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June 18, 2019  
UTERINE NEWS: Feature Story

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  • Preserving Continence as We Age

    Preserving Continence as We Age


    October 11, 2006

    By: Jean Johnson for Uterus1

    If wearing a tampon to help support the urethra so you won’t leak on your morning walk doesn’t sound like fun, read on. Medical director of the Providence Continence Center in Portland, Oregon, Lesley Otto, M.D., has some encouraging thoughts on breakthroughs as well as some comments on ideas that have been around for awhile.

    Urogynecologists: Specialists in Female Pelvic Floor Disorders

    Otto is what’s known as a urogynecologist. As readers of Uterus1 know, dentistry and medicine have changed considerably since the late 1960s when family practitioners and general surgeons ruled the roost. These days, there are specialists for everything and patients are better served as a result.

    Take for example, one reader who was going to have a hysterectomy but opted for uterine fibroid embolization once she discovered the world of interventional radiology. Or the woman who told us that she went to a dermatologist and discovered she had melanoma, even though her family physician assured her the bump on her leg was nothing to worry about. Or the man who decided to see a prosthodontist for a dental implant instead of having the bridge his regular dentist recommended.

    Urogynecologists are clinicians who specialize in the female lower urinary system.

    “Gynecologists do a great job, and so do urologists,” said Otto, “but urogynecologists focus specifically on pelvic floor problems including bowel and bladder control issues as well as vaginal support problems.”

    Otto goes on to explain that while men suffer from incontinence as well, women are considerably more prone given their anatomy and roles as the bearers of children. Not to say that women who have not had children don’t experience incontinence as well. The vagina and the urethra are in the lower abdomen and are susceptible to the stresses and strains of life that can weaken muscles and ligaments.

    “About 40 percent of women over the age of 60 have some form of incontinence, although there is also a subset of women that develop the problem earlier,” Otto said. Otto breaks the general incontinence problem down into two main categories: stress incontinence and overactive bladder.

    Stress Incontinence Defined

    “Stress incontinence typically stems from damage to the vaginal, bladder, and urethral supports,” Otto explained. “This is typically the leak that occurs with a cough or a sneeze. A sudden increase in intra-abdominal pressure forces some urine out. Chronic straining, childbirth, chronic coughing, are some of the reasons the urethral supports weaken and then over time leaking begins.”

    Overactive Bladder Defined

    “The overactive bladder is more of a neurological condition in which the nerves that are enervating the muscles to the bladder are irritable or overly stimulated,” said Otto. “When the bladder gets to a certain volume, nerves begin to fire and typically our brains say to the bladder, ‘no, not now.’” In the case of the overactive bladder, though, the bladder doesn’t respond to the brain’s message, and you can start to leak on your way to the toilet or leak before you get your pants down.”

    Otto also points out that people with overactive bladders will have urges to urinate that are not justified by the volume. And as far as having to get up to go to the bathroom at night, she said, “It’s not normal to get up more than one time.”

    That is, Otto confirmed, unless you’ve had a pint of Ben and Jerry’s during the ten o’clock news, or didn’t get thirsty until late in the afternoon and started drinking a lot of water then, or lingered at the dinner table over more beer or wine than you probably should have.

    Kegel Exercises

    Kegel exercises are exercises in which you contract your internal muscles like you do when you’re trying to hold in your urine. A person can do these anywhere, anytime and are supposed to help with incontinence, so we asked Otto what she thought.

    “Kegels are great. They’re really good for protecting and keeping the pelvic organs, like the vagina, bladder, and rectum in their proper positions so that when we strain down against strong muscles the energy bounces right off. That way it’s easier for the ligaments that support the upper vagina to do their job,” Otto said.

    “Sometimes it helps to visualize it, so I like to use the image of a ship in a slip. The muscles are the water and the lines that tie the boat to the dock are the ligaments,” she said. “So keeping the muscles strong protects the pelvic organs like the water supporting the ship, and makes things work better.

    “I don’t send a lot of patients off for Kegels as a treatment for stress incontinence per se, but encourage them to work with a pelvic floor physical therapist.” Otto explains that it all gets rather tricky when it comes to this type of problem and just doing Kegel exercises is kind of like shooting in the dark.

    “There’s a key that’s often missed here. The way it works is, if you’re somebody who leaks with coughing, you have to do the Kegel when you cough,” said Otto. “That’s the thing that people tend not to realize. They won’t work unless you use them at the time.

    “The other thing that is really important to let people know is that a Kegel can only do so much. If they are not helping, or if, for instance a patient is a runner who cannot do a Kegel while she is running, there are many other options,” Otto said. “We do have breakthroughs, and they are working well.”

    On the other side of the coin, Otto says that doing one’s exercises can help in other circumstances.

    “Kegels really do reduce the urgency and frequency of overactive bladders. They are good for people who are in the beginning stages of these problems, since what a Kegel does by contracting those muscles, is to send a message to your bladder to relax,” Otto said. “So for women who have an early condition of an overactive bladder, I recommend seeking the help of a pelvic floor therapist to maximize their understanding of conservative treatment for this condition before giving up and turning to other measures.”
    Take Action
    Tips on managing and seeking help for incontinence
  • Urogynecologists are trained specifically in female urinary tract issues. They are conversant in procedures, drugs, and surgery designed especially for women.

  • The same is true for therapists. Seek out ones who specialize in the pelvic floor.

  • Reconsider the eight glasses of water a day theory. Think in terms of the overall liquid you consume, from both drinks and food. Drink water in sufficient but moderate amounts.

  • Monitor your intake of acidic foods and drinks, all of which can stimulate an overactive bladder.

  • Breakthroughs in Treatment for Stress Incontinence

    To appreciate the latest and greatest, it’s helpful to know what women have tried and continue to try to prevent incontinence.

    “Some women can get by with wearing a tampon to give added support to the urethra,” Otto said, even as she agreed that women who have reached menopause generally don’t find this approach to be much fun.

    “There’s also something called a pessary that is specially designed to support the urethra. It’s like a diaphragm for birth control, and the patient places it up inside of the vagina,” said Otto. “We also have trans-urethral injections of collagen for people who have sphincter weakness.”

    Since Otto explains that “there really isn’t any medication that will treat stress incontinence,” the next stop is surgery. “Surgery is quite effective in these cases. It can change women’s lives.”

    In particular, Otto is referring to placing what’s known as a urethral sling. “This is a minimally invasive, outpatient procedure. It’s highly effective and is helping women get back into the game of life in a very significant way,” she said. “Incontinence sidelines so many people.

    “The urethral sling is a breakthrough that has been developed over the past 10 years, and can be done with minimal risks. Also it has much less impact than major surgery on women taking time off from work or managing the care of young children at home,” Otto said. “So this minimally invasive surgery really has made a difference.

    “We place a centimeter wide strip of mesh similar to what we use in hernia repairs and prolapse procedures beneath the urethra like a sling using a very small incision,” she said. “Patients are under a light general anesthesia where they can breathe on their own and do not have to be intubated.” (She notes that in Europe they tend to do the procedure under nothing more than local, adding that, “In this country we like to get people a little more comfortable.”)

    Recovery times are brief. “One to two weeks,” Otto said. “One woman went back to work after two days, but generally women that do office work go back in a week.”

    Approaches to Treating the Overactive Bladder

    “We have breakthroughs in treating the overactive bladder as well,” said Otto. “One of the things we look at is simply how much patients are drinking.”

    Gasp. Surely she’s not taking on our devotion to eight glasses of water a day?

    “I certainly am,” she said. “We’re all getting the message to drink, drink, drink, but there’s no data that has told us eight glasses are what we need to have. If your body’s already hydrated, you’re just going to pour it out,” said Otto.

    “There are people who come in to see us who drink three to four liters a day but who haven’t figured out that if they knocked that down they wouldn’t have a problem. We’ve cured a lot of people by just asking them to drink less. We recommend six to eight glasses of all fluids in a day.

    “Also very acidic foods and drinks with excessive doses of Vitamin C can irritate an overactive bladder,” said Otto. “And certainly, things that are diuretics like coffee and alcohol will cause the body to produce more urine.

    “The point is that there are certain dietary changes you can make that will help,” she said. “What I tell patients is that it’s a quality of life choice. If you enjoy a cup of coffee in the morning, but if it seems to be a trigger for your overactive bladder, then maybe you can skip it on the days that you’re going some place important. It’s the same with drinking that glass of orange juice. Once patients know the consequences, they can modify their behavior if they want.”

    That said, Otto observes that not everyone responds to the same things. “My patients fill out a diary for me, and I ask questions. If they seem to be on the earlier side of these diseases, making changes in the amounts and types of things they consume can have a positive impact.”

    As far as medications, Otto says that there are many, including some advertised on television that can make a real difference.

    “There are medications for overactive bladder that can be very helpful for women who are becoming more and more frustrated with overactive bladder problems,” said Otto. “People lose confidence with this type of incontinence because it happens out of the blue, and they can’t control it. With stress incontinence it’s more predictable and the leak is typically smaller.”

    Continued in Part Two


    Related Content
    If you enjoyed this article, you might also be interested in the following:
    Traumatic Brain Injury Leads to Urinary Incontinence
    In Women, Loss of Elastic Fibers Leads to Pelvic Floor Disorders
    The Secret’s Out: Pelvic Floor Disorders and How to Handle Them

    Last updated: 11-Oct-06

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