Continence Care for Menopausal Women
Treatment Options for Urinary Incontinence during Menopause
1. Healthy Bladder Habits
There are many things you can do on your own to improve your bladder health and decrease incontinence. Monitor your fluid intake, voiding frequency and volume with a diary. You may see trends that symptoms follow
- Keep yourself hydrated
Drink at least 4-6 cups (1000-1500ml) of fluid a day unless advised otherwise by your doctor. Don’t limit fluids in the hope of improving your incontinence. If you drink too little the urine becomes very concentrated. This will irritate your bladder and make it want to empty more often even if there is only a little in it. The best fluid to drink is plain water.
- Keep yourself hydrated
Don’t drink all of your fluids at once. Space your fluids out during the day. If you drink a lot at once, you can expect the need to go to the toilet urgently not too long afterward.
- Reduce intake of irritating fluids
Caffeine, alcohol and carbonated beverages may make your irritable bladder symptoms worse. Artificial sweeteners, citrus fruits and acidic foods, such as tomatoes may also cause trouble.
Try to reduce caffeinated drinks to 1 or 2 cups a day. Some people can be more sensitive to caffeine and it may be best to stop drinking all caffeinated beverages.
Be aware that decaffeinated beverages still contain some caffeine. It is best to stick to caffeine-free drinks.
- Void regularly throughout the day
Ignoring your body’s cues to void can lead to an overly full bladder, feelings of urgency, and leakage.
- Reduce your fluid intake in the evening and void well prior to bed
Drinking less in the evening reduces the need to get up at night to void.
- Empty your bladder completely with each void
You may need to shift positions, stand up and sit down again, lean forward or gently push on your lower abdomen.
- Stop smoking
Smoking irritates the bladder causing feelings of urgency. It can also be the cause of a chronic cough that can put pressure on the pelvic floor muscles. Stop smoking
- Manage a chronic cough
If you are a smoker or have asthma, COPD or bronchitis, these conditions can cause you to cough more weakening the pelvic floor muscles. Talk to your family doctor about controlling your asthma, COPD or bronchitis.
- Stay at a healthy weight
Weight loss has been shown to decrease urinary leakage by decreasing outside pressure on the bladder.
- Keep your bowels regular
Straining during bowel movements weakens the muscles used to control urine leakage. Keep stools soft and avoid constipation. Try to increase your fiber or take gentle stimulants and stool bulking agents such as natural fiber, milk of magnesia, Metamucil or mineral oil are recommended.
- Seek treatment for urinary infections
Watch for symptoms of urinary tract infections such as urgency, frequency, blood in the urine, or burning with voiding. Report to your doctor if you have these symptoms.
2. Pelvic Floor Muscle Exercises (Kegels)
Like any muscle your pelvic floor muscles need to be exercised so they remain strong. These muscles can become weakened after childbirth, after menopause and as a result of chronic coughing or heavy lifting.
By doing pelvic floor muscle exercises you can build up and strengthen the muscles of your pelvic floor to help you hold your urine and improve your bladder and bowel control.
These exercises are also known as Kegel exercises. When done properly and regularly they can make a big difference to your bladder control.
Kegel exercises can be done standing, sitting or lying down
Step 1: Learning to Feel the Muscles
- To locate the muscles, it is best to sit down on a firm chair. Try to squeeze the muscles which prevent you from passing rectal gas.
- Try not to tighten your abdominal or buttock muscles.
- Do not hold your breath
- Inhale as you relax your muscles and exhale as you squeeze them.
- Lie down and place one or two clean fingers into your vagina and try to squeeze your muscles around it.
Step 2: Learning to Isolate the Muscles
- Be careful not to tighten your stomach, legs, or other muscles at the same time as you contract your pelvic floor muscles. In particular, try to relax your stomach while you squeeze the pelvic muscles. Do not hold your breath.
Step 3: Practicing Pelvic Exercises
- Slowly tighten your pelvic muscles over a count of 1-2-3.
- Slowly relax your pelvic muscles over a count of 1-2-3.
- It is easier to start doing these exercises while sitting in a firm chair so you can make sure that you are not tightening other muscles like your buttocks and abdominal muscles.
- Once comfortable with the pelvic muscle exercises while sitting you can try them lying and standing as well.
- Start by doing this at least 3 to 4 times a week. As you get better at it, try to increase your exercises to one set (10 times) 5 times a day.
When Will I Notice Improvement?
Many women notice an improvement after 3-6 weeks of doing the exercises daily. It may even take up to 6 months, especially if you have gone through menopause.
After you train yourself to tighten the pelvic muscles, you will have fewer accidents.
These exercises need to be continued in order to have lasting effect, just like any other form of exercise.
What if I can’t contract my pelvic floor muscles?
If you are having a hard time doing these exercises or find you are not making progress, ask your health care provider whether a pelvic floor physiotherapist or biofeedback might be helpful for you.
3. Timed Toileting and Double Voiding
What is timed voiding?
Timed voiding refers to going to the bathroom to void based upon the clock, not how you feel. Often, by the time a woman feels the need to void, it’s too late. The purpose of timed toileting is to prevent the bladder from overfilling so that you don’t need to rush to get to the toilet in time and you have less leakage.
- When you wake up in the morning, the first thing you should do is empty your bladder.
- Watch the clock. You should try to void every 2 hours. If you drink a lot of fluids or have caffeinated drinks you may need to void every 1-2 hours.
- Try to not go more than 3 hours without visiting the toilet. If you wait too long you will be more prone to accidents.
- You should go to the washroom just before you go to sleep.
What is double voiding?
Double voiding refers to spending extra time on the toilet to try to empty your bladder completely. Many women rush to get off the toilet and leave urine inside the bladder. Over months and years of doing this, it may become harder for the bladder to fully empty. When urine is left inside the bladder it increases your risk of bladder infections, increases how often you need to void and you can have more leakage.
- When you go to the washroom, don’t rush!
- Relax when you void. Do not try to stop the stream of urine. This will help the bladder empty fully.
- When you think you’re done, use the following methods to try and void a second time.
- Sit for another 15-45 seconds
- Lean forward and sit up straight again
- Move side to side
- Stand up, move around and sit down again
- Some women have a prolapse of their bladder. If you feel a bulge in the vagina, you can use your fingers to push the bulge back up in to the vagina. Urine stuck in that pocket can then empty. You cannot hurt yourself doing this.
- At the end you should give a little push to make sure the last drops of urine get out. Do this by pushing your belly out and holding for a few seconds.
4. Bladder Training and Urge Control
Bladder training helps you increase the amount of time between visits to the toilet, increase the amount your bladder can hold, and control the feelings of urgency when the bladder contracts unnecessarily.
The best place to start is to limit substances that can irritate the bladder as outlined in the Healthy Bladder Habits section.
Part of this training is learning to understand the messages your bladder is sending you. You need to learn which messages to listen to and which ones to ignore. A bladder training program should help you recognize when your bladder is full and when it is not.
It may have taken weeks, months or even years to establish these bad habits so it will take time to fix the problem. Be encouraged, most people notice some improvement within 2 weeks although it may take 3 months or more to regain bladder control.
You should go to the bathroom every 2-3 hours during the day. If you are going more frequently, you need to try and increase the time between visits to the toilet. For example if you are going every hour set your target at an hour and 15 minutes. If you get the feeling of urgency before that time is up try techniques from the section below to control this feeling and make your bladder wait.
Urge control techniques
Tighten your pelvic floor muscles as hard as you can and hold on for as long as you can. Keep doing this until the feeling of urgency goes away or is under control. Contracting the pelvic floor muscles helps to squeeze the urethra (the tube from the bladder) shut and prevent leakage.
Tighten your pelvic floor muscles quickly and as hard as you can, then let go. Repeat this several times in a row. Some women find that several contractions in a row work better than trying to hold onto one contraction for a long time.
Put firm pressure on the pelvic floor. You can do this by crossing your legs or sitting down on a firm surface. This also sends a message to the bladder via the nerves that the outlet from the bladder is closed so it should wait before it tries to empty.
Place a rolled up towel between your legs to support the pelvic floor before standing to help with urine loss.
Change your position if this decreases the feeling of urgency. Some people find that leaning forward a little helps.
Stay still when you get an urgent bladder contraction and control the urge.
After menopause, the tissues in the vagina, urethra and bladder can lose their tone and elasticity. This makes it harder to hold your urine and can lead to stress incontinence and urge incontinence. Oral hormone replacement therapy does not reach these tissues and so it may be recommended that you apply intravaginal estrogen. Estrogen administered vaginally works locally to improve the health of the tissues with few side effects. There is no current evidence that vaginal estrogen has ever been shown to be associated with risk of heart disease, stroke or cancer. Estrogen can be inserted in the vagina via cream, tablet or ring.
Antimuscarinic medications like Detrol (tolterodine) and Ditropan (oxubutynin) are used mainly for the treatment of urge incontinence and overactive bladder. These medications can reduce the irritability of the bladder muscle allowing you to hold more urine for longer periods of time. This category of medication is known for causing dry mouth and constipation.
Mirabegron is a beta-3 adrenergic agonist indicated for the treatment of overactive bladder (OAB) and the symptoms of urge urinary incontinence, urgency, and urinary frequency. This medication works by relaxing the muscles of the bladder.
Antidepressants like imipramine can be used for stress incontinence as they can cause the muscles at the bladder neck to contract. The effectiveness varies between patients, so patients should seek the recommendation of their physician as to whether it can be considered. There are also anticholinergic effects with this class of drugs which can help with urge-related symptoms.
6. Continence Devices
A pessary is a device made out of silicone that is placed in the vagina to provide internal support to the tissues. Pessaries are generally used to treat prolapse. A pessary can reduce the feeling of a bulge from the vagina and can often improve bladder and bowel function. Some pessaries are designed to support the urethra (the tube from your bladder) helping to reduce stress incontinence.
Women who have prolapse of the vagina or uterus, or have urinary leakage due to prolapse, may find this device helpful in supporting the tissue to remain in place. Some women find it useful as a measure to avoid surgery or while they are waiting for surgery. This device can be used only when needed or it can be left in and removed for washing every few months.
A pessary can be worn all of the time to help manage prolapse or leakage or can be inserted only when you are participating in activities that are likely to cause leakage, such as jogging.
You need to have the proper sized pessary fitted by an experienced health care professional. It then can be removed and cleaned regularly by you. You should not feel it once it is properly fitted to you. There is a small fee for the device which may be covered by your private insurance.
- Surgical Options
Surgery may be an option for stress urinary incontinence if less invasive treatments fail.
Many surgical options have high success rates when performed for the first time. Repeat procedures often are not as successful. Therefore, it is important to discuss the appropriate treatment with your doctor.
Surgical procedures attempt to restore a normal position to the bladder base and urethra. These procedures may be done through an incision in the vagina or the abdomen. All surgeries have complications and it is important to understand these beforehand; your doctor will discuss these with you, but feel free to ask questions. There are many procedures not mentioned here. Your doctor will recommend options specific to your situation.
Tension-Free Vaginal Tape (TVT) Procedure or Transobturator Vaginal Tape
This procedure for stress urinary incontinence is done through a small incision in the vagina. A mesh tape is placed under the urethra like a sling or hammock. This sling provides support to the urethra and prevents leakage when you do things like cough, laugh or sneeze.
This procedure for stress urinary incontinence is done through an incision in the abdomen. Stitches are placed in the tissue beside the bladder base and urethra and brought up to the ligament behind the pubic bone. This can also be done through smaller incisions (keyhole surgery) with the help of a small camera and is called a Laparoscopic Burch Procedure.
Urge urinary incontinence does not respond well to typical surgical procedures for incontinence. In fact, symptoms may be made worse by surgery.
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