Surgery holds answer to incontinence
Incontinence is common— but it’s not normal, and treatments are improving, writes Kellie Bisset
WENDY Little is incontinent, and she’s not afraid to admit it. In fact, the Melbourne comedienne has even written a song about what many women regard as a taboo subject, and audiences have responded warmly: Just last week I had the flu I was kind of feeling blue Then a worse thing happened to me When I sneezed ... I did wee I’ve had one child and then one more The nurse told me ’ bout pelvic floor I thought it was a midwives’ tale Now my bladder’s starting to bale. Little says she can see the smiles of recognition among women in her audience when she sings her song Do the Pelvic Floor (which continues for several more verses).
‘‘ I think they are glad it is brought up and everyone can have a little laugh at it,’’ she says. ‘‘ Humour is a good way of looking at topics that can be serious, and bringing them into the public domain.’’
Little began to experience continence problems after the birth of her first child in 1995. Now that her children are 12 and 10, she says she never leaves the house without ‘‘ protection’’.
She’s in good company. More than one in three adult Australian women, and 13 per cent of men, suffer from urinary incontinence — but fewer than one-third seek treatment.
This appears to be partly due to the associated stigma and embarrassment, but it also may have something to do with being in denial about what incontinence actually is.
‘‘ People will tell you they don’t have incontinence, but then they will say ‘ yes, I leak’,’’ says Elizabeth Farrell, consultant gynaecologist at the Jean Hailes Foundation for Women’s Health.
So, if you’re in doubt, here are the features of normal toilet habits: having dry pants at all times; going to the toilet four to six times a day only; sleeping through or getting up once through the night; passing 300-400ml each time you go; passing urine easily — no straining, stopping or starting. If you don’t meet all these criteria, you have a problem.
Associate professor Pauline Chiarelli, who outlines these criteria in her book, Women’s Waterworks , says leakage is common but never normal. And if you don’t address the problem, it’s highly likely to get worse.
Chiarelli, an associate professor of physiotherapy at the University of Newcastle, says there are significant economic costs associated with incontinence.
A study published in the MedicalJournalof Australia (2001; 174:456-458), which she coauthored, predicted the cost of incontinence to Australian healthcare resources would balloon to $1.3 billion a year by 2018. This is likely to be a significant underestimate, she says, given that surgical treatments for incontinence have become much more common since the study was done.
According to Chiarelli, if elderly women could be kept continent they might be kept out of nursing homes for longer, saving the community considerable dollars: ‘‘ Often incontinence is the straw that breaks the camel’s back [in sending someone into care].’’
Many women can be cured by bladder retraining and exercise programs for the pelvic floor — the ‘‘ sling’’ of muscles that support the bladder. Topical oestrogen therapy is also useful in some women, particularly those who are post-menopausal.
However, if that fails, surgery for stress incontinence is now more accessible, particularly since the wider use of ‘‘ vaginal sling’’ procedures — where a narrow strip of mesh is inserted underneath the urethra like a sling, or hammock, to keep it in its normal position.
This type of surgery has a high success rate, only takes about half an hour to perform, and can be done as a day-stay or overnight procedure, according to Kate Moore, associate professor of women’s and children’s health at the University of NSW.
While the surgery has revolutionised treatment for stress incontinence, there are side effects. There is a risk of creating an overactive bladder (urge incontinence), or causing the bladder to stop being able to empty completely, Moore says.
But a new study published in The Lancet (2007;369:2179-2186) suggests surgical treatments for stress incontinence could change significantly in future, after researchers showed injecting patients’ own stem cells into their urethra successfully cured the condition.
Researchers used ultrasound to guide injections of myoblasts (a type of stem cell from muscles) and fibroblasts (connective tissue cells that secrete collagen proteins) into the urethra and the urinary sphincter — the muscular coat that surrounds it. The result was regeneration of urethra and sphincter.
Of the 42 women who received the procedure, 38 were completely continent after 12 months, and after three years no severe side effects were reported. An accompanying editorial in the journal said the results foreshadowed potentially ‘‘ one of the most important innovations in urology’’ since the development of shockwaves to shatter urinary stones, and tension-free vaginal tape for stress urinary incontinence.
Sydney urologist Phillip Katelaris agrees the results are exciting, and says they might also be applicable to men who have had prostate cancer surgery.
‘‘ If the technique could be applied to men post radical prostatectomy, that would be significant,’’ he says. ‘‘ But it’s not ready for prime time and we do have quite a lot of options for people already.’’
The authors acknowledge that more trials with larger patients are needed before stem cell therapy could become a standard surgical treatment. And there’s also the issue of cost — such therapy isn’t likely to come cheap.
The researchers compared their technique with collagen injections, delivered in a similar way. These can cost about $2000 an ampoule, and while used to treat incontinence by bulking up the urinary tract, they have a much lower success rate. They are less common than ‘‘ sling procedures’’ and only for women who have had previous, unsuccessful surgery and who meet certain clinical criteria.
While it’s still unknown whether stem cell therapy will eventually replace sling procedures as the surgical mainstay for stress incontinence, the director of the pelvic floor unit at Sydney’s Westmead Hospital, Jenny King, says urge incontinence is still a big problem that isn’t helped by surgery.
‘‘ These are the ladies we deal so poorly with,’’ she says.
And Farrell says that while stress incontinence can stop women from exercising at a time in their lives when they really need to combat obesity, urge incontinence can stop them going out altogether. ‘‘ Some women will say ‘ I know every toilet in Melbourne’,’’ she says. ‘‘ It can be totally socially limiting.’’
Katelaris says a group of drugs called anticholinergics are the mainstay of treatment for urge incontinence, and some doctors are even injecting Botox into the bladder muscle, although this is not yet widely used.
But according to Chiarelli, we need to get back to basics on the incontinence issue, educating women at a younger age about how to use their pelvic floor muscles and teaching people about good bladder habits.
Going to the toilet ‘‘ just in case’’, for example, is something most little girls are taught to do. In fact, this can lead to problems with frequency because the bladder is never given the opportunity to expand properly.
Chiarelli is also concerned about the amount of surgery being performed for stress incontinence, when less invasive measures such as pelvic floor training have not been tried first. She’s worried women see this as a quick fix, when in fact the need to continue to work on the pelvic floor muscles after any surgery is just as important as doing the exercises in the first place.
But as a nation, we’re not doing too badly, she says. We’re leading the world in continence promotion and the National Continence Management Strategy has just had its funding renewed — the federal Government expects to have spent $49 million on the issue by 2010.
The challenge at a national level it seems, is similar to that faced by any woman who’s ever forgotten to do her pelvic floor exercises: keeping the issue front of mind.
Muscle tone: Physiotherapist Gillian Marcham uses ultrasound equipment to teach women how to properly exercise pelvic floor muscles