“TOO EMBARRASSED TO TELL MY DOCTOR”

With new medical techniques, most incontinence sufferers can be cured — if only they will seek help
By Louise Waterson

Over 300 million people in Asia are afflicted by a condition they are too embarrassed to mention even to a GP. It can limit social life, rule out sports and make everyday activities an agony of anxiety.

Their problem is incontinence — an ability to control the bladder. Yet most victims suffer needlessly. With new medical techniques, incontinence can usually be cured or, at least, properly managed. According to urologist Dr Sahabudin Raja Mohamed of Kuala Lumpur General Hospital, almost a third of sufferers can be cured, while the rest can receive treatment that will substantially improve their quality of life. “For those we can’t cure, the aim is to keep them dry. For those we can’t keep dry, the aim is to keep them comfortable.”

Antonette Betita*, a 39-year-old Manila lawyer, never thought she had a medical problem. The sudden and often pressing need to empty her bladder was just an unpleasant part of her daily routine.

Then there were the times when Betita didn’t make it to the toilet. Once, during a particularly busy day at work, she wet herself. “I tried to conceal the wet spot by walking around with my blouse pulled out. I was terrified someone might notice.”

Finally, her sister, a doctor, insisted she seek medical help. An abnormally small bladder was diagnosed. Betita now limits the number of drinks she has when out with friends and makes a conscious effort to go to the toilet more regularly. Say Betita, “Understanding my condition means I’m better able to manage it.”

Widespread malady. Contrary to popular belief, incontinence is by no means confined to the elderly and senile. Sufferers include the girl who sought help when she was ashamed to go on holiday with her boyfriend; and the young man who, because he wets his bed would not leave home to go to university and turned down a promotion.

A 1998 survey of 11 Asian countries by the Asia Pacific Continence Advisory Board found that 14.6 per cent of women and 6.7 per cent of men reported having incontinence symptoms. Almost one in four women aged 29-39 said they suffered from the condition double the rate of women aged 60-69.

“For women, the risk of developing incontinence increase with childbirth,” explains urologist Dr Maric Lapitan of the Philippine General Hospital in Manila.

“By the time most women are in their late 30s, they will have had their children. And that’s when they begin to notice their pre-pregnancy bladder control has declined.”

The survey also found that the condition is often untreated. Only 43 per cent of participants identified as having incontinence said they would seek help, even though it disrupted their lives. Dr Peter Lim, chairman of the Asia Pacific Continence Advisory Board (APCAB) and a senior urologist at Singapore’s Changi General Hospital, regularly encounters patients who have suffered for years without seeking help. “Because they’re embarrassed or don’t know that treatments are available, they don’t consult a doctor,’ says Lim.

Dr Lapitan recalls a 55-year-old woman who came to her Manila clinic after suffering from incontinence for ten years. As a result of condition, she rarely left her house. “After surgery and five days in hospital, she returned home totally cured, “ Lapitan says.

Religious and cultural factors may dissuade some sufferers from seeking help. Despite Muslim customs that stress personal hygiene, a third of Malaysians and more than half of Indonesians and Pakistanis with the condition said they would not seek medical treatment. Explains Dr Sahabudin, “Muslims are more likely to resort to traditional herbal medicine as a way of managing the problem discreetly.’

Many parts of Asia have only recently started addressing the problem. Specialist nurses know as “continence advisers” began training throughout Asia five years ago. Today, there are still only 17 such advisers in Singapore, one in the Philippines, three in Thailand and two in Hong Kong, while Malaysia is about to begin training advisers for its regional hospitals.

The contribution of these nurses is invaluable. They consult with patients in hospitals and outpatient clinics, look at their lifestyle and build trust. “Incontinence isn’t just a bladder problem,” explains Chan Sau Kuen a Hong Kong continence adviser. “Incontinence is something that affects the way a person lives.”

Continence advisers are skilled at allaying embarrassment. Says Hwee Huang Chia of Singapore, “We try to reduce embarrassment by increasing awareness of the physiology of the urinary tract system and the underlying causes of incontinence.”

Investigation. The cause of incontinence can lie anywhere in the body’s complex waste-disposal system; in the bladder and the muscle that controls it; the urethra, the tube that takes urine away from the bladder; the urethral sphincter, a valve-like mechanism that opens and closes the bladder outlet; the pelvic floor muscles that support the bladder; or the spinal nerve pathways that carry signals between bladder and brain.

Specialists divide most incontinence into four overlapping kinds — stress, urge, overflow and continuous. Stress incontinence occurs almost exclusively in women at moments of physical stress: coughing, sneezing, laughing, lifting something, even climbing stairs, because of a weakening of the sphincter, often after a difficult childbirth, any pressure on the bladder forces some urine through. Usually the pelvic floor muscles are also weakened, so that the neck of the bladder descends, making the sphincter less effective.

Urge incontinence, which occurs in both sexes, is an inability to “hold back” urination, and can be caused by overactivity of the bladder muscle, a bladder infection, anxiety, neurological disorders such as a spinal injury, multiple sclerosis, stroke, dementia or obstructed urine flow.

Overflow incontinence occurs when urine continuously collects in the bladder until it overflows. It’s commonly caused by an enlarged prostate gland in men, and nerve or muscle weakness of the bladder muscle in women, usually following a womb operation.

The fourth type, continuous incontinence, occurs when, for example, the urethra from the kidney is joined to the perineum instead of the bladder, bypassing the sphincter. As a result, urine flows continuously.

To cure stress incontinence, a three-month regimen of exercises that strengthen pelvic floor muscles is frequently enough. The exercises, which involve contracting and then relaxing these muscles, can be done anywhere at intervals through the day — sitting on bus, watching television — and take just a few minutes each time. ‘A whole lot can be achieved if you work at it;’ says Hong Kong incontinence adviser Chan Sau Kuen.

Angela Gourdin of Kula Lumpur suffered from stress incontinence after having her fist child. She returned to work six weeks after the birth and was forced to wear p[ads because of constant leaking. Concerned that someone would notice she had a problem, Gourdin went out of her way to buy the pads at dozens of shops.

Then one day she went for a drive with her husband. “When I got out of the car, my dress was wet,” she says. “I was stunned — I never realized the condition could get that bad.” Nevertheless, she suffered through 30 years of incontinence – and was correctly diagnosed only last year when she had a hysterectomy. A regimen of pelvic floor exercises and drugs cured her in six months.

Rejuvenation. If exercises are not successful, doctors may do a simple 20-minute procedure in which an animal protein, collagen, is injected into the bladder walls through a needle inserted in the patient’s urethra. The collagen makes the bladder neck stronger by reshaping it and encouraging tissue regrowth. Regina Lai, a 61-year-old retired hospital clerk and mother of three from Singapore, underwent the treatment after suffering in silence for 15 years.

“I am cured now,” Lai says. “I used to feel too shy to go out in public in case I wet myself. I had to use up to six pads a day. Now I am so much happier.”

Sufferers of urge incontinence are asked to keep a chart of record how often they go to the toilet — four to eight times a day is normal — and the volume; a normal bladder can retain between 300 and 500 ml before it has to be emptied.

The chart is the starting point for bladder retraining. If, for instance, it shows that the person rushes to the toilet every two hours, they are encouraged to go every hour-and-a-half, and then gradually extend the intervals; this trains the bladder muscle to respond to commands. Tablets to help relax the bladder so that it does not need emptying as often can also be effective.

Determination. If the cause of incontinence is in doubt, doctors may order a urodynamic assessment — an examination of the bladder, urethra and sphincter done in hospital but lasting less than an hour. This may show that the urethral sphincter is not working properly, or reveal damage to the nerves that relay messages from the bladder to the brain — damage often caused by injury or birth defects.

For more severe causes of incontinence, like overflow and continuous, surgery is the only option, Seventeen-year-old Singapore student Prathiv Hashim was born with a small bladder.

Doctors said nothing could be done, and her endured continuous incontinence for 14 years. “Going out was the hardest thing because my shorts were always wet,” he says.

“People stared at me on the bus, and I had no friends.” Then, three years ago, Hashim’s father took him to see Dr Lim, who suggested he undergo an operation to enlarge his bladder. After a month in hospital, Hashim was cured. “Now I enjoy swimming and playing basketball, and I’m much more outgoing.”

Of the disabilities caused by spinal injury, many sufferers find incontinence the hardest to bear. “It was very difficult and embarrassing to be told that I had no way of controlling my bladder,” says Shirley Tan, a 46-year-old Singapore secretary, who was left a paraplegic after a motor vehicle accident seven years ago. For Tan, the answer was self catheterisation. By inserting a very thin metal tube into the bladder after she has been to the toilet, she is able to draw off any excess urine. This prevents bladder overfill.

“While incontinence is an embarrassing thing, you can overcome it,” Tan says. “Self-catheterisation has given me independence and control.”

New products for those whose incontinence cannot be cured include specially designed trousers and dresses, comfortable underwear, discreet pads and bed linen that does not retain moisture.

Concern about incontinence is found as far back as the writings of the ancient Greeks and Romans. But the modern medical profession has been slow to treat it seriously. While most doctors in Asia aren’t adequately equipped to deal with the problem, awareness is gradually improving.

In recent years, GPs have been taught to recognise the different types of incontinence,” says Goh Lee Gan, associate professor of family medicine at the National University of Singapore. “It has also been included in undergraduate and postgraduate family medicine programmes of many Asian universities.”

Specialists strive to combat the all-too-frequent response when an elderly person becomes incontinent: “It’s to be expected at your age.” As Dr Edward Leung Man-fuk, a geriatrician at United Christian Hospital in Hong Kong, insists: “Incontinence is a symptom of an underlying disease. It’s not necessarily a natural part of ageing.”

The condition can determine how elderly people spend their final years. Typical is a 75-year-old Hong Kong woman with a history of diabetes and hypertension. After enduring four years of incontinence, she was suffering from anxiety and severe sleep-deprivation.

Finally she sought help from Dr Leung’s Continence Clinic. Urge incontinence was diagnosed and she received treatment in the form of bladder retraining and pelvic floor exercises. After four months, she was cured. Her anxiety abated and she regained her independence.

Most incontinence sufferers, regardless of age, can be helped. Sums up Dr Peter Lim: “Incontinence is not a sign of senility or of a severe ailment. It’s merely a symptom of an ailment that often can be easily fixed with simple treatments — surgery is only needed for very severe cases. We must get that message across so that those who are suffering needlessly will seek help without delay.”

Some names of patients have been changed to protect privacy.
Reprinted with permission from the November 1999 Reader’s Digest copyright)

Prevalence of Urinary Incontinence
Nearly one in nine Asians experiences some form of this condition

Click to find out more from your local continence society