Health
Embarrassing problems Print E-mail
Written by Amanda Finn and Women's Health, 2008   
Amanda Finn looks at incontinence, a problem causing concern for thousands of women, and we look at sexual health during menopause.

Mending the leak

Amanda Finn, Senior Specialist Physiotherapist at Spire Health Care in Norwich, looks at incontinence, a problem causing concern for thousands of women

Incontinence, the involuntary loss of urine, is about four times more common in women than in men. By the age of 75 at least 16 per cent of women experience some incontinence, but younger women can also be affected. At our Women's Health Clinic, the Continence and Pelvic Floor Physiotherapists help women to improve and cope with the problems - there is no need to suffer in silence.

Urine is produced by the kidneys and collected in the bladder, which expands like a balloon as the volume increases. When full, the bladder empties to the outside through the urethra. Most people need to pass water every three to four hours during the day and up to once or twice in the night.

For normal urination, the muscular wall of the bladder has to contract at the same time as the valve mechanism of the bladder relaxes. Most incontinence in adults results from problems with one, or a combination, of these processes.

The following are a few of patients' commonly asked questions.

How do I know if I'm incontinent?

If you regularly pass urine accidentally or just leak for no reason, you may well have incontinence. Although many people try to manage on their own, often because it's a source of embarrassment, medical advice should be sought sooner rather than later because help is available.

What is stress incontinence?

This is defined as involuntary loss of urine from the urethra during physical exertion such as when you cough, sneeze, lift, pull, push or go from a sitting to a standing position.

What is urge urinary incontinence?

Urge incontinence is associated with the involuntary loss of urine associated with an abrupt and strong desire to urinate. A person with this problem will often urinate more than once in an hour.

What causes urge incontinence?

An unstable overactive bladder muscle is one cause. Certain foods and beverages such as alcohol, coffee and tea can cause someone to have increased urgency to urinate and often. It is also due to poor pelvic floor muscle strength. People with this problem cannot wait to go to the toilet and therefore leak.

Case study: Solution is in the pelvic floor

Mary is an active 50-year-old part-time teacher whose job involves prolonged standing, sit-to-stand transfers and lifting heavy books. She came to physiotherapy complaining of leaking with coughing and sneezing, but she also complained of urinary urgency and urge incontinence as well.

She drinks a lot of coffee and tea and her symptoms have apparently been ongoing for over 21 years. She says she has had symptoms of irritable bowel syndrome (IBS) since the age of 26. Her two children were born vaginally, of average weight. Mary herself is 168cm (5ft 6in) and weighs 75kg (165.5lb).

On further probing, she tells the physiotherapist that she was late stopping bedwetting in childhood and that she smoked. As well as IBS, she reported low back pain problems.

When she did an internal vaginal pelvic floor muscle assessment, the physiotherapist found that Mary's pelvic floor muscle strength was very limited and the speed of muscle contractions slow. She also needed to be told to hold in her pelvic floor muscles during coughing.

The physiotherapist taught her the correct way to do pelvic floor muscle exercises to build both speed and endurance of the pelvic floor muscles, which are essential to reduce low back pain and to decrease incontinence and urgency of the bladder.

The therapist discussed with Mary the importance of reducing caffeine and alcohol intake in order to reduce her tendencies to an over-active bladder and concentrated urine. She advised her to drink at least 6-8 glasses of water a day, but to stop drinking after 8pm to avoid waking for the toilet and disturbing her sleep patterns.

During the course of physiotherapy treatments, Mary learned to use a home electrical stimulation unit in order to strengthen her pelvic floor muscles and to decrease her over-active bladder. She also practised gaining more power to her pelvic floor muscle contractions as well as improving her timing, co-ordination and relaxation of her pelvic floor muscles through the use of biofeedback. Biofeedback allowed her to hear and see the activity of her pelvic floor muscle actions and nerve function.

The physiotherapist further developed her programme with accessory muscle strengthening and core stabilisation exercises. Physiotherapy emphasises the use of the pelvic floor muscles during episodes of increased intra-abdominal pressure such as lifting, coughing and sneezing.

Mary was discharged after six visits but she began to make improvements in her pelvic floor muscle function as bladder and bowel behaviour after just one assessment (visit). As she gained muscle strength in her pelvic floor, she began to notice improvements in her IBS as well.

Further information

If you are troubled by stress incontinence, ask your GP to refer you to a physiotherapist specialising in women's health, or visit www.acpwh.org.uk, the website of the Association of Chartered Physiotherapists in Women's Health, a UK based clinical interest group. You can also visit www.spirehealthcare.com/norwich

Sexual health during menopause

If sex has become an ordeal as a result of lowered oestrogen levels, there are treatments available

Results from a recent online survey have shown that many women are suffering from the menopausal problems of vaginal dryness and painful intercourse (dyspareunia) yet very few are asking health professionals for advice, even though effective treatments are available.

The survey on www.menopausematters.co.uk, which received over 1,000 replies, showed that although 88 per cent of respondents thought that continuing an active sex life was important, 53 per cent had experienced dyspareunia of which only a small percentage (12 per cent) had received treatment. Many hid their symptoms from their partner and made excuses to avoid having intercourse because of the discomfort.

Whether women are unaware that treatments are available or they are too embarrassed to ask for help, it is clear is that health professionals should be asking women specifically about the common menopausal problem of painful sex, both when discussing menopause issues and when older women are attending for smears.

Available treatments

The vagina is kept moist and supple by fluids and mucus produced by glands at the neck of the womb. During and after the menopause the body produces less oestrogen.

This is thought to lead to a thinning of the tissues around the vaginal area and in turn a loss of the mucus-producing glands. This cycle leads to the reduction of natural lubrication of the vagina.

The treatments available for vaginal dryness may depend on which symptoms - e.g. pain, discomfort, discharge, itching - are the most troublesome. One solution is localised oestrogen therapy in the form of vaginal tablets, pessaries or creams.

These are inserted into the vagina twice a week and act by delivering oestrogen directly where it is needed, to the dry thin walls of the vagina, and can help relieve painful intercourse by restoring the vaginal tissue. Unlike lubricants, such formulations do not need to be inserted into the vagina before sex.

HRT is usually taken by mouth, or as a skin patch, and helps deal with all oestrogen deficiency symptoms, including vaginal dryness. In some cases HRT is not enough to resolve the problem of painful intercourse and if this is the case the HRT and local oestrogen can be taken together.

Because of concerns regarding the link between HRT and more serious health complications, current safety advice is that HRT should be used for the shortest possible time at the lowest effective dose, with treatment reviewed annually in consultation with a doctor.

Vaginal lubricants can be useful for vaginal dryness, particularly for women who are not suited to oestrogen replacement. However, they can be messy and need to be applied each time before intercourse in order to be effective.

More information needed

Other surveys carried out on www.menopausematters.co.uk - a website providing up-to-date, non-biased information on many aspects of menopause - were also reported: for example, regarding women's views on HRT, 75 per cent of respondents were in favour of HRT, 36 per cent felt that media reports of the risks of HRT had been exaggerated, and 73 per cent felt that they did not know enough about HRT to make informed choices.

Hormones after surgery

If the menopause has been brought on as a result of surgical removal of either the ovaries or uterus, the symptoms are more sudden and pronounced since the ovaries and uterus are a source of both oestrogen and testosterone. Levels of testosterone may decrease by as much as 50 per cent within days after surgery.

Changes in oestrogen level at menopause are linked to hot flushes, sleep disturbances, vaginal dryness and mood changes. Testosterone is believed to be very important in female sexual function (sexual arousal, desire and pleasure). Another website www.desireandmenopause.co.uk addresses the issues, urging women to seek help from their GP.

 
[ Back ]