Dr. Mache Seibel
Urinary tract, bladder control and bowel problems are a major problem for over 20 million women and it’s one of the most embarrassing aspects of aging because the lining of the urethra and the fascia and pelvic muscles that surround them are sensitive to estrogen and may weaken when estrogen levels decline.
Half of all menopausal women will have at least some urine loss because the urethra – the tube that carries urine from our bladder out of the body – is much shorter in women than it is in men. The wear and tear of childbirth can weaken the pelvic muscles and fascia, the canvas sheath that reinforces and additionally supports the urethra. That’s why women who have had children are more likely to have urine loss than those who have not.
Sadly, most women wait 5 to 7 years to let their doctor know they are having a problem. Men with an enlarged prostate gland, (which up to 50% do after age 50) or who have had surgery to treat prostate cancer may also lose their urine or feces accidently.
There are several types of incontinence. One type is caused by the bladder muscles suddenly spasms which leads to a sudden, unstoppable urgency to urinate even if there isn’t much urine in the bladder. That’s called overactive bladder, and it can lead to urge incontinence. It’s often associated with frequency (urinating 8 times/24hours) and getting up at night at least 2 times, which is called nocturia. Overactive bladder affects about 17% of women but it increases to over 50% after menopausal. Women with an overactive bladder may not be able to get to the toilet in time to prevent leakage, even though they tighten up all of their pelvic muscles, because they can’t control the bladder and keep it in. It may be common but it isn’t a normal part of aging. Many end up slipping on the way to the bathroom and breaking a hip or other bone.
Another type of incontinence is called stress incontinence and it is much more common. Menopause contributes to this problem, but stretching and tearing of the pelvic muscles during childbirth definitely sets the stage. The reduced muscle tone causes the urethra to sag. When pressure builds up in the abdomen from a cough, sneeze, laugh, jump or lift, your internal organs put pressure on your bladder and a small amount of urine may escape. That is what makes it such an incredible nuisance and so embarrassing – it can occur at any time.
Overflow incontinence occurs when more urine collects in the bladder than the bladder can hold and the excess urine leaks out. It can be caused by blockage of the urinary tract or nerve damage caused by conditions such as diabetes, stroke, or injury. It is also common in men who have an enlarged prostate gland.
Functional incontinence is not really a medical problem. It happens to people who can’t move quickly, who have eye problems or who suffer from confusion or memory loss. They simply can’t get to the bathroom in time. The North American Menopause Society’s Menopause Guidebook points out that infection of the bladder (cystitis), other medical conditions such as multiple sclerosis, certain prescription drugs such as diuretics and some tranquilizers, and smoking and eating spicy foods or artificial sweeteners, or drinking alcohol and caffeine can irritate the bladder and worsen incontinence.
Twenty years ago the number of options for treating urinary tract problems was limited and the most common choice offered was a hysterectomy. Today, there are many more options to consider from a new device called InTone to surgery, medications, pads and diapers and pelvic floor physical therapy. Here are 8 options I offer my patients:
1. Bladder training – This approach teaches you to urinate only at scheduled times and waiting longer between trips to the bathroom. Start by going to the bathroom every 30 to 60 minutes while you are awake, even if you don’t have to go. After about one week, slowly increase the time interval by thirty minutes every week.
2. Kegel exercises – Dr. Arnold Kegel, a gynecologist at the University of Southern California, developed the exercises to strengthen pelvic floor muscles in 1948 and still, physicians to this day remind their patients, “do your Kegels!” Kegel exercises are the first line of treatment for over 20 million women in the U.S. suffering from unexpected bladder leakage due to coughing, sneezing, laughing or exercise often referred to “stress” incontinence but most women experience frustration because they unknowingly don’t perform the Kegels effectively, which leads to no improvement in symptoms. A new medical device called Apex is the first automaticpelvic floor (Kegel) exerciser. Apex automaticallystrengthens and tones pelvic floor muscles using mild muscle stimulation and an active resistance balloon to exercise the correct muscles every time. A strong, toned pelvic floor muscle (PFM) not only decreases involuntary loss of urine, but also improves sexual health and may decrease prolapse of organs such as the uterus and bladder into or out of the vaginal canal.
3. Pelvic Floor Electrical Stimulation with Biofeedback Therapy– This is an effective tool to teach you Kegel’s exercises and improve bladder control. It uses computer graphs and sounds you can hear to show you which muscles you are exercising so you can perfect the exercises. InTone is an FDA listed Class II Medical Device that effectively strengthens the pelvic floor muscles and helps to prevent embarrassing leakage without surgery, diapers, pads or medication and can be done in the privacy of home. InTone uses mild electrical stimulation to train the bladder muscles when and how to squeeze. In a way, it is a personal trainer for Kegel exercises.
5. Medications – Estrogen can be very helpful in improving the symptoms of some cases of incontinence. Studies have demonstrated improvement in 40- 70% of women. I have found that estrogen cream (one fourth to half an applicator) works better than either tablets or patches for this particular problem. Medications called antimuscarinic (examples are oxybutynin and tolterodine) can also help if the problem is caused by abnormal bladder contractions. Of course, antibiotics are the first line treatment for infection. If you don’t respond to these medications, you may be a candidate for Botox injections via cystoscopy directly into the bladder muscle.
6. Pessaries – These donut-like plastic or rubber rings are similar to a diaphragm used for birth control. They are fit into the vagina to lift and offer added support for the bladder when the pelvic muscles are weak.
7. Special devices – A new group of devices are constantly coming on to the market to block or capture urine leakage. They include absorbent products, external urine collection devices, and different types of catheters.
8. Surgery – There are many operations that have been developed to support the bladder and improve or correct incontinence. These include implanted sacral nerve stimulators that stimulate the lower area of the spinal cord to control urine and pulsed magnetic technology that stimulates nerve impulses for bladder control. It’s called Extracorporeal Magnetic Innervation (ExMI). You don’t need to have a hysterectomy unless there are other reasons to consider it as well. Most of these operations can be performed as day surgeries. Some use laparoscopy and others only small incisions. They all are designed to repair tears in the support tissue and/or strengthen or support the urethra. Talk with your doctor about them or get a referral to a urogynecologist.
Remember to ALWAYS talk to you doctor or medical team about anything you add to your health regimen.