Tuesday 23 January 2018

Dear Dr Nina: Ever since my first child, I leak urine when I laugh

In more severe cases of stress incontinence, surgery can really help
In more severe cases of stress incontinence, surgery can really help

Nina Byrnes

I am a 56-year-old woman and ever since I had my first child at 28, I have suffered from incontinence. It started off fairly mild but after another four children and the passage of time, it has got fairly bad, to the extent that I wear incontinence pads daily. It hits at the usual times - coughing, sneezing, laughing. Last year, my husband left me, probably partly as a result of the loss of confidence I suffered because of the incontinence, which wasn't good for our relationship. I would really like to get this sorted so that I can start a new life and maybe begin dating again. How would I go about it? Is there a procedure I can get done on the public system? If not, I have a bit of money saved, which I would be happy to spend.

Dr Nina replies: It appears you are talking about urinary incontinence. This is loss of bladder control. Leakage can occur when coughing or sneezing (stress incontinence) or you may have a strong urge to pass urine which may limit your ability to get to a toilet on time (urge incontinence). Mixed incontinence is a combination of the two. Incontinence of the bowel can also occur. Damage to the spinal cord or pelvic injury may also lead to incontinence.

Urinary incontinence is extremely common and is thought to affect up to one in three women. One in five will require surgery at some stage in their life for this condition. Pregnancy, childbirth, obesity and pelvic floor damage all increase the risk. It is important to know that, although it is more common with age, it is not a normal part of ageing.

Despite the fact that it is extremely common, there is still a huge stigma around urinary incontinence. Irish women are very slow to talk openly about their issues to friends and family and even their GP. This shouldn't be the case. There are treatment options available and they can be very effective.

Physiotherapy and Kegel exercises, which work on creating proper tone in the pelvic floor, are the first port of call. There are physiotherapists who specialise in this area and they can advise you as to how toned or untoned your pelvic floor is. There are a number of devices on the market that help tone the pelvic floor. The newest of these is the Innovo device produced by an Irish company. It has electrodes in pads that help stimulate pelvic muscles, thus enabling proper exercising of the pelvic floor.

Unfortunately, public access to pelvic floor physiotherapy can take months, and private access or devices such as Innovo can be expensive. It is a pity we are not more like France where pelvic physiotherapy and devices are refunded by the state.

In more severe cases of stress incontinence, surgery can really help. The procedure, called bladder taping, is done as a day case. Contrary to popular opinion, you don't have to have completed your family to undergo this surgery. Urogynaecologists are doctors who specialise in treating the pelvic floor. As with many specialities in Ireland, we don't have enough of these doctors to meet demand for treatment, so waiting times in the public system are extremely long, usually over 18 months. Many of these consultants also have private clinics and the procedure would be covered by most insurance providers. Paying for this kind of procedure yourself would be very expensive.

Urge incontinence often responds to medication, which calms down nerve impulses in the bladder wall, reducing the urge to pass urine.

The psychological impact of incontinence is not to be ignored. It has clearly knocked your self-esteem and self-worth, along with any confidence you have for yourself in a relationship.

A truly intimate relationship should be open to a frank discussion about these matters, and any loving partner should support you and encourage you to seek whatever advice you need. Talk to your friends, family and GP and get the help that is available to you.

Q. My four-year-old daughter has a fissure on her anus and regularly bleeds when she does a poo.

The GP said it was nothing to worry about. Is there anything I can do to help it heal?

Dr Nina replies: Fissures in children normally occur due to constipation. The best chance for allowing the fissure to heal is to ensure that stool is soft and passes easily. Constipation is the infrequent passage of hard stool. Normal stool should have the consistency of toothpaste and be the size of a banana. Constipated stool is usually hard, small and pellet-like.

The most common cause of constipation is poor diet and inactive lifestyle. The first thing to do is increase the amount of fibre and fluid in your child’s diet. Most children don’t get anywhere near the 20g or so of daily fibre that is recommended. Increase this gradually, as if you do it rapidly they may experience abdominal bloating and cramping, due to increased wind.

Getting a young child to drink plenty of water can be difficult but it is an important part of the treatment of constipation. This is needed to flush

stool through the bowel. Incorporate exercise and activity into your child’s daily routine — this helps keep the bowel moving well.

Having a regular toilet routine really helps too. The bowel reflex is strongest after eating a meal. Squatting in the right position is also important — some toilets can be quite high off the ground. Using a footstool to lift the feet may help promote a natural bowel movement. Allow a child to spend about 10 minutes on the toilet to ensure they have fully emptied their bowel.

Prunes are a common remedy, and many fruits are also high in fibre. Laxatives have a role, particularly in initiating bowel movement in cases of constipation. It is important to note that constipation and the behaviour associated may take a long time to resolve in young children so persisting with lifestyle change and using treatment for several months may be necessary.

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