Management of Urinary Incontinence

LBL was not a term I was aware of until relatively recently at which point advertisements for Poise incontinence liners and pads seemed to almost explode overnight on TV, in magazines and online. In fact I reckon the only people that this abbreviation meant anything to prior to the recent use of the initialism “LBL” (apparently it is not an acronym – fun fact for the day) were people from Latvia (and fans of the Latvian Basketball or Baseball league) and/or aficionados of the musical style of one DJ Lucas Cornelis van Scheppingen (otherwise known as Laidback Luke). Clearly it is the LBL of the poise variety that concerns more women than those of the other less common LBL varieties although I apologize in advance to any DJ loving Latvians out there who may be reading this blog. Yes – Wikipedia is indeed an amazing resource through which one can troll in order to amuse oneself.

LBL in my line of work refers to urinary incontinence. That is, the loss of bladder control leading to leakage. Urinary incontinence can occur at any age. Most commonly it is experienced by women who have had babies (either vaginally or by cesarean) but can also occur in women who have never been pregnant. Bladder leakage is most commonly seen in women over the age of 50. It is around this age where estrogen levels start to plummet and some of the functioning of the bladder and its supports in the pelvis start to weaken. Sometimes the simple use of estrogen vaginal cream to boost estrogen levels in the vagina can make all the difference to bladder function.

Many women these days are more open about problems with their bladders. This is evidenced by the fact that incontinence aids such as pads are now so widely advertised. However, many women also have difficulty in talking about these issues even with medical staff. Not dealing with their incontinence can give rise to problems such as skin rashes and infection, bladder infections and may also lead to social withdrawal because of fear of unexpected accidents and resultant embarrassment. For some women the resolution of the bladder leakage that they have sometimes suffered with for years can be life-changing.

There are several different types of urinary incontinence –

Stress incontinence – this is the most common type of leakage that women suffer from. This is the leakage that gives you problems when trampolining, coughing, sneezing, running after the kids. Any sort of activity which places pressure on the bladder. It is most commonly associated with having had a vaginal birth (or births) but can be a problem even after cesarean deliveries. Just being pregnant is a risk factor for stress incontinence. The leakage is due to a loss in support of the bladder outlet or neck. When support is weakened –control over your bladder when pressure is placed on it is weakened or lost. The good news is that this leakage can in some instances be reduced or stopped completely with pelvic floor rehabilitation alone – i.e. pelvic floor exercises. Some women poo-poo the idea that a pelvic floor physiotherapist might be able to stop their leakage. However, not only will a good pelvic floor physiotherapist sort out your pelvic floor muscles, they will also look at many other things which will have an impact on not only your bladder but your other pelvic organs as well. They will look at your dietary and fluid intake, your bowel function (constipation is often a big factor in bladder issues) and they will assist with sexual function and dysfunction (if necessary). I send ALL my patients initially to a good pelvic floor physiotherapist as I know that many of them will have their problems sorted WITHOUT the need for surgical intervention. I’ve had some patients that have solemnly declared that they have been doing pelvic floor exercises “for years” since the births of their children, only to discover that “for years” they had been doing them wrong. Once corrected in their technique – whaddya know – some of them are significantly improved to the point where they don’t require my services.

There are minimally invasive (compared to previous operations) surgeries that can be performed for stress incontinence. These surgeries involve placement of a “sling” under the bladder neck in order to replace the support that has been lost. These sling procedures have a long term success rate of 70-80% and the risk of complications is low

Urge incontinence – this is the leakage that occurs when women have such strong a strong urge that they cannot hold on to get to the toilet in time. This sort of leakage happens with women with Overactive Bladder Syndrome (but also other conditions) which I have discussed previously in one my blogs HERE. Urge incontinence is the leakage that women suffer from when they get home from the shops and are struggling to get the key in the door of their house quick enough to get inside to the toilet. I have known patients who have had this urge SO BAD that they have squatted in their own garden rather than have an accident at the front door.

The pelvic floor physiotherapists again come into their own here with the use of not only pelvic floor exercises but also bladder retraining protocols. Sometimes, the development of urgency and frequency (going lots) can be a learnt behaviour which can also be unlearnt. Sometimes, the development of urgency can be a simple sign of a bladder infection which can be treated with antibiotics. The use of medications to suppress the urge sensation in the bladder can be extremely effective. The Neotonus magnetic chair can also assist in strengthening the pelvic floor muscles and modulating the urge sensation in the bladder. It is most effective in women with urge incontinence. Sometimes (not often) severe urgency can be a sign of more sinister conditions in the bladder so it should be investigated thoroughly.

Overflow incontinence – this is uncommon and often consists of a constant drip of urine cause by leakage from an overfilled bladder. It can be caused by either a blockage of the exit of urine from the bladder or by disturbances of the nerve supply to the bladder. Medications can sometimes cause this problem. This sort of incontinence is usually treated by a urologist and can sometimes necessitate the use of catheters – either temporary or permanent. This sort of incontinence is very uncommon.

Functional incontinence – this is most commonly seen in elderly patients who have ambulatory difficulties rather than bladder issues per se. In other words, their bladders function relatively normally but due to certain issues (e.g. severe arthritis) they just can’t get to the toilet in time.

So what happens when you see a doctor regarding your bladder leakage?

The first thing they will do is take a detailed medical history – most specifically about your leakage: how long have you had the leakage, when does it occur, what have you tried already, what is your understanding of the problem? They will then go on to take a detailed history focussing on your bladder function in general, bowel function and any problems with sexual activity. You’re probably thinking, “What a nosey parker!!!”. However, this information is useful as many women with bladder issues also have problems with their bowel function and not infrequently pain with intercourse. Most women will not spontaneously tell even their gynaecologist about issues they have with intercourse or with their bowels. If you never ask the question, in most cases you will never find out about the problem until it’s so far down the track that it will take ages to get things back to normal.

Part of the history will also look at past medical issues, past surgery, allergies, smoking (yes it makes your bladder worse as well as pretty much everything else in your body), and alcohol and caffeine intake (irritates the bladder – but you didn’t need me to tell you that), medications (some of which can worsen bladder function). Even some foods can irritate the bladder. Curries, tomatoes, chocolate and citrus fruits are good examples.

Physical examination will tell us not only about the anatomical state of your bladder and vagina but also whether there are significant signs of lack of estrogen which can be reversed with the use of estrogen cream.

Further investigation might include a urine test (to check for infection or blood in the urine), pelvic ultrasound (to check for pelvic masses e.g. ovarian cysts, which may be pressing on the bladder and to ensure that your bladder is emptying properly) and a bladder diary (a record of how much and when you emptied your bladder).

Once all the information is collated, an individual plan for the treatment of a woman’s leakage can be formulated. Ongoing monitoring of the effectiveness of the treatments is necessary but usually once a level of acceptable control is attained most women can return to their GP for ongoing care.

On a final note – I think that the use of the term LBL to some extent trivialises the potentially devastating effect that even a small amount of urinary incontinence can have on a woman’s life. Let’s call it for what it is – it’s not light bladder leakage, it’s “peeing your pants”. Even the packaging for Panadol warns “Consult your healthcare professional is symptoms persist”. Yet, we as a society seem to think that it’s okay to use a chronic Band-Aid solution such as pads in order to ameliorate a condition that not only might have an underlying sinister cause but also might in fact be curable or at least significantly improved. If urinary incontinence is a problem for you – don’t cover it up – see your GP and get it sorted sooner rather than later.