A Going Phenomenon: Pelvic Floor Disorders

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The next time you’re in the grocery store or drugstore, take a look at all the boxes of sanitary pads in the “feminine protection” aisle. Then consider this fact: As much as 30 percent of sanitary pads sold in the United States aren’t used for menstruation, but rather for urinary incontinence.

In some cases, women using pads for these purposes may just be in the “baby’s sitting on my bladder” stage of pregnancy, but many more have some type of pelvic floor disorder that causes urinary incontinence.

This isn’t a health issue most people are comfortable talking about. The guy next to you at dinner may be quite proud to relate the details of his quadruple bypass, but his wife is hardly likely to tell you that she’s been ordering Depends online for the past year.

The embarrassment factor may be why we don’t realize just how many women face pelvic floor problems. Estimates indicate that between 30 percent and 40 percent of women will cope with urinary incontinence at some point in their lives, and a survey of working women presented to the American Urological Association by Temple University researchers in 2005 found that 72 percent had suffered from some kind of pelvic floor disorder—but a staggering 70 percent of those women had not sought medical help for their condition.

That’s unfortunate, said Dr. Tiffany Sotelo, who directs the Pelvic Floor Center at George Washington University Hospital, because these conditions can be treated. “There are very few patients that I see that I can’t help in some way.”

Urinary incontinence affects two primary groups of women, according to Sotelo: women who have just given birth and women who are postmenopausal. “The stress of being pregnant and giving birth can cause some laxity and changes in the pelvic floor,” Sotelo explained. “And in postmenopausal women, the estrogen and hormonal changes they go through actually cause changes in the physical makeup of the tissues of the pelvis.”

Many women with urinary incontinence also turn out to be suffering from other problems, such as uterine or rectal prolapse (basically, a hernia into the vagina from the uterus or the rectum). Some of these women experience what’s called “stress incontinence”—accidents that occur when you cough, sneeze, laugh or lift something hard.

“The most conservative approach to treating stress incontinence is through exercises that strengthen the pelvic floor muscles, specifically Kegels,” said Sotelo. Any woman who’s been pregnant knows her Kegels—the exercise that involves contracting and releasing the same muscles that start and stop the flow of urine while on the toilet.

There are also some medications that have been designed to relax muscles and prevent bladder spasms, which can be helpful in treating incontinence. Pessaries—stiff rings that support the walls of the vagina—help position the urethra, leading to less stress incontinence. And believe it or not, collagen injections—yes, like the kind actresses often get to give themselves bee-stung lips—can also be used to bulk up the tissues and close the opening of the bladder to relieve stress incontinence. (These injections generally must be repeated about every six months, Sotelo noted.)

But when conservative methods fail, there are also multiple, newer surgical options that can help restore normal urinary function. “We have a lot of what are called mid-urethral mesh slings, which are placed during minimally invasive, outpatient surgery,” explained Sotelo. These slings support the bladder in its normal position, and some 80 percent to 90 percent of people who undergo these surgeries for stress incontinence are cured, according to the National Library of Medicine’s MedlinePlus service.

The best candidate for a sling procedure would be a woman who purely has stress incontinence, with no other type of incontinence, and who uses one to two pads a day to deal with the leakage.

“The sling actually supports the urethra in doing what it normally would do,” Sotelo said, adding that sling procedures may about to become even easier. “I think in the next year or two, we’ll have slings that we can actually place in the clinic, not in the operating room, using local anesthesia or conscious sedation only. Because these newer ones are so minimally invasive, the only area of incision is in the vagina.”

The other most common type of incontinence is called urge incontinence. “Women will either not be aware that they have to go and will have a sudden episode, or will get the message, but if they don’t get there at the exact right moment, will have incontinence,” Sotelo said.

This has probably happened to all of us at one time or another when we’ve “held it in” too long, but with urge incontinence, it happens continually. In other cases, certain behaviors—like putting the key in the door or hearing running water—can cue the bladder to squeeze.

Urge incontinence—also called “overactive bladder”—can be treated with Kegel exercises as well as behavioral changes such as avoiding caffeine. “If that doesn’t work, we sometimes can use Botox, although it is not FDA approved for that indication,” said Sotelo, citing one of her favorite treatment options, InterStim Therapy, which is “basically a pacemaker for the bladder.”

“If your quality of life is bothered by urinary habits or symptoms, no matter what, there are things I can do,” said Sotelo. “Now, we have to set realistic goals. Can we get someone who has over two liters of incontinence a day to completely dry? It may take a long time, and may take significant surgery, but we could easily get them to a point where they’re using half the pads they’re using now. There’s no reason to let embarrassment keep you from getting treated. Incontinence and pelvic floor problems are not a normal’ part of aging, and you shouldn’t have to just live with it.”

About the Author

Gina Shaw is a contributing writer for The Washington Diplomat.

Last Edited on November 29, 1999