Dr. Mary Brandes (Guest): Well, Melanie, stress incontinence is a condition that is very common for women at all ages, and it affects their lives differently. Most importantly, it can often restrict the woman’s activities, particularly when it comes to being active in exercising, which as we all know is very important as we get older.
Melanie: What are the causes of stress incontinence, and when do we know that that’s what we’ve got?
Dr. Brandes: Well, stress incontinence is defined as urinary leakage, involuntary, that occurs when someone has a physical activity or sudden movement. And the leakage is a small amount that occurs just with that activity. The causes are many. The biggest risk factor is having had childbirth, which can disrupt the pelvic floor musculature and nervous system in such a way that it makes our normal mechanisms of controlling our urine impossible.
Melanie: Well, we certainly know we’ve heard so many women after having babies, every time I cough or laugh, they say we leak a little bit. If this becomes something that is really uncomfortable, embarrassing, annoying, something we just cannot live with anymore, we come to see you. What’s the next step in dealing with stress incontinence?
Dr. Brandes: Melanie, the first thing we do is just confirm that this is indeed the type of incontinence that you have. There are other reasons that a woman might have incontinence, and we want to make sure that this is indeed what we’re treating. In order to do that, we do a simple test called a cough stress test, which involves having a full bladder and actually performing a cough in the office to see if leakage occurs. It’s surprisingly reliable that if we see it, you probably have the condition. Once the condition is confirmed, the woman will be asked about lifestyle and things that aggravate her incontinence, such as does she smoke, does she have a cough, does she do other activities that require a lot of strenuous activity which might aggravate this condition. In general, it would not be my goal to restrict the person’s activities to accommodate the condition, but rather to try to treat the condition so the person can continue their activities. Treatments can range from simple modification of fluids and activities to physical therapy to try to improve pelvic floor muscles. That famous Kegel exercise can be very helpful if done regularly and often. Finally, there are surgical interventions that can help a woman with stress incontinence. Right now, in the United States, there are no medications approved for the treatment of stress incontinence.
Melanie: Then Dr. Brandes, let’s start with those behavioral techniques, and tell us a little bit about Kegel. I teach it myself to patients and clients. Give us your best advice on how women should work on this—and actually men, too—but how women should work on this Kegels to help strengthen those pelvic floor muscles.
Dr. Brandes: Pelvic floor muscles are affected during childbirth in variable ways. Some women can have stress urinary incontinence and have excellent pelvic muscle strength. Other women, when their pelvic floor muscle strength is assessed, find that they really can’t even identify the muscle to squeeze. In women who have some capability of identifying their pelvic floor muscle, which is the muscle that you would squeeze if you were trying to stop your stream in a toilet, those women will benefit from regular squeezing exercises throughout the day. My recommendation is often 20 squeezes two to three times a day in any way that they can be done. There are many different recipes to advise a person, but I think the big message is regular and often. In order to see a benefit from those pelvic muscle exercises, the woman needs to be consistent and probably perform them for three to four months in order to assess whether her pelvic floor can be strengthened enough to impact her incontinence. In women who have trouble exercising this muscle, physical therapists can be very helpful in providing biofeedback to start identifying the weak muscles and also providing necessary coaching to help the less motivated patient.
Melanie: Well, that’s a good point because it is hard to find for some people. They don’t have that feeling of how to actually tighten those muscles. It’s sort of a proprioceptive technique that you learn to find out where those muscles are and be able to do this, as you say, as many times a day as you would be liking us to do that. What about things like alcohol intake and fluid intake? Does that affect stress incontinence? Should we be drinking less water through the day or does alcohol contribute to this?
Dr. Brandes: Drinking fluids or consuming liquids that could be considered diuretics—that is, something that makes us produce fluid more; alcohol would be one, caffeine another—these types of things fill your bladder faster and certainly can make you more susceptible to urinary leakage. But in and of themselves, they do not cause stress incontinence. If you have a very full bladder and you cough, you’re certainly more likely to leak than if you have a bladder that’s less full. However, drinking more or less isn’t going to change the fact that you’re going to have a full bladder from time to time and you may leak. It might reduce the number of leakage episodes, but it certainly isn’t going to cause you not to have the condition. That is very different than urgency disorders, where someone feels like they’re going to the bathroom more than they wish, in which case, fluid management can become a very important form of treatment.
Melanie: When does it turn to surgical or interventional therapies? When does that happen for a woman with stress incontinence? Does it happen?
Dr. Brandes: Well, many women are treated surgically for stress incontinence, and the answer to the when is when the woman wishes. Stress incontinence is not a serious condition in the fact that it’s going to cause long-term health consequences, but the determination as to when incontinence is bothersome must be based on the woman’s own issues. One woman’s problem can be another woman’s minor bother. I do not feel it’s my place to tell a woman when she’s bothered enough to consider a surgical intervention. I simply present the options, risks, and benefits, and then most women are able to make that decision for themselves.
Melanie: Then tell us what are the surgical options available.
Dr. Brandes: Surgical options for stress incontinence have been around for decades and decades. Right now, we are fortunate to have some minimally invasive, fairly successful procedures for women to opt for. When I was training as a young physician in the 1980s, most of the procedures that we had for stress incontinence involved major operations with a high rate of complications and unacceptable success rates. Nowadays, women can opt for a day procedure and be fairly active and back to their normal activities within a few days to a couple of weeks. The most common surgical intervention for stress urinary incontinence is the mid-urethral sling. This is the insertion of a one-centimeter width tape under the urethra, placed under local anesthesia, in many cases. They provide the backstop for the urethra to compress against when a woman coughs or sneeze or laughs or does other physical activities. The tape sits in this position, most of the time in a very innocuous way, and can provide longstanding relief of stress incontinence for many women.
Melanie: In just the last couple of minutes, Dr. Brandes, give us your best advice for women suffering from stress incontinence and why they should come to Maine Medical Center for their care.
Dr. Brandes: Well, I would advise that a woman go to an experienced physician in whatever geographic region that she is. Maine Medical Center has the advantage of providing complete evaluative services so that women can get the proper diagnosis, and then we can offer a full range of treatment options, whether it’s stress incontinence or other types of incontinence. Certainly, these services can be provided in other areas, and I would not travel hours and hours to have my stress incontinence treated unless it was particularly complicated and it’s major. Maine Medical Center would be an excellent choice because of the experience and breadth of services that we can provide.
Melanie: Thank you so much. It’s really great information. You are listening to MMC Radio. For more information, you can go to mainemedicalcenter.org. That’s mainemedicalcenter.org, mmc.org. This is Melanie Cole. Thanks so much for listening and have a great day.