With approaching menopause and during the years that follow, normal aging and declining estrogen levels may affect the lining of the urethra (the tube through which urine empties from the bladder), causing it to become thin and the surrounding muscles to weaken. As a result, a woman may have involuntary leakage –called incontinence (especially when sneezing, coughing, laughing, or lifting), more frequent urination, urgency (suddenly needing to urinate even though the bladder may not be full), nocturia (getting out of bed to urinate several times during the night), and painful urination. Other common causes of these problems are urinary tract infections, other medical conditions (such as nerve disorders), and certain prescription drugs (like diuretics and tranquilizers). Therefore, a diagnosis must confirm the exact cause –one should not just assume it’s old age or menopause.
Early diagnosis and treatment can often completely cure the problem; if a complete cure is not possible, at least comfort can usually be improved. Although as many as 40% of women aged 45 to 64 have urinary incontinence, fewer than half seek help –often because of embarrassment or the misconception that the condition is an inevitable consequence of aging and cannot be treated.
Stress Incontinence – On the underside of the bladder and the urethra, the tube that drains the bladder to the outside when you urinate, there is a strong band of tissue which extends from both sides of the pelvic bone. This has various names such as the posterior urethro-vesicular ligament. When a woman has a baby, or after years of hard work and lifting, or after menopause when there is less hormonal support, this band of tissue can either weaken or rupture. This causes the bladder and the anterior wall of the vagina to descend. This results in the sudden leaking of small amounts of urine with laughing, coughing, jumping and other stresses which apply a force on the pelvic floor. Often, it is easy to diagnose this by simply putting a Q-tip (Q-tip test) in the urethra and having someone strain down. If the Q-tip descends and you can see leakage on coughing, you have a diagnosis. This is best treated with simple surgery which reconstructs the “sling.”
Urge incontinence – This is caused when the bladder becomes unstable and cannot tolerate stretching. The most common cause is a urinary tract infection but there are other causes including interstitial cystitis, an inflammatory disease of the bladder, lack of hormones, irritation by medications etc. The typical clinical story is the individual who has to map out every restroom in the Mall because when they develop the urge to void, they must go immediately or they will completely empty their bladder and soil their clothes. This is best treated with medications.
Neurogenic incontinence – this is, tragically, a common problem in the elderly, in diabetics, people with strokes and other neurological conditions and leads to total loss of control of urination. It needs to be diagnosed with uro-dynamic studies.
A thorough assessment involves a comprehensive medical history and physical examination – both general and neurological, and an examination of the urine for blood and signs of infection. If these studies are unremarkable, some simple measures make by taken to try to relieve the symptoms such as treatment of an infection, pelvic floor exercises, changing of medications, or topical hormones. If things are do not improve with a reasonable period of time, further assessments of the functioning of the bladder and kidney may be necessary including looking inside of the bladder with a cystoscope, checking the urine for the presence of malignant cells, and studies of the function of the bladder through pressure studies called urodynamics. If specific functional abnormalities are founds, medications may be used to improve the functioning of the bladder and give better control. If the problem is an anatomical weakness of the bladder supports (and this is the most common cause of persistent incontinence, particularly in women age 30-60) than surgery may be indicated. There are many surgical approaches including vaginal, abdominal, and laparoscopic approaches as well as the placement of mesh slings under the bladder and urethra.