Ending the silent suffering of urinary incontinence
Written by Michael Seringer
Increasing awareness about safe and effective interventions and dispelling myths about urinary incontinence are important first steps in significantly improving the quality of life for an aging population.
Urinary incontinence is common in both older women and men: Half of postmenopausal women and more than 25% of men over the age of 60 experience an overactive bladder. Despite its prevalence, urinary incontinence is not inevitable.
Sylvia Botros-Brey, MD, associate professor of urology and program director of the Female Pelvic Medicine and Reconstructive Surgery Fellowship at UT Health Science Center San Antonio, points to common misperceptions about urinary incontinence as the main reason many women with the condition fail to seek treatment. The belief that incontinence is a normal part of aging and the idea that it can be managed with over-the-counter products designed to disguise the problem prevent many women from seeking care, Botros-Brey said.
Older populations are particularly affected by urinary incontinence mythology and are often told to alter their lifestyle and to start budgeting for adult diapers or pads. This conventional thinking fails to consider the real costs of urinary incontinence and diminishes access to effective interventions, she said.
“There are too many myths about urinary incontinence, and it limits patients from wanting to go out and do things,” Botros-Brey said. “Patients suffering from urinary incontinence limit their social interactions. They plan their interactions around bathroom visits. They are embarrassed to spend the night at friends’ or family members’ houses because they might leak in the bed. There are lots of ways these misperceptions contribute to debilitating social isolation among older populations.”
Urology and Department of Medical Education, and program director
of the Female Pelvic Medicine and Reconstructive Surgery Fellowship
Misperceptions about lifestyle and incontinence keep many patients and their physicians in a “just deal with the symptoms” mindset that dictates the trajectory of their treatment, she added. Lifestyle changes often fail to consider the patient’s reality. For example, obese older adults suffering from urinary incontinence are told losing weight will improve the condition. In reality, the threat of a leak prevents many people from increasing their activity, making the prospect of losing weight all the more challenging.
“The trick with losing weight first is that it is difficult to lose weight when leaking, and I have had patients who, once we treat the incontinence, can then go out and exercise to lose the weight,” said Botros-Brey. “I try in my practice not to say, ‘Oh, go lose weight and come back.’ I realize if they could have lost weight, they probably would have.”
Botros-Brey combats misperceptions regarding urinary incontinence in her clinical practice as well as in her role supervising fellows who are focused on patient-centered medicine, in which shared decision-making between the patient and physician is part of a comprehensive care plan. This approach prioritizes listening to the patient to target therapies to the patient’s needs while reducing barriers to care.
Effective interventions for women
Two effective clinical interventions exist for women seeking treatment. Both the midurethral sling and Botox injections in the pelvic floor are procedures that are easily tolerated with proven results among women suffering from incontinence. The midurethral sling has a long history of being a safe and effective procedure for stress incontinence, while Botox injected in the bladder has become a game-changing treatment for urgency incontinence, Botros-Brey said. With each of these treatments, patients can go home the same day.
The midurethral sling acts like a hammock, helping to lift and support the urethra to prevent leakage during moments of increased pressure that cause stress incontinence. Stress incontinence happens when pressure is placed on the bladder muscles during activities such as sneezing or getting up from a seated position. By providing support to the urethra, the mesh sling improves bladder control. Midurethral slings have demonstrated effectiveness for years depending on contributing factors such as the type of sling used, patient comorbidities and age.
Botox (botulinum toxin) injections in the pelvic floor are an effective treatment for an overactive bladder or urge incontinence. Urge incontinence is characterized by a sudden and frequent need to urinate, often leading to involuntary leakage. By temporarily relaxing the muscles in the bladder, Botox reduces the urge to urinate and provides effective relief for six to 12 months.
“Botox in the bladder has done for urgency incontinence what slings have done for stress incontinence,” said Botros-Brey. “The treatment is reproducible; anybody can do it. It’s an office procedure, so you don’t have to go to the [operating room] to get it done. I have seen life-changing results with Botox.”
A masterclass in innovation for men
Urinary incontinence in men results primarily from benign prostatic hyperplasia (BPH), also known as prostate gland enlargement. A common condition that affects older men, BPH involves the noncancerous growth of the prostate gland, which can lead to urinary incontinence due to pressure on the urethra. As with women, many men with BPH don’t learn about effective interventions for urinary incontinence and instead focus on hiding the symptoms instead of solving the cause of the problem.
BPH is the most common prostate problem for men older than age 50, affecting about 50% of men between the ages of 51 and 60 and up to 90% of men older than 80, said Ahmed Mansour, MD, assistant professor of urology and endowed professor of the Walsdorf Family Professorship in Urology at UT Health Science Center San Antonio. Many men simply learn to live with BPH-induced urinary incontinence because the symptoms are seen as an inevitable result of aging. Ignoring the lifestyle limitations and social isolation that occurs with urinary incontinence has a negative impact on men as they age, often leading to more serious problems.
“It is a hard thing when urination becomes the center of your day,” said Mansour. “The urgent need to urinate frequently can often limit their ability to travel for long periods of time or attend long meetings because they must constantly be near a bathroom. The most bothersome symptom is patients’ frequent need to get up at night to urinate, which disturbs their sleep. This can cause daytime fatigue, affect their daily activities and increases the risk of falling.”
A life-changing procedure
Mansour stated that there is a non-pharmacological intervention that can effectively treat BPH and reduce incontinence called the Holmium Laser Enucleation of the Prostate (HoLEP) procedure. HoLEP provides an effective, less-invasive treatment for BPH that results in less bleeding, fewer blood transfusions, shorter time with a catheter in place and reduced hospital stays. While HoLEP does not cure all urinary incontinence, it can reduce symptoms in the lower urinary tract by shrinking the enlarged prostate.
“HoLEP is a procedure in which the prostate is approached internally [endoscopically], through the urethra, without any cuts on the skin. The laser is used to peel the enlarged part of the prostate from its outer capsule, just like peeling an orange without cutting it into pieces,” said Mansour. “This leads to maximal relief of prostate obstruction with less bleeding risk and less chances of recurrence of symptoms.”
HoLEP is available in only a few medical institutions nationwide. Although HoLEP is a technology that has been around for more than 30 years, it has failed to catch on among urologists and represents only a small fraction of prostate interventions. The lack of HoLEP expertise and training leads to a lack of access to this noninvasive procedure and forces most men into the more traditional surgical interventions or simply altering their life to manage symptoms.
“Although considered as the new gold standard, HoLEP currently represents less than 5% of BPH surgical procedures performed annually in the U.S.,” said Mansour. “It is performed mainly in limited centers of excellence nationwide, including UT Health Science Center San Antonio.”
To increase access to HoLEP interventions, UT Health Science Center San Antonio incorporated HoLEP training into its residency program and created the inaugural “HoLEP Masterclass,” a two-day, intensive training course for urologists across the globe. For the first time in the U.S., this training includes HoLEP training on cadavers. The intensive masterclass curriculum is popular among urologists and is an important first step in increasing access to HoLEP interventions for men suffering from BPH.
Because the HoLEP procedure is difficult to perform, requiring a high level of training, the class is critical to get urologists prepared to provide the intervention to their patient populations. UT Health Science Center San Antonio’s HoLEP masterclass faculty work closely with urologists after the class ends to support their efforts to bring HoLEP to their health care organization, Mansour said.
Increasing awareness of interventions and dispelling myths about urinary incontinence are important steps in improving a patient’s quality of life, from minimizing costs for absorbent pads to removing the resulting social isolation of a life largely controlled by proximity to a restroom, he said. Educating patients and physicians helps reduce the hidden costs and stigma of this condition. By promoting effective, non-invasive interventions, physicians at UT Health Science Center San Antonio are breaking the silence long associated with urinary incontinence.
