Cough…cough…ker-choo! Not again!
When you cough, suddenly sneeze, lift, laugh, exercise or do other movements that put pressure on your bladder, do you pass urine?
After having children, many of us lose control of our bladder and involuntarily leak urine - maybe just a few drops or maybe larger amounts. Leaking urine involuntarily is frustrating, upsetting and disruptive and, for many of us, it can be too embarrassing to talk about.
Involuntary leaky bladders may not be the most appealing topic for discussion at coffee group or playgroup, but it is the most common form of bladder control problem. Leakage occurs because the pelvic floor muscles have been weakened, often as the result of pregnancy and childbirth, and are no longer strong enough to prevent urine from escaping.
One in three women suffer from this problem so it’s highly probable you’ll know someone who is experiencing the same. Being able to talk about it is a great starting point.
where to go for help
The first step for getting help is to visit your GP who may refer you to someone who specialises in treating incontinence so they can establish what type of continence issue you have, e.g. stress, urge or an overactive bladder.
Specialists can include urologists, who focus on conditions involving the urinary tract, gynaecologists and obstetricians who specialise in the health of the female reproductive system and childbirth, and urogynaecologists who specialise in urinary and associated pelvic problems in women. In addition, there are specialist women’s physiotherapists who provide women with advice and appropriate exercise programmes, as well as nurse continence advisors.
Auckland-based urogynaecologists Dr Brenner and Dr Macpherson believe specialist physiotherapists should ideally be your starting point. Conservative treatment, aimed at increasing the strength and tone of your pelvic floor muscles, generally works well for most women. However, it does take time and may be anywhere between 4-12 weeks before any real improvement is able to be seen.
treating incontinence
Generally incontinence is treated through bladder training and pelvic floor exercises.
On your first visit to a specialist physiotherapist, a detailed history will be taken about your symptoms and your medical history, including information on your bowel habits (constipation and straining can cause bladder leakage).
You may also have a physical examination of your pelvic floor muscles to assess if they are working, and you may be asked to keep a bladder diary over several days to accurately record your fluid intake and urine output and frequency.
Most physiotherapists will give you a pelvic floor exercise programme to do at home and will show you how to do the exercises correctly.
pelvic floor exercises
- Sit tall on a chair. Relax your shoulders, tummy and pelvic floor as you continue to breathe gently.
- See if you can gently squeeze, lift and hold the pelvic floor muscles inside your pelvis while you breathe. Nothing above your belly button should tighten or tense. Some tensing or flattening of the lower part of your tummy wall will happen but this isn’t a problem as this part of your tummy works together with the pelvic floor muscles.
- If you can’t feel your muscles contracting, change your position and try again, e.g. tip forward a little or lie on your side.
- If you are doing your pelvic floor exercises correctly, you should feel a ‘lift and squeeze’ sensation inside your pelvis and a ‘lift and squeeze’ sensation in your urethra, anus and vagina; then a sensation of ‘letting go’ when you relax your muscles. After a contraction it is important to relax the muscles so they can recover from the previous contraction and prepare for the next one.
- It's easy to try too hard and have too many outside muscles tighten. Try to remember this is an internal exercise and correct technique is vital. Doing pelvic floor exercises the wrong way can be harmful so if you can’t feel your muscles hold or relax as you do the exercises, you may benefit from seeing a specialist physiotherapist.
- If you have mastered the art of contracting your pelvic floor muscles correctly, try holding the inward squeeze for longer (up to 10 seconds) before relaxing. Make sure you can breathe easily while you squeeze; don’t hold your breath. Breathing is important because it helps relax your upper and lower abdominals, thereby forcing the pelvic floor muscles to perform the contraction on their own. Repeat this exercise up to 10 times, then have a small rest and try another set of up to 10 contractions.
Generally speaking, the more often you do pelvic floor exercises, the greater the improvement in control although 40 per day is the ideal number.
Once you learn ‘the knack’, you can use it in your daily activity to brace and protect your pelvic floor. So before you cough, sneeze, blow your nose or lift a child or object, squeeze up and hold your pelvic floor muscles. The lower part of your tummy should gently tighten as well.
incontinence pads and vaginal exercisers
In conjunction with doing your pelvic floor exercises, products such as incontinence pads and vaginal exercisers can also help.
There are many different types of incontinence pads, all specifically designed for women with slight urine leakage. Unlike sanitary pads and panty liners, incontinence pads are super absorbent and will draw the wetness away from the skin to keep you dry and fresh without any odour. Incontinence pads come in different sizes depending on the level of absorption required, and are designed with discretion in mind.
Vaginal exercisers are pelvic floor muscle exercisers that are used vaginally and work against resistance to help strengthen, tighten and build up the muscles of the pelvic floor. When used correctly, vaginal exercisers can be very effective in minimising general incontinence complaints including weakened bladders.
medication
If you have an overactive bladder, your doctor may prescribe medication to help block the nerve signals that cause the frequent urination and urgency. Medication may be prescribed either alone, or in combination with behavioral treatment to help restore bladder control.
Biofeedback treatment may also be recommended to help you identify and control your pelvic muscles through the use of small sensors placed on your body. Your doctor or specialist will advise what is right for you.
surgery
Most women have significant improvement after conservative physiotherapy treatment aimed at strengthening their pelvic floor muscles. However, a small percentage of women do require surgery.
In the case of surgery, your specialist will perform a physical examination involving a pelvic examination of your uterus, ovaries and bladder to check for signs of medical conditions causing incontinence. Other more advanced tests may be required to measure your bladder function, pressures and weaknesses. The tests are also important for differentiating between stress incontinence and urge incontinence, and to determine the severity of your problem.
In the case of stress incontinence (the most common cause of urinary incontinence in women), the aim of surgery is to correct and support any weakness affecting the bladder or urethra. While a number of surgical options are available, the most common and increasingly popular technique uses mesh as a sling for support of the organs. It's normally a minimally invasive procedure of about 15 minutes and requires a stay of about two hours in hospital.
When one or more of your pelvic floor organs sags down into your vagina, this is called pelvic prolapse. Surgical treatment aims to restore the organs to their correct position. There are a variety of procedures and techniques available and your specialist will discuss which is best suited to your particular form of prolapse as every woman is different.
So, while leaky bladder problems are very common in women, the good news is you don’t have to live with it. Your chances of recovery from an incontinence problem after childbirth are very good, if you seek the right advice. Ignoring the problem will most certainly not help.
case studies
Catherine (37) is mum to two young boys, age three and seven. While Catherine occasionally experiences a minor leak when she sneezes with a full bladder, it is a far more serious issue when she exercises. “The leakage can be quite a lot, especially when I go on a long run. If I run in knee-length tights, I’ll be wet down to my knees. The problem is I don’t feel myself wetting, it just comes out like a continuous leak and I feel no sensation of needing to go to the toilet.
“After talking with some other mums by chance, I realised I wasn’t alone with my problem. I’ve now tried two different types of vaginal exercisers which have helped, although in my case they haven’t fixed the problem completely. Sometimes it’s hard to find the time to use the exerciser regularly, but I’m definitely going to keep at it. I’m also seeking professional help now I know there are things that can be done and I don’t have to put up with it for the rest of my life.”
Sarah (42) is mum to three children aged 14, 12 and 6, and suffers from heavy leaking and urge incontinence. “The problem started when my youngest was about four years old, and has got worse over the past couple of years. Leaking makes me feel revolting and very unglamorous. When I drink lots of water, it only gets worse. When the leaking became unbearably heavy, I mentioned it to my gynaecologist and she referred me to an urogynaecologist and physiotherapist who told me I need surgery.
“I wear an incontinence pad whenever I go out and am always mindful of where the toilets are. Pads are a positive thing and a great solution. I go to a women’s-only gym and it’s amazing how many other women there suffer similar problems. We all wear pads so it’s a great environment in which to have a good laugh about it. I’m yet to book in for surgery and I’m looking forward to regaining a quality of life again. Even though I know the urge thing may never go, I am looking forward to jumping on the trampoline again with the kids, wearing nice lingerie, and being able to go out and dance and do exercise.”
Jayne (34) is mum to a two year old and four year old and says she describes her bladder problem as ‘key in the door’. “No sooner do we get home and I’m at the front door when I suddenly have the urge to go to the toilet. I’ll stand jiggling up and down trying to hold on while I get the key in the door and am usually so desperate by the time I get the door open, I push the poor kids out of the way to rush to the toilet. Most times I’m already leaking on the way down the hall.
“I’ve done some Pilates in the past, and I do pelvic floor exercises when I remember, but my problem is that I never get much warning before I have to go. The urge comes on really strongly, as though I’ve just drunk a big glass of water and it’s flushed right through me. It’s literally a split second from the feeling of wanting to go and then needing to go. Besides the frustration of wetting myself, it’s not nice for my children, especially when I tell them not to push and shove each other and I do it to them nearly every time.
“Occasionally I’ll wear a small pad if we go out somewhere that has limited toilet facilities as it buys me some time if I have trouble getting to a toilet. I probably need to make more time to do pelvic floor exercises, but I feel like I have quite strong pelvic muscles. I just thought this problem was normal and not such a big deal, but now I’m wondering if it’s something else and I should see a doctor, especially if it’s likely to get worse with age.”
For more information on bladder and incontinence issues, phone Bladder Help Line on 0800 650659 or visit www.continence.org.nz
