Mind Over Bladder: A Step-by-Step Guide to Achieving Continence

Preface

If Not Now, When?

Urinary Incontinence (UI), as defined by the International Continence Society, is the complaint of any involuntary leakage of urine.¹

Ten years ago, when this book was first published, I said I would retire when adult women no longer needed diapers. Clearly, this has not yet happened and may take a while longer. Retirement is not on the horizon (nor in my lexicon). Luckily, I am patient (the use of this word to refer to a person receiving medical treatment must not be an etymologic accident, since patients spend so much of their time waiting). Although there are solid, scientific reasons why the continence we learned so well as children may occasionally or even frequently elude us as we get older, as you read this book you will see that urinary incontinence is not an inevitable part of aging. Furthermore, it is not shameful, and when already present, it is treatable in almost every situation. Having said this, millions of women worldwide have experienced urinary incontinence.² This is due to several factors: the fact that women’s urethras are shorter than men’s, at about four centimeters (less than two inches), the changes to pelvic organs and tissues associated with childbirth, and menopause, to name just a few.

The question remains: Why a revised version of Mind Over Bladder? Women’s anatomy has not changed and there is no substitute for finding a good doctor to talk to (your primary doctor, gynecologist, urogynecologist, or urologist) about incontinence. Taking a complete medical history and the need for a full physical exam hasn’t changed, nor has the need for a solid diagnostic workup been altered. The answer is very simple and straightforward: our treatment alternatives have greatly improved and, therefore, our patients can expect better outcomes. This newer edition of our book includes all the latest treatment options for each type of incontinence (including the newer, minimally invasive surgeries and newer techniques to quiet an overactive bladder without medication).

When you’re ready to address your incontinence head-on, there is no substitute for a thorough diagnostic workup. This starts with a full medical history shared with a physician (or other qualified healthcare provider) whom you trust and who will listen carefully and seriously to your concerns. Explain exactly to him or her in detail how the loss of bladder control is affecting your life physically, socially, and emotionally. Since this issue may have started for you months, or even years ago, and since much water has passed under the bridge (pun intended), you might want to write down your questions and concerns ahead of time so you don’t miss any important details.

Once a diagnosis has been firmly established, you and your healthcare partner can discuss the various treatment options open to you. Often, in formulating your long-term treatment plan, several options may be chosen and used either simultaneously or sequentially in order to maximize your continence margin (the combination of physical factors that keep you dry at any given point) over the course of your life. Each person’s continence margin varies at different times in life. Generally, our margin is wider when we are young, and it may take many factors being out of sync to make us lose urine. As we age, our continence margin may be narrower, and a simple urinary tract infection may push us, possibly only temporarily, into the leakage zone. Nevertheless, it is useful to think of continence as a zone we want to try and remain in as much as possible during the course of our lives and not necessarily as a yes or no, or black and white (or, in this case, yellow or white) issue.

A word about absorbent products (diapers and pads) is in order here. They are, overall, very useful, and their rightful place in the medicines, equipment, and techniques available to a medical practitioner should not be underestimated. Having said this, I believe that these products work best when utilized as part of the overall plan and not viewed as a treatment, since pads and diapers do not treat urinary incontinence.

Urinary incontinence plagues over half of all nursing home residents and is one of the most common reasons that women enter long-term care and nursing facilities.³ In the process of losing control of their bladders, they often lose control of their lives as well. Much has been written about the depression associated with untreated incontinence and how lives are negatively affected through the social isolation, emotional turmoil, and physical debilitation that this condition brings. Do not despair! Effective treatments to improve incontinence are currently available, and newer, better treatments are continually being developed while older ones are refined.

Billions of taxpayer dollars—the current estimate is now over thirty billion—are spent on urinary incontinence each year. This money primarily funds the routine care associated with incontinence (such as diapers, skin breakdown care, home health aides) and some of the inadvertent consequences that may be associated with incontinence (e.g., treatment of a hip fracture resulting from a fall on a puddle of leaked urine). In comparison, little money is spent on diagnosis and treatment of this debilitating condition. We all must help to spread the word and work together if we are ever going to make a significant difference.⁴

It is estimated that even today, after all this time, fewer than half of incontinent women share their bladder control issues with their healthcare provider.⁵

It is high time for urinary incontinence to come out of the water closet. The gestation period of our original book was approximately twelve times the normal nine months, or about nine years! A colleague first proposed the idea to write a book of this nature in the late 1980s. At that time, at the annual meeting of the American Urogynecologic Society, we were two of the first half-dozen or so female members. Over the next ten years, this colleague’s enthusiasm about such a book was echoed by countless patients I had the privilege of helping with their bladder problems, along with the concerns of their spouses, partners, and families. For as I am sure you understand by now, urinary incontinence is a condition that affects not only patients, but whole families and our entire society. This book focuses on the patient, and it is written, for the most part, in and with the voices of my patients. This journey to continence will reassure you that you’re not alone in what you’re experiencing. All attention is focused front and center on the ones whose lives are touched personally by this condition. This revised edition represents a journey that began nearly two decades ago. Certainly, as our understanding of incontinence improves, we can offer our patients better and more effective treatments. Although we still have a long way to go, for now, this journey continues thanks to my colleagues, teachers, and patients: my medical family.

Now is the time to take charge of your condition, in order to have control over your bladder for life. This book is for all of you—all of us—who know the location of each bathroom in every mall and public place, who spend hours each week doing countless loads of laundry, and whose lives are ruled by their bladders. I believe in mind over bladder. And at this moment in our history, when we finally know that ‘women are not simply small men,’ when gender-based research is at the forefront of medical science, the time for us truly is now. If not now, when?

Jill Maura Rabin, MD

Introduction

So You’ve Finally Had Enough

What’s in it for you?

You’ve just picked up this book, and you’re giving it a quick once-over, trying to decide whether or not to purchase it. Here are five compelling reasons why you should grab this copy and read it from cover to cover:

1.It’s honest, direct, and to the point.

2.It’s co-authored by an understanding, sympathetic expert in gynecology and urology and by a completely satisfied, virtually cured patient.

3.You can understand what’s being said because we’ve eliminated unnecessary medical mumbo jumbo.

4.It includes the latest, up-to-the-minute information available on this topic.

5.The approach is user-friendly.

Recent studies indicate that as many as 50 percent of all women are affected by incontinence. Undoubtedly this is an underestimate, since most women are just too embarrassed to seek help. You don’t have to be one of them.⁶

This book seeks to educate women of all ages about the many causes of incontinence and the variety of treatment options available. In chapter 1, we define incontinence and explain some of the primary factors that can cause it. We also discuss some of the myths and legends surrounding incontinence.

Chapter 2 explores the female urinary tract and explains the anatomical components of this complex system. We discuss how the brain and spinal cord coordinate the muscles and organs that regulate the flow of urine.

Chapter 3 addresses the conditions and causes of incontinence in women. We discuss risk factors, chemicals that stimulate the urge to urinate, and how natural events in the body, such as pregnancy and menopause, can affect incontinence.

In chapter 4, we discuss the process of selecting a physician to treat your incontinence, as well as what to expect from the initial round of tests that will be performed. You’ll review a list of questions to ask potential physicians and learn what questions you should expect from your physician.

Stress incontinence is one of the most common diagnoses that incontinent women receive, so we devote chapter 5 to a discussion of the definition, triggers, sources, and results of stress incontinence. We differentiate between minimal, moderate, and severe forms of the condition and discuss a variety of treatment options.

The second most common form of incontinence is urge incontinence, the frequent sensation that urination is imminent and cannot be postponed for long. And though it is rare that an actual cause can be determined for urge incontinence, in chapter 6 we discuss likely sources that exacerbate the condition and some potential treatments.

Aside from the two common forms of incontinence, there are other types of urinary incontinence, which we review in chapter 7. These conditions vary widely in their symptoms and preferred methods of treatment.

At the other end of the spectrum from incontinence is urinary retention, a condition in which the bladder does not empty properly. In chapter 8, we examine the symptoms, likely causes, and remedies for this condition.

More than 5.5 million Americans suffer from fecal incontinence, so we devote chapter 9 to a frank discussion of this condition.⁷ Because physicians’ methods for diagnosing this ailment obviously differ from the tests we’ve discussed for urinary incontinence, we’ll cover the procedures and examinations you could expect to undergo during a preliminary diagnosis. Because some symptoms of fecal incontinence can be managed with dietary adjustments, we review changes you can easily make with the approval of your physician.

Because of the complications and risks inherent in surgery, it’s usually a good idea to explore non-surgical treatments for incontinence first. So chapter 10 explores the wide variety of non-surgical treatment options for urinary incontinence. Physical therapy, behavior modification, voiding diaries, bladder training, Kegel exercises, vaginal cones and weights, biofeedback devices, pessaries, intravaginal devices, acupuncture, and forms of medication are all safe and effective treatments for incontinence, and we discuss them in turn.

Unfortunately, despite any number of safer treatments considered or tried, patients must sometimes undergo surgery to achieve the control over incontinence they desire; we discuss such conditions in chapter 11. Surgery for incontinence is almost always an elective treatment option, though it is a medical necessity in rare circumstances. We review some of the different forms of surgical treatment and the risks and outcomes that surgical patients can expect.

Chapter 12 considers some naturally occurring conditions that lend themselves to incontinence, such as pregnancy, menopause, and illnesses such as interstitial cystitis, multiple sclerosis, and Parkinson’s disease. We also discuss the implications of birth defects like spina bifida and other medical conditions like strokes and Alzheimer’s.

Throughout this book, we employ a number of elements to draw your attention to topics of interest. One of the most common of these is Tech Terms, which defines important terminology surrounding incontinence. Q&A boxes complement frequently asked questions about incontinence with straight-talk answers. Dos and Don’ts offer practical tips for dealing with situations surrounding the management and treatment of incontinence. In the Believe It or Not boxes, my patients recount some of their more dramatic experiences with incontinence; they make you laugh or cry, and they’ll definitely assure you that you’re not alone in what you’re experiencing. Finally, each chapter concludes with The Wrap-Up, a summary of the most important points to remember.

Now that we’ve explained the intent of our book, we encourage you to turn the page and begin what we hope will be an educational and, ultimately, healing experience.

Why Read This Book?

Chapter Highlights

•Why Us?

•Staggering Statistics

•Myths and Legends

•Developing a Strategy: Never Say Die

•What We Offer

•The Wrap-Up

Incontinence! Face it, ladies. Doesn’t the sound of that word make you want to cringe? How about run and hide? If your answer is a resounding Yes! followed by a sense of panic, and perhaps even tears, there’s good news! Your fears are unfounded, and it can be possible for you to be high and dry forever.

TECH TERMS

Urinary Incontinence (UI), as defined by the International Continence Society, is the complaint of any involuntary leakage of urine.⁸

Why Us?

Girls, the sad but true fact is that incontinence primarily strikes women. Whoever said that life is fair? So why does this happen to us? Unfortunately, our pelvic anatomy works against us.

DOS AND DON’TS

Do feel free to discuss any bladder control or incontinence problems you may experience with a qualified professional. You aren’t alone, and no one is going to make fun of you.

Women are susceptible to bladder infections, also known as urinary tract infections (UTIs) or cystitis.

Have you ever had one? If so, you know that the pain, burning, and urinary frequency are symptoms you’d like to avoid at all costs. Bacteria can easily enter women’s bladders because our vagina, urethra, and anus are close together and because our short urethras make it easier for germs to travel where they shouldn’t go.

TECH TERMS

Located above the vaginal opening, the urethra is a short, narrow tube that carries urine from the bladder out of the body.

We get pregnant. You might expect some leakage during pregnancy as the uterus enlarges and puts increased pressure on the bladder. Why? The bladder and pelvis undergo changes during pregnancy to accommodate the growing fetus and the mother. The bladder may not empty as well because of pressure from the enlarging uterus or fetus, which may lead to an increase in the amount of urine left in the bladder after urinating. This remaining urine may be the perfect environment for bacterial growth, which may cause the increased occurrence of urinary tract infections during pregnancy. There is also an increase in the amount of urine produced by the kidneys. As a result, pregnant women have to urinate more frequently. Several hormones produced during pregnancy (especially estrogen and progesterone) cause relaxation in pelvic tissues and organs, including the bladder and ureters (tubes leading from the kidneys to the bladder). This relaxation is helpful because it allows the pelvis to become more flexible and to make room for that baby; however, it may also lead to incomplete bladder emptying and UTIs. In addition to this, pregnancy and delivery may also cause nerve damage to the pelvic muscles, which may not heal completely and cause subsequent problems.

TECH TERMS

Prolapse is the dropping of the uterus, the bladder, or rectum into the vagina. Prolapse occurs when the uterus protrudes or sags into the vagina.

A woman’s first delivery carries the greatest risk of long-term incontinence. Pregnancy and delivery can damage the muscles, nerves, and other structures supporting the pelvis, causing a loss of support of the uterus, bladder, and rectum. If recovery is not complete, incontinence may result, in large part due to prolapse of these organs. Vaginal delivery has been shown to be the single largest predictor of incontinence. There is a statistically significant relationship between the number of vaginal deliveries and the incidence of incontinence: as the number of vaginal deliveries for a woman increases, so does the probable incidence of incontinence.⁹

Deliveries that are performed with the assistance of instruments, such as forceps, carry an even higher risk than normal vaginal deliveries. Caesarean section may minimize some of the effects of incontinence and prolapse.

Menopause is another leading cause of incontinence. Estrogen levels drop during menopause, the muscles and tissues in the pelvis lose strength and support due to lower levels of collagen (a supporting protein in the skin), and organs prolapse. Low estrogen levels