incontinence explained
by Jenny Bryan
At 47, Lynn was almost a recluse by the time she was wheeled into theatre for a second operation to try and cure her incontinence. Two years earlier, successful surgery to replace a bladder valve had left her dry for the first time in 10 years. But the artificial device had to be removed when it became infected. Lynn was also left with two hernias – tears in the muscles of her abdomen which allow structures underneath to push through. Now, her trusted surgeon, Miss Christine Evans, from Glan Clwyd Hospital, in North Wales, was planning a double operation – to tackle Lynn's incontinence again and repair the hernias.
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'I want to go dancing, I want to go on bikes, I want to go swimming,' says Lynn. 'I want to be normal, I want a normal family life with the children. I want to walk down my drive and not wet myself.'
Miss Evans believes that people are at last starting to talk about incontinence and to seek help when they have a problem. She is prepared to admit that she has a mild continence problem herself.
'Incontinence hasn't quite come out like impotence has. Erectile dysfunction is almost something you boast about now in pubs, but incontinence is totally embarrassing,' she says.
female incontinence
About three million people in the UK have a continence problem – one in ten men and one in four women. Fortunately, most women aren't as badly affected as Lynn.
Stress incontinence due to a weakening of the pelvic floor muscles, often after childbirth, is one common cause of female incontinence. The pelvic floor muscles stretch like a hammock from the pubic bone at the front of the abdomen to the base of the spine at the back and are supposed to hold the bladder, womb and bowel in place and keep the outlet tubes from the bladder and bowel closed. With age and childbirth, the hammock sags and the contents move downwards. The valve that normally keeps the bladder closed becomes less effective and, at moments of physical stress, urine leaks out.
Sue's story is typical. Her womb sagged downwards back and front as a result of her pregnancies and put pressure on her very weak pelvic floor. Soon she found herself leaking and dribbling urine when she coughed, sneezed, or bent over.
'I noticed that I couldn't stop my wee at all and, if I had the urge to go, I had to go there and then. There was no waiting around for it.'
pelvic floor exercises
Pelvic floor exercises proved the answer to Sue's problem and they have also helped thousands of other women with stress incontinence. An estimated 25% of stress incontinence is cured by exercises. Like arm and leg muscles, pelvic floor muscles get bigger and stronger with training. Learning to contract and relax them can help pull them back into shape and stop embarrassing leaks (see exercises, exercises).
To be sure that your pelvic floor muscles really are at the root of the problem, it's advisable to get a referral from your GP or practice nurse to a continence advisor or physiotherapist who specialises in continence problems.
Sue's specialist helped her see just how well she was doing with her pelvic floor exercises. By inserting an electrode into her vagina before squeezing her muscles, Sue was able to see her muscle activity on a TV screen. This helped her work out how strongly she needed to squeeze in order to prevent her stress incontinence, especially when she was going through the exercise routines she performed as an aerobics instructor.
'It's nice that I can now incorporate my treatment into my everyday life and I can do whatever exercise I want without being desperate for a wee,' Sue explains.
exercises, exercises
To work out which are your pelvic floor muscles, sit in a comfortable chair with your knees slightly apart. First, imagine you are trying to stop yourself passing wind and feel yourself squeezing and lifting the muscles around your anus. Next imagine you are trying to stop yourself passing urine. You'll feel yourself squeezing and lifting the same muscles as before, but you may find it slightly more difficult.
There are two types of exercise to strengthen your pelvic floor muscles – slow pull ups and fast pull ups. For slow pull ups, sit, stand or lie with your knees slightly apart. Slowly tighten and pull up your pelvic floor muscles as hard as you can. Hold them tight for at least five seconds and then relax. Repeat this exercise five times.
For fast pull ups, stay in the same position but pull the muscles up quickly and tightly and relax immediately. Again, repeat five times.
The success of pelvic floor exercises – like any form of activity – depends on doing them regularly. They need to be done at least 10 times every day and, as the muscles get stronger, you should be able to hold the pull ups for longer and repeat them more often.
Some women find it helpful to insert cones of different weights into their vagina, usually for a few hours a couple of times a day. These cones are usually provided by specialist continence advisors or physiotherapists. Holding the cone in place gradually strengthens the muscles.
Inserting a tampon instead of a cone will help keep the bladder outlet closed, but won't do much for the pelvic floor muscles. The vagina lies behind the neck of the bladder so anything in the vagina will help push the walls of the bladder neck together. Specially-designed incontinence tampons are made of sponge and do not absorb the natural lubricating fluids in the vagina.
a novel approach
For those who don't get enough improvement in their symptoms by strengthening their pelvic floor muscles, a new approach is an injection to 'bulk up' the wall of the outlet tube from the bladder – the urethra. This makes it narrower so that it closes better when you don't want to pee.
To do this, specialist urologists and gynaecologists are using many of the materials they already use in cosmetic procedures to make lips plumper and lines and wrinkles less visible.
The latest of these, called Zuidex and newly licensed in the UK for treatment of stress incontinence, contains hyaluronic acid – a sugar molecule that is found in most tissues and bodily fluids where it provides structure and lubrication – and dextranomer – a sugar derivative that has been used for wound healing. Injected into the urethra as a gel, it appears to help at least seven out of ten women with stress incontinence who try it.
unstable bladder
Another common cause of urinary incontinence in women is an unstable bladder, resulting from excessive contraction of the bladder muscles so that urine is pushed out even when the bladder is not full. People with this urge incontinence have to keep going to the toilet, and sometimes the urge is so strong and sudden that it is impossible to control the flow.
Unstable bladder may be treated by calming the bladder down and gradually increasing the interval between visits to the toilet. Cutting down on coffee and alcohol can help as can bladder training to teach people to 'hold on'. Doctors may prescribe medicines that stop the bladder muscles from contracting so often but some of these cause unwanted effects such as dry mouth and constipation.
surgery
lynn's best chance to be dry
In a final effort to relieve Lynn's severe incontinence, her surgeon, Miss Evans, wanted to support the neck of her bladder so it would be less easy for urine to come out when Lynn didn't want it to. This is often done using a technique called tension-free vaginal tape (TVT). The tape acts as a net around the neck of the bladder and supports it like a hammock.
After Lynn's previous serious infection, putting artificial tape near her bladder was not an option. The risk of re-infection was too great. Instead, Miss Evans decided to use Lynn's own tissues to form the sling to support her bladder. Knowing that she would have to open up Lynn's abdomen to repair her hernias, Miss Evans had decided to use the opportunity to slice out a strip of flesh about 20cm long and 5cm wide to form a sling under Lynn's urethra.
The two hour procedure wasn't as simple as it sounds. Miss Evans needed to burrow through Lynn's tissues to make a channel for the sling and then stitch it firmly in place – and that was before she even tackled the hernias. After a lot of pushing and pulling, carefully coordinated with the help of a miniature telescope to ensure that she wasn't causing any unseen damage, Miss Evans was finally ready for her assistants to close the gaping incision she had made right across Lynn's lower abdomen.
Lynn won't know straight away whether the operation has been a success, she will need to give her tissues time to heal.
bed wetting
No family gets through the transition from nappies to pyjamas without a few wet beds. But some children seem to find it especially hard to make it through the night without pee-ing in their sleep. One in seventeen children aged 6-17 wet their bed at night, and seven-year-old Kenzie is one of them.
'The first time I realised there was a problem was when she was still in nappies at night at three and she was waking up every morning still soaked. I didn't like to take her out of the nappies until she was drier but it never happened,' explains Kenzie's Mum. 'It gets her down. I've told her it happens to other children, but she can't understand because she doesn't know anybody else it happens to.'
There's no miracle cure for bed-wetting, also called enuresis. An estimated 1% never grow out of it but the vast majority will no longer find it a problem.
Limiting the amount children drink before bedtime and waking them for a pee just before their parents go to bed can reduce the amount of fluid in their bladder. Some children have alarms on their bedclothes which wake them at the first sign of a leak so that they can get up and go to the toilet. But some children, like Kenzie, manage to sleep through the alarms.
Punishing children for wet beds is unlikely to help and may make them so nervous that the bed wetting gets worse. A system of rewards works for some youngsters while, for others, it's best not to make an issue of the problem – just use protective bedding and wait for them to grow out of it.
Kenzie's mother decided to give medical treatment a try. For several weeks, Kenzie took a drug which reduced the amount of urine produced by her kidneys at night. The downside is that it interferes with the kidney's natural function and the effects may not last when treatment stops. Unfortunately, Kenzie wasn't one of the successes and she continued to wet her bed during treatment. Her mother decided to leave well alone and hope that Kenzie would stop bed-wetting by herself:
'It's unfortunate that it didn't work, but I think Kenzie's been through too much. I think I'll call it a day until Kenzie becomes dry naturally.'
help and info
Channel 4 is not responsible for the content of third party sites.
If you'd like to find out more about how complementary therapies might help, why not take a look at the article about cystitis in the complementary medicine part of the health site.
organisations
Continence Foundation
307 Hatton Square
16 Baldwins Gardens
London ECIN 7RJ
Helpline: 0845 345 0165 (Mon-Fri 9.30am-1pm)
E-mail: continence-help@dial.pipex.com (please include postal address in e-mail so you can be sent relevant leaflets etc.)
Website: www.continence-foundation.org.uk
Confidential advice and information to those who have problems of bladder and bowel control, their relatives, carers and professionals.
Continence Resource Centre and Helpline (Scotland)
c/o Southern General
1345 Govan Road
Glasgow G52 4TF
Helpline: 0141 201 1861 (Mon-Fri 9am-4pm)
E-mail: mary.ballentyne@sgh.scot.nhs.uk or lynn.cherry@sgh.scot.nhs.uk
Help and advice on continence issues for anyone in Scotland via the helpline number or e-mail contact. Clinics are run in the Glasgow area but advice and further contact details can be provided for any area of Scotland.
ERIC (Enuresis Resource and Information Centre)
34 Old School House
Britannia Road
Kingswood
Bristol BS15 8DB
Helpline: 0117 960 3060 (Mon-Fri 10am-4pm)
E-mail: info@eric.org.uk
Website: www.eric.org.uk
Provides resources, advice and information to younger children, teenagers, parents and professionals on the common and stressful condition of nocturnal enuresis or bedwetting.
Incontact
United House
North Road
London N7 9DP
Tel: 0870 770 3246
E-mail: info@incontact.org
Website: www.incontact.org
Information and support, a quarterly magazine and a pen-pal scheme for those affected by bowel and bladder problems, and their carers.
NASPCS (National Advisory Service to Parents of Children with a Stoma)
51 Anderson Drive
Valley View Park
Darvel KA17 0DE
Tel: 01560 322024 (Mon-Fri 9am-5pm, answerphone available)
E-mail: john@stoma.freeserve.co.uk
Website: www.naspcs.co.uk
A national charity that provides information and advice to parents of children who have had stoma, ileostomy, colostomy or urostomy.
websites
Association For Continence Advice
www.aca.uk.com
An association for health care professionals with a special interest in the problems of bladder and bowel and the management of incontinence. Does not provide direct personal advice on continence matters.
Bladder and Bowel Foundation
www.bladderandbowelfoundation.org
The UK's leading charity dedicated to supporting people living with bladder and bowel disorders.
Bristol Urological Institute
www.bui.ac.uk
Contains information on incontinence problems for patients, plus details of clinical specialists.
Continence Worldwide
www.continenceworldwide.org
The website for the Continence Promotion Committee of the International Continence Society.
reading
A Healthy Bladder – And What To Do If Things Go Wrong |
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Keeping Control: A practical guide to the prevention and treatment of stress incontinence by Jane Smith, Raj Persad, Phillip Smith and Ann Winder (Vermilion, 2001) |
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The Urinary Incontinence Sourcebook by Diane Kaschak Newman (Contemporary Books Inc, 2000) |
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A Woman's Guide to Regaining Bladder Control by Eric Rovner, Alan Wein and Donna Caruso (M Evans & Co, 2002) |
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(June 2003, resources updated January 2005)
