Childbirth delivers a low blow

PUBLISHED : Tuesday, 15 May, 2012, 12:00am
UPDATED : Tuesday, 15 May, 2012, 12:00am


The birth of her second child 14 years ago left Judy Wong with an embarrassing problem: urinary incontinence. She would often leak urine, especially in the early days after delivery, but Wong (whose name has been changed for patient confidentiality reasons) quietly accepted the condition as an inevitable and common side effect of child birth. Besides, she was too shy to speak to even her doctor about the problem.

Wong was right that urinary incontinence is not uncommon after childbirth. The pelvic floor muscles, vagina and ligaments help to support the bladder. But the physical stress of pregnancy and trauma of childbirth can sometimes weaken these support structures, and the bladder pushes slightly out of the bottom of the pelvis towards the vagina.

Dr Winnie Lau Nga-ting, a specialist in obstetrics and gynaecology at the Hong Kong Sanatorium and Hospital, says that the bladder and bladder neck normally rest on top of a taut pelvic floor muscle. Childbirth can cause the muscle to lose some of that tension and sag a little.

These changes prevent the muscles that squeeze the urethra shut from working as forcefully and effectively. Called stress incontinence, urine leaks out when sudden and vigorous pressure from coughing, sneezing or other activity is exerted on the bladder.

However, what Wong did not know is that incontinence is treatable. Hence, she spent more than 10 years suffering in silence. When the leakage was bad, especially when she had a cold that caused her to cough and sneeze, she coped using sanitary pads. When leakage was light, she made do with panty liners. But the condition improved such that she would only suffer urine leaks once or twice a year so she continued to bear with the occasional inconvenience.

When Wong reached menopause two years ago at age 51, she found that the incontinence worsened. According to Lau, the drop in oestrogen after menopause causes changes in the tissue texture of muscles and fibre, and that in turn can aggravate an incontinence problem.

Moreover, Wong had put on weight over the past decade, which prompted her to exercise more. Unfortunately, the physical exertion also increased the incidence of urine leakage. Frustrated by the leaks, Wong scaled back her jogging and badminton routine.

Wong only found out that incontinence was treatable from her girlfriends, whom she confided in about her problem. One friend had even had surgery to address the condition. Encouraged, Wong approached Lau for help.

Lau first interviewed Wong to find out if she had other types of urinary problems such as frequent night urination or problems passing urine. A physical exam confirmed that Wong leaked urine when she coughed, and a basic urine test ruled out infection.

Next, Lau asked Wong to keep a diary of her fluid intake, urine excretion amounts and frequency, as well as leakage incidents to have a better idea of her bladder habits. The diary showed that Wong had normal fluid intake and excretion, and leaks were limited to about twice a week, usually as a result of coughing or exercise.

All indicators pointed to stress incontinence. Hence, the first line of management was physiotherapy to help Wong strengthen her pelvic floor muscles. Although the pelvic muscle exercises are fairly simple, a physiotherapist was needed to ensure that Wong was doing the exercises correctly and squeezing the right muscles.

Wong was encouraged to exercise her pelvic floor muscles daily. Her condition improved after the first few lessons and stabilised for the next three to four months. Lau notes that most patients who conscientiously do the exercises see a 40 to 60 per cent improvement.

However, during winter, Wong's symptoms worsened as reduced perspiration in the cold resulted in increased urination. Colds and flu are also more common during the season, and the increase in coughing and sneezing aggravated the problem. Furthermore, Wong didn't do the exercises as frequently.

She did eventually resume the exercise regimen, but the incontinence worsened. More drastic measures were necessary.

Lau suggested surgery. Of the options available, the gold standard and most commonly used procedure for stress incontinence is Tension-Free Vaginal Tape surgery, which cures 85 to 90 per cent of women. TVT involves placing a 1cm wide mesh tape under the urethra to support it and keep it closed. Whenever the woman strains, coughs or sneezes, the urethra will press on the tape and the resulting kink will prevent urine from leaking out.

The advantage of TVT is that it requires only three 1cm long incisions in the patient's vagina, lower abdomen and/or thighs near the groin. Needles are used to pass the mesh tape into the body via the tiny incisions. Once in place, the needles are removed. The procedure involves little pain and quick recovery. Over time, the body will encase the mesh tape in fibrous tissue and it becomes a permanent part of the body structure.

Wong agreed to the surgery. It took about 30 minutes and she was discharged in two days. She has remained dry since, and has resumed her exercise routine.

Lau says that while stress incontinence is not a life-threatening condition, it can have a devastating and debilitating effect on a woman's self-esteem and quality of life. Some women grow increasingly isolated because they fear leaving the house and may become depressed. Many are also too embarrassed and ashamed to speak to anyone about the problem. The biggest fallacy is that stress incontinence is an inevitable part of being female or ageing.

As Wong has shown, sufferers can indeed reclaim their quality of life.