2023 IPHA Report: Female Incontinence / Overcoming The Stigma

WOMEN'S DIAGNOSTIC NETWORK UPDATE

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Mental Health 101: Treating Incontinence Starts With Overcoming The Stigma

By:  Jessica Connell-Glynn, LCSW
Edited by: Roberta Kline, MD

Health issues are often linked to a range of emotional distress, but a major contributor to the progression of chronic issues such as urinary incontinence starts with the sufferer's instinct to conceal the problem.  This reactive response from embarrassment and shame drives many women (both men and women) to hide their condition from their closest supporters as well as their physicians, making incontinence go unchecked and unaddressed.   Over time, it is this level of clinical neglect that brings bladder health issues and urinary incontinence to grow into a more challenging health condition.[1]

Internalizing reactive shame plays a critical role in the effects of STIGMA and its self-propelling negative cycle, further driven by self-esteem issues, depression and hopelessness.  From a 2002 World of Psychiatry report, both public and self-stigma may carry three components: stereotypes, prejudice, and discrimination.  These elements are observed to be quite powerful in driving human activity and decision-making as they align with our sense of social acceptance, personal safety and survival.[2]

Treatment experts identify the critical progression of incontinence to start from the sufferer isolating themselves in secrecy.  According to Daphna Ross, PT, owner of Women's Health and Healing Physical Therapy, Inc., "it is extremely embarrassing and uncomfortable for women to talk about this topic. They often hide it from friends or family but also from their doctors.  This often contributes to worsening of their condition.  At first it starts as a small leak and an annoyance but then it gets worse when left untreated; they require the use of pads, start limiting their social activities their exercise, or how long they're willing to be outside the home. The leakage will affect their quality of life.  They often limit their fluid intake as well, which actually worsens their condition and causes other issues.   It's really important to see the sufferers when it's just a small issue- women should know that there are tools to manage their condition and  ensure that they don't go down this trajectory".

There have been many studies evaluating groups of sufferers of urinary incontinence directly reflecting emotional distress.  Under varying conditions of functional loss, the investigative teams in these studies tend to conclude similar association between this physical impairment and levels of anguish and anxiety where the embarrassment of incontinence would often lead to self isolation- where seeking direct care or proper counsel is often compromised.[3]

References:

1) The impact of stigma on emotional distress and recovery from psychosis: The mediatory role of internalised shame and self-esteem  https://pubmed.ncbi.nlm.nih.gov/28531822/ 
 2) Understanding the impact of stigma on people with mental illness  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1489832/ 
 3) Urinary Incontinence and Psychological Distress in Community-Dwelling Older Adults  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2827934/ 

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MedReview: FEMALE INCONTINENCE EXPLAINED

Written by: Dr. Bobbi Kline

INTRODUCTION:
In my experience as an ObGyn, urinary incontinence is the unspoken secret among women. It affects up to 1 in 4 women, and this increases with age so that by age 65 up to 75% of women are affected [1]. And yet, most women never seek help. In a study published in 2013, 95% of women reported a negative impact on their quality of life, and yet 64% of the women had never received any medical help [2].  So often hidden out of shame, many women suffer in silence despite many efforts to raise awareness. Even those that are aware there is help may not seek it. What’s the point of speaking up when you fear it will only lead you down a path full of embarrassing conversations, invasive testing or procedures– and often does not produce effective or long-lasting results?

THE 'UNSPOKEN FEMALE DISORDER'
While urinary incontinence is most common in women over age 50, it can happen to women of all ages. More recent research is also showing that ethnicity plays a role. Sometimes the cause is temporary, as can happen with a urinary tract infection. Pressure on the bladder, as we see in pregnancy or from fibroids or other pelvic masses, can also lead to incontinence. Addressing the underlying issue typically leads to resolution of the urinary leakage.

But most commonly, the involuntary loss of urine is not so easily fixable. The causes of urinary incontinence are grouped into four different categories: urgency, stress, functional and overflow incontinence. Functional and overflow incontinence are typically due to non-bladder related causes, while urgency and stress incontinence are closely linked with dysfunction of the bladder or other structures in the pelvic floor.

The bladder is a sac made up of smooth muscle, and when it fills up with urine there is a reflex that results in release of that urine. Early in life we learn to control when those muscles contract, and thus control when we urinate.

URGENCY INCONTINENCE occurs when there is some loss of that control (3). This is often called “overactive bladder”, or OAB. Certain substances, such as caffeine or wine, or changes in hormones related to menopause, are known to aggravate this. But most often, we don’t know why this occurs. As a result, lifestyle or medication treatments are often less effective because we aren’t addressing the root cause.

STRESS URINARY INCONTINENCE is most often caused by trauma to the pelvic floor during childbirth, when the muscles that are designed to support the bladder are weakened (3). As a result, women leak urine when the bladder is put under pressure such as with coughing, sneezing, laughing or jumping. This is fairly common immediately after vaginal delivery, and many women will notice their symptoms improve with Kegel exercises designed to strengthen these pelvic floor muscles, along with the natural healing process. In my experience, many women are not sufficiently educated and supported in this. Or, as is especially the case with new moms, they are so busy taking care of everyone else that they neglect their own health needs.

Some women never fully recover, and even those that do often see the stress incontinence symptoms return later in life. And to make things even more challenging, often women have both urgency and stress incontinence. So women hide, often arranging their whole lives around avoiding leaking urine because they are ashamed to seek help. They change their exercise routine. They forego activities that bring them joy and pleasure, including sex. They buy pads and hope no one notices. They are always worried about a leak that reveals their shameful secret.

In my opinion, it’s part of a larger problem in how we view and treat women’s bodies. But fortunately, things are starting to shift thanks to technological advances in both our understanding and treatment. Even Personalized Medicine is yielding breakthrough insights into underlying causes. We are learning how each woman’s DNA related to pelvic floor muscles and collagen, and the DNA of her urinary microbiome, can impact her risk as well as the effectiveness of current treatments. 

I am optimistic we may someday soon be able to truly tailor both prevention and treatment in a way that is much more accessible and effective in addressing urinary incontinence in women.

Why I wear Pull-Ups… By: Jesi Stracham  When Depends became too baggy after my weight loss causing leaks and the pads would slide to the side, I switched to GoodNites brand children’s diapers. Immediately, my confidence was boosted with the cute designs and panty like fit. Even though I have my bladder well managed, I still wear them daily. With my active lifestyle I like the piece of mind that if I have an accident my wheelchair cushion and clothes will still be dry. I simply rip the diaper off, clean my downstairs “area” with a baby wipe, put a new diaper on and wheel on my way.  Often times SCI survivors suggest Botox Injections and pharmaceuticals to help with my incontinence. I used both up until April 2017 when they quit working. I searched high and low for natural alternatives after realizing how well my body felt after getting off of the pharmaceuticals. The uncomfortable constipation and dry mouth ceased within days! Early summer 2018 I had a bladder study done. The nurse who perform the study shamed me for refusing to take the prescribed medicines. She put me in tears saying due to the amount of spasms my bladder has shrunk significantly.  She continued on with a shame train because I refused pharmaceuticals after explaining they didn’t work and made me feel funny. She placed fear deep within my soul threatening that I would need a permanent catheter in my stomach with a bag or bladder augmentation (surgery where they take a piece of your bowel to make you bladder bigger) before I knew it.  (see complete Blog entry) About the Author JESI STRACHAM is a trauma survivor on a mission to help individuals see the opportunity in their obstacles. She is the founder of Wheel With Me Foundation, the owner of Wheel With Me Consulting, and a fitness and growth coach. Through her struggles, she works for teaching individuals the power of our mindset. Jesi is an honest, authentic, America-loving athlete. Over the past several years, she has generated a significant following among both the spinal cord injury and able-bodied community. Her goal is simple: show the world there is an opportunity in their obstacles, restoring hope during life’s difficult moments. She helps people achieve their dreams through the importance of goal setting, taking control of what we have control over, and showing YOU what’s possible with consistent hard-work.

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Using Ultrasound for Evaluation of Incontinence

Written by: Dr. Robert L. Bard

Prolapse of the pelvic floor contents (the uterus, bladder or the anus) is also associated with incontinence. 3-D pelvic floor ultrasound is performed in two ways: 

1) transvaginal probe which goes inside the vagina 

2) transperineal scan which is a more common way for evaluating stress urinary incontinence since the trans perineal probe is applied at the outside of the pelvic floor in the area between the vagina and the anus which is called the perineum.

MRI has been used for years to image the prolapse of the pelvic organs but is being replaced by the 4D real time transperineal sonogram as it is quicker and instantaneously shows the tear in the muscular ring (levator sling) that is associated with the trauma of birth. This exam is done in the privacy of an office instead of an MRI center or hospital setting and may be completed in a few minutes by the physician or specially trained technician. The muscle bundle that supports the bladder is white on the sonogram while the tear is black and readily distinguished.   During the examination the patient participates actively by bearing down or straining (Valsalva maneuver) to provide an exact measurement of the degree of the descent of the uterus, urethra, bladder or rectum.

THERAPY

Stress urinary incontinence (SUI) is distinct from overactive bladder (OAB) while both may be problematic in older patients with weaker muscle tone. The KEGEL maneuver is a common therapeutic approach to improve muscle strength and diminish the loss of urine when coughing, sneezing or laughing. While the technique is simple, the learning curve is often difficult for women who are accustomed to bearing down rather than “sucking up” the anus or vagina. While 4D ultrasound is optimal for diagnosing the cause, it is sophisticated equipment and requires advanced medical skills.  It can go beyond diagnosis and aid in treatment: the demonstration of the bladder change in the proper Kegel contraction is visible to the patients as a dynamic training guide by the physical therapist.  

The bladder descends during the Valsava while the bladder and urethra move upward in the correct maneuver.  This equipment is portable so it may be brought to the patient rather than a clinic visit or a treatment facility.  The technology is also wireless and point of care (POC) images may be transmitted to a reading site for interpretation as is done in ambulances where the EKG is read remotely by the Emergency Department physician while the patient is in route.

FIG-1: Postpartum delivery and difficult childbirth are a major cause of pelvic floor trauma, muscle tears and of course, urinary and fecal incontinence.  The ovoid white muscular ring in this case on the right shows a star, which indicates that the white muscular lining, which is smooth on the right hand side of the picture is bulging and actually torn and disappeared by a black area, indicating the exact location at the extent of the tear.  This is important preoperatively for reconstructive pelvic floor surgery.  While the 3d probe takes 15 seconds to scan the entire pelvic floor surface, it takes training and of course the specialized ultrasound technology, which shows the location and the depth of the disease. More importantly, the patient dynamically assists that is active patient participation to bear down or Valsalva or hold the urine for a varied period of time is important for measuring the descent of the bladder and the uterus in the pelvic floor. Thank you very much for your attention.

For the reasons of accurate diagnosis and ease of use, pelvic floor ultrasound is widely used in Europe and becoming popular in the US. The technology is safe and a “black and white” visual aid for learning the Kegel maneuver.  Additionally, during the diagnostic evaluation, the physician will look for other etiology of the voiding dysfunction such as bladder stone, bladder cancer and cystitis as well as inflammatory urethritis which is seen with treatments such as transvaginal tape (TVT) or surgical devices that are implanted.  Complications of endometriosis and cervical, ovarian or uterine tumors may be detected and definitive treatment may be timely instituted. 

Reference:

Dietz, H.P.,  Pelvic Floor Ultrasound Ultrasound, Atlas and Textbook , 2016 Obstetrics and Gynaeoclogy- Springwood NSW Australia

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Pelvic Floor and Physical Therapists

Written by: Joshua T. Schueller, PT

Edited by: Bobbi Kline, MD

There has been a recent surge in interest in physical therapists who specialize in Pelvic Floor Rehabilitation, and more therapists are choosing to specialize to address this need. These highly trained professionals are giving people their lives back. The days of labeling Pelvic Floor treatments under one umbrella are long gone.  The physical therapist is an integral aspect of the profession that has been misunderstood and underutilized in the past.  Standard Physical Therapy programs currently are not doing an adequate job of educating on the pelvic floor.  This has forced the therapists to pursue post-graduate certification through continuing education courses.

The pelvic floor plays a vital role in the whole-body function in both men and women, and Pelvic Floor Rehabilitation needs to treat the whole person.  Due to the variety of conditions that begin in the pelvic floor a thorough evaluation of history, exam, and intervention that is individualized from a therapist that specializes in Pelvic Floor Rehabilitation is a vital aspect to success. By treating only the symptoms, you may miss the underlying cause. 

While Pelvic Floor Rehabilitation is the generalized term, there are many layers and conditions that could be causing your problem. In the past, physicians recommended treatments for pelvic floor dysfunction that concentrated on pelvic floor exercises (kegels), medications, internal medical devices, injections, and complicated surgeries. Aside from the kegel exercises, these treatments are costly and invasive despite having varying degrees of success.

In speaking with many experts in the field of Pelvic Floor Rehabilitation, there is not one cookie-cutter approach to diagnosis or treatment.  A comprehensive evaluation by a highly trained experienced therapist is essential in providing success.  A thorough examination, both externally and internally, determines Interventions. A holistic approach is the most successful way to determine the appropriate course of action. Lifestyle, nutrition, activity levels, and past medical history can all play a role in what is causing the problems. Education to the client is also essential.  Knowing what is going on and why helps the person understand causes, and rationale for treatments.

Common Physical Therapy treatments focus on muscle imbalances.  Weakness, spasm, misalignment, or poor recruitment of muscles are common in Pelvic Floor conditions.  This can lead to incontinence or pain among other dysfunctions.  Educating the person on strengthening exercises or relaxation techniques can be very beneficial.  Demonstrating the proper way to engage different muscle groups can be done through biofeedback.  Therapists use manual therapy techniques to reduce pain, improve stability, decrease inflammation, improve movement, and improve function.  

Currently, many non-invasive treatment techniques are gaining in popularity and have shown significant promise in the treatment of many pelvic floor dysfunction conditions including incontinence.  Electrical stimulation, biofeedback and pulsed electromagnetic field therapy have shown the most promise.  Utilizing these products for home use has allowed the individual users to achieve success outside of the clinics, often saving them time and resources in addition to having the benefit of privacy that these effective treatment options offer.

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Groundbreaking New Solution for Incontinence: Meet ELITONE
2/22/2022- Health and Healing 101 reviews the latest innovation in addressing female incontinence. A wearable medical device called ELITONE (by Elidah, inc.) hit the market in 2019, offering a non-intrusive incontinence treatment as an alternative to pads.  Team Kolb shares their valuable insights on the creation of this remarkable device, while also discussing the road to achieving regulatory approval for product launch.  (See complete article)

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References

(1) https://www.mayoclinichealthsystem.org/hometown-health/speaking-of-health/is-urine-incontinence-normal-for-women

(2) Sensoy N, Dogan N, Ozek B, Karaaslan L.  Urinary incontinence in women: prevalence rates, risk  factors  and  impact on quality of life. Pak J Med Sci 2013;29(3):818-822

(3) Aoki, et al. Urinary Incontinence in Women. Nat Rev Dis Primers. ; 3: 17042

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CONTRIBUTORS

BOBBI KLINE, MD (Educational Dir. /Women's Diagnostic Group)

Dr. Kline is a board-certified ObGyn physician, Integrative Personalized Medicine expert, consultant, author, and educator whose mission is to change how we approach health and deliver healthcare. She helped to create the Integrative & Functional Medicine program for a family practice residency, has consulted with Sodexo to implement the first personalized nutrition menu for healthcare facilities, and serves as Education Director for several organizations including the Women’s Diagnostic Health Network, Mommies on a Mission. Learn more at https://bobbiklinemd.com 

 

ROBERT L. BARD, MD  (Diagnostic Imaging Specialist)

Having paved the way for the study of various cancers both clinically and academically, Dr. Robert Bard co-founded the 9/11 CancerScan program to bring additional diagnostic support to all first responders from Ground Zero. His main practice in midtown, NYC (Bard Diagnostic Imaging- www.CancerScan.com) uses the latest in digital Imaging technology has been also used to help guide biopsies and in many cases, even replicate much of the same reports of a clinical invasive biopsy. His most recent program is dedicated to the reporting of mental health diagnostic and innovative solutions including the use of modern neuromagnetic technologies and protocols in his MEDTECH REVIEWS program. 

 

JESSICA CONNELL-GLYNN, LCSW, CPC, CEC - (Mental Health Dir.)

As a therapist and mental health coach for the Women's Diagnostic Network, Jessica's expertise is highly in-demand in many areas of pre/post procedural care. She provides direct support in managing personal anxiety, panic, targeting TRAUMA and residually related fear.  This is specialized work honed by her extensive experience and research with the general public and within the Women's Wellness community. Jessica is also currently leading an interdisciplinary research project with a team of mental health and professionals in neurology, assessing psychological disorders. (Visit her website- www.jagtheracoach.com 

 DAPHNA ROSS, PT, PRPC, WCS (Guest contributor / technical advisor)

Daphna is the owner or Women's Health and Healing Physical Therapy, Inc with 20 years as a practicing physical therapist, specializing in Women's Health for the past 10 years. She is a board certified specialist in the field of Pelvic and Women's Health Physical Therapy, served on faculty at the Rehabilitation Institute and now proud owner of Women's Health and Healing. Daphna's focus is on treatment of women of all ages including pregnancy and postpartum, incontinence, urinary urgency and frequency, prolapse, and pelvic pain. She utilizes evidence-based treatment in a warm and nurturing environment. www.womenshealthhealingpt.com 

JOSH SCHUELLER, PT (Assoc. Editor)

Josh supports the treatment chronic pain and disorders with non-invasive, effective treatment solutions. He is the VP of Clinical Operations and Business Development at AxioBionics LLC. and the Clinical Director for Orthopedic Physical Therapy Clinics (Rockford, MI).  He is an active member of APTA with advanced certification in Physical Therapy treatment techniques including the McKenzie method of patient empowerment.  He has over 20+ years experience in the treatment of neurological conditions such as Spinal Cord Injury, Traumatic Brain Injury, CVA, Cerebral Palsy etc.   

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