Published Sep 15, 2014
If you are a woman who is afraid to laugh without crossing her legs, you are hardly alone. A whopping 57 percent of mid-life women and up to 75 percent of elderly women suffer from urinary incontinence. The impact of urinary incontinence on health and quality of life is dramatic.
- Odor and embarrassment lead to social isolation and avoidance of intimacy.
- Fear of losing urine is correlated with avoidance of exercise.
- Many osteoporotic bone fractures are a direct result of a fall from a desperate attempt to get to the bathroom before losing urine.
In spite of the prevalence of the problem, most women do not report their incontinence. Sometimes this is due to embarrassment, but also can be because of the assumption that a leaky bladder is a “normal consequence of aging” without effective treatment options beyond medication or surgery. Approximately half of women who do report leakage to a healthcare provider are inadequately treated. Pads and diapers are commonly recommended, but they should be thought of as a means to manage — not treat — incontinence.
New Treatment Rules: A Good Start
With all this, it’s welcome news that the American College of Physicians (ACP) has published new treatment guidelines to address the fact that urinary incontinence is underreported, under-diagnosed, and under-treated.
The ACP stresses that the type of incontinence, “stress” or “urge,” dictates treatment. Stress incontinence means the loss of urine with cough laugh sneeze, while urge incontinence means “I’ve gotta go, and I’ve gotta go right now!
Stress? Start with Kegel exercises. Since most stress incontinence is a result of weak pelvic floor muscles with subsequent inadequate support of the bladder neck and descent of the urethra, I could not agree more that pelvic floor muscle strengthening is the first step. But Kegel exercises?
It’s true that Kegel exercises are commonly recommended. And almost as commonly, they fail. Multiple studies show that few women do them correctly or consistently. Success is most likely in the young, highly motivated patient who works with a pelvic floor physical therapist. Face it, if Kegel exercises worked, the adult diaper industry would not be advertising on prime time television and would not be a gazillion dollar a year industry. The ACP recommends Kegels for “pelvic floor muscle training.” But what the ACP does not acknowledge is that success is dramatically higher if they are done in conjunction with pelvic floor physical therapy.
Urgency? Go with bladder training. Bladder training is behavioral therapy. It involves urinating on a set schedule and gradually increasing the time between voids. This sometimes helps and is recommended for women with urgency incontinence. It will do nothing for stress incontinence.
Consider watching your weight. Obesity contributes to both urge and stress incontinence, and when women are informed that excessive weight is a factor, it can be a significant motivation for weight control. Having said that, many thin women are incontinent.
Know when to turn to medication.The ACP correctly points out that medication treats overactive and urge incontinence, not stress incontinence and should never be a first treatment.
So there you have it. The ACP recommendation is to do Kegels, which commonly fail, bladder training which may help with urgency not stress, and weight loss, which is often unrealistic and not always the problem. If all else fails, ACP recommends medication, which only helps urgency, must be taken for a lifetime, and is not without side effects.
More Options for Incontinence
Where does that leave the woman who follows these recommendations and is still peeing in her pants? Pretty much nowhere since the ACP did not include in their recommendations other effective nonsurgical treatments. These include:
- Formal pelvic floor physical therapy
- InTone home therapy
- Botulinum toxin
- Percutaneous nerve stimulation
- Electrical stimulation
While not a first line option, sling surgery should be offered and considered for women with stress incontinence who have failed non-surgical options. I have had dozens of patients that as a result of a 15-minute vaginal sling procedure are able to jump, skip and run without wearing diapers.
The ACP recommendations are a good start and since the internists no longer recommend an annual pelvic exam it is reassuring to know they are not completely overlooking the lower half of a woman’s body. Still, a majority of women who fail these primary interventions are left not knowing about other options when Kegels and weight loss fail. The guidelines should make it clear that women with incontinence who are not successfully treated can still be helped, and should be referred to an expert for treatment options beyond what an internist is able to offer.