Surgery holds an­swer to in­con­ti­nence

In­con­ti­nence is com­mon— but it’s not nor­mal, and treat­ments are im­prov­ing, writes Kel­lie Bis­set

The Weekend Australian - Travel - - Health -

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.

Pic­ture: Amos Aik­man

Mus­cle tone: Phys­io­ther­a­pist Gil­lian Mar­cham uses ul­tra­sound equip­ment to teach women how to prop­erly ex­er­cise pelvic floor mus­cles

Newspapers in English

Newspapers from Australia

© PressReader. All rights reserved.