Incontinence Often Undiagnosed, Overlooked

(WOMENSENEWS)–Stress urinary incontinence is problematic for about 13 million adults in the United States, 85 percent of whom are women, most in middle age.

When women with the problem cough, laugh, sneeze, exercise, have intercourse or do other kinds of exertion, urine leaks out. The condition varies in frequency, but usually a diagnosis involves urine leakage several times a week.

In addition to physical stressors that cause the bladder to sag, doctors think urethral nerves may malfunction and allow urine to escape. Lower estrogen levels can affect these nerves, so menopause may worsen symptoms.

The annual cost of treating women’s incontinence is estimated in a July article published in the Journal of the American Medical Association to be $12.4 billion, about the same as for osteoporosis, Alzheimer’s disease or AIDS.

However, even though the condition responds well to therapy, most with incontinence don’t talk to their doctor about the problem, according to an editorial accompanying the article by Dr. Neil Resnick, professor and chief of geriatric medicine at the University of Pittsburgh School of Medicine.

“Some women don’t mention incontinence because they believe that it is a normal ‘part of being a woman’ especially after having children,” said Resnick, “which is incorrect, or that their doctor is not interested in it. Some may be content with the newer, more absorbent and less odorous and less noticeable pads.”

Resnick said that as the pressure grows on clinicians and researchers to see more patients, “doctors focus on immediate problems like emergency room visits, then on practical issues such as insurance forms or medication renewals. Last, if time remains, they focus on an issue the patient raises. Researchers tend to gravitate to problems that the National Institutes of Health has committed substantial resources to or problems that society considers important, which usually means associated with death, disfigurement, contagion, etc . . .”

Problem of Anatomy

Women are more vulnerable to incontinence than men for several reasons, including childbirth and pelvic anatomy.

Weakened pelvic muscles can bring on the problem in pregnancy and childbirth, as can pressure on pelvic nerves. Women who have hysterectomies or other pelvic surgeries sometimes develop urinary incontinence as a result of nerve damage or impaired muscle function. Some families seem genetically predisposed to the condition. Men may develop incontinence after having their prostate gland removed. Their anatomy protects them from developing symptoms while they are young because they have stronger muscles and longer urethras.

Riesa Gusewelle, an advanced nurse practitioner in Little Rock, Ark., started experiencing incontinence in the last trimester of her first pregnancy at age 23. After her daughter Jessica was born, the symptoms persisted, although she remains fit and active.

Women aren’t routinely taught pelvic-floor exercises when they are pregnant, but they should be, said Dr. John Fantl, a, urogynecologist in practice at the State University of New York at Stony Brook and New York University. “These therapies could benefit women both before and after delivery, but studying such preventive techniques is difficult and expensive,” he said. “As a result, insurance doesn’t reimburse for prophylactic programs” that prevent the pelvic muscles from becoming weak in the first place.

The exercises, often called Kegels, isolate the muscles of the pelvic floor, which stretch like a hammock from pelvic bone to tailbone to hold your bladder, uterus, and other organs in place. When the pelvic floor sags, so does your bladder, putting pressure on the sphincter muscle that closes your urethra. It opens involuntarily.

“Most physicians have never received training regarding incontinence or the more recently emerging data that shows how treatable it can be, so they may not be anxious to hear about a problem that they have not been trained to manage,” said Resnick. “And to date, managed-care organizations have not been keen to open this box either since it will result in increased costs for the insurer; costs that the patient now bears herself.”

Not an Elderly Disease

The likelihood of urinary incontinence increases with age, but it’s not an elderly disease, said Michael Chancellor, a neurourologist from the University of Pittsburgh.

Dr. Patricia Goode, associate professor of medicine at the University of Alabama in Birmingham, agreed. “There’s not really an average age for those with stress urinary incontinence,” she said.

An example of a younger person with the problem is Kelly Breidenstein, in her late 20s, who trekked 3,000 miles from Vancouver Island to the Arctic Circle in 2001 and participated in almost every outdoor sport imaginable. But later that year a serious car accident shattered part of her pelvis and she developed the problem.

Breidenstein is recovering from her injuries and works at a rehabilitation hospital in Chicago, but is frustrated by the problem’s intrusion on her sports activities and feels it acutely in personal relationships. “Being 28 and single, I have to retell my story whenever I start dating,” she said. “You want to be sexy, which doesn’t really fit with ‘by the way, I pee in my pants.'”

In older patients, the problem can contribute to a downhill spiral of ill health, said the University of Alabama’s Goode. Women are embarrassed to go out because they might have an accident, so they don’t have the same social interactions, or even exercise. It’s certainly not the only factor responsible for people becoming frail and depressed, but it’s an important one.

Treatment Spans Exercise, Surgery, Drugs

In many cases, the problem can be cured or markedly improved with treatment, which usually consists of behavioral therapy, surgery or pharmacotherapy.

“Behavioral therapy should be first-line treatment because it is least hazardous and works so well,” said Goode. In studies to identify which incontinence treatments work best she taught women to isolate and strengthen their pelvic muscles, which can be a little tricky at first. They’re the muscles that stop the flow of urine midstream and can be identified by inserting a finger into the vagina and squeezing while keeping the abdominal, buttock and thigh muscles relaxed. Women in the study were also trained to contract their pelvic floor when they coughed, got up from a chair and other routine events.

After receiving training from a nurse practitioner, study participants had a 70 percent decrease in accidents. Participants who used a self-help booklet on their own had a 50 percent reduction–still very high.

Like other women, Gusewelle, the nurse practitioner, lowers her risk of potential accidents by limiting liquid intake, avoiding caffeine and emptying her bladder frequently.

Others try collagen injections to tighten the urethra or complementary therapies such as acupuncture. Surgical procedures for serious cases of the problem can bring improvement by repositioning or “resuspending” the bladder or supporting it with a “sling.” This holds the bladder up and compresses the urethral sphincter, making it less likely to leak.

Many women who see little improvement with behavioral treatment but prefer not to have surgery, “defer to the diaper,” said the University of Pittsburgh’s Chancellor. Since patients are embarrassed to talk about it, practitioners should inquire about it routinely, he said.

“There is no drug approved for this common condition, Chancellor said. “It’s time to find an effective pill to treat a problem many people would rather not have surgery for.” Some use Sudafed, an over-the-counter antihistamine that constricts the muscles around the bladder neck, which can sometimes lessen leakage in those with severe symptoms. Two drugs–Detrol and Ditropan XL–are used for “urge incontinence”–when urine leaks out along with the urge to urinate badly, even if the bladder is not full. The drugs don’t work for stress urinary incontinence.

The pharmaceutical companies Eli Lilly and Company, Indianapolis, Ind., and Germany’s Boehringer Ingelheim are developing a drug that they hope will fill this treatment gap. The drug, duloxetine, is still undergoing clinical testing but appeared to reduce incontinence episodes in patients who tried it for 12 weeks. It was given conditional approval in early September and Lilly expects it to be approved by the U.S. Food and Drug Administration next year.

Kathleen Nelson writes about health and medicine for general and specialist audiences.