Dr Sanjay Sinha, Honorary Professor and Senior Consultant Urologist, Apollo Hospitals, Hyderabad.
International Continence Society (ICS) is promoting awareness regarding urinary incontinence, as this condition is poorly understood, and most patients suffer in silence and consider it to be a cause for shame. The ICS World Continence Week (WCW) is an annual initiative with the primary aim to raise awareness about incontinence related issues. WCW was initiated at ICS 2008 in Cairo with the first-ever World Continence Day.
Urinary incontinence is common. Population studies show a prevalence of 10-42% in Indian women. There is a clear trend toward an increase in prevalence as well as severity with age (5.6% in the 3rd decade to 39% in the 7th decade). Incontinence is less common in men and there are no population studies from India. International studies show a prevalence of 3-5% in young men increasing to 11-34% in elderly men. Men may also develop urinary incontinence as a consequence of radical prostatectomy surgery for cancer.
Incontinence has a profound impact on the quality of life, while incontinence is usually not a health hazard, there is an association with depression and social withdrawal. More importantly, such patients are more likely to suffer from falls (presumably when they rush to the toilet) that may become a sentinel event resulting in fracture and mortality.
Most patients suffer in silence. Over 2/3rd of women fail to seek help even in the West. Studies from India show that embarrassment is perhaps more of an impediment than financial constraint. The situation is probably worse in India.
There are several causes. The process of childbirth stresses the pelvic muscles and support structures and can predispose to incontinence. Other causes could be age-related changes in the bladder or outlet, neurological disease such as stroke, multiple sclerosis or Parkinsonism, diabetes and dementia. It can be aggravated by constipation, concomitant medication or obesity.
Lifestyle changes can help. Reduction of fluid intake and reducing the quantity of coffee, tea and alcohol can reduce symptom severity. The Urological Society of India guidelines also recommends counselling regarding weight loss and avoidance of constipation.
Conservative treatments such as pelvic floor muscle training to strengthen the pelvic floor can improve incontinence. However, many women are unable to contract the pelvic floor at all, or worse, contract the wrong set of muscles. It’s important to start training under supervision. The continence nurse can teach the correct technique as well as use special devices such as the Urostym, a state-of-the-art device that can help women suffering from incontinence, both stress as well as urgency incontinence. Medication such as antimuscarinics and beta-3 agonists can help with urgency incontinence.
Advanced treatment for urgency and urgency incontinence. For those who fail to respond to medication, botulinum toxin bladder injections or sacral neuromodulation can be effective. These therapies are expensive and need an invasive procedure but for those who have severe symptoms, there can be dramatic improvements in the quality of life. Botulinum toxin typically works for about 9-10months while the battery of the neuromodulation device needs to be replaced after about 5 years.
Surgery for stress urinary incontinence. Women with severe stress incontinence can benefit from stress incontinence surgery. This includes a variety of surgical options. Minimally invasive synthetic tapes continue to be effective and are recommended by the Indian guidelines. However, a small proportion of women have adverse outcomes and this needs to be discussed.
For those who prefer a native tissue repair without synthetics, autologous pubovaginal sling is the most effective and durable procedure. Careful counselling is recommended. Young women may be better off choosing a natural tissue repair since the consequences of synthetics over the really long term (such as 40 or 50 years) remain uncertain. Those who haven’t completed their family should avoid surgery since future childbirth could compromise the outcome.
Apollo Hospitals, Hyderguda, Hyderabad has a state-of-the-art department for urinary incontinence and is arguably the country’s most advanced unit with unique facilities. It is widely regarded in the urological community as a national referral centre for such problems.
· This is the first comprehensive unit in India that houses facilities for pelvic floor training and biofeedback, video urodynamics, urethral pressure profile and all forms of conservative treatment for urinary continence in India all under one roof.
· The centre offers all forms of therapy for urgency urinary incontinence including Botulinum toxin therapy and sacral neuromodulation.
· The centre offers all forms of stress incontinence surgery both using synthetics as well as natural tissue surgery. We have demonstrated stress incontinence surgery across India in over two dozen workshops including training programs of the Board of Education of the Urological Society.