Maria Dube is a 37-year-old Burlington woman with two young sons who has a problem that’s often hushed up, though it’s shared by 20 million Americans, two-thirds of them women.
The wear and tear of childbirth left Dube, a telephone service representative for a Boston bank, with stress incontinence, which meant that every time she sneezed, laughed, jumped or chased her kids, she leaked urine. Asthma made things even worse. “I coughed so frequently, I had to use a pad all the time,” she said.
But several months ago, Dube underwent a 30-minute, minimally invasive surgical procedure that, some doctors say, is the most dramatic improvement in incontinence treatment in years.
While Dube was awake but under local anesthesia, her physician, Dr. George Flesh, head of urogynecology and pelvic reconstructive surgery at Harvard Vanguard Medical Associates, implanted a ribbon called a Tension-free Vaginal Tape between her urethra, through which urine flows, and her vagina. The tape is designed to act like a sling to support the urethra. The procedure is so new that only 20,000 patients worldwide have had it. Many doctors, even in a medical mecca like Boston, haven’t yet had the special training to perform it. But a three-year study in Sweden, where the procedure was developed, shows it works 90 percent of the time, and it clearly did for Dube.
Urinary incontinence comes in two basic forms: urge problems, in which bladder muscles go into spasm, making it impossible to stop urine flow once it starts; and stress problems like Dube’s, in which weak sphincter or pelvic muscles fail to keep the bladder neck closed during sudden physical stresses like coughing or exercising.
Incontinence can also occur in men when an obstruction – such as an enlarged prostate – blocks urine flow, leading to overflow or urge problems.
While the vaginal tape procedure is creating the biggest buzz, other new approaches – including an acupuncture-like system called SANS and a muscle-stimulating device called NeoControl – also may dramatically improve the quality of life for millions of incontinence patients.
For those with mild incontinence, the best way to start is with the simplest, least-invasive options.
For stress incontinence, this means doing Kegel exercises to strengthen pelvic floor muscles (the muscles that support pelvic organs). To identify these muscles, try stopping urine flow in midstream. If you can, you’ve found the right muscles. Once you’ve located them, practice this maneuver 100 times a day, but not during voiding, lest you retain urine.
If you can’t pinpoint the right muscles on your own – and many people can’t – go to a continence center (many hospitals have them) and ask for biofeedback training. Biofeedback is a system in which electrical sensors are placed on patches of skin or in the vagina or rectum; they send a painless signal to let you know you’re contracting the right muscles.
A new alternative, NeoControl, may be more appealing for some people with stress or urge incontinence. You sit on a special chair, fully clothed, with an empty bladder. Magnets under the chair produce a pulsed magnetic field that acts on nerves to cause pelvic muscles to contract.
“When you stand up, you feel like you just got out of the gym, but only in the pelvis. It feels sore but not unpleasant, like a workout,” said Dr. Peter Rosenblatt, a urogynecologist and codirector, with Dr. Neeraj Kohli, of the Cambridge Continence Center at Mt. Auburn Hospital in Cambridge.
About 60 percent of patients who use NeoControl improve after two months of twice-weekly sessions, Rosenblatt said.
Vaginal cones, which are available by prescription, are another simple solution for stress and urge problems. These are tampon-like devices held in the vagina for 15 minutes twice a day to strengthen muscles.
Other devices, also available by prescription, include Capsure and FemAssist, which are reusable suction cups that cover the opening of the urethra and are pulled off before urination. There is also a disposable patch called Impress that sticks to the urethral opening like a BandAid; it, too, must be changed before urination, but it may be available over-the-counter soon.
If urge incontinence is your problem, bladder retraining may help. The idea is to stick to a pre-set schedule, urinating regularly before the bladder gets too full, and learning to suppress the urge to urinate at other times. A variant on this is the AcuTrainer, a prescription beeper that your doctor programs to tell you when to urinate. The program gradually increases the interval between voids.
Recently, the US Food and Drug Administration approved another option for urge incontinence, the SANS (for Stoller Afferent Nerve Stimulation) system, after research showed that 55 percent of women who tried it had at least a 25 percent reduction in urgency or frequency.
In SANS, the tip of an acupuncture-type needle is placed just under the skin above the ankle, a site known to acupuncturists as “spleen 6.” A mild electrical current is passed through the needle to stimulate a nerve that controls the sacral nerve in the lower back, which in turn controls the bladder. The treatment calms the nerves to the bladder, which are hypersensitive in many people with urge incontinence.
The SANS treatment is similar to a more invasive, and expensive, surgical procedure in which a device called InterStim is implanted in the lower back to control nerves to the bladder.
And there are other options, too. For stress incontinence, especially a severe form called intrinsic sphincter deficiency, collagen injections – via a needle passed through the urethra – fill the space around the urethra, squeezing off urine flow.
A similar approach involves injections with Durasphere – carbon pellets in a gel-like suspension. Unlike collagen injections, whose effect tends to wear off after two years, Durasphere injections should last longer because the material is not absorbed by the body.
For sheer convenience, however, many people opt for medications rather than devices.
Estrogen can make the urethra more pliable and help it close more easily. It can be taken as pills, patches, vaginal cream or a vaginal ring called Estring that releases the hormone slowly over three months.
Nasal decongestants like Sudafed and a prescription decongestant called Entex can also help with stress incontinence because, as a side effect, these drugs act on proteins called alpha-receptors, which help the urethra contract.
For urge incontinence, other drugs help – notably the old standbys Ditropan and Levbid, and newer ones such as Detrol and Ditropan XL (extended release). These drugs block acetylcholine, a chemical secreted by nerves that tells muscles to contract. The newer drugs cause fewer side effects like dry mouth and constipation.
Tofranil, an antidepressant that, like the decongestants, has the useful side effect of relaxing bladder spasms and tightening the urethra, can also help. For men with incontinence caused by an enlarged prostate, drugs like Hytrin or Flomax that relax the urethra also work. So does shrinking the prostate itself – with drugs or surgery.
Surgery is an option for some women, too. For those with stress incontinence, the traditional approach is the Burch procedure, a “suspension” technique in which surgeons tighten up the pelvic fascia (fibrous tissue that lies on top of muscles) by stitching it to ligaments near the pubic bone.
Traditionally, this is done through an open abdominal incision, which means the patient spends several days in the hospital, but can count on an 80 to 90 percent chance of being markedly improved for at least five years.
Recently, some surgeons – perhaps half a dozen in Boston – have been using a laparoscopic approach. Instead of making a 4- to 5inch abdominal incision, they operate through two tiny incisions using miniature TV cameras to guide their way. The surgery is technically difficult, but appears to have the same success rate as the standard Burch procedure.
But it’s the new vaginal tape procedure that may prove most appealing for women whose main problem is a sagging urethra, not a sagging bladder as well.
“It’s fantastic,” said Rosenblatt of Mt. Auburn Hospital, who has done 150 such procedures. So far, it seems to enable women to have less pain, a shorter recovery and to solve the problem in 85 to 90 percent of cases.
Dube, the energetic mother who had the tape procedure, agreed. “I used to have to cross my legs every time I sneezed,” she said. “Now I swim, run, everything. I don’t have to use pads.” Her advice? “Just do it. It will take a week of your time” to fully heal. “But it’s worth it.”