URINARY INCONTINENCE: SUFFERING IN SILENCE

Urinary incontinence affects as many as one in four women in the developed countries¹. In Malaysia the true figure is hard to get, as there is no nation wide study on prevalence. It is estimated that there are more than 1 million suffers. Pelvic organ prolapse and urinary incontinence is the most common chronic condition in women, accounting to about 35% of all chronic medical condition, much more common than hypertension (25%), depression (20%) and diabetes (8%).  Many of them regard it as normal and as part of aging or as embarrassing complaint and did not seek any medical advice. Many of them suffer in silent. It contributes to tremendous physical and emotional trauma to the individual and the financial cost is enormous².

Women suffer incontinence more than women, with a third of suffers are in the childbearing age and the rest are postmenopausal women. Urinary incontinence is divided into four groups. The commonest being the stress and urge incontinence. The other groups are overflow and functional incontinence. Stress incontinence is basically means leakage of urine upon coughing, laughing or sneezing. It is contributed by childbirth, the menopause, previous surgery and chronic cough. Urge incontinence is leakage of urine before being able to reach the toilet. It is caused by detrusor instability (80 percent idiopathic and 20 percent due to infection, inflammation, stones, foreign bodies, tumors and others). The other two groups are rare and have it own factors contributing to the incontinence.

The impact of urinary stress incontinence on the quality of life includes social isolation, and depression. Many of them suffer in silent and will not seek help. In our country many had and would take this problem to grave without realizing that majority of urinary problems can be treated by simple conservative methods or surgically. Some doctors or medical carers are also partly to be blamed. A few would just pat them and say that this problem is basically as a result of childbirth and aging and nothing can be done. This is not true. In fact 70 percent of sufferers can be helped and taught to manage their incontinence better.

Patients seeking advice on urinary incontinence should be assessed with sensitivity and empathy. A detailed history, including details of fluid consumption, severity of incontinence, and other associated medical or surgical problems. If a patient has a bladder diary for three to seven days, this can be of help in assessing the pattern of incontinence and bladder function. A urine test should be carried out to rule out underlying urine infection. Clinical assessment includes measurement of height, weight and blood pressure. The abdominal examination may reveal a distended bladder or a pelvic mass. Vaginal examination may reveal stress incontinence, urogenital atrophy, genital prolapse, fistula and pelvic muscle strength.

Pelvic Health Concept

Ipoh hospital is the first public hospital to set up the Pelvic Health Unit (urogynaecology and pelvic reconstructive unit) under the department of obstetrics and gynaecology. The first line of management is to educate patients about good bladder habits, such as posture during micturation, avoidance of bladder irritants, pelvic floor exercises and maintenance of good general health. Our unit has started the “Beat the Bladder Blues” campaign to create awareness among public and how to seek advice with regards to their bladder or prolapse problem.

In terms of posture for urination, we advice patients to sit firmly on the seat and lean forward with their feet flat on the ground, in order to empty the bladder completely³. ‘Hovering’ or ‘hanging the feet’ would only partially empty the bladder. One could also do double voiding if the feel the bladder is not completely emptied by simply leaning back for 10 seconds and then lean forward again to empty any residual urine. It is also important to avoid bladder irritant if patients bladder is sensitive and if they have urgency and urge incontinence. They should avoid caffeine drinks or drink less than 2 cups of coffee/tea/coke/chocolate per day. Alcohol is also bladder irritant. Other bladder irritants are concentrated urine, infection, atrophy and constipation. Patients should avoid or treat the under lying cause as appropriately. Good bladder habits include drinking about 6-8 cups (2 liters) of fluids a day. Avoid drinking anything within 2 hours of going to bed. Avoid ‘just in case’ visits to the toilets. Topical vaginal estrogen creams are helpful in alleviating irritative lower urinary tract symptoms⁷. Treating underlying urine infection and constipation is also important to improve the bladder function. Pelvic floor exercises have been shown to improve incontinence in about 65 percent of patients⁴. These exercises can be learned by reading the brochures or can be explained in sessions by the physiotherapist.

Based on information, it is estimate that, about 55-60 percent of patient’s presents with stress incontinence, while 35-40 percent presents with urge-like symptoms. Evidence has shown that up to 60 percent of patients reported improvement or cure with the conservative management alone without any surgical intervention. For those who did not improve or requires surgical intervention, a special test called ‘urodynamics’ are carried⁶, This test would provide a more detailed diagnosis and assist management in most cases.

With the advent of minimally invasive surgery such as the suburethral sling procedures, the surgical management of stress incontinence has become more successful and less painful and with shorter hospital stay. Most of these surgeries can be done as daycases. Surgery should be performed by a surgeon who has been trained in the operation and who has a caseload to provide good long-term success rate. The primary surgery is the most important operation as subsequent operation for stress incontinence has been shown to provide poor outcome. Newer drugs, which are organ specific, and have fewer side effects and improved patient’s compliance, are currently available in the market⁸. Research continues to find new drugs for both stress and urge incontinence that are effective and have few side effects if any.

Where are we heading?

The concept of pelvic health needs expansion. Women spend lots of attention in taking care of hair, face and skin, since it promotes body image. However more than half the female population in developed and developing countries suffers from pelvic health problem such as incontinence, genital prolapse or lower bowel and sexual problems. Very little attention is made to promote good bladder habits from early age, regular pelvic exercises and bladder retraining. Little attention is made to improve the quality of life of such patients. Vast majority of women spend their life in the perimenopause and postmenopausal period, suffering in silence and feeling unwanted, isolated in their golden years¹⁰.

In conclusion, there is various strategy and treatment for most of the pelvic health problems, from simple conservative management to minimally invasive surgery for stress incontinence and drug therapy for urge incontinence. Challenges remain, in promoting the concept of pelvic health and make people and care providers to aware that help is available.

 References

1. Chiarelli P, Brown W. Leaking urine: prevalence and associated factors in Australian women. Neurourol Urodyn 1999; 18(6): 576-7.
2. Moore K. The cost of urinary incontinence. Med J Australia 2001; 174: 436-7.
3. Rane A, Corstiaans A. Does leaning forward improve micturation? J Obstet Gynaecol 2000; 20(6): 628-9.
4. Hay-Smith EJ, Bo K, Berhmans LC. Pelvic floor exercise training for urinary incontinence in women. Cochrane Database Syst Rev 2003; CD001407.
5. Bezerra CA, Bruschini H. Suburethral Sling operation for urinary stress incontinence in women.  Cochrane Database Syst Rev 2002; CD001754.
6. Glazener CMA, Lapitan MC. Urodynamic investigation for management of urinary incontinence in adults. Cochrane Database Syst Rev 2003; CD003195.
7. Moehrer B, Hextall A, Jackson S. Oestrogen for urinary incontinence in women. Cochrane Database Syst Rev 2003; CD001405
8. Abrams P, Rentzhog L, Stanton S, et al. Efficacy and tolerability of tolterodine vs oxybutinin and placebo in patients with detrusor instability. Br J Urol 1998;81(1):42-8
9. Royal College of Obstetricians and Gynaecologists Guideline No 35.
10. Ismail NN. A study on the menopause in Malaysia. Maturitas 1994; 19(3): 205-9