Most people come home from Paris remembering the crepes, the Louvre, the River Seine, the views of the Eiffel Tower. Suzanne Tucker, 65, mostly remembers the bathrooms. She traveled to France last year knowing she would have to manage the urinary incontinence that had worsened over 10 years. She had to plan long walks carefully and limit her fluid intake.
“You know how people say to drink eight glasses of water a day? You can’t, not if this is your issue,” says Tucker, a retired university administrator.
Tucker’s story is a common one. Urologist Leslie Rickey, MD, and colleagues at Yale Medicine anticipate the incidence of incontinence and other pelvic floor disorders—conditions affecting the muscles, ligaments and connective tissue in the lower pelvis—will increase by as much as 50 percent over the next two decades as baby boomers age.
Despite research showing that such pelvic disorders negatively impact women’s quality of life about as much as diabetes, an estimated 50 percent of women do not seek treatment. While the average woman may go to the bathroom eight times in 24 hours, including once during the night, women with pelvic disorders may be up several times a night. Many are used to carrying a change of clothes in case of involuntary leakage.
“These disorders don’t usually appear out of nowhere,” Dr. Rickey says. “A patient may have some symptoms and then they get a little bit worse, then a little bit worse.”
Women normally control bladder and bowel movements by contracting and relaxing the pelvic floor muscles, which form a hammock-like support for the bladder, rectum, small bowel, uterus and vagina. Changes such aging and childbirth (especially vaginal birth) can cause these muscles to weaken or tear, in some cases leading to prolapse, in which the bladder, urethra, cervix and/or rectum slip out of place.
With each patient we have a discussion about all the options, her lifestyle and treatment goals and come up with a plan that’s right for that individual woman. Leslie Rickey, MD
The longer a woman waits to seek treatment, the worse the condition can get, says Richard Bercik, MD, a urologist who specializes in urogynecology. He says he has seen patients who have used protective pads for years, which do not solve the problem and can cause irritation and infections.
Yale Medicine’s Pelvic Medicine & Incontinence Center includes physicians who specialize in urology and gynecology. Pelvic disorders may also affect the digestive tract, so Yale gastroenterologists and gastrointestinal surgeons are often consulted.
Many women find there are noninvasive solutions to their problems. “As many as a third of women who are referred to us for surgery don’t even go to surgery,” says Dr. Bercik. “If we can avoid surgery and treat with medicine or physical therapy, that’s our first approach.”
“I was very skeptical,” says Tucker, who had seen other doctors and had tried medication by the time she saw Marsha Guess, MD, formerly a Yale Medicine urologist, gynecologist and obstetrician (now at the University of Colorado), and Yale’s Cherrilyn Richmond, a registered nurse with advanced training in specialized pelvic physical therapy.
Richmond suggested Kegel exercises, typically taught to women to tighten pelvic muscles after giving birth. Kegels are performed by squeezing the muscles around the vagina. Biofeedback allowed Suzanne to watch the force and strength of her contractions on a screen.
Suzanne’s fluid intake turned out to be a problem as well. Many patients drink too much water or too many caffeinated beverages, which can exacerbate incontinence. Suzanne replaced most of her coffee with herbal tea, “and I don’t feel in any way that I’m thirsty now.”
Another patient, who is 67, gave Dr. Rickey a list of things urinary incontinence kept her from doing: exercise, dance, putting on a bathing suit. She says: “It affects all parts of your life, including your sex life.”
She wondered if she would have to undergo surgery. Instead, Dr. Rickey proposed injecting a gel-like material called Coaptite into her urethra, the tube that carries urine from the bladder. This would increase resistance to urinary flow and prevent leakage. The patient was able to watch the procedure on a monitor. “It’s really made my life much more pleasant,” she says.
Care and compassion
Patients worry about pain, but effective local anesthesia is available. Many women find the procedures are not painful. Discomfort during a cystoscopy, which involves inserting a scope into the urethra to look into the bladder, is minimized by using a topical anesthetic.
Richmond believes compassion is also a critical part of care. “We give women information before and during a procedure,” Richmond says. “I tell them every step of the way what’s coming next and what will happen after that.”
When surgery is necessary, even the most complex operations are often minimally invasive, and patients go home the next day. Drs. Bercik and Rickey have provided surgical interventions for women into their 80s. Minimally invasive surgeries may include reconstruction for pelvic organ prolapse, or slings to help support the urethra for incontinence.
Often, women are able to choose the treatment they feel most comfortable with. “Some people come into the office right away saying, ‘I’ve been dealing with this for 10 years. I just want the surgery,’” Dr. Rickey says. “Other want to try conservative options first. With each patient we have a discussion about all the options, her lifestyle and treatment goals and come up with a plan that’s right for that individual woman.”
Surgery was one of the possibilities that originally concerned Suzanne Tucker. Now she doubts she will need it.
“My ultimate goal is to never again require medication if possible,” she says. She has cut down to one cup of coffee a day and does her Kegels every night. “It takes all of 5 to 10 minutes at the most,” she says. “I don’t get up five times at night anymore. I can go on hikes.”