Urinary Incontinence, Stress: Treatment Options

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Stress Urinary Incontinence: Treatment Options

WebMD Live Events Transcript

U.S. speed skater Bonnie Blair was one of the fastest women on ice. But after giving birth, she was slowed down by a common post-childbirth condition -- stress urinary incontinence (SUI), the leaking of urine during day-to-day activities. Blair and her doctor, urogynecologist Dennis P. Miller, MD, joined us on Jan. 13, 2005, to chat about Bonnie's experience and discuss treatment options for SUI.

The opinions expressed herein are the guests' alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

MODERATOR:
Welcome to WebMD Live, Bonnie and Dr. Miller.

MILLER:
Thanks for having us.

BONNIE:
Ditto.

MODERATOR:
Bonnie, please tell us how you discovered that you had stress urinary incontinence (SUI)?

BONNIE:
About two months after I had my first child I wanted to get back to my active lifestyle. I went for a run and got about a half a block and my shorts were soaked. It was embarrassing; it was disheartening; it was frustrating. And I thought, is this something normal that happens after you have a child? It took me a couple of months before I discussed the situation with my husband and about a year before I brought it up with a doctor.

MILLER:
Bonnie's story is so typical, which is why we're happy to have someone people respect so much come forward and tell her story. Women, on average, will suffer the condition three to ten years before talking to their doctor or even their husband about it, and they end up suffering in silence.

Bonnie: "I thought, is this something normal that happens after you have a child?"

MEMBER QUESTION:
Bonnie, I understand your reluctance to talk about this problem. What finally changed your mind about talking to the doctor?

BONNIE:
When I went to my doctor's visit I believe it was more her asking me, do you have a problem, and with leaking of urine. She had known that I had had a difficult delivery with my first child and that's why I had switched doctors to begin with. It was really something more she brought up to me and then I kind of let it all out, and was then freer to talk about it.

MEMBER QUESTION:
What is a urogynecologist? Do I have to see one or can I see my gynecologist or should I see my family doctor for leaking?

MILLER:
That's a good question, and it depends on whether you ever discussed it with a physician before. A urogynecologist is a physician who specializes in problems that fall between gynecology and urology, notably, incontinence and prolapse, problems specific to women. It never hurts to first discuss it with your primary care provider; however, it is often treated by a specialist.

BONNIE:
My normal OB doctor sent me to Dr. Miller who then performed the surgery on me.

MODERATOR:
Bonnie, what did your doctor recommend as a first treatment?

BONNIE:
I think first you have to realize that you need to make the decision you're done having children before having the surgery. Since I had only had one child, even though my doctor discussed surgery with me at that visit, the year after I had my child, I knew I still wanted more children. So at that time I tried doing what they call pelvic floor exercises; I tried weights and electrical stimulation, and really gained little or no ground. Then we decided, because now I had had my two children, and my husband and I knew we were done having kids, that it was time for surgery. I had the surgery a year ago December. And I have been symptom free ever since.

MODERATOR:
Doctor Miller, can you please explain "weights" and "electrical stimulation?"

MILLER:
There are several conservative options, particularly for people with mild problems or who cannot currently have surgical treatment. Electrical stimulation is a small device placed in the vagina to assist at the exercise. Cone weights are less commonly used but are tampon-shaped weighted devices placed in the vagina that reflexively cause the pelvic floor muscles to contract. Used 15 to 30 minutes per day, they are just another way of improving the success of the pelvic floor exercise.

MEMBER QUESTION:
Is the Kegel method effective alone or do you have to use it with biofeedback?

Quick GuideUrinary Incontinence in Women: Bladder Control and More With Pictures

Urinary Incontinence in Women: Bladder Control and More With Pictures

MILLER:
That's another good question. Kegel exercises have been widely used since 1949. They're not harmful and may be of small benefit. My experience has been that for people with significant bladder problems they are very unlikely to be successful as a sole treatment. We are much more likely to recommend a biofeedback program or a highly successful, minimally invasive surgical procedure, known as TVT. TVT stands for tension-free vaginal tape (by GYNACARE).

MEMBER QUESTION:
What other pelvic floor exercises are there?

MILLER:
In addition to simple Kegel exercises, there is a physical therapy program that can go by the name biofeedback or pelvic floor rehab (all of which mean the same thing). That involves exercising multiple groups of the pelvic floor muscles, and is taught and reinforced by a specially trained bladder therapist. The exercises in a pelvic floor rehab program work better because you're using modern principles of exercise physiology: sets, reps, targeted exercises by a specially trained therapist.

You can find these programs through most hospitals or most independent therapy centers. However, it will ultimately require a physician's order for you to participate in the program.

MODERATOR:
Bonnie, it's great that you were able to have the surgery and that it went so well. But you said you couldn't have it until you were done having children. What did you do between your first and second child?

BONNIE:
Between my first and second child and after my second child was when I was doing the biofeedback, the weights, the electrical stimulation and gaining little to no ground and discussing with my husband that we were done having children, we realized it was time to have surgery.

MODERATOR:
Dr. Miller, can you explain the surgical options for treating SUI? You mentioned TVT. Can you explain what that involves?

MILLER:
There are multiple surgical procedures that have been available for over 50 years. The current standard of care and state-of-the-art procedure is the TVT. With seven years of data to back up its high rate of success, it is currently the only procedure advocated by most experts. TVT is a minimally invasive outpatient procedure that involves no incisions in the abdomen and requires the placement of a small mesh tape under the urethra to create a supportive sling. During movement or exercise the mesh supports the urethra, allowing it to maintain its seal and prevent urine loss during those movements or exercise.

MODERATOR:
And if you change your mind about having more children, is it reversible?

MILLER:
No. The procedure should not be done in a woman who is uncertain about future childbearing. The reason why you must be absolutely certain about the end of childbearing is because this procedure is not reversible or removable. Subsequent surgery may cause a return to incontinence and make future treatment more complex. You are always wise to consider the conservative measures, such as exercise, until you are absolutely certain about childbearing.

MODERATOR:
Are there any medications you can take to treat SUI if you are not a candidate for surgery?

MILLER:
There are no current medications available and FDA-approved for SUI. Women can suffer from two different conditions of the bladder. In addition to SUI, there is also Overactive Bladder. Overactive Bladder is treatable with medication but presents with a different set of symptoms, characterized by excessive frequency and urgency of urination.

MEMBER QUESTION:
What are the risks of surgery of this kind?

MILLER:
The fortunate thing about a minimally invasive procedure like TVT is that it is associated with an exceptionally small risk of complication; 700,000 procedures have been performed worldwide with only a small number of reported serious complications. When they occur, they would include injury to a blood vessel or organ such as the bowel during the performance of the surgery. In addition, under rare circumstances, the sling could be inserted too tightly and would need to be released. In general, however, the procedure is performed with an exceptional safety record. In my practice, I have performed over 1,100 of these procedures without serious complications.

MEMBER QUESTION:
Can your partner feel the mesh when you are having sex?

BONNIE:
Not to my knowledge.

MILLER:
The mesh is placed under the vaginal skin and is not felt by the partner during sex. In a rare number of patients, a very small amount of the mesh could be exposed, which would then be felt by the partner. This is easily correctable by having it trimmed.

MODERATOR:
What is the recovery time following surgery?

BONNIE:
The surgery was so easy, and two days later I was at an ice ring watching a competition. Dr. Miller, knowing I was an athlete, encouraged me not to do any physical activity for about 8 weeks, thinking I'd make it 6 weeks. But actually I am a coachable person and I listened to him. I waited all 8 weeks for my first run and to this day still have no problems.

MILLER:
For people without 5 gold medals, we generally recommend abstaining from heavy lifting or strenuous exercise for four weeks.

Miller: "The effects of pregnancy upon your bladder are out of your control."

MEMBER QUESTION:
I'm well acquainted with running to the bathroom all of the time while pregnant. But what is it about pregnancy that makes the problem continue after you give birth? And is there anything you can do when pregnant to prevent having this problem afterwards?

MILLER:
For the most part, the effects of pregnancy upon your bladder are out of your control. The nerves of the deep pelvis are stretched as the uterus and baby grow. These stretched nerves are often damaged and function less efficiently, leading to weak muscles and bladder symptoms. There is a theory that if you do pelvic floor exercises, possibly even Kegel exercises, while pregnant, you may help to minimize or delay these symptoms of incontinence.

Quick GuideUrinary Incontinence in Women: Bladder Control and More With Pictures

Urinary Incontinence in Women: Bladder Control and More With Pictures

MEMBER QUESTION:
Is being overweight a problem with this issue? It seems to me that excess weight would push on your bladder and make this worse.

MILLER:
I don't like to overly attribute incontinence to weight issues because it leads to an incorrect assumption of it being your fault. This is a problem of damage to the pelvic floor that is generally out of your control. However, it is noted that when overweight women lose weight their incontinence symptoms will often improve.

MODERATOR:
Is this nerve damage the reason you have to urinate so frequently while pregnant?

MILLER:
Surprisingly, no. Even though the symptoms during pregnancy and after are quite similar, their cause is different. During pregnancy the bladder is physically limited by the size of the uterus. You urinate often because you don't have room to fill your bladder.

After pregnancy it is the nerve damage and muscle weakness that results in those same symptoms, even after the compression of the bladder is relieved.

MEMBER QUESTION:
At what point do you advise a patient to have the surgery?

MILLER:
This surgery can be performed on any patient who is significantly bothered by incontinence. Any woman who's had to change her life, which includes the way she dresses, reduced sports activities, or avoiding being in situations where bathrooms are not close, will find this a significant detriment to their life and therefore qualify for the surgery.

MODERATOR:
Bonnie, you are obviously pleased with your decision to have the surgery.

BONNIE:
Yes, very much so. It was very easy and if I had to do it all over again, I wouldn't hesitate, but I don't have to, because I'm cured.

MODERATOR:
You are skating again but no longer competing, correct?

BONNIE:
I exercise. There's a difference between exercising and training and competing.

MODERATOR:
What kind of adjustments did you have to make before treatment?

BONNIE:
Wearing dark shorts; wearing bigger baggy t-shirts, wearing pads, changing your underwear and sometimes clothes more frequently. Before going on a run trying not to drink as much, not so much to dehydrate myself, but I definitely tried to cut back on liquids.

MODERATOR:
It must have been a relief to get back your life.

BONNIE:
Quite a relief, correct.

MEMBER QUESTION:
What kind of anesthesia is used in TVT surgery?

MILLER:
The anesthesia is variable and involves a discussion between the patient and doctor. It is very exciting that when desired, this procedure can be performed under local anesthesia. This avoids the nausea and dizziness associated with anesthetic medications. Regardless of the type of anesthesia, however, patients go home within three to four hours.

MEMBER QUESTION:
Does drinking water help prevent bladder problems?

MILLER:
It is often good to stay adequately hydrated and drink plenty of water for your general health. However, drinking excessive water will often negatively impact your bladder symptoms. It is a mistake to believe that drinking large amounts of water will have any beneficial effect on your bladder.

MODERATOR:
So how much water should we be drinking a day to maintain good bladder health?

MILLER:
With regard to the bladder, there is no specific amount to drink. You need to maintain hydration and not avoid water drinking. You need to stay away from excess caffeine and alcohol, but to drink only reasonable amounts when you're thirsty is the best way to avoid bladder symptoms. Often this might total 6 to 8 glasses in a 24-hour period. More than that, while good for other parts of your body, may exaggerate your bladder symptoms.

MEMBER QUESTION:
How long does the mesh last?

MILLER:
When you're gone, the last thing in your casket is your breast implants and your TVT mesh.

BONNIE:
In my case it will just be my mesh.

MILLER:
Seriously, TVT mesh is not absorbable and is therefore permanent. When successful, the procedure is a lifelong correction of symptoms.

MEMBER QUESTION:
Isn't leaking just an inevitable part of getting older?

MILLER:
This is the most important myth that we want to dispel. Just because a problem is common does not make it normal. There is no reason why any woman needs to live with these symptoms when treatment is readily available.

BONNIE:
I waited a year to talk to my doctor, and in my eyes that was a year too long. But it is actually a short time, compared to most women. In the long run, I spent five years dealing with the problem and trying to correct it before I had the surgery and was cured, and in my eyes, the five years was way too long, but since I had one more child, that brings me down to three years, and that was still too long.

Miller: "(You) don't have to keep this a secret ... SUI is a real medical condition that can be completely treated."

MEMBER QUESTION:
I am considering a vaginal rejuvenation and labia reduction. Is there anything I should know about these procedures?

MILLER:
These procedures will have no effect on bladder symptoms. These procedures are gaining popularity in many circles where plastic surgery is common. My personal opinion is that they are unproven, potentially dangerous and may leave women with sexual dysfunction. Women's anatomy varies from person to person. I think it is dangerous to begin to convince women that their labia or their very natural anatomy is in some way unattractive.

Quick GuideUrinary Incontinence in Women: Bladder Control and More With Pictures

Urinary Incontinence in Women: Bladder Control and More With Pictures

The other reason some women pursue these surgeries is to improve their sexual life. There is no current evidence that surgical tightening procedures will accomplish that goal. On the contrary, they may have the opposite of the desired effect and create sexual pain.

MODERATOR:
We are almost out of time. Before we wrap things up for today, do you have any final words for us?

BONNIE:
I think what most women need to realize is they don't have to keep this a secret, that SUI is a real medical condition that can be completely treated with TVT and you can get your quality of life back. Don't be scared to go and talk to your doctor and get the help that you need.

MILLER:
Bonnie Blair's brave, uninhibited involvement in the Breaking the Ice campaign, shows us that this problem can occur to anyone, from housewife to Olympic athlete. It's not just racing around the rink; it's also racing around the house. All women bothered by incontinence deserve to speak to their physician and if necessary, speak to a urogynecologist or specially trained incontinence specialist. At Milwaukee Urogynecology/Advanced Health Care, we see women of all ages to treat their incontinence.

BONNIE:
For more information, there's a toll free number, 888-496-3227, and a web site, www.beatsui.com.

MODERATOR:
Our thanks to Bonnie Blair and Dennis P. Miller, MD, for joining us today. And thanks to you, members for your great questions.

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Reviewed on 1/18/2005 11:19:23 PM

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