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Elizabeth Howell, M.D., OB/GYN at McKee Center for Women’s Health in Loveland. Photography by Warren Diggles

“Most women who come to me don’t come to be treated for incontinence,” according to Elizabeth Howell, M.D., OB/GYN at McKee Center for Women’s Health in Loveland. In fact, were it not for Dr. Howell’s well-placed questions and routine concern, many women would not bring the subject up at all.

“During the course of their general check-up I often ask women if they are experiencing any leakage. Surprisingly, many tell me that they have been suffering with the condition for years,” she adds.

Today, approximately 30 to 50 percent of women and 17 percent of men over the age of 60 suffer from urinary incontinence. Furthermore, one-half of those suffering from the condition do not report the condition to their healthcare provider, according to statistics presented by Dr. Howell. Incontinence can range from a leak every so often to daily leakage requiring a pad.

Types of Incontinence

Three types of incontinence are most common: stress, urge and mixed. Stress incontinence is a condition where downward pressure from a physical stressor overcomes the muscles and causes the bladder to leak. Physical stressors can be a sneeze or cough. This type of incontinence often occurs during and after pregnancy, though the condition generally resolves itself within a year after childbirth. However, it can predispose women to stress incontinence later in life.

Urge incontinence is involuntary leakage of urine caused by a spasm of the detrusor muscle of the bladder. This spasm is accompanied by a sensation of urgency. Mixed incontinence, the most common type, according to Dr. Howell, is a combination of the two, with one type being generally more dominant.

Women who come to Dr. Howell specifically for incontinence issues are “generally at their wit’s end.” Coming to her often in tears, Dr. Howell says these women have lived for some time with the far-reaching impacts of incontinence. Many women are forced to continually wear pads to protect against leakage. With daily incontinence comes a host of other side effects: rashes, recurring urinary tract infections, low self-esteem, depression. Women can even leak during intercourse, further impacting their physical and emotional state.

Pamela Morrison, a patient of Dr. Howell, was treated for stress incontinence in 2008. “I had incontinence for years, but it gradually got worse.” A cough, even sudden physical movements could cause a bout of incontinence. Morrison had taken to wearing a pad everyday. “It had gotten to the point where I didn’t know when it would happen. I had to wear a pad day and night and it was inconvenient and embarrassing.”

Part of Morrison’s reluctance in having the condition treated was a fear that it would be more painful to treat than it was to live with the inconvenience. But when her incontinence finally got in the way of her golf game, Morrison decided to take action. She went to Dr. Howell.

Treatment Options

Treating incontinence may be easier than you think, says Dr. Howell. Initially, there are several lifestyle changes that can be made. Quit smoking; the smoker’s cough can contribute to instances of leakage with urge incontinence. Give up coffee, tea, carbonated beverages, alcohol and chocolate as caffeine can stimulate the urge to urinate. Sometimes something as simple as changing a prescription may reduce or eliminate incontinence issues. Habit training (planning out the day to go to the bathroom at regular intervals, then extending the intervals to train the bladder) can also work to control incontinence.

If those changes do not significantly reduce the problem, Dr. Howell recommends physical therapy. She has had very successful results from patients working with a qualified physical therapist. The therapist should be specifically trained to work with the pelvic muscles. Physical therapy can include Kegel exercises to strengthen pelvic muscles, retraining exercises (for women who have trained their bladder to like to be empty and have reduced the ability to resist bladder spasms), and even electronic stimulation to force muscles to contract.

“Even practicing Kegel exercises by squeezing and relaxing the muscles slowly 10 times, three times a day, three times a week can make a huge difference,” she says, adding, “There is no surgery or medication involved and the therapy can help both kinds of incontinence. However, this involves a patient being willing to do the work and some women just choose not to follow through.”

Those who have, says Dr. Howell, are amazed at the results. “I have patients who come back to me after therapy and tell me that their lives have been changed.”

For some cases, more assistance is required. Those women with urge incontinence have a variety of anticholinergic medicines available. These help to decrease bladder spasms. They are not foolproof. Dr. Howell estimates they work approximately 20 to 40 percent of the time and side effects range from severe dry mouth to constipation to impairment in cognitive function.

For stress incontinence, surgery is the recommendation. Several sling procedures exist to help women. Most procedures can cure the incontinence 80 to 90 percent of the time. The procedure can be done as outpatient surgery; however Dr. Howell prefers to keep her patients overnight to make sure there are no complications.

The sling often used by Dr. Howell is called a tension-free vaginal tape (TVT). A TVT procedure involves a small piece of polypropylene monofilament mesh, approximately as wide as your finger, inserted into the bladder near the urethra. The mesh supplies extra support to the pelvic floor, with collagen forming around the mesh and providing further support in the form of scar tissue.

The procedure involves a tiny incision in the vagina. After the procedure a catheter may be inserted until swelling subsides to ensure patients can urinate correctly.

“There is minimal pain,” adds Dr. Howell, and the procedure is available to most women, though it is suggested that a sling not be inserted until after childbearing is done. Fifty percent of slings do not make it through the childbearing process.

Morrison had the TVT procedure for her stress incontinence. “It was a very easy surgery with no pain. I was amazed. I thought, ‘why hadn’t I done this years earlier?’” She was so impressed that she brought up the subject with her sister who had the same type of incontinence. Her sister, located in Indiana, visited her own doctor and requested the same procedure. “She was just as amazed as I was at the outcome,” adds Morrison.

In addition to treating her patients physically, Dr. Howell says that this is one health problem that calls on physicians to exercise an extra amount of empathy. “This condition really affects the lives of our patients in a private way. So many of my patients are just grateful to have someone who will listen to them and recognize that it is a problem.” +