MedTech1 Discussion on Incontinence with Laura Meeks, MD
February 20, 2002

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Moderator: Welcome to MedTech1.com 's moderated discussion on female incontinence. Incontinence is a condition that affects million of Americans. It is largely untreated and most often impacts women. Our guest today is Dr. Laura Meeks. Dr. Meeks is a Resident in Obstetrics and Gynecology at Massachusetts General/Brigham and Women's Hospital. She received her M.D. from Harvard Medical School and her A.B. from Harvard University. She recently received the Brigham and Women's Hospital Harvard Medical School OB/GYN Resident Teaching Award, and has performed over 350 infant deliveries and 150 gynecolgical surgeries. Dr. Meeks will be discussing "Female Incontinence and Potential Surgical Solutions."

Saria: What is urinary incontinence?
Dr. Meeks: Urinary incontinence is the involuntary loss of urine from the body.

Nona : Can medications I take affect my bladder or bowel control?
Dr. Meeks: : Yes. There are many commonly used mediations that affect bladder control. Some cause retention of urine and other can cause loss of urine. Examples include many medications used to treat hypertension particularly diuretics, which cause mobilization of fluid. Additionally many psychiatric medications such as anti-depressants can also contribute. If you have concerns about a specific medication contributing to a problem of incontinence you should consult your physician as medication changes are a simple, reversible way to treat urinary incontinence. Medications can also affect bowel control by contributing to diarrhea or constipation. Only such medications that cause significant constipation can through this mechanism affect bladder function.

Kelly: Is incontinence more prevalent at a certain time of day? Like at night? Is this why bedwetting is common among children?
Dr. Meeks: First of all, children rarely have true urinary incontinence but the bedwetting is a different disorder called nocturnal enuresis. The correlation of incontinence with time of day varies greatly depending on the type of incontinence and the individual person. For example stress incontinence happens more during the day whereas overflow incontinence can happen at night. Additionally, people with lower extremity swelling or heart failure are more prone to night time leaking of urine.

Alecia : Can my diet affect my bladder control?
Dr. Meeks: Yes. The two biggest dietary contributors to loss of urine are excessive alcohol or caffeine intake. To maintain a healthy bladder physicians recommend that people drink 6-8 cups of fluid per day. Excessive fluid intake can also contribute to loss of urine. Also acidic foods (citrus, tomato...) have been suggested to irritate the bladder.

Kelly: Why are women more prone to incontinence than men?
Dr. Meeks: Incontinence is more common in women. Factors that contribute to this are that the woman' urethra (the tube that carries urine out of the body) is much shorter then in men. Additionally, menopause (lack of estrogen) and childbirth (which can lead to relaxation of the pelvic floor muscles) are specific to women.

Moderator: Dr. Meeks, can you address how age impacts incontinence?
Dr. Meeks: Incontinence is not a NORMAL part of aging but does become more common as people age. This is especially true for men as most men with incontinence are elderly.

Moderator: Is incontinence hereditary?
Dr. Meeks: Incontinence is a multi-factorial problem meaning that many things contribute to whether some is incontinent. Incontinence is not specifically hereditary but there are some medical conditions that do have an inheritable component and can contribute to incontinence. To get back to the question about aging. As people age they tend to acrue multiple medical problems that contribute to UI (urinary incontinence). Also, the decrease in estrogen with menopause contributes in women. Many elderly people who have dementia, strokes or other injuries have a hard time getting to the toilet or recognizing the urge to void which all contribute.

Donah: Are there different kinds of incontinence?
Dr. Meeks: There are four different kinds of incontinence: stress, urgency, overflow and mixed.

Moderator: Can you elaborate on this?
Dr. Meeks: Stress incontinence is the most common kind, especially in women. It usually results from the urethra (the tube that exits the bladder) failing to maintain a tight seal. The main symptom of stress incontinence is the sudden leaking of urine with increased abdominal pressure (cough, sneezing...) or with movement.

Moderator: What about urge overflow - can you talk about this?
Dr. Meeks: I think you mean urge or overflow incontinence. Urge incontinence comes from over activity of the bladder muscles, which will contract spontaneously. People with urge incontinence have a sudden, abrupt urge to go to void.

Moderator: Now what about overflow? And in your experience, which type of incontinence do patients have the most difficulty talking about?
Dr. Meeks: Overflow incontinence is a condition when the bladder is always partially flow and thus leaks because either the bladder muscles do not contract well or there is an obstruction to outflow of urine. Many women are embarrassed to talk about incontinence! Over 20-50% of affected women do not discuss incontinence with their physicians. I find that younger, healthier patients are often the most embarrassed, which is a shame because the treatment options for them are excellent. Mixed incontinence is like it sounds a combination of either urge, stress or overflow...

Sandra: I am a woman in my early 50's who has a problem with incontinence when I sneeze, and occasionally when I cough. It also happens to me when I exercise and am doing some type of jumping motion. I notice this getting worse as I am getting older and is beginning to be embarrassing. Am I a candidate for surgery or are there other methods to try before resorting to surgery?
Dr. Meeks: Although it would be inappropriate to make a diagnosis over a chat these symptoms sound most consistent with stress incontinence. Of course you should consult your physician for a proper evaluation. Regardless of the kind of incontinence you have Sandra there are many treatment options. For a person with stress incontinence there are many options. The first option is always conservative treatment which include exercises to strengthen the pelvic floor muscles (see the below diagrams the first with weak pelvic floor muscles with poor urethral support the second with strong pelvic floor muscles which can be built up by doing simple exercises)
Dr. Meeks:


Dr. Meeks:


Dr. Meeks: Other options for treatment of stress incontinence include a pessary in certain women (to support pelvic organs if prolapse is present) or estrogen cream. If conservative measures do not satisfactorily improve a woman's symptoms with stress incontinence then there are very effective, minimally invasive surgical options. Certainly before considering surgery one should work closely with a physician to try the more conservative approaches.

Moderator: Dr. Meeks, can you expand on the surgical options involved in treating incontinence?
Dr. Meeks: I will focus on stress incontinence, which is the type which is very effectively treated with surgery. The types of surgery include: -abdominal surgery to suspend the bladder neck -needle vaginal suspension -sling procedures
Dr. Meeks: Sling procedures are currently the most commonly used as they are very effective, with lower complication rates. The GYNECARE TVT sling is becoming the standard of care for treatment of genuine stress incontinence.
Dr. Meeks: This is a relatively new procedure that takes less then 30 min, can be done under local anesthesia and involves supporting the mid-portion of the urethra with a mesh sling. It is done through a vaginal approach so there is minimal scarring.

Cecilia: What kind of doctor should would visit for an evaluation of incontinence?
Dr. Meeks: You should start by visiting either your primary care physician or gynecologist. They will initiate a simple evaluation. Ultimately, some more difficult cases to diagnose or those who need surgical management may then be referred to an urogynecologist (gynecologist specializing in incontinence and pelvic floor disorders) or a urologist.

Jennifer: When would you consider incontinence to become severe enough to consider treatment?
Dr. Meeks: Any incontinence symptoms should be discussed with your physician, as I mentioned there often simple conservative treatments either behavior modification, adjusting the diet, treating a urinary tract infection or pelvic floor strengthening exercises, biofeedback that can make a large difference. If symptoms persist or get more severe medication or surgical management can then be discussed with your physician.

C: Are there exercises which can strengthen the muscles to prevent incontinence?
Dr. Meeks: Yes. The exercises take discipline and effort on the part of the patient but are very effective particularly in the treatment of stress incontinence (50-90% improvement in symptoms). The exercises are called Kegel exercises which strengthen the pelvic floor muscles. Your physician can help teach you how to do them but it involves tightening of the pelvic floor muscles (muscles used to stop the flow of urine) done in sets of 10 (holding for 10 seconds each) up to 10 times a day.

C: Dr. Meeks, how much pain is involved in the surgical procedure that you described?
Dr. Meeks: The TVT procedure?
Moderator: I think that is the procedure this person was talking about.
Dr. Meeks: The pain is usually minimal. Many patients do not even need to take additional pain medications once they leave the hospital (usually the same day as the surgery). Within 2-4 weeks most patients have made a full recovery.

Angela: How does caffeine intake affect the bladder?
Dr. Meeks: Large amounts of caffeine can contribute to urinary incontinence as it acts as a diuretic so this is one of the first things to try and cut back on if one has symptoms of urinary incontinence.

Jason: What is good proactive practice to keep a healthy bladder?
Dr. Meeks: Drink 6-8 cups of fluid a day. Limit alcohol, caffeine and acidic food intakes. Try to void at regular interval every 2-3 hours while a wake. Voiding once during the night is considered normal but more than this should be discussed with a physician. Have regular bowel movements. Do not smoke! tobacco and particularly chronic cough can contribute to incontinence.

Moderator: What is the morbidity associated with incontinence, other than just leaking urine, etc.
Dr. Meeks: Good question... One of the major morbidities of incontinence is the social and psychological embarassment and withdrawal. Additionally, women who leak urine or prone to perineal yeast infections, irritation/ulcers of the groin area from irritation from urine, urinary tract infections, sleep interruption from having to void at night. All reasons to speak with your physcian regarding treatments of urinary incontinence.

Lynnette: Can I just live with my bladder control problem?
Dr. Meeks: It is certainly an individual's choice, if the leaking of urine is manageable and not truly bothering a patient. Though I recommend in all cases discussing incontinence symptoms with a physician as there may be some simple treatment options.

Jerel: How can I get more information?
Dr. Meeks: There are many web-sites with information on urinary incontinence and women's health issues such as medtech1.com and body1.com. Additionally, there are many advocacy groups for people suffering from incontinence that are excellent support networks and information sources. Your physician should also be an excellent source of information.

Moderator: Thank you for all your questions today. Please look for upcoming chats soon. Dr. Meeks, thanks for answering the questions of our MedTech1 viewers today and for generating such a lively and informative discussion.