Spirit Summer 2011 DuBois Regional Medical Center : Page 5

Incontinence Help at DuBois Regional Medical Center I ncontinence can occur for different reasons and, therefore, is treated in different ways. At DuBois Regional Medical Center and Brookville Hospital, we’ve got it covered. Upon having a problem, a family or internal medicine doctor may send a patient for further evaluation from a urologist, a specialist in the urinary tract, or a gynecologist, a women’s health doctor. The first step in getting help is to find out why someone is incontinent and what type of incontinence is occurring. “These patients usually have an anatomic abnormality that prevents the intrinsic continence mechanism of the lower urinary tract from holding back urine,” according to Dr. Gary Ott, obstetrician and gynecologist with Women’s Care of Western Pennsylvania. This results in a leak. It is up to the practitioner to identify where the anatomic defect is in the patient. Typically stress urinary incontinence is as-sociated with supportive defects or weakness in the neck of the bladder and/or the urethra (tiny tube that leads out of the bladder). Some women may have an inherent weak-ness in the connective tissue, but the most common cause for defects is pregnancy and child-bearing made worse by patients who carry too much weight or smoke. Think how many times stresses – laughing, coughing or sneezing – occur and multiply these day after day. Weakness pro-gresses in a slow steady fashion, Ott said. Though people are more prone as we age and muscles get weaker, this can happen to anyone at any age, www. s p i r i t o fw o m e n . c o m according to Candy Cerracchio, physician assistant at DRMC Urology. Ott agreed that it’s not just the senior population. Some things make people more at risk, such as having a hysterectomy, or a 20-year-old may have just had a baby and now has leakage. In order to determine where a weakness exists, a thorough exam in the office is done with tests to rule out urinary tract infection, unrecognized diabetes which can overproduce urine and/or exacerbate a problem bladder. Tumors of the lower urinary tract and lower genital tract can also be found in association with issues of incontinence. Patients can also undergo a bladder study. The study looks at issues such as how a patient voids, bladder ca-pacity, irritability and stability of the muscle wall or the bladder. It measures the extent to which the patient leaks with a full bladder during a stressful situation. The test can be simple by using a soft rubber catheter in the bladder and saline solution. Or it can be complex which involves using sensors and pressure transducers. The complex test is used less often unless a person is difficult to treat. Once studied, there are two most common categories of urinary incontinence to be treated. These include urge and stress incontinence. Urgence incontinence -also known as bladder spasms – is usually treated with medicines, Cerracchio said. “Some women just have an overactive bladder,” she said. It squeezes so much that it leaks. Continued on page 8 SUM M E R 2 011 SP I R IT O F W O M E N 5

Medical Central: Incontinence

Incontinence can occur for different reasons and, therefore, is treated in different ways.At DuBois Regional Medical Center and Brookville Hospital, we’ve got it covered. Upon having a problem, a family or internal medicine doctor may send a patient for further evaluation from a urologist, a specialist in the urinary tract, or a gynecologist, a women’s health doctor. The first step in getting help is to find out why someone is incontinent and what type of incontinence is occurring. “These patients usually have an anatomic abnormality that prevents the intrinsic continence mechanism of the lower urinary tract from holding back urine,” according to Dr. Gary Ott, obstetrician and gynecologist with Women’s Care of Western Pennsylvania. This results in a leak. It is up to the practitioner to identify where the anatomic defect is in the patient. Typically stress urinary incontinence is associated with supportive defects or weakness in the neck of the bladder and/or the urethra (tiny tube that leads out of the bladder). Some women may have an inherent weakness in the connective tissue, but the most common cause for defects is pregnancy and child-bearing made worse by patients who carry too much weight or smoke. Think how many times stresses – laughing, coughing or sneezing – occur and multiply these day after day. Weakness progresses in a slow steady fashion, Ott said. Though people are more prone as we age and muscles get weaker, this can happen to anyone at any age, According to Candy Cerracchio, physician assistant at DRMC Urology. Ott agreed that it’s not just the senior population. Some things make people more at risk, such as having a hysterectomy, or a 20-year-old may have just had a baby and now has leakage. In order to determine where a weakness exists, a thorough exam in the office is done with tests to rule out urinary tract infection, unrecognized diabetes which can overproduce urine and/or exacerbate a problem bladder. Tumors of the lower urinary tract and lower genital tract can also be found in association with issues of incontinence. Patients can also undergo a bladder study. The study looks at issues such as how a patient voids, bladder capacity, irritability and stability of the muscle wall or the bladder. It measures the extent to which the patient leaks with a full bladder during a stressful situation. The test can be simple by using a soft rubber catheter in the bladder and saline solution. Or it can be complex which involves using sensors and pressure transducers. The complex test is used less often unless a person is difficult to treat. Once studied, there are two most common categories of urinary incontinence to be treated. These include urge and stress incontinence. Urgence incontinence - also known as bladder spasms – is usually treated with medicines, Cerracchio said. “Some women just have an overactive bladder,” she said. It squeezes so much that it leaks. Sometimes, retraining the muscles helps and at DRMC, the Physical Therapy Department has a program in place to train the bladder muscles, Cerracchio said. Treatments that are used include biofeedback training, Kegel exercises and bladder retraining, according to Missy West, physical therapist. The goal is to strengthen the floor and gain more control of the muscles. The second kind is stress incontinence. This is leaking that comes with laughing, coughing, sneezing or jumping, Cerracchio said. It is usually associated with weakness of the pelvic floor muscles and can be fixed in several ways. First, a patient could be sent to DRMC Physical Therapy for retraining. If that doesn’t work, in a situation where you have isolated issue of stress urinary incontinence from a weak outlet of the bladder, most patients can be a candidate for a supportive procedure performed as an outpatient. It involves three tiny incisions, one leading out of the tube by the bladder and two tiny ones – about half a centimeter wide - above the pubic bone in the lowest part of the belly, Ott said. The mesh tape is a surgical mesh band that adheres to abdominal wall and holds the urethra in place.The scars that form continue to hold the mesh as the body heals during a short recovery period. The urology office also does injections of collagen into the base of the bladder to give a barrier for urine that “sneaks” out. It is something you can do up to three times in life, Cerracchio said. A lot of women do once and that is all they need. It is also reversible. If there is ever a problem for any reason, doctors can pull it out. “A lot of women do really well with that,” she said. “It is a good option for some people.” Another non-surgical option, Ott said, is a device called a pessary. This is very similar although more rigid to contraceptive diaphragm. It is a supportive to structure that helps hold the defect in place. It provides a treatment but not a cure. It must be carefully maintained with prescribed schedule of removing, cleaning and replacement. If the reason for incontinence is that the bladder dropped out of place, patients go to a gynecologist, like Ott, for an invasive bladder lift. The repairs can often require more than just a bladder lift. The repairs often entail finding the defect, isolating it and suturing back together the defects in the supportive tissue that lead to the problem. These traditional repairs alone - even if performed by skilled surgeons with healthy tissue - can be associated with a high failure rate, Ott said, because the surgeon is working with thin materials. For that reason, numerous mesh kits have become available to surgeons for reinforcing the surgical repair with thin sheets of surgical mesh that provide a longer lasting reinforcement of the surgical repair. It is a mesh that is used at the level of the bladder, the apex of vagina or over laying the rectum.Mesh is a substitute for the weakened supportive tissue. Although this can provide a supportive framework in the pelvis, it can be associated with a unique complication spectrum related to the mesh itself with regard to erosion, rejection or infection of the mesh, Ott said. It is very important that candidates for this type of repair are carefully selected. A procedure like this can be done on the same day with most arriving early in morning and home by lunch time. There is a high satisfaction rate with this procedure, Ott said. Patients come to the hospital leaking and the majority of the time walks home dry. Every surgery has risks, but this is generally regarded as a very safe and effective procedure when performed by a highly qualified surgeon who specializes in this work. With so many choices, we can see the care for incontinence can have many layers. Most of the time, there is not one easy answer but a mixed picture of symptoms and causes. But no matter the reason, Cerracchio encourages women and men who are incontinent to get help. “Patients always say, “Why didn’t I do this sooner?” Every one who comes in feels it is embarrassing to talk about, Cerrachio said, but “I assure each one that I see at least 10 other people in the same day with the same problem.” “What is refreshing to me is that the younger generation – in their fourth and fifth decades – are actively pursuing treatments and evaluations and not accepting this as part of aging process,” Ott said. It’s no longer that one’s mother and grandmother suffered silently and I should, too.Women are not suffering in silence any more. Depending on the urgency, stress and what percentage better the person wishes to be can guide the choices for treatment. For example, someone who leaked several times a day may be happy to only have a problem when laughing.“I never promise that someone will be 100 percent dry, but there is always improvement,” Cerrachio said.

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