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BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CASE NOTES 2. - Urinary Incontinence
RADIO 4
THURSDAY 21/12/04 2100-2130
PRESENTER:
MARK PORTER
REPORTER: TRISHA MACNAIR
CONTRIBUTORS:
MARK SLACK
KATIE JEITZ
JUDITH WARDLE
LINDA CARDOZO
ELLIS DOWNES
PRODUCER:
PAULA MCGRATH
NOT CHECKED AS BROADCAST
PORTER
Hello. Today's programme is all about the bladder - a part of the body that's rarely given a second thought, unless it needs emptying. But it's a very different matter for the one in six of the population with urinary incontinence, many of whom think of little else.
VOX POP
You are very concerned during the summer months when it's warm, is there a smell, you need to wear pads which are not very pleasant, I mean it's not very nice to have to deal with at all.
PORTER
Few things are more embarrassing than wetting yourself and incontinence can have a profound impact on psychological and social wellbeing, affecting everything from what a person wears to what they do and who they see. Little wonder so many suffer in silence, putting up with their symptoms for years before plucking up the courage to seek help, if they ever do.
We're going to be concentrating on incontinence in women because the vast majority of sufferers are women. First up: pelvic floor exercises, which are supposed to help bladder control but only if they're done probably.
CLIP
Women should really be doing pelvic floor exercises throughout their life, you don't need to do it as many as three to four times a day about 50 contractions, you only need to do it maybe two to three times a week but doing a full set of contractions - both slow holds and quick holds.
PORTER
Next the world's first ever pill for stress incontinence, launched amid much publicity a few months ago, we sent Trisha Macnair to find out if it's living up to the hype. And if pelvic floor exercises and pills don't help then what about surgery? The latest techniques can be done as day cases and have success rates approaching 90% in expert hands. I'll be finding out what's involved.
My guest today is Mark Slack, he's a consultant gynaecologist, specialising in urinary problems and works at the Addenbrookes Hospital, Cambridge.
Mark, let's start with the basics - how much urine does the bladder hold or can it hold, how does it let us know when it's full and what stops it emptying inappropriately?
SLACK
The bladder's actually an amazing organ, I mean it holds about between 250 and 500 mils.
PORTER
So up to a pint - just over a pint.
SLACK
Almost just over a pint. And the amazing thing about it is it's an organ which actually holds the urine when you need it to hold until the point comes that you want to empty and it empties. And it's incredibly complex and surprising - it's not surprising it does go wrong.
PORTER
So what's it doing - how does it let me know - in that urge that you get to pass water, is that when the urine gets to a certain level in the bladder?
SLACK
Sure, I mean it's got lots of receptors in and what it does is as it fills up, at a certain point, it starts saying to your brain - look, you know it's time we went and did something about that. And there's usually - in a normal person - time to actually find an appropriate place or time to go and pass urine. In the sufferers they don't have that sort of luxury.
PORTER
Why are women more prone to urinary problems than men?
SLACK
I mean I use the term - and I'm quite careful here - but it's essentially a design fault in many respects. The male urethra is a lot longer than the female urethra and they're far more capable of actually maintaining urine continence.
PORTER
The urethra being the pipe from the outlet of the bladder to the - in the case of the men - to the end of the penis?
SLACK
Correct. And in the female this is only two and a half centimetres long and yet it's got the responsibility of keeping all the urine, up to a pint, in the bladder all the time. And so things that go wrong with the female urethra, with the pipe, and things go wrong with the pelvic floor lead to these problems.
PORTER
And talking about pelvic floor of course one of the big associations with urinary incontinence in women is childbirth - most women who have had a baby have got some problem, haven't they, some ...
SLACK
Yeah, I mean you're basically, for the vast majority of people, you've got to have a child to have this problem. The difficulty for us is knowing the precise relationship between pregnancy and what's causing this because in a lot of people we think it's just the pregnancy alone, not necessarily the act of delivering the child.
PORTER
What so you still get problems even if they have the baby by caesarean section?
SLACK
Some women even despite a caesarean section and that's an area of enormous study and activity and interest. And basically as well it's also the first baby you've got to avoid, so you really should start at the second.
PORTER
Easier said than do. What about the different types of incontinence?
SLACK
Right there are lots of different types of incontinence and I think for the sack of our chat between the two of us I'm going to concentrate on two. The really common one is stress urinary incontinence and that's a loss of urine when the person coughs, moves, jumps, sneezes, laughs - sudden involuntary efforts - and they get a tiny loss of urine, usually small amounts but enough to wet their clothing, enough to irritate, enough to embarrass. And the other one is overactive bladder incontinence and that's a condition where people need to go many, many times, so the bladder's not working properly anymore, it's not holding the urine like it should do, not giving you the warnings, not giving you the time. So people go frequently during the day, they get up two, three, four, five or more times at night. We find that people suddenly get an urge to go and before they can pass urine the bladder starts to work and they wet their clothing with all the attendant embarrassment. You can also then get a sort of mixture of those two.
PORTER
And that's quite common isn't it.
SLACK
Very, very common, you get a bit of stress and you get a bit of urge.
PORTER
Where do pelvic floor exercises come in? I mean we're always hearing about them being taught as a first line intervention in women with urinary problems, presumably they're helping stress incontinence.
SLACK
Sure, they help stress incontinence principally, they also have some help for overactive bladder. The great thing about exercises is they do you no harm, they can only do you good, for a percentage of people they'll cure them.
PORTER
And they're actually working by presumably tightening up the valve at the bottom of the bladder, they're helping you retain that voluntary control.
SLACK
Correct, they tighten up the valve, they also tighten up the pelvic muscles which hold the bladder in the right position.
PORTER
But there is one problem with them isn't there that they have to be done properly to work.
SLACK
Absolutely, I think it's no use - we've done - they've done studies, they've done science - it's no use giving people a little booklet or piece of paper and saying go and do this, they really, really need an expert to make sure that they're doing the right muscles, doing the right exercises.
PORTER
Well as Mark says one way to ensure you do the exercises properly is to be taught by an expert and physiotherapist Katie Jeitz, from the Whittington Hospital in North London, is just that. But how difficult can it be?
JEITZ
Studies have shown that about 50% of women are doing it right and they're the people that actually benefit out of it and 50% of women are actually doing the wrong thing or maybe nothing at all, maybe actually hurting the pelvic floor muscles by stretching them more. So the way that you do it is very important.
PORTER
Well let's start with that and how do you do pelvic floor exercises?
JEITZ
Okay, well the pelvic floor muscles actually run from your pubic bone at the front of your body to the tail bone at the back, so they sling across the pelvis. And they support the bladder, the womb and the bowel at the back and they also have the passageways - the urinary passageway, the front passageway and the back passageway running through them. So those muscles act to squeeze those passageways shut and to lift and support the organs. So when you're actually doing the exercise it's really important that first of all you squeeze both the front and back passage, as if you're stopping yourself from weeing or stopping yourself from passing wind in a public place. And also that you get the lift effect, so almost as if you're lifting your bladder up nice and high inside your pelvis.
PORTER
That's quite difficult to imagine how you're going to lift your bladder, I mean do you actually show people, when a person comes to you do you actually sit there and show them how to do it?
JEITZ
It's actually a great way, diagrammatically, if you can show people a picture of their pelvis and what it's doing and most people will get a very good idea of how to do it. But there are cases, if people are having difficulties, it's much, much, much better to have a personal examination of your pelvic floor muscles and then I can show people exactly what they're doing right, exactly what they're doing wrong and give them specific feedback and that makes such a difference for people who are doing it wrong.
PORTER
What about this advice that when you're having a pee the same muscles that you use to stop your urine flow midstream - do you use that?
JEITZ
Absolutely, yes, people at home can test their pelvic floor muscles by stopping the flow of urine midstream. It's not something that we actually recommend that people do as an exercise because if you do it all the time your bladder learns to half empty and there's a small increased risk of infection. But certainly it's a great way and perfectly safe to do it once a week, just to make sure that you're doing the right thing. And if you can stop the flow of urine, or even if you're just slowing it down if you're a little bit weak, then you know that you're doing the right thing and you're on the right track.
PORTER
Now if you're doing pelvic floor exercises nobody else should be able to tell - I've often see friends of my wife after they had children were doing their pelvic floor exercises, you see them squeezing their bottoms and they're going up and down in their seat, that's not right.
JEITZ
That is absolutely not right no. You should be able to relax all the external muscles quite well, so nobody should be able to tell that you're doing it. What you can get a little bit of is your lower tummy muscles working, and I'm not talking about sucking in the entirety of your tummy so that your ribs sort of move up and down, just a really small tightening down in the lower abdominal regions and that's fine.
PORTER
And how often and for how long should you be doing them to get results?
JEITZ
Right well again the studies vary in how much you do. But basically if you aim to do exercises about three to four times a day, so that you're getting about 50 contractions in, then you're on a strengthening programme, that's for somebody who's actually weak. There are two types of exercises that you need to actually do to effectively strengthen the muscle, it's not just all quick contractions, because they're quite easy and people like to do those. You actually - actually need to do some long holds as well.
PORTER
So this is contracting and then holding the muscles contracted?
JEITZ
Absolutely, so squeezing your front and back passages as if you're stopping yourself from weeing and passing wind, lifting it up high in your pelvis, holding it for as many seconds as you can until it starts to falter and then let it go. And then give it a few seconds rest, do it again, keep on going until the one that you're doing isn't as strong as the first one or you can't hold it for as many seconds.
PORTER
Now the effect will obviously vary from woman to woman, but how long, on average, might it take before a woman could expect to see an improvement in her symptoms, simply from doing pelvic floor exercises?
JEITZ
Well sometimes women actually find an improvement in the first few weeks and that's more to do with your body being more aware of the muscle and using it more than anything else. It takes six to eight weeks to actually start to get a strengthening effect and most cases it takes about 20 weeks - so about five months to get a good strengthening response. So it isn't a short term thing, you do need to stick at it if you have weak muscles.
PORTER
Physio Katie Jeitz.
Mark, what sort of success rates do you see with pelvic floor exercises? Is this something you recommend to everybody that comes to your clinic?
SLACK
You know the success rates are probably 40-50%, in some patients as high as 60%, some patient groups. I recommend it to absolutely everybody, it's safe, it's non-interventional, they've lost nothing but time if it doesn't work. At the same time they're getting exercise, they're chatting to the physio, they're getting information about their condition. So everybody gets it.
PORTER
What about vaginal weights and electrical stimulators - these sort of enhanced pelvic floor exercises you read about?
SLACK
They've been round the block and there's not a lot of science behind them. They can be useful in certain people again and some physios might use them. So for a person who needs extra motivation, possibly cones are useful. I'm not dismissing them entirely but I think there's nothing that beats a good physiotherapist with instruction.
PORTER
Well if pelvic floors don't help then the world's first licensed medicine for stress incontinence might. Trisha Macnair investigates.
VOX POPS OF SUFFERERS
If I was laughing, if I was coughing, sneezing I'd get the odd leakage. After having two children I wanted to get myself back in shape. I tried to do things like jogging and going to aerobic classes but found that that was becoming very embarrassing, not necessarily because I couldn't keep up with the exercise but the fact I couldn't cope with the leakage.
I used to do a bit of running and I did one race and I was determined to do quite a good time and by the end I'd finished the race there was actually urine running down my legs because I'd run that hard.
I've got my own health clothes and when my condition was at its peak it was when lycra was very much in vogue, so absorbent pads and that kind of kit didn't go together.
You are very concerned during the summer months when it's warm - is there a smell, you need to wear pads which are not very pleasant, it's not very nice to have to deal with at all.
I'd definitely plan shopping trips to make sure that I was selective about the stores and where the toilets were. I even resorted to carrying spare underwear at one point.
MACNAIR
Simone and Carole's experience of stress incontinence is typical. Even in its milder form it affects many of the simple aspects of life that we take for granted. And, as Dr Judith Wardle, director of the Continence Foundation explains, when SUI becomes more severe it can be very disruptive.
WARDLE
Laughing is something people avoid, can you imagine how miserable some people are when they're just trying not to laugh. If it's more extreme they can avoid going out, they avoid contacts with their friends, they don't go and spend a night with somebody, they might be afraid that somebody's chair may end up wet. And in the most extreme circumstances it affects people's relationships because there are women who leak during sexual activity and that means that they pull away from their partner or they don't want to start new relationships. Most people do try going to their GP first but sadly there are still some GPs out there who will say - How old are you Mrs so and so, how many children have you had, well what do you expect then?
MACNAIR
So why does urine leak in stress incontinence? There's usually nothing wrong with the bladder. Instead the problem lies with weakness of the muscles which form the floor of the pelvis and of the urethral sphincter which tightens to close off the flow of urine from the bladder. Linda Cardozo is Professor of Urogynaecology at King's College Hospital in London.
CARDOZO
It's often possible to cure women with stress incontinence. It's nearly always possible to improve them and it's always possible to manage the situation. So first of all, all women should be given lifestyle advice, so women should be advised to do all the things they hate doing - give up smoking, give up alcohol, lose weight, give up caffeine. Then after that physiotherapy - pelvic floor exercises - which are really best taught by a dedicated expert physiotherapist. Just giving a woman a leaflet doesn't really motivate her very well and often she'll end up squeezing her buttocks or tightening her tummy muscles rather than actually contracting her pelvic floor. Then after that it used to be that the next option was surgical but we now in addition have a drug. And the first drug to be developed specifically for stress incontinence is Duloxetine, which is available, given twice daily, and it can be very effective in at least 50% of women in improving or curing their stress incontinence.
MACNAIR
Duloxetine is a type of drug known as a serotonin noradrenaline reuptake inhibitor or SNRI. This type of drug has been used for years now in the treatment of depression, but it has a different action in stress incontinence.
CARDOZO
It works via the pudendal nerve to increase the tone in the urethral sphincter mechanism during the storage phase that allows complete relaxation during the voiding or emptying phase. So it doesn't stop women from emptying their bladders but it does make them more continent because of greater efficacy of the urethral sphincter mechanism for most of the time.
MACNAIR
Some might think it strange that an antidepressant drug also works in incontinence. So does it have any effect on the women's mood ?
CARDOZO
It's an SNRI and they are used for depression, that class of drugs is. It is used in a different dosage regimen for women who have depression. It doesn't change the mood of women who are incontinent unless they have depression and it doesn't make women with depression hyper continent - it doesn't have an effect on their lower urinary tract. So it does work differently via different pathologies.
MACNAIR
Duloxetine doesn't work for everyone with SUI and some experience side effects such as nausea although this usually subsides. Carole has been taking the drug for some time now and is delighted with its effect.
CAROLE
The idea of there being a drug on the market to help the muscle tone is absolutely fantastic. You do need to take it pretty much for ever more, once you start on it, you know it's not a quick fix, it won't fix what the problem is and then you can stop taking it. I have no problem with that because the alternative is take the drugs or have surgery and I certainly don't want surgery. So I am more than happy to continue taking this drug.
CARDOZO
We've had some very happy patients who've been pleased to take it and in fact we were involved in a clinical trial of Duloxetine which looked at women who were on the waiting lists for surgery, so they were the women who were self-selected as going to have an operation and therefore the most severe of the women with stress incontinence. And amongst those women who were entered into this trial a fifth of them - 20% - said that they were no longer interested in surgery when they were taking Duloxetine.
CAROLE
Taking the drug I have a much better - I have control of it, it does not have control of me anymore.
PORTER
Carole Nott talking to Trisha MacNair.
You're listening to a Case Notes special on incontinence in women, I'm Dr Mark Porter and my guest is consultant urogynaecologist Mark Slack.
Mark, we've talked about pelvic floor exercises for stress urinary incontinence, we've talked about medication, what's on offer for others and how do you know - at the beginning of the programme you talked about there being two main types, this sort of irritable bladder type and the stress incontinence - how do you know what type a woman's got - are you going solely on the story?
SLACK
Well initially yeah we do go solely on the story. So you meet the patient in the outpatients and have a chat and if the patient complains about these small losses with exertion - jumping, moving - we would tend to think that sounds like stress urinary incontinence. And if you take a good history - and there quite a lot of other things we'd look for - that's fairly accurate. If the patient on the other hand says they're going frequently, they're having to get up at night, they can't hold on, they've got to run for the loo, they're coming from Sainsbury's they've got to rush and get the key in the door, as they get the key in the door they start to lose water, that sounds much more like an overactive bladder.
PORTER
And is there an acid test besides the stories - is there an acid test?
SLACK
Absolutely, the trouble about those is that we always say that the bladder is a poor witness, it fibs a bit. And so what we actually have to do is test them and actually make a diagnosis and for that we use this rather grim term called urodynamics, which is a really fancy term for testing the bladder and working out how much it holds and we also work out the pressures in the bladder and from that we try and make a diagnosis.
PORTER
Presumably women can assess themselves can't they? I mean they go on story but also they can actually measure how much urine they're passing when they get the urge to go.
SLACK
Very, very useful for them, we use things called frequency volume charts. So what we do is we give them a chart and over a 24 or 48 hour period they write down everything that they drink over that period of time and everything that they pass and they measure it. And they should be passing somewhere between 300 and 400, 450 mils...
PORTER
That's a good full bladder.
SLACK
That's a good full bladder, they shouldn't get up more than about once at night after retiring and that gives us, plus it gives the patient a lot to understand about their bladder, and gives us a huge amount of information.
PORTER
Right let's say they've got an irritable bladder. What can you do to help them without resorting to any medication?
SLACK
We do bladder retraining, as we call it, and if you think about it when you start of as a little child and in nappies your brain isn't really involved and your bladder fills and it empties until you get to an age where you think gee this is inconvenient and you start training yourself to prevent that and your brain says no we won't empty now we'll wait until there's a loo. And likewise in adults, we don't know quite why all these people get this problem, but one of the possibilities is poor habits. So people go too frequently ...
PORTER
Have a pee before I go shopping.
SLACK
Sure, yeah, you should never allow your children to actually have a pee before they go out, they must only go when they need to go.
PORTER
Listen parents because that's what every parent does isn't it - go and have a pee, I don't care if you don't want one, go and have one.
SLACK
Absolutely and we try and stop that, we just say let them go when they need to so they develop an appropriate capacity.
PORTER
So basically you stretch them out, you're stretching the bladder. What sort of period of time would you be talking about?
SLACK
We retrain them, I mean the difficulty is it takes months again. So if a person starts with a functional capacity, if they can only hold a 100 mils, it could take us six, seven months to get them up to 500 mils, 400 mils and you can get spectacular results.
PORTER
And drugs can help with that too?
SLACK
Sure drugs are - form the backbone of the treatment of the overactive bladder. The drugs, we call them anticolonergics but basically in layman's terms these are drugs that relax the bladder muscle, they prevent it contracting. So they're prevented, because in overactive bladder it's not the valve that's at fault, it's the body of the bladder and it contracts when it should be relaxing and pushes the water out. And we use drugs to try and prevent that muscle contracting down.
PORTER
I want to move on to surgery now, conservative measures, drugs haven't helped, a lot of women are offered surgery and I've got to say that looking at my own patients over the last 20 years it's had a relatively poor track record, it's not that successful or hasn't been that successful has it.
SLACK
Well let's divide them again into two. Overactive bladder surgery almost never, those are very, very severe intractable cases which we do see but those really you'd only see in tertiary centres. Stress urinary incontinence, yes surgery doesn't have a great track record and there are over at least 150 operations described for the treatment and that only tells ...
PORTER
Always a bad sign.
SLACK
Yeah one thing it does mean they're just not all working. In about the late '60s one of the new operations then came up called a Birch colpo-suspension and that started getting good results. But still a big operation, serious anaesthetic, quite a lot of complications until the 1990s when some people in Scandinavia introduced a new operation called the TVT.
PORTER
So the so-called tape operation.
SLACK
This is the tape - this is a so-called minimally invasive operation, which no operations are truly minimally invasive, they all have problems, they should be taken seriously.
PORTER
And what are you actually doing?
SLACK
The tape - it's putting a plastic-type tape underneath the pipe that leads from the bladder to the outside and it essentially acts like a hammock - it holds it still in one position so when people cough or move it basically pins it at that point and they don't leak.
PORTER
Well we caught up with Elena Nicolas at Chase Farm Hospital in North London who's opted to try the new tape operation to see if it cures her stress incontinence, for which she holds her three much loved children responsible. Her surgeon is Mr Ellis Downes.
NICOLAS
I can't jump because I wet and I can't run and it's so uncomfortable. If I laugh - I can't laugh a lot because I'm worried just in case. And it's uncomfortable. I have got three children - one is 29, 27 and 21 - it's their fault. But I do love them.
DOWNES
Right so we've emptied the bladder. Okay right let's have a seat, thank you very much - can the light be adjusted please? So really we're going to start the operation by making an incision about one and a half centimetres below the urethra - which is the outlet of the bladder. So we basically put some surgical instruments there and I'm now making an incision into the wall of the vagina, which is about two centimetres long and we're then going to just try to develop that incision because we need to just find a plane either side of the neck of the bladder in order to pass the TVT sling. So we just open that up a little bit there and you always get a little bit of oozing from the veins there. [Indistinct word] please. And I'm going back and down until I can feel the underside of the bone of the pelvic girdle which allows me to know where I'm going. So we're okay on that side and you can see we've gone in about two inches on that side and we're going to do the same on the other side. So what I want to do now is basically put a special wire in the catheter which keeps the bladder neck out of the way to minimise the risk of damage - inadvertently damaging that. Good. Okay so we're now going to pass the tape, and as you can see the tape is attached to these rather frightening needles that have to be pushed through the pelvic floor and it's covered with this plastic tape, just to protect it as we're putting it through. The needles are rigid and the tape itself is a little mesh and it's got little hooks in it and the tape itself isn't rigid and the tape will adjust to the actual position of the bladder neck. And I'm now just feeling for the tape to come up from above and I'm pushing down into the buttocks and up it comes. So it's come out there in a rather frightening fashion. So we're now going to empty the catheter and have a look in with the cystoscope - what we're trying to do is very accurately position the tape, either side of the neck of the bladder so we can see exactly what's going on.
So we're in the bladder and we're having a good look inside the bladder just to make sure there's no inadvertent perforation and I'm having a good look round and that looks fine - and I'm happy with the position there. It's not uncommon to occasionally make a hole in the bladder, it's quoted about 10%. If there was and you don't see it very often at all but you might actually see the tape going through the bladder or a little bit of metal in the bladder where the needle has inadvertently gone through. But again I mean it's not seen very often and the more you do the less often you see it. It's of absolutely no consequence as long as you recognise it at the time and then you just take the needle out and you reposition it. So we're up at the top and we've now got, I would guess, about a 150 mils of saline in and we're basically looking round and we're going round the bladder and we're coming right to the bladder neck now and there's no sign of any problem there. So let's switch the water off and empty the bladder. So we've now got the tape nicely secured in the right place and our only job now is to position the tape and to correctly tension it which really means not applying too much tension and then to close up our incisions and then we've completed the TVT sling procedure.
PORTER
Mr Ellis Downes at the Chase Farm Hospital. And I'm pleased to say that Elena's operation has been a success or so far.
Mark, what sort of success rates do you get doing these sorts of procedures?
SLACK
I think the quoted success rate, which probably most of us subscribe to, is about 85% and that's with the patients being happy with the operation. How you define success is an issue in itself but what we're aiming for is people who have an improvement in quality of life, who are happy with the outcome of their operation and that's about 85% for both operations. The real issue that actually determines success is who's doing it, you need to do a lot to actually get good results - Tiger Woods doesn't hit 10 golf balls a week he hits thousands. Surgeons who do a lot, who have the appropriate training, who pick the patients carefully, who inform them well, they get the good outcomes.
PORTER
I mean that was going to be my next question - is the operation available everywhere across the UK on the NHS?
SLACK
Yes I think they are - the operations are widely available but they really should be being done by either urologists with the appropriate interest or gynaecologists with a special interest in urogynaecology who do enough, have the right training and follow their cases up carefully.
PORTER
And quickly, talking about follow up - how long do we think these are successful for, what sort of evidence have we got?
SLACK
We've got about eight years of evidence with the TVT and 15 for the Birch colpo-suspension.
PORTER
And they look to be long lasting at that stage?
SLACK
And they look to be long lasting at that stage.
PORTER
That's all we have time for - Mark Slack thank you very much. Next week's programme takes a timely look at dyspepsia - indigestion and heartburn - anyone for another mince pie?
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