable briefs (adult diapers) can help you maintain your lifestyle while dealing with incontinence. They come in a variety of sizes and levels of absorbency, and some are specially designed to accommodate the differing needs of men and women. Don't rely on menstrual pads, as they are designed to absorb blood, which has a different consistency from urine.
Tip:
Before you meet with your health-care provider to talk about incontinence, keep a bladder diary for a few days and jot down what you drink, and how often and how much you urinate.
