Ob.gyns. and other primary care providers play a major role in helping women identify and manage symptoms of urinary incontinence, a condition estimated by the American Urogynecologic Society to affect 30%–50% of women, but that notion appears to be lost on some generalist clinicians.
“Since we know it's such a problem, maybe we should be asking our patients more about it and have them 'fess up, but we don't, because we only have 15 minutes of managed care time where we're assessing risks for heart disease, cancer, and other medical conditions,” said Dr. Cheryl Iglesia, who directs the Section of Female Pelvic Medicine and Reconstructive Surgery at Washington (D.C.) Hospital Center. “Urinary incontinence is a quality of life issue that's not going to kill you, but it really does take away your quality of life.”
Some physicians take a fatalistic view of the condition, she continued, telling women “there's nothing that can be done about it. There's where we go wrong. It's a highly prevalent condition, and we have a growing Medicare population,” said Dr. Iglesia, who is also associate professor of obstetrics and gynecology and urology at Georgetown University in Washington. “In fact, 80% of women by the time they're 80 have some form of incontinence. At the same time there's a misconception that incontinence happens as a normal part of aging, [the notion of] 'What do you expect? You're getting older. Just deal with it. Wear the incontinence pads.' That message is always wrong.”
Then there are the patients who avoid discussing the issue during office visits. “A lot of patients are so embarrassed by the situation that they become reclusive, or it's affecting their quality of life but they don't want to bring it up with their physician because of the shame factor,” she said. “They become more isolated, not wanting to be physically active, wearing pads, or bringing along changes of underwear, so coping in a way, but they don't want to talk about it.”
According to a recent review from the Agency for Healthcare Research and Quality, some degree of involuntary urine loss is experienced by 25% of young women, 44%–57% of middle-age and postmenopausal women, and 75% of elderly women in nursing homes. It went on to note that in 2004, annual costs associated with treating the condition averaged $19.5 billion.
The two main types of incontinence are stress incontinence and urge incontinence, although most women have a mix of each, said Dr. Linda Brubaker, who directs the division of Female Pelvic Medicine and Reconstructive Surgery at Loyola University Chicago, Maywood, Ill. “It's kind of like height and weight: You can be tall and fat, short and skinny, or tall and skinny. You can have any combination of stress incontinence or urge incontinence.”
In stress incontinence, women experience loss of urine during physical activities that increase abdominal pressure, such as sneezing, coughing, or exercising. In this form, the urinary sphincter “may not be doing its job well because it's lost some of its normal function or it's lost some of its normal anatomic positioning,” explained Dr. Brubaker, who is also interim dean of medicine at Loyola University Chicago. “The function doesn't usually get restored, but what we do with surgery is add a material that is a secondary mechanism, which helps the sphincter do its job. So while the sphincter itself isn't any better, the backup team is on board now. That usually will bring a patient to have resolution of stress incontinence.”
Urge incontinence, also known as overactive bladder, is more common with advancing age. It is characterized by a sudden need to urinate with or without urinary leakage. This form is generally treated behaviorally by decreasing intake of caffeine and other known bladder irritants, and by strengthening the pelvic floor muscles, but some patients require treatment with medications that impact the muscarinic receptors in the bladder. Pregnancy commonly contributes to incontinence, as can chronic constipation and disorders associated with chronic cough.
“There is also an increasing relationship between obesity and urinary incontinence,” said Dr. Dee Ellen Fenner, professor of obstetrics and gynecology at the University of Michigan, Ann Arbor. “It's been shown that even modest weight loss in women who have urinary incontinence and obesity can greatly reduce their symptoms. Losing 10 or 15 pounds for a patient who is morbidly obese can help reduce her symptoms.”
According to the American Urogynecologic Society, other causes of urinary incontinence include pelvic radiation, occupations that require heavy lifting or exertion, medications taken for other conditions, and stones or tumors in the bladder.