HEALTHWATCH
No need for secrecy
DR. KARTHIK GUNASEKARAN
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No one talks about it, but there are many sufferers. Here’s how to deal wth Stress Urinary Incontinence.
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No need to suffer: There may be a simple solution.
Nothing can be more embarrassing than urinary leakage. It’s a topic that a woman feels uncomfortable discussing even with her best friend. It makes a woman a complete recluse, since she is afraid of a humiliating situation.
Stress urinary incontinence (SUI) is the leakage of urine due to any activity that causes an increase in intra-abdominal pressure (coughing, sneezing, laughing, lifting weights and sports). The term refers to the stress of the abdominal pressure over-riding the bladder’s control.
Question of pressure
Normally in a continent woman, the urethral pressure should be greater than the pressure in the bladder. Also, the muscles and ligaments supporting the urethra should be strong. When the pressure in the urethra falls either due to displacement of the bladder (cystocele) or due to damage to its supports or due to damage to the sphincter mechanism itself, SUI results.
Urinary problems are more common than many realise. Stress urinary incontinence is the most common type of UI in women. About half of all incontinent women have complaints of SUI. The prevalence of SUI is more common in the younger age group (<55 years) with a peak in the fourth decade.
SUI seriously impacts the well being of not only the woman but also her partner. Because SUI is mainly prevalent in young and middle aged women who still have an active professional and social life, this may have an even greater impact.
They may experience limitations in terms of physical (e.g. weight lifting, sports), occupational and social activities because of fear of leakage and related consequences (e.g. smell of urine, wetness, pad visibility). The very presence of SUI can affect confidence and self perception of women.
Despite the high degree of bother associated with SUI and its impact on the quality of life, many women do not consult a physician but suffer in silence. Fear of surgery or belief that their condition is a normal consequence of aging or childbearing may be another reason.
As SUI is a quality of life issue, it is important to determine at the outset how each woman is affected. A QOL questionnaire given to women will help determine this. Degree of bother is usually marked on these questionnaires and helps the physician to decide management.
A patient should keep a bladder diary. Careful records will help determine the severity and also identify trigger factors. Urine analysis and culture helps identify infection.
Screening for diabetes, thyroid and kidney function are important and a thorough pelvic examination to identify internal organs is a must.
An ultrasound may pick up gross abnormalities in the uro-genital tract. Cystourethroscopy allows the physician to look into the urethra and bladder for problems. Tumour infection and inflammation can be seen as well as obstruction or malformation of the urethra.
An urodynamic study may be done. In this test, the bladder is filled with water and measurements are made with the patients in various positions and in urinating. It determines the functional ability of the bladder, urethra and sphincter muscles in holding and releasing urine.
There are three types of treatment options: Conservative, medicines and surgical.
Treatment options
Conservative treatment options include lifestyle interventions and pelvic floor muscle training (PFMT). Lifestyle interventions such as weight loss, stopping smoking and fluid management are often recommended as supportive measures, in order to prevent further aggravation.
PFMT is the most commonly recommended conservative treatment but the problem is that identification and localisation of pelvic floor muscles have always been difficult.
Bio-feedback uses visual feedback to identify and isolate the correct muscles. Results take a long time and invariably patient compliance drops.
Until recently there was no globally developed and widely approved pharmacological treatment for SUI. The few available drugs had considerable side-effects and had to be removed.
Recently, Duloxetine is being widely tested and tried in Europe and is said to be quite effective. Nausea, however, is a very troublesome side-effect limiting its use.
Surgery
If conservative treatments fail or if the problem is severe, surgery may be considered. This can either be Bulking agents, Colposuspensions or slings.
Bulking Agents is the least invasive. It can be done under local anaesthesia in patients unfit for regional or general anaesthesia. Various substances like fat, blood, collagen and silicon particles can be used as bulking agents. The flip side is that its efficacy drops over time. Repeat injections are often required and prove costly.
Colposuspensions, also known as the Burch procedure, can be done laproscopically or by the open technique. It is easily the gold standard surgery with good success rates over long follow-up periods.
Slings, along with the Burch procedure, are being used. Sling surgeries usually involve a piece of material (permanent or biodegradable) being kept under the urethra by means of a small vaginal incision. This replaces the ligaments of the urethra and maintain continence only when there is an increase in intra-abdominal pressure.
They are done as day-care surgeries with minimal pain and blood loss. Tension-free slings like the TVT have been around for 10 years with phenomenal success rates. The newer Trans-obturator slings (TOT) have revolutionised sling surgeries and reduced complication rates.
People with SUI often find it dominates their lives. They must cope with shame, anger, fear, depression, risk of accidents in public, insensitivity of others. Many often feel their lives are out of control.
Remember, there may be a simple solution. The key is to seek an incontinence specialist. While there are many products to deal with incontinence, do not assume they are the only choices. Get expert advice and find relief.
The author is a Chennai-based Uro-gynaecologist.
Causes of Stress Urinary Incontinence
UI is the symptom of a problem. It can be the result of disease, injury, birth defect or aging changes. Women are more predisposed to SUI due to their shorter urethras and childbearing.
The risk of a woman having SUI increases if her mother and grandmother suffered from incontinence. Congenital problems in the urethra or bladder or spinal abnormalities or injuries to the spinal cord may increase the prevalence of UI. Weak muscles are often the culprit.
Strong pelvic muscles are important in maintaining continence. Loss of support of the bladder and urethra resulting in incontinence is often the result of combined effects of gravity, loss of estrogen and poor muscle tone.
Childbirth may also play a role. Nerve and muscle damage from big babies and forceps is a contributing factor. The lying-down position of childbirth, which forces women to push uphill, is another.
Gynaecological Surgery through the vagina can cause damage to the nerves or muscles or may cause scarring of the urethra. Some women have problems after hysterectomy, as they lose that support for the bladder.
Bladder infections can also be a cause. The toxins released by the bacteria can cause the urine tube to relax and might result in a low pressure causing leakage.
Radiation therapy can also damage the urethra.
Obesity is another important cause. The increased intra-abdominal pressure and weak muscles in obese women predispose them to SUI.
Chronic cough and constipation put a lot of stress on the pelvic muscles.
Repeated stress and medications like diuretics and anti-hypertensives, which relax the urinary sphincter, can cause UI.
