Women's Health Matters

Text Size
Jump to body content

Incontinence

In August, our guest experts in Le Club's Ask the Expert segment formed a mulitdisciplinary team from the Canadian Continence Foundation, comprised of Claudia Brown, physiotherapist; Dr. Scott A. Farrell, urogynecologist; and Fran Rosenberg, registered nurse.

Claudia Brown, PT, has served on the board of directors of The Canadian Continence Foundation (TCCF) since 1998. She has been practicing pelvic floor physiotherapy for more than 15 years, treating patients affected with urinary incontinence, pelvic pain and ano-rectal disorders.

A graduate of McGill University, Claudia has lectured nationally and internationally on the subject of pelvic floor physiotherapy and incontinence, and is responsible for the first pelvic floor physiotherapy course at McGill. Claudia has been involved in several research projects in this field, and teaches post graduate courses on the subject for physiotherapists. She is the owner and manager of two physiotherapy clinics in the Montreal area that specialize in pelvic floor disorders.

Dr. Scott A. Farrell,BA, BEd, MD, FRCSC, completed his MD and residency training in Obstetrics and Gynaecology at Dalhousie University. Subsequently he completed a Fellowship in Urogynaecology with Donald Ostergard and Alfred Bent in Long Beach, California.

Scott is a full professor at Dalhousie University and Head of the Urogynaecology Division in the Dept of Obstetrics and Gynaecology. He chairs the Urogynaecology Committee of the Society of Obstetrics and Gynaecology of Canada and is a member of the International Urogynaecology Association and the American Urogynecologic Society. His areas of research interest include conservative management of urinary incontinence, in particular, the use of pessaries for incontinence and obstetrical effects on pelvic organ function.

Fran Rosenberg, RN, BN, NCA, has specialized in the area of continence care for over 14 years. In her position at Riverview Health Centre in Winnipeg, she manages the only nursing focused, conservative treatment clinic in Manitoba. Since 2000, she has seen approximately 1,000 people with bladder control problems.

Fran's clients range in age from 14 to 104. Fran was the first Western Canadian graduate of the Nurse Continence Advisor Program from McMaster University. She also has her Advanced Certificate in Gerontology from the University of Manitoba. Presently she is enrolled in the Masters of Advanced Practice Program.

Here are the group's answers to your questions about Incontinence:


Q: I had suffered from large fibroids for a few years, one of which was pressing on my bladder. I found that I had terrible urinary frequency and urgency - sometimes I would be walking and all of a sudden I would almost pee without warning. Recently I had a myomectomy (surgical removal of the fibroids) and it seems the problem is much better.

The frequency is gone; however, I still get the urgency sometimes, without warning. I was just wondering why this is. Is it because the muscles in the bladder have to be "retrained" or are still weak from being stretched before? Or could it be nerve damage from having the pressure for so long from the fibroid? Would Kegels likely help?

A: (Scott): The symptoms you were experiencing, urgency and frequency, were most likely a result of a combination of factors. These factors can include:

1) intake of caffeinated beverages (coffee, tea, pop)
2) bladder infection
3) something irritating or pressing on the bladder (your fibroid uterus)

Since you have had the myomectomy, one of the causes of these symptoms (the fibroid) has been removed.

If you drink more than one cup of tea, coffee, or other caffeinated beverages per day your bladder may be irritated by the caffeine. Many women get significant relief from urgency and frequency when they give up caffeinated beverages.

If your urine has not been tested for infection, this should be done to ensure infection is not causing your symptoms.

 


Q: I'm in my early 40's and I suffer from mild incontinence - this has only started in the last year or so. Besides Kegel exercises is there something else I can do to eliminate this condition? I've been told that stress can play a role in making this situation worse. Is that correct?

A: (Scott): Stress incontinence is caused by a failure of the urethra (the tube at the base of the bladder through which the urine flows). The urethra normally acts as a valve to keep the bladder closed when you are physically active. Failure of the urethra is caused either because the muscles and tissues around the urethra are not squeezing hard enough to keep the urine in the bladder and/or the urethra has lost its normal support in the pelvis. This loss of support is common, especially in women who have had children.

Kegel exercises are designed to work on one of these factors, the weak muscles. It may be that Kegel exercises will eliminate the leaking problem. In some women something must be done to restore the support of the urethra before they will be dry. The options for restoring the support of the urethra are either to use a supportive pessary device or surgery. These options can be provided by a physician who specializes in problems of incontinence.

Personal stress can make any medical problem seem worse. There is no direct connection between emotional stress and stress incontinence.

(Claudia): Kegel exercises should include training for strength, endurance, contraction speed and control of the pelvic floor muscles. Biofeedback and electrical stimulation may assist in this training. Also, it is important to learn to use the muscle contraction at the appropriate time, for example by contracting before the cough and maintaining the contraction until the cough is over.

 


Q: I have had obesity-related incontinence as an adult. I am losing the weight now. Will my incontinence cease or will the bladder retain its inability to contain urine?

A: (Scott): Obesity causes a type of incontinence known as stress incontinence. Stress incontinence is leaking which occurs, usually with physical activities, coughing or sneezing and is caused by a failure of the urethra, the tube at the base of the bladder through which urine flows. Failure of the urethra is caused either because the muscles and tissues around the urethra are not squeezing hard enough to keep the urine in the bladder and/or the urethra has lost its normal support in the pelvis. Obesity adds pressure to the bladder and this pressure is so high that the urethra cannot stay closed and keep the bladder from leaking.

When you lose weight this pressure is relieved. It may be that if your weight loss is sufficient, your leaking problem will stop. However, the leaking could be caused by other factors which may not be improved with weight loss. Please review the section womenshealthmatters.ca on Stress Incontinence and its causes.

 


Q: Is there any relationship between incontinence and sexual relations? In other words will increased sexual activity in any way increase stress incontinence symptoms? Or will lack of sexual activity increase stress incontinence?

A: (Scott): Sexual activity does not cause urinary incontinence. Some women develop problems with bladder infections as a result of intercourse and bladder infection in turn can cause symptoms of urinary incontinence. These symptoms are usually frequency and urgency incontinence. Stress incontinence is caused by a failure of the urethral sphincter to stay closed when women are physically active, cough or sneeze. Failure of the urethra is caused either because the muscles and tissues around the urethra are not squeezing hard enough to keep the urine in the bladder and/or the urethra has lost its normal support in the pelvis. Sexual activity does not affect these factors either positively or negatively.

 


Q: I have fibromyalgia, which causes all my body systems to be out of whack at the best of times. I do pelvic-floor (Kegel) exercises, and have been doing them for over 20 years. Unfortunately, with allergies and chemical sensitivities, I cough often. Long coughing fits or intense ones invariably cause my bladder to leak. I take a lot of medications for my allergies, including allergy shots, and I take Detrol to try to control my bladder, but neither of these measures is solving my problem currently. Is there anything else I can do?

A: (Scott): Leaking from the bladder associated with coughing (or sneezing) is usually known as stress incontinence. Stress incontinence is caused by a failure of the urethral sphincter to stay closed when women are physically active, cough or sneeze. Failure of the urethra is caused either because the muscles and tissues around the urethra are not squeezing hard enough to keep the urine in the bladder and/or the urethra has lost its normal support in the pelvis. Detrol is a medication designed to treat the symptom called urgency incontinence.

Urgency incontinence can be caused by a bladder muscle which is overactive and Detrol works by making the bladder muscle relax. It is not surprising therefore that Detrol is not helping the leaking caused by coughing.

Treatment for stress incontinence involves doing pelvic exercises as you have been doing, to strengthen the muscles surrounding the urethra and restoring the support to the urethra. The options that are available to restore support to the urethra are an incontinence pessary and surgery. Both options are available through a health care professional who deals with urinary incontinence such as a urogynaecologist.

(Claudia): You may consider consulting a pelvic floor physiotherapist to make sure that you are doing the exercises properly. Training techniques for these muscles have improved over the past 20 years, and it may be helpful for you to learn how to do different types of pelvic floor exercises for complete training of all muscle fibre types. You will need to work on muscle strength, muscle endurance and functional control.

The physiotherapist may use a biofeedback device to help you to visualize the muscle contraction on a computer screen, and she may use manual techniques or even an electric current to help stimulate the muscle activity. She may also be able to determine whether your complications from the fibromyalgia are having an impact on your ability to train properly.

 


Q: I'm 47, female and had my last child at age 38. My first two were only 13 months apart and I was 25 years old. I am healthy and at an ideal weight. I suffer from "stress incontinence" - an out of the blue sneeze or a quick run up the stairs and I'm leaking. Recently I added a "rebounder" to my exercise equipment but I leak the whole time I'm using it! (Very frustrating.) I'm OK with jogging moves but jumping jacks or legs apart moves are much worse.

I have done Kegels (properly) for years and my doctor says that everything appears to be where it belongs. I can hold urine in my bladder for some time without leaking - it's just the violent up/down movement that is a problem. I walk a lot for exercise and don't have leaking then. Even if I void before rebounding I still leak. Any ideas? Thanks. I really want the lymphatic drainage/movement I can get on the rebounder!

A: (Scott): Although Kegel exercises often will improve stress incontinence they may not resolve it completely. A technique used by some women who are able to anticipate the stress on their bladder which causes leaking is called the 'knack'. This involves contracting the urethral muscles just before the stress, in your case this would be the bounce. The other option for treating this problem is to use a supportive pessary device. There are a number or such devices available. Health care professionals who treat urinary incontinence are familiar with them and can offer them to you.

(Claudia): Be sure to include abdominal muscle training in your exercise regimen, as this may improve the related dynamics in the abdominal and pelvic areas. Studies have shown that urine leakage is quite common during trampoline jumping. In fact, a surprising proportion of young female gymnasts who have never had children will leak while jumping on the trampoline.

 



Q: Why do I have extreme urgency when I approach the toilet? I seem to have matters under control but as soon as I get near the toilet, I can barely make it. What can I do to prevent this from happening?

A: (Scott): Women who experience the so-called "garage door syndrome" (urgency comes on suddenly when the garage door is going up as they arrive home) usually complain of urgency frequency and urgency incontinence from the bladder. Your complaint of urgency when you see a toilet is a variation of this syndrome. Urgency incontinence is caused by a number of factors, but most commonly, by irritation to the bladder. If you are going frequently to the bathroom and have significant urgency your urine should be tested to see if it is infected.

Once infection has been ruled out or treated if it is present, the next step is to look at your lifestyle. If you drink a significant amount of caffeine, this can irritate the bladder and give you urgency and frequency symptoms. Eliminating caffeine from your diet makes a significant difference to the bladder functioning. Some women are able to control an episode of urgency by stopping and strongly contracting the pelvic floor muscles. This interrupts the nerve reflex which is causing the bladder to contract and create a problem for you.

(Claudia): It could be that your sudden urgency when seeing a toilet is a conditioned response. It is possible that over the course of the day, each time you have felt an urge to go, you have been telling yourself to wait until you see a toilet. The next time you feel an urge to go, tell yourself you will wait until you are sitting on the toilet. This will teach your brain to inhibit the bladder until you are actually sitting down and ready to go! You can also train yourself to control by contracting your pelvic floor before passing a toilet, telling yourself you don't have to go just yet. The brain is a powerful bladder inhibitor, and 'mind over matter' really works.

 


Q: I have a prolapsed bladder and uterus causing incontinence. I was sent to a gynecologist to try to use a pessary, but it would not stay in for more than five minutes. I am trying to convince my GP to send me to a better gynecologist. What should I do?

A: (Scott): The options available to treat prolapse of the bladder and uterus are limited. Aside from just putting up with the condition the other options are to use a pessary or to undergo surgery. Some women can successfully use a pessary and others cannot. The size and type of pessary often makes a difference. Where one type of pessary does not work, another type may work very well. A more permanent approach to the problem is to undergo pelvic surgery.

Surgery can treat both the prolapse and the urinary incontinence at the same time. If you are comfortable with the gynaecologist who fitted you with the pessary, it may be worth seeing him or her again to let them know that the pessary didn't work for you. He or she may be able to offer you the surgical correction mentioned above. On the other hand, if you are not comfortable with the gynaecologist you have seen, you may wish to request a referral to a urogynaecologist, a gynaecologist who specializes in problems of pelvic prolapse and incontinence in women.

 



Q: I had surgery two years ago, and during the surgery my bladder was damaged (it was "repaired" but is permanently changed). I now have to urinate frequently and often feel the urge when my bladder is empty. At the moment, I have very few "leaking" episodes, but fear that that could change as time goes on. Is there anything I can do to help this problem - non-medication wise?

A: (Scott): Your question suggests that the primary symptoms that you are experiencing are urinary frequency, urgency and urinary incontinence. These symptoms are caused by a number of factors. The first and most common would be a bladder infection. The urine should be tested to make sure that it is not infected. If infection is present, treatment with antibiotics will usually clear up the infection and also the symptoms. In your case, where you have had surgery to the bladder, there is a slightly increased risk that there is something in the bladder causing irritation such as a suture or a stone or some other abnormality. The way to identify these things is to have cystoscopy performed by either a urologist or a urogynaecologist.

You should try to identify any factors in your own lifestyle which could aggravate these symptoms. The most common factor is consumption of caffeinated beverages. If you drink a significant amount of tea or coffee, and in some people only one or two cups per day is significant, then you should try to decrease or eliminate caffeine. This often causes dramatic improvements in the bladder.

(Claudia): It may be helpful for you to fill out a 'urinary diary', noting the time at each intake of fluid, at each visit to the toilet, at each episode of urgency and at each episode of leakage. You would also note the amount of fluid you drink, and the amount of urine excreted at each visit to the toilet.

This could help you and your health professional to determine whether there is a pattern to your problem and to see if there may be ways to modify that pattern. The normal urine frequency is between five and eight times per day. If your diary shows more than the normal amount of visits to the washroom, you can try to decrease your number of visits by increasing the interval between each visit. If you are able to do a good pelvic floor contraction, you can use that contraction to help you hold on before your next visit to the washroom.

Also, if you see that you are often visiting the washroom for a very small amount of urine, and sometimes for large amounts, you will come to realize that your bladder has a good capacity and you will be more easily able to convince yourself that you can wait a while before having to empty it again.

 


Q: Almost two years ago I had a hysterectomy. One year ago I had 25 external pelvic radiation sessions and three brachytherapy for Clear cell endo cancer, 3C stage 2. I began to " dribble" and still do. My gynecologist has suggested a TVT. I am concerned because I use a dilator now three times per week (sometimes with bleeding). I am not sexually active. Since most descriptions of this procedure indicate no sexual activity for six weeks, how will this affect the required use of the dilator?? My Doctor has said I can still use the dilator, I guess I just need a second opinion.

A: (Scott): The TVT procedure is performed by making a small incision in the vagina under the urethra and two small incisions above the pubic bone on the abdominal wall. The incision in the vagina is about 1 cm in length and when the procedure is completed this incision is closed with several small sutures. Because it is such a small incision and because it is on the anterior wall of the vagina just under the urethra it is very likely that you could continue to use the dilator in the vagina without causing any harm to this small incision. It is however not possible to give you a second opinion over the internet and if you have significant concerns, you should see a second physician to assure yourself that there is nothing to be concerned about.

 


Q: Some times when I sneeze I lose partial control of my bladder; I'm only 21 years old. Why does this happen and can I stop it?

A: (Scott): Leaking from the bladder associated with coughing (or sneezing) is usually known as stress incontinence. Stress incontinence is caused by a failure of the urethra (the tube at the base of the bladder through which the urine flows). The urethra normally acts as a valve to keep the bladder closed when you are physically active. Failure of the urethra is caused either because the muscles and tissues around the urethra are not squeezing hard enough to keep the urine in the bladder and/or the urethra has lost its normal support in the pelvis. This loss of support is common, especially in women who have had children.

Kegel exercises are designed to work on one of these factors, the weak muscles. It may be that Kegel exercises will eliminate the leaking problem. In some women something must be done to restore the support of the urethra before they will be dry. The options for restoring the support of the urethra are either to use a supportive pessary device or surgery. These options can be provided by a physician who specializes in problems of incontinence.

(Claudia): Some women of your age have what is termed pelvic floor dysfunction, which means that the pelvic floor muscles do not contract properly. This may be due to abnormal amounts of tension in the muscle, making it difficult to contract and difficult to relax. This sometimes affects other functions in the area, making sexual intercourse uncomfortable or going to the washroom for stool difficult. If you are also affected by these other problems, discuss this with your doctor. It may be a good idea to see a pelvic floor physiotherapists for treatment and a specific exercise program.

 


Q: Do you have any information on the ways that recreational drug use can interfere with urinary health? Specifically, I am interested in knowing if ketamine has been associated with issues of frequency and/or pain? What might be involved in this process?

A: (Scott): A review of the literature on ketamine shows that it is an anaesthetic drug and is most commonly used in veterinary clinics. The main effects are central nervous system and respiratory and there is nothing listed in the way of bladder side-effects. It is unlikely that ketamine is the cause of urinary frequency or bladder pain.

There are a number of potential causes for urinary frequency and bladder pain and these are best explored with a physician who can conduct the appropriate investigations and offer the appropriate treatments.

 

Jump to top page

Connect with us


Subscribe to our E-Bulletin


  • A publication of:
  • Women's College Hospital