London - Though few discuss the subject even with their closest friends, around half of all women suffer from a dysfunctional bladder at some point.
“These involuntary leaks are incredibly embarrassing and can cause huge problems in women’s lives,” says Mark Slack, a consultant urogynaecologist at Addenbrooke’s Hospital, Cambridge.
“A typical case is the woman who has a leak on the train, and has to stay on till the end of the line because she’s too embarrassed to let anyone see the wet patch.”
There are two main types of incontinence - an overactive bladder and stress incontinence. Normally when the bladder has filled to its capacity of around 400 ml, a signal is sent to the brain telling it to empty. Women with an overactive bladder feel the urge to go before the bladder is full.
“Something goes wrong in the messages passing between the bladder and the brain, which sends faulty signals to the bladder telling it to empty,” says Mr Slack, who is also spokesman for the Royal College of Obstetricians and Gynaecologists. Around one in five women over the age of 40 is affected.
An overactive bladder can cause a range of problems, including urinary frequency, nocturia (needing the lavatory at night), urgency and urge incontinence (feeling you only just make it to the loo in time, or even getting ‘caught short’).
Patients with stress incontinence leak urine when they laugh, run, sneeze or cough - this is triggered by weakening of the muscles supporting the bladder, which can happen in pregnancy and childbirth. This makes up 50 percent of all incontinence cases, although a large number of women have both stress incontinence and an overactive bladder.
Sometimes simple measures such as losing weight or avoiding substances that inflame the bladder - cigarettes and caffeine - can make a big difference. A 10 percent loss in weight can give a 50 percent improvement in incontinence symptoms.
But if these won’t help, doctors can offer a range of treatments. Here the experts reveal what’s on offer and the pros and cons.
FOR OVERACTIVE BLADDER
DRUGS TO STRENGTHEN YOUR MUSCLES
Anti-cholinergic drugs strengthen the sphincter - the muscles supporting the bladder - reducing the urgency, frequency and number of leaks.
Advantages: These improve symptoms for 70 per cent of patients.
Disadvantages: Side-effects can include dry mouth, blurred vision and constipation - in elderly people, they can also affect cognition and memory. Studies show only 30 percent of patients are still taking them after a year. “But newer drugs are more specific, targeting receptors in the bladder more than other organs, and so reduce side-effects,” says Mark Slack.
BOTOX JABS
Small doses of botulinum toxin injected into the bladder work by paralysing the bladder muscle so it doesn’t contract so readily.
Advantages: Patients given Botox suffered fewer feelings of urgency and passed water one to two times less often, according to a major study just completed by Professor Douglas Tincello, honorary consultant gynaecologist at University Hospitals of Leicester NHS Trust. “Most excitingly, about four in ten women became completely continent after six weeks and a third were still continent six months after treatment,” says Professor Tincello. The treatment takes five to ten minutes and is done under local anaesthetic as a day case.
Disadvantages: The effects start to wear off after about six months, so treatment may need repeating every six to 12 months.
Around one in eight women has difficulty emptying their bladder in the eight months after treatment, and have to learn to use disposable catheters.
BACK IMPLANT
Surgeons are now using nerve stimulation to tackle incontinence. The most common procedure is to implant an electrode and stimulator permanently in the back, close to the sacral nerve - which runs through the lower back to the bladder and helps to control the bladder. It’s thought stimulating the nerve may reduce the faulty signals from the brain that cause the bladder to empty.
Advantages: Between 40 and 70 percent of patients see a 50 percent improvement. “For patients who have failed to respond to standard management and medication, this can be an extremely effective way of managing overactive bladder,” says Mark Slack.
Disadvantages: Requires a 20-minute operation under general anaesthetic and recovery time of a day. The electrode can move in the body in time - between 20 and 40 percent need further surgery. At £10,000, it’s not cheap.
SKIN PATCH
VERV is a new, small, waterproof patch you place on your back, and activate using a remote control. It contains a battery and sends high- frequency signals through the skin to stimulate the sacral nerve.
Advantages: “For the first time, patients have a non-surgical, drug-free, discreet and effective option,” says Ash Monga, consultant gynaecologist at the Princess Anne Hospital, Southampton, who helped to research the device. A clinical trial found that in four weeks symptoms more than halved for 60 percent of patients.
Disadvantages: The patch must be replaced once a week. It can cause some skin irritation when worn over six months.
FOOT ZAPPER
Another form of nerve stimulation, this time targeting an ankle nerve - the posterior tibial nerve - which partly controls the bladder. Using a similar method to sacral nerve stimulation, an electrode is put against the bottom of the foot.
This is done as an out-patient treatment, and does not involve a permanent implant.
Advantages: Works in around half of patients for whom other methods have failed; no general anaesthetic or incision.
Disadvantages: Patients must come for a session every week for 12 weeks. May need repeating six months later.
FOR STRESS INCONTINENCE
PELVIC FLOOR EXERCISES
The pelvic floor muscles support the bladder but can become weakened by ageing and childbirth.
Advantages: Easy to do at home or in a supermarket queue. Up to 70 percent effective if done properly and regularly.
Disadvantages: Many women do them incorrectly and get no benefit. “These exercises are very effective, especially when taught by a physiotherapist who can also use a scan to show women which muscles to use,” says Faz Pakarian, consultant gynaecologist at the Montefiore Hospital, Hove, West Sussex, and Worthing NHS Hospital.
DRUGS TO STRENGTHEN YOUR MUSCLES
Stress incontinence may be treated with the drug duloxetine, which works by strengthening the muscle below the bladder.
Advantages: Worldwide trials have shown it can have a 50 percent improvement in more than 50 percent of patients, working within 12 weeks.
Disadvantages: “Nausea is the commonest side-effect,” says Mark Slack. “It can be mild or moderate, though usually resolves within a month.”
MINI HAMMOCK
A so-called Burch colposuspension involves stitching the tissue under the urethra - the tube which carries urine from the bladder - to a ligament in the pelvis. This creates a small hammock to provide support for the bladder neck, so that it stays closed under pressure.
Advantages: Effective for up to 90 percent of women in the first year, and 70 percent for the following five years.
Disadvantages: Surgery under general anaesthetic, with a recovery time of up to three days in hospital. Some 10 percent of women have trouble emptying their bladder afterwards.
VAGINAL TAPE
The tension-free vaginal tape (TVT) sling procedure uses a special tape under the urethra, to give extra support to the bladder entrance.
A small incision is made in the vagina and two in the abdomen, the tape is positioned under the urethra and then the two ends are threaded through the incisions in the abdomen. Women may also be offered transobturator tape (TOT) which is threaded through incisions in the groin.
Advantages: A 20-minute day case procedure. Around 80 percent of women are permanently dry, and 94 percent improve.
Disadvantages: Ten per cent of patients experience thigh pain. More recently there have been concerns raised over the safety of the tape itself - with the tape disintegrating, triggering inflammation and infection.
“There have been studies showing risks of over four percent which can crop up decades later for TVT, and as high as 10 percent for TOT,” says Mark Slack. “But done properly, this is a very good and safe operation.”
BULKING INJECTIONS
Soft fluid material - similar to that used to create fuller lips - is injected into the ring of muscles that control the exit of urine from the bladder. This expands and strengthens the muscles.
Advantages: The procedure takes under 15 minutes with a local anaesthetic and has a 70 percent success rate. “This can help women who cannot have a general anaesthetic, women who have not completed their family (as pregnancies or births may make vaginal tape lax and less effective), or have had previous incontinence surgery that has not been so effective,” says Faz Pakarian.
Disadvantages: The jabs may need to be done again three or four years later. - Daily Mail