• Dr Peter Chew

Awkward Situation

When housewife, Mrs. T, 40, first came to see me, she was wearing a diaper.

“I have been suffering for a while,” she said, embarrassed. “It has become worse in the last few months. I had an occasional leak when I coughed or sneezed after the birth of my son, but it got worse after I had my second child.

“My family physician taught me exercised to strengthen my pelvic muscles. It did not help. I have to wear a diaper all the time now and it’s uncomfortable. I also feel uneasy and am afraid that other people may notice the smell. Do you have any solution?”

Mrs. T was slightly overweight. Her abdomen was soft. There was no abnormal swelling or lumps in the pelvis. The womb was normal in size but drooped slightly downward due to childbirth.

Her bladder sagged and protruded slightly out of the vagina forming a bulge. A small amount of urine leaked out when I asked her to strain. Ultrasound scans of the abdomen and pelvis did not reveal any abnormality. I took a urine sample for culture of bacteria. The result was negative. A special X-ray of her urinary system was normal.

Further investigation (an urodynamic test) indicated that she had stress urinary incontinence (SUI), a condition where urine is released involuntary with a sudden rise in the abdominal pressure.

SUI is the most common type of urinary incontinence in women. The “stress” here refers to the sudden increase in abdominal pressure on the bladder brought about by movement or activity such as coughing, sneezing or heavy lifting. It has nothing to do with psychological stress.

Normally, the bladder is well supported by the pelvic muscles which keep the urine in place. In older women, who are obese, smokers, near menopause or have had many vaginal births, these muscles are weakened. Any stress on the bladder will result in urinary leakage.

Depending on the severity, SUI can be managed in various ways. Mrs. T was put on a weight reduction programme as obesity aggravates incontinence. She was also advised not to hold her urine as someone with a distended bladder would be more susceptible to SUI. Constipation can make urinary incontinence worse. I told her she had to have regular bowel movements.

The pelvic muscle training exercises that she tried, which improve the strength and function of the erethral muscles, did not benefit Mrs. T. But they could help a patient with mild symptoms.

Some women may use a device called a vaginal cone along with pelvic exercises. The cone is placed in the vagina and the woman tries to contract the pelvic muscles in an effort to hold it in place. The device may be worn for up to 15 minutes. Again, it may benefit those with mild symptoms.

In severe SUI, as in Mrs. T’s case, surgical treatment is necessary and a sling operation is the procedure of choice. A sling comprises a synthetic mesh material in the shape of a narrow ribbon and is placed under the urethra. It strengthens the urethral muscles and provides a “backboard” or “hammock” of support under the urethra.

A year after the operation, I received a Christmas card from Mrs. T which read “Dear Doc. I am now in Korea learning how to ski. Thank you for giving me a new lease of life. I don’t have the problem any more.

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