Saturday, January 11, 2014

Please don't make me pee my pants

Ladies, raise your hands if you have ever peed your pants. And, by peed your pants, I mean coughed out a few drops, sneezed out a squirt or two, emitted an undisclosed volume as you stood in line at a public restroom, or maybe even lost your entire bladder in a fit of laughter.
http://lerablog.org/wp-content/uploads/2013/09/Urinary-Incontinence.jpg
http://lerablog.org/wp-content/uploads/2013/09/Urinary-Incontinence.jpg
Take heart. Wherever you happen to be reading, either your seatmates won't realize why in the world you are raising your hand, or those that do will feel in good company. And men, well, please keep quiet. Most of you with a Y chromosome happen to have much longer urethras than those of us XXers. Lucky you. You also cannot birth babies. And you don't live as long as we do. Lucky us.  (Oh, and in case you're a man thinking a post about pants-peeing might be irrelevant for you, turns out that men and women who live past 80 have the same rates of incontinence. So read on if you're planning to live a long life).

Urinary incontinence-- the involuntary loss of urine--is one of those hush hush taboo topics that even over-sharing women don't like to discuss. It is right up there with bowel movements, vaginal discharge, depression, and sexual dysfunction.  In fact, most of my female patients are happier to discuss the shape and color of their poop than the fact that they cannot always hold onto their own urine. Studies show that half of people who suffer from incontinence never bring it up with their primary care provider.

However, urinary incontinence is extremely common. (This probably explains the plethora of adult diaper commercials featuring grandmothers running through fields of flowers). Because so many people keep their situation private, it's hard to get perfect data, but studies estimate between 25-50% of adult women have lost their urine at least once in the last year. One study found 10% of women experience this problem at least weekly. That means that up to half of women reading this post have peed their pants this year, and 1 in 10 did it in the last week. And it's not limited to those women who have had babies. While 30-60% of pregnant women have peed their pants, 12.6% of women between the ages of 16 and 30 who had never been pregnant reported incontinence.

Unfortunately, as alluded to above, the problem gets worse with age: while 7% of women ages 20-39 report having had some incontinence, the percentage increases to 17% for women 40-59, 23% of those 60-79, and 32% for women over 80.

Ugh.

Urinary incontinence can have a seriously negative impact on a woman's quality of life, potentially complicating and/or interfering with everyday activities like work (frequent pad changes or limited physical activity for fear of being far from a bathroom when the time comes), exercise (especially anything that involves jumping up and down), household activities (e.g. heavy lifting), travel (who wants to be stuck on a bus without a toilet?), sexuality (it's hard to feel sexy when you cannot keep your undies dry), social interactions (embarrassment about look/smell), sleep (frequent night wakings), self-esteem, and even clothing choice.

While many women with incontinence can get by wearing a panty liner in their underwear to catch unanticipated droplets or make sure to take themselves to the toilet on a scheduled basis, other women can be so severely affected that they feel they must abandon activities they love. Incontinence can be so severe, in fact, that women feel confined to their house, for fear of an embarrassing accident. I have had patients who've memorized bathroom stops along a 500 mile drive, who've stopped playing tennis with their spouses, and who no longer walk in the mornings with their friends for fear of wetting themselves.

Triple ugh.

The process of peeing (in doctor-speak micturition)--filling and emptying the bladder--seems simple, but it is much more complicated than filling and emptying a water bottle. Micturition is an intricate dance involving our central, peripheral, and autonomic nervous systems. It also depends on well-functioning muscles down there. Our central nervous system (aka brain and spinal nerves) control the when and when not; our peripheral and autonomic nervous systems control the how. To not pee, we have to maintain relaxation of the smooth muscles of the bladder and then simultaneously inhibit and contract the muscles of the sphincters. Then, to pee we must do the opposite: contract the smooth bladder muscles, followed by disinhibition and relaxation of the sphincter muscles. 

Ask any potty-training toddler-- keeping one's pants dry is not easy. Just getting to the potty can be a challenge! (By the way, same goes for older adults, where limited mobility plays an important role in increasing rates of incontinence).

For women who experience incontinence, the problem comes in one of five flavors: stress, urge, mixed, overflow and functional incontinence. By far, stress incontinence is the most common.

1) Stress incontinence: anything that puts stress (added pressure) on your bladder. This includes coughing, sneezing, jumping, weight lifting. This often causes intermittent and/or episodic incontinence. Please note, that while stress incontinence may cause you psychological stress, it is not being "stressed out" that causes women to lose control of their bladders.
2) Urge incontinence (overactive bladder): involuntary contraction of the bladder muscles causing you to feel an intense "urge" to go to the bathroom right away, leaving you little time to get yourself there.
3) Mixed incontinence: a mixture of 1 and 2.
4) Overflow incontinence: as you might imagine, when the bladder reaches a certain level of fullness, the sphincter just quits doing its job and the urine overflows (aka leaks) uncontrollably.
5) Functional incontinence: mental or physical disabilities that limit a person's ability to get to the toilet in time, to get their pants on, to realize and respond to bodily cues, etc

We know that childbearing, obesity and functional impairment (e.g. cognitive issues after stroke, mobility issues after a fall, inability to plan and execute) are the three main risk factors for incontinence. There is a lot more controversy about other things that may contribute to urinary incontinence, including: childhood bed-wetting, high impact physical activities, diabetes, stroke, depression, vaginal deliveries, episiotomies, low estrogen levels, female surgeries (e.g. hysterectomy), and radiation.

So, for women who are overweight or obese, there is really good evidence that losing weight helps reduce frequency and severity of incontinence. If you could lose a few pounds (or more), one more reason to be motivated to do it! You might also hear advice to lay off caffeine, alcohol, carbonated beverages, and sugary foods. There isn't much data behind this advice, but it doesn't hurt to try.

But what if you aren't overweight? What if you've abandoned Starbucks, wine, and your favorite chocolate, and you are still wetting your pants. What can you do? Incontinence is super frustrating, and there are no quick fixes. However, there are interventions that have been shown to help. Yes, here are the options. The goal is to start with 1, 2, and 3 before moving onto medications because the behavioral changes actually work a good percentage of the time!

1) Bladder retraining: boot camp for the bladder. Works particularly well for urge incontinence. See an example of a bladder retraining program here. It's not rocket science but definitely can work!
http://www.cardiodesign.com.au/page6.html

2) Pelvic floor muscle exercises: often called "Kegel exercises", have been shown to be helpful in both stress and urge incontinence, despite popular belief that they only help with stress incontinence. One 1998 study found that these exercises worked better than medications! See an example of Kegel exercises here. And I know many of you are Kegeling right now as you read-- just seeing the word makes those exercises involuntary-- you go, ladies!

Random sidebar: Dr. Kegel was a gynecologist who invented an instrument called a perineometer, for measuring the strength of those very exercises he invented in 1948. 

3) Neuromodulation devices that can either be inserted in the vagina or external on the leg. See weird contraption above. See video example here. Studies show they help in 75% of urge in continence. Not too bad!

4) Medications: used mostly to treat urge incontinence. There are several different medications out on the market, most of which target the nervous system and belong to a group of medicines called antimuscarinics. None have been shown to help much with stress incontinence, and as for urge incontinence, studies found that only 1 in 5 women will achieve continence using this type of medication. Not great odds, unless you happen to be that 1.

5) Electrical stimulation: either electrodes placed on the thigh and/or implanted under the skin of the buttocks (sacral nerve stimulation). I've never actually met anyone who has done this-- would love feedback from any readers who have had success or failure.

6) Vaginal inserts/urethral plugs: Most commonly an insert called a "pessary". Looks like an over-sized diaphragm (if any of you remember those from old school birth control days), placed inside the vagina to literally help hold things up. You have to be fitted by a physician, but can be a simple fix especially for someone who doesn't want to go through surgery. They are pretty easy to get in, don't hurt, and can really help!

7) Surgery: I have been witness to some great success in several women who struggled for a long time with incontinence and finally decided to go for surgery, which is, of course, both invasive and scary. Generally, surgery should be considered if the behavioral changes discussed above don't really work and after a woman is done having children. Something to ponder, especially for women whose lives are being impacted negatively.

Now that you've been slogging through this post for at least the last fifteen minutes and you've done your requisite Kegel exercises, it's probably time to get up and pee. Hopefully you learned a little something!
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References:
http://www.aafp.org/afp/2013/0415/p543.html
http://www.aafp.org/afp/2005/0115/p315.html
http://guidance.nice.org.uk/CG171/KingsHealthQuestionnaire
uptodate.com: Epidemiology, risk factors, and pathogenesis of urinary incontinence
http://www.iciq.net/ICIQ.LUTSqolmodule.html 


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