Most people come home from Paris remembering the crepes, the Louvre, the River Seine, the soaring views of the Eiffel Tower. Suzanne Tucker, 65, can tell you where the bathrooms were. She traveled to France last year knowing she would have to manage the “urinary incontinence” or “stress incontinence” that had been growing incrementally worse for 10 years. She had to plan long walks carefully and limit her fluid intake.
“You know how people say to drink eight glasses of water a day? You can’t, not if this is your issue,” said Suzanne, a retiree from a job as a university administrator.
Suzanne Tucker’s story is a common one. Urologist Leslie Rickey, MD, and colleagues at Yale anticipate the incidence of incontinence and other pelvic floor disorders—conditions affecting the muscles, ligaments and connective tissue in the lower pelvis—will increase by as much as 50 percent over the next two decades as baby boomers get older.
Despite research showing that such pelvic disorders negatively impact women’s quality of life about as much as diabetes, an estimated 50 percent of women do not seek treatment. The average woman may go to the bathroom eight times in 24 hours, including once during the night. Women with pelvic disorders may be up several times a night and are used to packing a change of clothes in case of involuntary leakage.
“These disorders don’t usually appear out of nowhere,” Dr. Rickey said. “A patient may have some symptoms and then they get a little bit worse, then a little bit worse.”
Aging, childbirth and incontinence
Women normally control bladder and bowel movements by contracting and relaxing the pelvic floor muscles, which form a kind of hammock-like support for such organs as the bladder, rectum, small bowel, uterus and vagina. Changes such as aging and childbirth (especially vaginal) cause these muscles to weaken or tear, in some cases leading to prolapse, a condition in which the bladder, urethra, cervix and/or rectum literally slips out of place.
The longer women wait to seek treatment, the worse a problem can get, indicated Richard Bercik, MD, who has seen patients who’ve used protective pads for years—which he said can cause irritation and infections, and do not solve the problem.
Yale’s division of Female Pelvic Medicine and Reconstructive Surgery includes physicians who are specialists in urology and gynecology. Pelvic disorders may also affect the digestive tract, so Yale gastroenterologists and gastrointestinal surgeons are often consulted.
Many women find there are better solutions that are not invasive. “As many as a third of women who are referred to us for surgery don’t even go to surgery,” said Dr. Bercik. “If we can avoid surgery – and treat with medicine or physical therapy – that’s our first approach.”
No longer a skeptic of nonsurgical solutions
“I was very skeptical,” said Suzanne Tucker, who had already seen other doctors and tried medication by the time she saw Dr. Guess and Yale’s Cherilynn Richmond, a registered nurse with advanced training in specialized pelvic physical therapy.
Richmond suggested Kegel exercises, typically taught to women to tighten pelvic muscles after giving birth. Kegels are performed by squeezing the muscles around the vagina. Biofeedback allowed Suzanne to watch the force and strength of her contractions on a screen.
Suzanne’s fluid intake turned out to be a problem as well. Many patients drink too much water or too many caffeinated beverages, which can exacerbate incontinence, Richmond said. So Suzanne replaced most of her coffee with herbal tea, “and I don’t feel in any way that I’m thirsty now.”
Another patient, who is 67, gave Dr. Rickey a long list of things urinary incontinence kept her from doing: exercise, dance, putting on a bathing suit to go to the beach or a swimming pool. “It affects all parts of your life, including your sex life. The thing that was a killer was picking up my grandson,” her patient reported. “I would pick him up and have absolutely no control over my bladder.” For a while she convinced herself this was something she simply had to accept as part of menopause. “But I was too young for this,” she concluded. “This wasn’t living.”
She wondered if she would have to undergo surgery. Instead, Dr. Rickey proposed injecting a gel-like material called Coaptite into her urethra, the tube that carries urine from the bladder—this would increase resistance to urinary flow and prevent leakage. The patient was able to watch the procedure on a monitor. “I didn’t know that this was an option,” the woman said. “It’s really made my life much more pleasant.”
Extra care and compassion
Patients worry about pain, but effective local anesthesia is available. Richmond believes compassion is also a critical part of care.
“We give women information before and during a procedure,” Richmond said. “I tell them every step of the way what’s coming next and what will happen after that.” Many women find the procedures are not painful at all. Discomfort during a cystoscopy, which involves inserting a scope into the urethra to look into the bladder, is minimized by using a topical anesthetic.
When surgery is necessary, even the most complex operations are often minimally invasive, and patients go home the next day, said Drs. Bercik and Rickey, who have provided surgical interventions for women into their 80’s. Minimally invasive surgeries may include reconstruction for pelvic organ prolapse, or slings to help support the urethra for incontinence.
In many cases, women are able to choose the treatment they feel most comfortable with. “Some people come into the office right away saying, ‘I’ve been dealing with this for 10 years. I just want the surgery,’” Dr. Rickey said. “Other want to try conservative options first. With each patient we have a discussion about all the options, her lifestyle and treatment goals and come up with a plan that’s right for that individual woman.”
Surgery was one of the possibilities that originally concerned Suzanne Tucker. Now she doubts she’ll ever need it. “My ultimate goal is to never again require medication if possible,” she said. She has cut down to one cup of coffee a day and does her Kegels every night – 15 sitting, 15 standing and 15 lying down. “It takes all of 5 to 10 minutes at the most,” she said. “I don’t get up five times at night anymore. I can go on hikes.” It gives her new vigor to realize she has recovered the thing she thought she had lost: her freedom.
Source: Yale University