What's New For Women To Treat Pelvic Support/Incontinence Problems

Today’s and next week’s articles are devoted entirely to two subjects women think about a lot but seldom comment on “in public” (except maybe to their closest friends): Incontinence, and vulvar aesthetics (what it looks like and feels like “…down there…”.)

Urinary incontinence, the loss of usually small amounts of urine either secondary to urgency (“gotta go…gotta go…”) or increased abdominal pressure (cough, sneeze, laugh, exercise, lifting, etc.) is an unfortunate fact of life for many women, especially after childbirth and as they age.

This is a solvable problem. You do not have to be incontinent. There are many solutions. Arriving at the right one for you, however, requires the service of an experienced and up-to-date diagnostician and clinician. As in much of medicine, one size does not fit all; the perfect therapy for one woman may be inappropriate for the next.

“Urge incontinence” (the loss of small to moderate amounts of urine on the way to the bathroom, especially with a full bladder and the feeling of “having to go” all the time) may be secondary to low estrogen levels, bladder spasms or excessive intake of acidic foods.

For urgency in women with lowered estrogen levels (as in menopause, just after childbirth or in other women with lowered estrogen levels) local vaginal estrogen therapy frequently works wonders. Tempering bladder irritants, including acidic foods such as chocolate, coffee, tea, many fruits, tomatoes, alcoholic beverages, chili/spicy foods, etc., helps. If these therapies are less than curative, adding in an antispasmodic medication such as oxybutynin, Detrol®, Vesicare®, etc. frequently helps. A new electrical stimulating device (“Athena®”) also helps and will be discussed in detail later.

“Genuine stress incontinence”, the involuntary loss of usually small amounts of urine with activities that increase intra-abdominal pressure, is the most common type of incontinence and is due to a laxity of the muscles of the pelvic floor diaphragm, allowing the “neck” of the bladder to slip down and straighten out when intra-abdominal pressure increases. Sometimes other things (uterus, apex of the vagina, the rectum bulging into the vagina) slip down or “prolapse” as well.

Why does this occur? Genetics certainly play a major role, as does the breakdown of collagen and the muscular support with aging. That said, however, undeniably the major causative factor for the stretching and tearing of fibromuscular pelvic support is childbirth, especially long and difficult labors, and associated tearing of vaginal tissues during delivery.

(In many countries, women opt for “elective” cesarean section, specifically to prevent the incontinence associated with vaginal birth).

The therapy of stress incontinence is aimed at strengthening the muscles of the pelvic floor and in some way tightening, repairing, or “suspending” the previously tough and tightly woven fascial support that has been loosened and/or torn by childbirth. This can be done by exercise and biofeedback, the new Athena® Pelvic Muscle Trainer, major bladder suspension surgery and the new minimally invasive SURx®, Radiofrequency Wave Pelvic Support Procedure (which can also be used for the “vaginal tightening” in vaginal rejuvenation–see next week’s column). Any physician treating urinary incontinence should be able to offer you all of these alternatives.

Although Kegel’s exercises, isometric contraction or “squeezing” of the levator muscles of the vagina, can increase muscular tone, this laxity is only part of the problem; Kegel’s do not change/repair fascial defect(s).

The Athena® Pelvic Muscle Trainer is a new concept (access www.athenaft.com) in muscle strengthening whereby a pelvic floor electrical stimulator built into a wireless remote controlled vaginal device gently stimulates the pelvic floor muscles to strengthen and tighten with minimal effort.

Pelvic floor exercises via Kegels, biofeedback or the Athena® device help some women with minimal incontinence. For more moderate or severe situations and those not corrected by exercises, especially when associated with prolapse, surgery is the better option.

Surgical procedures may be divided into two categories: Major and minor. If your incontinence is significant/severe, especially with major prolapse, major surgery (abdominal or vaginal) producing some sort of permanent suspension and repair of the fascia is best. “Burch” suspension, TVT (transvaginal tape) and TOT (transobturator tape) are three of the most common procedures performed. All have excellent five-ten year success rates, but all involve hospitalization, post-op catheter use, and have the potential for significant complications.

For those with mild/moderate incontinence, without or with only a small degree of prolapse, the new SURx® procedure offers a significantly easier recovery. SURx® uses radiofrequency thermal energy (“controlled heat”) to increase the stability of the pelvic floor; heating the tissue improves its stability because the tissue contains collagen, and collagen reacts to heat by shrinking and tightening. A small incision is made in the anterior vagina and the radiofrequency probe is applied to the fascia underneath the bladder to shrink and stabilize it. Any tears encountered can be repaired at the same time. Although patients must limit strenuous activities and intercourse for approximately six weeks (as in other surgical procedures), SURx® is an outpatient procedure (a total of only three-four hours in the hospital), there is virtually no pain involved, and recipients may return to usual work activities in two-three days.

This is an overview only of female urinary incontinence. Remember, you do not have to suffer (either vocally or in silence)! Help is available.