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Another form is urge incontinence where a woman has a sudden strong urge to urinate and leaks before she can get to the bathroom. It’s sometimes called “overactive bladder.” Urge incontinence usually gets worse with age, and is often caused by nerve damage that results from certain diseases or surgeries. Some women can have a mixture of both.

Smith, who weighed 87 pounds as a teenager, gave birth to an 8 ½ pound baby at 17. She developed the problem in her early 20s and lived with the condition 24 hours a day. She wore pads all day every day and based her choice of clothing on what would best hide the fact that she was wearing bulky pads. She could leak urine when she coughed, laughed or sneezed, but also when she stood or sat – basically any time during any activity, including sexual intercourse.

“The worst part for me was living with the threat of always being embarrassed, that there could be an accident at any time,” she said. After an unsuccessful attempt to fix her problem in her 40s (urethral plication), she continued to live her life with the condition, figuring she had no choice.

But once she hit 60, she had had enough. “I got to the point where I said ‘to hell with this. I can’t put up with this any more for whatever time I have left,’” she said. In early 2007, her local gynecologist referred her to Vanderbilt’s Daniel Biller, M.D., a urogynecologist who performed a minimally invasive transobturator suburethral sling which has eliminated her incontinence.

Suffering in silence
Having some type of urinary incontinence is common, a normal part of aging, and there are usually two peaks of occurrence– at childbirth (transient incontinence related to the birth process) and either before or after menopause.

But it doesn’t mean women who have severe cases have to live with it, Biller says. Many women struggle with it until their mid to latter years before finally having it fixed, he said.

It wakes them up at night, limits their time away from home or from the nearest bathroom, forces them to wear bulky pads or adult diapers, and causes skin irritation and sometimes infections. The National Association for Continence estimates that about 25 million adults in the United States experience urinary incontinence. Despite its prevalence, many women are reluctant to talk to their physician about it or to seek treatment. A 2001 survey of U.S. adults, sponsored by the NAFC, indicated that only one-fourth of those who had symptoms discussed them with a doctor. A 2004 survey showed the women who do seek care do so after living with their symptoms for more than six years.

It’s not known exactly what causes incontinence, but several factors are believed to predispose women to the condition, including genetics and those who have multiple vaginal deliveries resulting in the stretching of the nerves as well as weakness of the pelvic floor musculature. Menopause is also a risk factor because of lack of estrogen, which maintains blood flow to the vagina as well as to the urethra. When a woman loses the engorgement of blood flow from lack of estrogen, she loses some urethral function.

Prior pelvic surgery, particularly hysterectomy, and other factors such as lifestyle issues like smoking might also contribute to the onset of urinary incontinence, said Harriette Scarpero, M.D., assistant professor of Urologic Surgery.

“Many put off coming in to see someone about this problem for many years, in some cases,” she said. “They can live in isolation a lot of times, thinking they are the only person with this problem, when in fact it’s a very prevalent problem in the post-menopausal population. Women often can’t predict when they are going to leak, and when they do, it can be quite profound. We’re not talking about just a few drops or wetting a pad, it can be a full out flood in many women, something that can’t be contained with any of the barrier methods that exist.”

Often women put off addressing their problem because they can’t afford to take time away from their other duties – caring for children, a spouse, grandchildren, parents. In many cases they are taking care of multiple generations. “Women have a lot on their plate,” Scarpero said.

Can it be fixed?
At Vanderbilt, urologists and urogynecologists both see women with incontinence. The two specialties work closely together, even sharing a fellowship.

Before any type of treatment is selected, women must first undergo an extensive evaluation process called urodynamics – an evaluation of bladder function, including storage, emptying and urethral function. As part of the consultation process, women take home a voiding diary for homework.

Sometimes incontinence is related to other pelvic floor dysfunction, such as pelvic floor prolapse, or to a patient’s neurologic problems. It’s because of the varied causes of incontinence that urologists and urogynecologists at Vanderbilt work together, sometimes performing different procedures on the same patient.

The three major types of incontinence are treated in different ways. Urge incontinence is treated by anticholinergic medications of the “gotta go” variety seen on TV – such as Ditropan and Detrol – and behavioral therapy like Kegel exercises (contracting and relaxing the pelvic floor muscles) to strengthen the muscles below the bladder, Biller says. The drugs work by decreasing urgency and frequency and urge incontinence by blocking the nerve impulses to the bladder that cause it contract and leak. But there are side effects, including dry mouth, constipation, headache and blurred vision.

Depending on the findings on the urodynamics testing, women with stress incontinence are encouraged to try Kegel exercises first. Biofeedback or pelvic floor muscle training also may be attempted before the patient and her doctor consider surgical therapies for those not successful with conservative attempts.

Biller recommends that patients try the conservative route first, and also try avoiding caffeine (a diuretic) and overfilling their bladder by drinking a normal amount of fluid each day – six to eight glasses a day.

“Studies show that menopausal patients who rigorously adhere to bladder retraining, timed voiding and Kegels, improve their symptomatology about 60 to 65 percent. That’s absolutely remarkable,” Biller says.

But if surgery is necessary, the common way to repair stress incontinence is to stabilize the urethra so that with coughing, sneezing and laughing, it is able to maintain its higher pressure or functionality, Scarpero says.

Over the past 20 years, tremendous progress has been made in the development of minimally invasive surgical procedures with faster recovery time, and fewer complications. One of the first procedures to repair stress incontinence was the Burch urethropexy, a more invasive procedure originated by Vanderbilt’s John C. Burch, M.D., MD’23.

Surgeries today are called sling procedures. A sling is formed by taking a piece of the abdominal tissue (fascia) or synthetic material. The man-made sling pushes on the urethral sphincter, thus preventing leakage of urine during stressful movements. These procedures require a small cut in the abdomen and vagina. The procedure can be performed in one of two ways: just above the vagina on the lower abdomen (retropubic) or into the groin creases (transobturator technique). Many different types of the sling procedure have been developed, including a transvaginal tape procedure which uses smaller cuts and can be done as an outpatient surgery.

“In most cases, surgeons choose a sling or two they are comfortable with, and use them all the time,” Biller said. “We are on the forefront of performing these sling procedures, and we tailor our treatment plans to the patient based on her individual goals and urodynamics findings,” Biller said. “We can offer the least invasive procedure with the fewest complications, and the quickest recovery time to our patients.

Success rates are high, but no patient can ever be 100 percent guaranteed there will be improvement or a cure. And the word “cure” can mean different things to different patients, Scarpero said.

“Is cure zero leakage by pad tests or is cure when the patient tells you she is dry? The two may be very different, therefore many argue it’s only a perception of the patient’s level of cure that’s important,” she said, adding that a patient may be cured of one type of incontinence only to develop another.

“It gets very complicated when you try to fully determine what is cure, so it’s important to counsel patients about success rates and percentages,” Scarpero said. When you look at the literature, the success rates at one year are very high with mid-urethral slings and pubovaginal slings – 90 to 95 percent – but if you look at longer term data, at five years, it drops to about 75 to 85 percent. So it may not be 100 percent, but the success rates are good and durable.”

Smith said she was skeptical about the success of her procedure because she had had poor results with the prior procedure 20 years ago. “But the medical profession keeps making great strides. This has absolutely changed my life.”

She doesn’t have to plan outings anymore bathroom by bathroom, and recently spent two and one-half hours in the dentist’s chair only having to worry about her teeth.

In the fall, she attended a family reunion at the beach in Ocean City, Md. Two years ago, at the last reunion, she wore a bathing suit, but had to head straight to the ocean to get her suit wet – so if she leaked urine it wouldn’t be so noticeable. This year, she waited awhile. VM

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