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No Laughing matter

Oprah Winfrey has a trademark skill of getting folks to open up and talk about the things that really bother them. Her audience often reveals the hidden but common issues and challenges we all face.

Her show on things that change after you’ve had a baby was no different, generating candid comments on everything from less sleep to less sex. The studio audience’s most sympathetic nods, however, began when the talk turned to those irritating little “leaks” many women feel postpartum, when they laugh or sneeze or lift something heavy. Some women reluctantly admitted that the leaks lasted for years-or began in earnest once they hit menopause. With each new confession, women in the studio clapped loudly in compassion and camaraderie.

No doubt thousands of viewers were clapping at home as well. Although incontinence, or the loss of bladder or bowel control, is arguably one of the most common conditions in the U.S-some 13 million Americans are incontinent, according to the Agency for Health Care Policy and Research-it remains one of the least-discussed, least-acknowledged health problems. “Talking about incontinence can make people so uncomfortable they simply choose not to have it treated,” says Stuart Boyd, M.D., professor of urology and director of the Comprehensive Continence Center at USC University Hospital. “I think it is one of the most undertreated, hidden conditions in the U.S.”

That is unfortunate, he adds, because contrary to popular mythology, incontinence is very treatable. According to the National Association for Continence, approximately 80 percent of those affected by urinary incontinence can be cured or improved. “The perception is that incontinence is a natural part of aging and should just be accepted,” says Boyd. “In reality that’s not what happens. A lot of women do have problems with incontinence because of childbearing combined with aging. As men age and develop problems with their prostate, urinary incontinence can happen. But both situations can be reversed in most cases.”

Not all incontinence stems from aging or childbirth. Any condition that affects the nerves or muscles of the urinary or bowel system, including injuries or surgeries to the pelvic area or spinal cord, neurological diseases, multiple sclerosis, infections or diabetes, can cause incontinence. Sometimes incontinence involves both the urinary and bowel systems simultaneously, or the bowel system alone. But the majority of patients seen for incontinence have urinary incontinence, says Boyd.

For most patients, stress brings on incontinence, says Boyd, because gravity adds to the inability of the sphincter muscle to resist pressure. For females-who make up approximately 85 percent of all incontinence patients-the muscles in the perineum (around the bottom of the pelvis) instinctively contract in reaction to the pressure generated by coughing or sneezing or standing up. Thanks to the position of the bladder, that contraction pinches the urethra shut. “If the muscles are weakened in any way, the urine leaks out,” he says. “And as a woman ages, especially after having children, the support of the bladder, which sits on top of the vagina, starts to give way, almost like a hernia. The bladder sinks down into the vagina and shields the urethra away from that supporting, pinching pressure. So when the pressure hits against the bladder, you can’t pinch off the urethra as well any more.”

Although many people begin to experience incontinence in their 50’s or 60’s, many delay treatment. What finally brings patients in to the urologist varies from person to person. “For some people, the idea of losing even a few drops is intolerable,” he says. On the other hand, “some people come in wearing five adult diapers a day and feel like, well, ‘I can deal with it.'” Physicians often observe that people with incontinence seek treatment because they have a sense that there is an odor of urine about them, because they suffer from “diaper rash” irritations. Or they find themselves changing their lifestyle, staying home instead of venturing out because they aren’t sure where bathrooms are located.

Treatment recommendations are also tailored to how much the problem is bothering the patient, says Eila Skinner, M.D., associate professor of urology and a physician at the Continence Center. “We can do different kinds of testing to see what causes the incontinence, but we don’t always have to spend a lot of time trying to measure it,” she says. “Sometimes patients simply want to be reassured that nothing is seriously wrong, because bladder cancer and some prostate problems can present as incontinence. Others opt for exercise programs and physical therapy to strengthen the pelvic floor, and sometimes that’s enough. Others want whatever surgical or medical interventions will eliminate the problem as much as possible.”

David Ginsberg, M.D., assistant professor of urology and chief of urology at Rancho Los Amigos Medical Center, says the best diagnostic tools are often the simplest: a good medical history and a general physical exam.

“Those things are easy and non-invasive but they can tell you a lot and are usually enough to point you in the right direction,” he says.

When taking a history, physicians ask how often patients experience incontinence, whether the episodes occur during day or night, whether patients are taking medication or have undergone surgical procedures that could contribute to the problem.

When those steps fail to reveal the exact cause of a patients incontinence, physicians turn to a procedure called “videourodynamics,” which Ginsberg calls “the gold standard of diagnostic procedures.”

Videourodynamics involves placing a pressure catheter in the bladder and slowly filling the organ with fluid to mimic the problem the patient faces in real life settings and then taking a series of X-rays during the procedure.

“The patient tells us when they have their first sensation of needing to urinate, when they have a strong urge to void the bladder and when they feel that the bladder is full. We may also have them cough or sneeze or perform other behaviors that tend to get them in trouble” to help pinpoint their problem, Ginsberg says.

For a more complete understanding of the patient’s condition, doctors may also simultaneously employ a procedure called “cytoscopy,” during which a flexible fiber optic scope produces pictures of the bladder’s interior.

“Between those tests, you can really identify what’s causing the problem and determine where to focus their therapy,” he says.

Patients today are lucky in one sense: drugs and techniques developed within the last decade make treating incontinence easier than ever. For example, a new drug released last spring seems very effective at relaxing the bladder and lowering the pressure in the bladder so the “urge” to urinate is not as intense. “The less pressure there is in the bladder,” explains Boyd, “the less efficient the sphincter muscle has to be.”

Although it would seem more intuitive to take drugs that strengthen the muscle at the outlet instead, such medications are not really that efficient, says Boyd. “There should be a coordination between the bladder and the sphincter muscle. In order to urinate, the sphincter muscle has to be able to relax. There are not a lot of medications that can make that type of muscle, a striated muscle like the muscle in your biceps, squeeze tighter. But there are a lot of anti-spasmodic medications to relax the smooth muscles like the bladder.”

For many women, incontinence can be treated with hormone replacement therapy. “The tissues around the bladder neck and in the urethra all have hormone receptors,” notes John J. Klutke, M.D., assistant professor of obstetrics and gynecology and a physician with the Continence Center. In fact, concentration of hormone receptors in this area is among the highest in the body. “So it’s pretty clear,” says Klutke, “if someone’s deficient in estrogen, the tissues become atrophic and that can lead to problems with voiding.”

The most successful treatment of incontinence in women, particularly when stress is a factor, remains surgery-with 85 percent of those who undergo surgery remaining continent after five years. Physicians use two different procedures to reposition a bladder that has slipped. In suspension surgery, the position of the bladder is reestablished by suturing it to the abdominal wall. With the sling procedure, a strip of the patient’s own rectal muscle is used as a “sling” under the bladder to replace the muscles that have weakened.

Researchers are also developing new materials to take the place of collagen, which is used successfully to treat incontinence. Injecting collagen into the muscle around the urethra causes a narrowing of the outlet and successfully prevents leakage, says Skinner. The reason new materials might be preferable: collagen, a natural protein, is slowly reabsorbed into the body.

At USC, many patients avoid both medications and surgery thanks to an innovative rehabilitative therapy based on biofeedback. Working with electrodes that give positive feedback, therapists help patients gain greater control of the muscles involved in urination. “Most of the time you can’t train smooth muscle like the bladder or heart,” says Boyd. “But research has shown that with biofeedback and yoga you can actually affect heart rate. By focusing a patient’s energy, therapists can help them affect smooth muscles like the bladder.” That training is augmented with supervised exercises to increase control at the outlet.

Unfortunately, says Boyd, incontinence is unlikely to just “go away” without treatment-unless it stems from some underlying problem, like a back injury, that is subsequently reversed. In fact, today’s active lifestyles that often include rigorous physical activity like jogging might exacerbate an existing incontinence problem.

Boyd, Skinner and others are hoping increased media attention to incontinence on shows such as Oprah will heighten awareness of the problem and remove some of the reluctance to seek treatment. “For most people, continence is an obtainable goal,” Boyd reiterates. “More so today than ever.”

Like a Leak in the Dam

There are five basic types of urinary incontinence, according to the National Association for Continence:

*stress incontinence, which occurs when the pelvic muscles have been damaged, causing the bladder to leak during exercise, coughing, sneezing, laughing;

*urge incontinence, the urgent need to pass urine and the inability to get to a toilet in time, which occurs when nerve passages along the pathway from the bladder to the brain are irritated or damaged, causing a sudden bladder constriction that cannot be consciously inhibited;

*overflow incontinence, leakage that occurs when the quantity of urine produced exceeds the bladder’s holding capacity;

*reflex incontinence, the loss of urine when the person is unaware of the need to urinate, may result from an abnormal opening between the bladder and another structure or from a leak in the bladder, urethra or ureter; and

*incontinence from surgery such as hysterectomy, Cesarean sections, prostatectomies, lower intestinal surgery or rectal surgery.

In the functioning urinary system, the kidneys remove waste from the blood and produce urine. The urine is pushed via two tubes-the ureters-to the bladder, where it is stored before being expelled through a single tube called the urethra. At the end of the urethra is a muscle called the sphincter, which resists the build-up of pressure in the bladder until “instructed” by the brain to relax for urination. “Continence has to do with a bladder that’s supposed to act as a reservoir and a muscle at the outlet that’s supposed to prevent leakage,” explains Stuart Boyd, M.D., professor of urology and director of the Continence Center at USC University Hospital. “We have a certain ability in the muscle to hold back whatever pressure is created in the reservoir. If we have a condition that creates abnormal pressure, then it will leak. Childbirth and prostate problems actually weaken the muscle.”

No Laughing matter

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