A Flood of Relief for Incontinence

As an artist, teacher and mother, Marilyn (not her real name), manages a busy life in Edmonton. She also manages a condition not uncommon to her middle-aged peer group: urinary incontinence.

“I’ll be working in my office. I’ll feel the need to go and I run for the bathroom, but sometimes I won’t make it,” she says. It’s been an issue for her since childhood. She was embarrassed and too humiliated to talk about it.   

Then, about 20 years ago, something shifted. She and a friend were giggling during a visit, her bladder let go and she wet her pants. “There was no way she could not see what had happened, so I came clean. She told me her sister did that all the time. 

“I learned I was not alone and that it wasn’t my fault,” Marilyn says. “It was such a turning point.” Today, she wears maxi-pads, uses the bathroom whenever she can and makes sure she knows where the nearest one is.  

Women like Marilyn are the kinds of patients Jane Schulz, ’90 BMedSc, ’92 MD, sees in her position as professor and chair of the obstetrics and gynecology department in the Faculty of Medicine & Dentistry. (She also holds the Alberta Women’s Health Foundation Chair in Women’s Health Research.) 

Schulz and her team are leading innovation and research in treating urinary incontinence and creating new best practices that have the attention of other clinical centres. The first step, she says, is to acknowledge how common a problem it is. 

“We get peed on every day,” says Schulz, who does clinical work at the Lois Hole Hospital for Women in Edmonton. “Body fluids do not faze us. We want to see what is going on so we can help people.” She is also a member of the University of Alberta’s Women and Children’s Health Research Institute (WCHRI). 

Everybody’s (Quiet) Problem

Urinary incontinence is estimated to affect one in four women over her lifetime. It happens frequently in women over 60 due to age and menopausal changes. It can also occur in women who are pregnant or who’ve had children, as well as in elite athletes. Many athletes have low body mass index, which is associated with lower estrogen levels and weaker connective tissues. Add in high-impact activities like jumping or running, which put extreme pressure on the pelvic floor, and you are at risk for dribbling. Schulz estimates that up to 70 per cent of high-level athletes such as Olympic gymnasts and weight lifters will have unwanted leakage during their training or competitive activities. 

“Fifty per cent of women who have had children will have prolapse, where the bladder drops and pushes against the vagina, or herniates through the vaginal wall,” says Schulz. After pregnancy, damage to the nerves or tissues of the urethral sphincter can result in unexpected loss of bladder control. 

Women who are incontinent may also have urinary frequency — constantly running to the bathroom, feeling the urge when water is running, having difficulties completely emptying the bladder and/or getting up many times in the night. The disrupted sleep, if pervasive, can result in anxiety or depression. About 25 per cent of women experience mental health problems as a result of the stress of pelvic floor issues.

What To Do?

“Not everyone is bothered by urinary incontinence,” says Schulz. “If the leakage is just a spritz, you might just wear a light sanitary pad and call it a day.” But if you are active — for example, you spend hours on the golf course or on the tennis courts — and the leakage is significant, it could be bothersome. 

“The good news is it’s highly treatable,” she says.

The first line of management is to discuss the situation with your primary health care provider, who may make suggestions or refer you to an expert like Schulz. (This is not as obvious as it sounds; due to the stigma of this condition, many women have not told their spouses about this let alone their primary health care professionals.) 

The Lois Hole Hospital for Women, where Schulz works, is home to  a multidisciplinary pelvic health team team of urogynecologists, nurses, urologists, a pharmacist, physiotherapists and a dietician. They will suggest you avoid bladder irritants like alcohol, caffeine, citrus, tomato and aspartame. “They’ll ask you to keep a bladder diary,” Schulz says, “and note how much you are peeing and what you are drinking.”

Next up is help with urge-suppression to increase the time between trips to the bathroom; Kegel exercises, for example, strengthen the pelvic floor and help contain urine in 60 per cent of cases. Vaginal estrogen taken twice a week can help with pelvic floor symptoms including overactive bladder. If necessary, you can get a ring-like device called a pessary inserted that will lift the pelvic organs — the uterus, bladder and rectum — back into a supportive place.

If your condition is more complex or these conservative management efforts don’t do the trick, there is always surgery: bladder slings, prolapse repairs, hysterectomies or vaginal vault suspensions. 

New Developments

Schulz says her position as research chair will allow her to collaborate with researchers in other disciplines. And her team has received grant funding to support randomized controlled trials to look at antibiotic use in preventing urinary tract infection when performing botox injections for overactive bladder. “Urinary tract infection is very common post surgery,” she explains. The urogynecology team is also involved in a UTI prevention bundle as part of quality improvement initiatives in perioperative care.

One recent innovation in patient care came not from the purchase of new equipment or the development of a new drug but by revolutionizing how the incontinence team triaged patients. For a long time, one barrier to treatment has been the two- to three-year wait times just to get in. Schulz wanted to reduce that.

“WCHRI funded a student summer project for $5,200,” she says. Through support from the Alberta Women’s Health Foundation the group was able to run classes of up to 20 new patients to provide them with information and strategies to manage their conditions. “It allowed us to streamline care and allowed patients to be more active in their own care.” That helped move patients with more severe conditions into the most appropriate care sooner. Prior to the onset of COVID-19, the team had cut the wait time for surgical consultation to three months. The team has worked with regional hospitals to develop clear guidelines to manage surgical cases that are less complex and don’t need the highly specialized care provided at the Lois Hole Hospital for Women. 

Driven by COVID-19, Schulz’s patients have also participated in a trial “virtual hospital,” where post-surgical patients are monitored remotely in their homes. “The idea was to get them home and out of the hospital sooner,” she says. It makes sense, when processes are arranged around patient care and comfort.

Through research and better methods of preventing and treating the condition, the hope is fewer people will suffer embarrassment or restrictions of urinary incontinence.

- First published in Hope magazine, 2015; updated with files from Mifi Purvis.