Ask questions to get past social stigma of pelvic floor disorders

Fecal and urinary incontinence are estimated to affect more than one-quarter of U.S. adults during their lives, yet many cases go untreated largely due to the social stigma attached to having such conditions and lack of awareness about effective treatments. However, recent research suggests that a simple screening process can lead to more diagnoses and that the disorders can be successfully treated through a variety of drug and non-drug strategies.

“Patients don't like to talk about these things,” said Karl M. Luber, MD, clinical professor of urogynecology at the University of California, San Diego and urogynecologist at Kaiser Permanente, Southern California. “If they do bring them up, it took a lot. They may not bring it back up. And it has a big impact on quality of life.”

Since patients who suffer from urinary or fecal incontinence often actively try to hide their condition out of embarrassment, it is important for physicians to ask the right questions, said Catherine DuBeau, MD, professor of medicine and geriatrics at the University of Chicago. She recommends that clinicians ask all patients whether they have any trouble with bladder control and, if they answer yes, how it affects them.

Diagnosis is crucial because pelvic floor disorders can have serious health consequences for the patient, according to a National Institutes of Health report in the March 18, 2008 Annals of Internal Medicine. Patients with the disorders often experience stresses in relationships, jobs and daily activities, and their social isolation and discomfort can lead to clinical depression.

According to the report, urinary incontinence in a community-based population increases with age, from 19% at age 45 or younger and then leveling off until age 70, at which it begins to rise again to 29% in age 80 years or older.

More than 20 million women have urinary incontinence or have experienced it at some point in their lives, the report estimated. Stress incontinence decreases with age, whereas urge incontinence increases with age. Urinary incontinence is prevalent in all ethnic groups, with some suggestion of higher rates among white women, according to Annals.

Urinary incontinence affects 5% to 15% of men and exhibits a more steady increase with age than women. While 5% of men younger than 45 have it, it increases to 21% in men 65 years or older. This increase primarily reflects urge incontinence and mixed urinary incontinence, with stress incontinence decreasing after age 65 years. About 6 million men have urinary incontinence in their lifetime.

Non-drug interventions

After determining that a patient has urinary incontinence bothersome enough to warrant treatment, a reasonable first strategy is to offer behavioral instruction, namely muscle strengthening exercises (Kegels) and advice about toileting scheduling, along with a look at medications or medical conditions that may be contributing to the disorder.

Alayne Markland, ACP Member, assistant professor of medicine and geriatrics at the University of Alabama at Birmingham, tests the strength of women's pelvic muscles during their annual exam.

“Have them squeeze and try to see how much they can maintain a vaginal squeeze,” she said. “Reinforce that this is an exercise they should be doing, 10-15 repetitions, and they should consider doing it every day.”

If symptoms continue to bother a patient, move to the second level of assessment in a timely manner and tease out whether the incontinence is “stress” or “urge” (also called “urgency” and “overactive bladder”).

Although there are many potential treatments available, pelvic floor muscle conditioning is the only one that works for both types. Other non-pharmacologic interventions include:

• Address common misconceptions. Assure patients that there is no medical need to drink eight glasses of water a day or that green tea does have caffeine, which can increase the need to urinate. Internists can also teach “mind over bladder” urge suppression techniques. The most common of these involve teaching patients to stop, stand still for a minute and then walk to the bathroom, rather than rushing right away, when they feel the urge to urinate. According to Dr. DuBeau, there are now functional MRI studies that have pinpointed parts of the brain that do not function the same in people with urgency incontinence as in other people.
• Counsel about weight loss. Advise moderately obese women that losing at least 5% of their weight may halve their incontinence episodes, said Jeanette S. Brown, MD, professor of obstetrics and gynecology at the University of California, San Francisco and director of the UCSF Women's Continence Center. Research has shown a link between obesity and incontinence, she said.
• Review medications. Dr. DuBeau noted that she has cured stress incontinence by simply getting someone off her ACE inhibitor, thereby alleviating the common side effect of coughing episodes that caused the incontinence.
• Control co-morbid conditions. Urine output can be reduced by controlling diabetes and sleep apnea, said Dr. DuBeau.

Pharmaceutical options

About eight different incontinence drugs are on the market. All are versions of antimuscarinics and work only for urge incontinence. Generally, they improve incontinence by 70%-80%. All of the currently available drugs have been proven to work as well and be as safe, said Dr. DuBeau. The difference has to do with how patients tolerate common side effects of dry mouth and constipation. It is not yet clear whether the drugs differ regarding the potential side effects of confusion and memory problems. The only available generic drug is oral oxybutynin; oxybutynin also is available as a topical patch. The other commonly used antimuscarinics include Detrol, VESIcare, Enablex and Sanctura.

Drugs can work an additional 11%-30% when combined with pelvic muscle conditioning and other non-pharmacologic treatments, according to Dr. Markland, as reported in the April 2000 issue of the Journal of the American Geriatrics Society.

Another Annals study from the Aug. 5 edition concluded that combining behavior and drug therapies for urge incontinence benefited patient satisfaction. While urge incontinence, or “overactive bladder,” is commonly treated with pharmacotherapy and behavior modification, most patients do not achieve complete continence with either therapy alone. In a trial, 307 women with urge incontinence were randomly assigned to 10 weeks drug therapy plus behavioral training or drug therapy alone. Six months later, 41 percent of women in both groups reported a 70 percent or greater reduction in the frequency of incontinence episodes without additional treatment. However, more women in the combination therapy group reported that they were completely satisfied with their progress than did women in the drug therapy-alone group. According to the authors, the study results suggested that patient satisfaction may be influenced by other features such as volume of urine loss, frequency of voiding, or intensity of the urge sensation.

In terms of stress incontinence, it is now known that estrogen does not help, and in fact can make incontinence worse, Dr. DuBeau said. It had long been common practice, but a Feb. 23, 2005 study in the Journal of the American Medical Association concluded that conjugated equine estrogen with or without progestin should not be prescribed for the prevention or relief of UI.

There are no other drugs in the development pipeline for stress incontinence, but many types of surgery are being used, developed, compared and debated. For urge incontinence, much research is underway on drugs that work differently than the antimuscarinics, including injecting botulium toxin into the bladder wall, which is not yet FDA-approved for that indication.

Other considerations

Although most attention to urinary incontinence has been paid to women, it also affects some men and isn't always related to an enlarged prostate, said Dr. DuBeau.

“What we now realize is that even if they have an enlarged prostate, the really bothersome symptoms that should be targeted for treatment may not be those related to any obstruction, but to bladder spasm,” Dr. DuBeau said. This has led to recent use in men of the antimuscarinic drugs most commonly prescribed for women with urge incontinence. It had been thought men might be unable to urinate and require catheterization if prescribed these drugs, she explained. A series of studies, however, has now shown them to be safe and effective for men.

Pelvic organ prolapse is a less-common but still significant pelvic floor disorder that may present in a primary care office. In a study by Kaiser Permanente of 4,000 women (80% had given birth), 6% percent had dropped pelvic organs compared with 25% with anal incontinence and 15% with stress urinary incontinence. The findings were published in the March 2008 issue of Obstetrics & Gynecology.

If a patient complains of something bulging out of their vagina, physicians should explain that it's rarely an emergency, said Dr. Luber. Commonly, he said, primary care doctors tell these patients that their “bladder has dropped,” and then women are terrified that their bladder is falling out of their body.

Instead, he recommends internists use anatomically correct language when talking to patients. Explain that they are seeing “skin on the wall of the vagina” and that they don't need to worry about it causing cancer or an infection.

In most cases of pelvic floor disorders, immediate referral to specialists usually is not necessary unless one of the following is present: sudden onset of incontinence; a urinalysis shows blood in the urine; a patient has a complex neurological disease (such as Parkinson's or multiple sclerosis); there is urinary retention; or a patient has had previous incontinence surgery or persistent and significant post-prostatectomy incontinence.