tag:theconversation.com,2011:/global/topics/urinary-incontinence-3285/articlesUrinary incontinence – The Conversation2023-09-13T20:05:28Ztag:theconversation.com,2011:article/2108082023-09-13T20:05:28Z2023-09-13T20:05:28ZDoes running water really trigger the urge to pee? Experts explain the brain-bladder connection<figure><img src="https://images.theconversation.com/files/547929/original/file-20230913-19-o53nya.jpg?ixlib=rb-1.1.0&rect=103%2C103%2C5647%2C3733&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>We all know that feeling when nature calls – but what’s far less understood is the psychology behind it. Why, for example, do we get the urge to pee just before getting into the shower, or when we’re swimming? What brings on those “nervous wees” right before a date?</p>
<p>Research suggests our brain and bladder are in constant communication with each other via a neural network called the <a href="https://www.einj.org/journal/view.php?doi=10.5213/inj.2346036.018">brain-bladder axis</a>. </p>
<p>This complex web of circuitry is comprised of sensory neural activity, including the sympathetic and parasympathetic nervous systems. These neural connections allow information to be sent <a href="https://doi.org/10.3390/diagnostics12123119">back and forth</a> between the brain and bladder. </p>
<p>The brain-bladder axis not only facilitates the act of peeing, but is also responsible for telling us we need to go in the first place. </p>
<h2>How do we know when we need to go?</h2>
<p>As the bladder fills with urine and expands, this activates special receptors detecting stretch in the nerve-rich lining of the bladder wall. This information is then relayed to the “periaqueductal gray” – a part of the brain in the brainstem which <a href="https://www.nature.com/articles/nrn2401">constantly monitors</a> the bladder’s filling status. </p>
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<a href="https://images.theconversation.com/files/547931/original/file-20230913-19-2kgkhk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/547931/original/file-20230913-19-2kgkhk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/547931/original/file-20230913-19-2kgkhk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=454&fit=crop&dpr=1 600w, https://images.theconversation.com/files/547931/original/file-20230913-19-2kgkhk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=454&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/547931/original/file-20230913-19-2kgkhk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=454&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/547931/original/file-20230913-19-2kgkhk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=570&fit=crop&dpr=1 754w, https://images.theconversation.com/files/547931/original/file-20230913-19-2kgkhk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=570&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/547931/original/file-20230913-19-2kgkhk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=570&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">The periaqueductal gray is a section of gray matter located in the midbrain section of the brainstem.</span>
<span class="attribution"><a class="source" href="https://en.wikipedia.org/wiki/Brainstem#/media/File:1311_Brain_Stem.jpg">Wikimedia/OpenStax</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
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<p>Once the bladder reaches a certain threshold (roughly 250-300ml of urine), another part of the brain called the “pontine micturition centre” is activated and signals that the bladder needs to be emptied. We, in turn, <a href="https://pubmed.ncbi.nlm.nih.gov/16254993/">register this</a> as that all-too-familiar feeling of fullness and pressure down below.</p>
<p>Beyond this, however, a range of situations can trigger or exacerbate our need to pee, by increasing the production of urine and/or stimulating reflexes in the bladder.</p>
<h2>Peeing in the shower</h2>
<p>If you’ve ever felt the need to pee while in the shower (no judgement here) it may be due to the sight and sound of running water. </p>
<p>In a 2015 study, <a href="https://doi.org/10.1371/journal.pone.0126798">researchers demonstrated</a> that males with urinary difficulties found it easier to initiate peeing when listening to the sound of running water being played on a smartphone. </p>
<p>Symptoms of overactive bladder, including urgency (a sudden need to pee), have also been <a href="https://www.alliedacademies.org/articles/environmental-cues-to-urgency-and-incontinence-episodes-in-chinesepatients-with-overactive-urinary-bladder-syndrome.html">linked to</a> a range of environmental cues involving running water, including washing your hands and taking a shower.</p>
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Read more:
<a href="https://theconversation.com/does-it-matter-if-you-sit-or-stand-to-pee-and-what-about-peeing-in-the-shower-206869">Does it matter if you sit or stand to pee? And what about peeing in the shower?</a>
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<p>This is likely due to both physiology and psychology. Firstly, the sound of running water may have a relaxing <em>physiological</em> effect, increasing activity of the parasympathetic nervous system. This would relax the bladder muscles and prepare the bladder for emptying.</p>
<p>At the same time, the sound of running water may also have a conditioned <em>psychological</em> effect. Due to the countless times in our lives where this sound has coincided with the actual act of peeing, it may trigger an instinctive reaction in us to urinate. </p>
<p>This would happen in the same way <a href="https://www.simplypsychology.org/pavlov.html">Pavlov’s dog learnt</a>, through repeated pairing, to salivate when a bell was rung.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/547933/original/file-20230913-21-yn86yb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/547933/original/file-20230913-21-yn86yb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/547933/original/file-20230913-21-yn86yb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/547933/original/file-20230913-21-yn86yb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/547933/original/file-20230913-21-yn86yb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/547933/original/file-20230913-21-yn86yb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/547933/original/file-20230913-21-yn86yb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/547933/original/file-20230913-21-yn86yb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Over our lifetimes we may become conditioned to associate peeing with running water, due to the concurrence of these events.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
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<h2>Cheeky wee in the sea</h2>
<p>But it’s not just the sight or sound of running water that makes us want to pee. Immersion in cold water has been shown to cause a “cold shock response”, <a href="https://pubmed.ncbi.nlm.nih.gov/19945970">which activates</a> the sympathetic nervous system. </p>
<p>This so-called “fight or flight” response drives up our blood pressure which, in turn, causes our kidneys to filter out more fluid from the bloodstream to stabilise our blood pressure, in a process called “<a href="https://link.springer.com/article/10.1007/BF00864230">immersion diuresis</a>”. When this happens, our bladder fills up faster than normal, triggering the urge to pee. </p>
<p>Interestingly, immersion in very warm water (such as a relaxing bath) may also increase urine production. In this case, however, it’s due to activation of the parasympathetic nervous system. <a href="https://doi.org/10.1007/s004210050065">One study</a> demonstrated an increase in water temperature from 40°C to 50°C reduced the time it took for participants to start urinating. </p>
<p>Similar to the effect of hearing running water, the authors of the study suggest being in warm water is calming for the body and activates the parasympathetic nervous system. This activation can result in the relaxation of the bladder and possibly the pelvic floor muscles, bringing on the urge to pee.</p>
<h2>The nervous wee</h2>
<p>We know stress and anxiety can cause bouts of nausea and butterflies in the tummy, but what about the bladder? Why do we feel a sudden and frequent urge to urinate at times of heightened stress, such as before a date or job interview?</p>
<p>When a person becomes stressed or anxious, the body goes into fight-or-flight mode through the activation of the sympathetic nervous system. This triggers a cascade of physiological changes designed to prepare the body to face a perceived threat.</p>
<p>As part of this response, the muscles surrounding the bladder may contract, leading to a more urgent and frequent need to pee. Also, as is the case during immersion diuresis, the increase in blood pressure associated with the stress response may <a href="https://doi.org/10.1172/JCI102496">stimulate</a> the kidneys to produce more urine.</p>
<h2>Some final thoughts</h2>
<p>We all pee (most of us several times a day). Yet <a href="https://doi.org/10.5489/cuaj.1150">research has shown</a> about 75% of adults know little about how this process actually works – and even less about the brain-bladdder axis and its role in urination. </p>
<p><a href="https://www.continence.org.au/about-us/our-work/key-statistics-incontinence#:%7E:text=Urinary%20incontinence%20affects%20up%20to,38%25%20of%20Australian%20women1.">Most Australians</a> will experience urinary difficulties at some point in their lives, so if you ever have concerns about your urinary health, it’s extremely important to consult a healthcare professional. </p>
<p>And should you ever find yourself unable to pee, perhaps the sight or sound of running water, a relaxing bath or a nice swim will help with getting that stream to flow.</p>
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Read more:
<a href="https://theconversation.com/is-urine-sterile-do-urine-therapies-work-experts-debunk-common-pee-myths-191862">Is urine sterile? Do urine 'therapies' work? Experts debunk common pee myths</a>
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<img src="https://counter.theconversation.com/content/210808/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Helen O'Connell is the current president of The Urological Society of Australia and New Zealand (USANZ).</span></em></p><p class="fine-print"><em><span>David Homewood, James Overs, and Simon Robert Knowles do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A shower, a swim, a warm bath: there are a number of common pee triggers. So how much of our need to pee comes down to psychology?James Overs, Research Assistant, Swinburne University of TechnologyDavid Homewood, Urology Research Registrar, Western Health, Melbourne HealthHelen Elizabeth O'Connell AO, Professor, University of Melbourne, Department of Surgery. President Urological Society Australia and New Zealand, The University of MelbourneSimon Robert Knowles, Associate Professor and Clinical Psychologist, Swinburne University of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1905322022-09-20T03:25:23Z2022-09-20T03:25:23ZAction on faulty vaginal mesh took too long, now women struggle to access mesh surgery that works<figure><img src="https://images.theconversation.com/files/485259/original/file-20220919-27-xj3xmf.jpg?ixlib=rb-1.1.0&rect=395%2C1047%2C4586%2C2397&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/GcUe00s585w">Gwendal Cottin/Unsplash</a></span></figcaption></figure><p>Last week, Johnson & Johnson reached a <a href="https://www.theguardian.com/business/2022/sep/12/johnson-johnson-reaches-300m-settlement-over-pelvic-mesh-implants?CMP=share_btn_tw">A$300 million settlement</a> for two class actions brought by Australian women affected by complications from vaginal mesh products. </p>
<p>The products are surgically implanted to correct urinary incontinence or prolapse, where the vaginal tissues weaken and sag outside the vagina. </p>
<p>However, women involved in the class action experienced a <a href="https://www.theguardian.com/business/2022/sep/12/johnson-johnson-reaches-300m-settlement-over-pelvic-mesh-implants?CMP=share_btn_tw">range of issues</a> with vaginal mesh implants, including chronic pain, painful intercourse and incontinence.</p>
<p>The first of the Australian class actions against Johnson & Johnson was filed in <a href="https://www.lexology.com/library/detail.aspx?g=f0f3eaf1-8edb-4384-a0e2-c3ea7097eb61">2012</a>. Justice Katzmann <a href="https://jade.io/j/?a=outline&id=675422">ruled</a> the company hadn’t fully researched these products (which carried significant risks), was motivated by commercial factors, and failed to give doctors or patients adequate safety information.</p>
<p>The following ten years have seen a radical overhaul in the use of vaginal mesh implants in Australia and throughout the world. But we’ve also seen unintended consequences, with some women not accessing care. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1569181114367082500"}"></div></p>
<h2>What has changed?</h2>
<p>We now have strict <a href="https://www.safetyandquality.gov.au/sites/default/files/migrated/Credentialing-of-Senior-Medical-Practitioners-to-Undertake-Transvaginal-Mesh-Implant-Surgery-forStress-Urinary-Incontinence.pdf">training and credentialing guidelines</a> for surgeons using vaginal mesh, plus detailed management protocols for pelvic floor disorders. Only surgeons with advanced training in pelvic floor surgery following their specialty training are able to perform vaginal mesh surgery. </p>
<p>All patients are <a href="https://www.safetyandquality.gov.au/our-work/health-conditions-and-treatments/transvaginal-mesh/resources-consumers-clinicians-and-health-service-organisations-transvaginal-mesh-and-sacrocolpopexy#care-pathways">first referred</a> for extensive pelvic floor muscle training. Only those who don’t respond to conservative treatment and whose incontinence has a major impact on their quality of life are referred for a surgical review. </p>
<p>Mesh repair for prolapse is considered only in patients with severe or recurrent prolapse in whom basic surgery using the patient’s own tissues has failed. This tends to be patients with multiple health problems who are not fit enough for major abdominal surgery. </p>
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Read more:
<a href="https://theconversation.com/vaginal-mesh-controversy-shows-collective-failure-of-the-tga-and-australias-specialists-78605">Vaginal mesh controversy shows collective failure of the TGA and Australia's specialists</a>
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<p>Registration for mesh products has been rigorously upgraded and requires extensive pre- and post-marketing audit. This means implants are tested in lengthy clinicial trials before and after they’re implanted in patients. Trials also compare the outcomes and complications to women having surgery without mesh. </p>
<p>Formal <a href="https://www.monash.edu/medicine/sphpm/registries/apfpr">audit systems</a> monitor women’s long-term outcomes. And next year, all implants will have a <a href="https://www.tga.gov.au/sites/default/files/2022-07/presentation-arcs-annual-conference-establishing-the-australian-unique-device-identification-system.pdf">unique device identifier</a>. Similar systems are used for joint replacements and breast implants, allowing prompt review if there are concerns over a device.</p>
<p>All of these changes should have been standard practice a long time ago and will hopefully prevent similar mistakes in future. </p>
<h2>Some women not seeking treatment</h2>
<p>Through media coverage of the vaginal mesh issue, most of the population learned “mesh was bad”. They may not have known anything about prolapse or incontinence but they clearly got the message mesh was something to avoid. </p>
<p>Following the 2011 United States Food and Drug Administration (FDA) safety update citing possible complications associated with vaginal mesh, there was a <a href="https://journals.lww.com/fpmrs/Abstract/2013/07000/Impact_of_the_2011_FDA_Transvaginal_Mesh_Safety.2.aspx#:%7E:text=p%20191%2D198-,doi%3A%2010.1097/SPV.0b013e31829099c1,-Copy">marked reduction</a> in the use of vaginal mesh implants for prolapse surgery. </p>
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<img alt="Woman walks in the country with her dog" src="https://images.theconversation.com/files/485457/original/file-20220920-21052-deaukn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/485457/original/file-20220920-21052-deaukn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=477&fit=crop&dpr=1 600w, https://images.theconversation.com/files/485457/original/file-20220920-21052-deaukn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=477&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/485457/original/file-20220920-21052-deaukn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=477&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/485457/original/file-20220920-21052-deaukn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=600&fit=crop&dpr=1 754w, https://images.theconversation.com/files/485457/original/file-20220920-21052-deaukn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=600&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/485457/original/file-20220920-21052-deaukn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=600&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Patients haven’t wanted procedures with mesh.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/Z3uWkv8Ovtc">Caspar Rae/Unsplash</a></span>
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<p>Over the past ten years, fewer women have had surgery for pelvic floor weakness. </p>
<p>This is most noticeable for a type of surgery for urinary incontinence, mid-urethral sling, which <a href="https://www.aihw.gov.au/reports/hospitals/procedures-data-cubes/contents/data-cubes">has dropped 64%</a> from its peak usage in 2010–2011. A mid-urethral sling uses a thin band of mesh under the urethra to manage incontinence. </p>
<p>Prolapse repair requires a larger patch of mesh to support the weakened vaginal walls. </p>
<p>Both these products are made from the same polypropylene mesh. This is the same material used in sutures (stitches) for many decades. </p>
<p>However, prolapse repair is more complex and has a higher risk of complications than mesh continence surgery, where short- and long term outcomes are <a href="https://pubmed.ncbi.nlm.nih.gov/30357298/#:%7E:text=PMID%3A%2030357298,10.1001/jama.2018.14997">very good</a>. </p>
<p>Yet we have <a href="https://www.aihw.gov.au/reports/hospitals/procedures-data-cubes/contents/data-cubes">not seen</a> any significant increase in other non-mesh continence surgery to compensate for this. </p>
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Read more:
<a href="https://theconversation.com/urinary-incontinence-can-be-a-problem-for-women-of-all-ages-but-there-is-a-cure-49365">Urinary incontinence can be a problem for women of all ages, but there is a cure</a>
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<p>It’s possible more women are turning to physiotherapy treatment which can improve incontinence symptoms and is recommended as first-line treatment. Physiotherapy can also <a href="https://www.cochrane.org/CD005654/INCONT_pelvic-floor-muscle-training-urinary-incontinence-women#:%7E:text=Cochrane%20Database%20of%20Systematic%20Reviews%202018%2C%20Issue%2010.%20Art.%20No.%3A%20CD005654.%20DOI%3A%2010.1002/14651858.CD005654.pub4">benefit</a> women with mild to moderate vaginal prolapse. </p>
<p>However private physiotherapy care can be costly and difficult to access. There has also been an ongoing <a href="https://treasury.gov.au/sites/default/files/2022-03/258735_continence_foundation_of_australia.pdf">decline</a> in physiotherapy and nurse continence services in public hospitals and community centres. </p>
<p>It is likely many women are not seeking help at all.</p>
<h2>Mesh still has a place</h2>
<p>The problem is, mesh is not inherently bad. Mesh has enabled surgeons to treat many women, including older or more frail patients, who aren’t suited to more major surgery. </p>
<p>Vaginal mesh surgery for prolapse is well tolerated in elderly and frail patients. Since its introduction, the <a href="https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/ajo.12445?saml_referrer#:%7E:text=https%3A//doi.org/10.1111/ajo.12445">greatest relative uptake in continence procedures</a> has been in women 75 years and older. </p>
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<img alt="Older woman sits near the beach" src="https://images.theconversation.com/files/485455/original/file-20220920-3237-c5izqq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/485455/original/file-20220920-3237-c5izqq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/485455/original/file-20220920-3237-c5izqq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/485455/original/file-20220920-3237-c5izqq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/485455/original/file-20220920-3237-c5izqq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/485455/original/file-20220920-3237-c5izqq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/485455/original/file-20220920-3237-c5izqq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Mesh is still a good option for many women.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/jeEedhJXoR0">sk/Unsplash</a></span>
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<p>For incontinence, a mid-urethral sling is <a href="https://pubmed.ncbi.nlm.nih.gov/20434257/#:%7E:text=PMID%3A%2020434257,j.eururo.2010.04.022">more effective</a> with fewer complications than other procedures for incontinence.<br>
The most effective surgical repair for severe and recurrent prolapse, particularly in younger women, is a sacrocolpopexy. Generally performed via keyhole surgery, this technique uses a mesh strip anchored to the triangular bone at the base of the spine to support weakened vaginal tissues. </p>
<p><a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012376/full">Sacrocolpopexy</a> has a good safety profile, is effective and durable – and wasn’t part of the recent class actions. </p>
<p>But this is no longer available, as the <a href="https://www.health.gov.au/news/phi-circulars/phi-8920-removal-of-urogynaecological-mesh-devices">manufacturers</a> of mesh for sacrocolpopexy in Australia <a href="https://usanz.org.au/publicassets/d5d87991-454e-ec11-9103-0050568796d8/ANZ-Mesh-Sales---Customer-Letter---FINAL-11-17-2021.pdf">recently removed</a> their products from the market. This was likely a commercial decision: the long-term studies required for registration of mesh products used in pelvic floor surgery are expensive and time consuming, and Australia is a relatively small market.</p>
<p>Mesh for vaginal prolapse had already been removed from the <a href="https://www.tga.gov.au/news/safety-alerts/tga-actions-after-review-urogynaecological-surgical-mesh-implants#:%7E:text=The%20TGA%20decided%20on%2028,of%20Therapeutic%20Goods%20(ARTG).">Australian Register of Therapeutic Goods</a> in 2018, meaning it can’t be supplied in Australia, after Australia’s regulator classified it as high risk. </p>
<p>Progress has been made to protect patients from the harms of faulty mesh implants but we need to ensure women have access to safe, effective surgical procedures to treat incontinence and prolapse – and for some women, this will include mesh. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/not-all-vaginal-implants-are-a-problem-and-treating-them-the-same-puts-many-women-at-risk-94403">Not all vaginal implants are a problem and treating them the same puts many women at risk</a>
</strong>
</em>
</p>
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<img src="https://counter.theconversation.com/content/190532/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jennifer King is affiliated with International Urogynaecological Association, Continence Foundation of Australia NSW Branch </span></em></p>We need to ensure women have access to safe, effective procedures to treat incontinence and prolapse – including those using mesh.Jennifer King, Senior Clinical Lecturer, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1870832022-08-23T02:18:37Z2022-08-23T02:18:37ZPessaries are still a taboo topic – but these ancient devices help many women<figure><img src="https://images.theconversation.com/files/480485/original/file-20220822-22-j0vkv.jpg?ixlib=rb-1.1.0&rect=1497%2C14%2C7335%2C3308&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://image.shutterstock.com/image-photo/dressed-woman-wants-pee-600w-2143814309.jpg">Shutterstock</a></span></figcaption></figure><p>A vaginal <a href="https://www.yourpelvicfloor.org/media/vaginal-pessary-for-pelvic-organ-prolapse-english-1.pdf">pessary</a> is a removable device inserted in the vagina to support its walls or uterus (support pessary) or for bladder leakage (continence pessary). </p>
<p>Pessaries have been around for a very long time, the <a href="https://www.sciencedirect.com/science/article/abs/pii/S0301211503006511">oldest</a> known pessary – as described by the ancient Greek physician Hippocrates – was a pomegranate soaked in vinegar! </p>
<p>Nowadays, pessaries are made from silicone which is non allergenic, long lasting, pliable and can be sterilised. Some are worn continuously for weeks, months or years with appropriate maintenance, while others are inserted as needed. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/vaginal-birth-after-caesarean-increases-the-risk-of-serious-perineal-tear-by-20-our-large-scale-review-shows-173249">Vaginal birth after caesarean increases the risk of serious perineal tear by 20%, our large-scale review shows</a>
</strong>
</em>
</p>
<hr>
<h2>What they are good for</h2>
<p>There are many <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2876320/">types</a> of vaginal support pessaries with (mostly) descriptive names: ring, Gellhorn, donut, cube, C-POP and more. At least two models of continence pessaries – branded <a href="https://contiforminternational.com/">Contiform</a> and <a href="https://coowee.me/">Coo-Wee</a> – are relatively new on the market as well as the continence <a href="https://www.researchgate.net/figure/ncontinence-ring-and-incontinence-dish-courtesy-of-Milex-web-site_fig1_225762597">ring and dish</a>. </p>
<p>Continence pessaries are used for stress urinary incontinence or “light bladder leakage” that occurs with coughing, sneezing or exercise. These act to support the urethra, as can a vaginal tampon, and can prevent leakage in <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9119894/">up to 60%</a> of women. They are especially useful if leakage is predictable, such as when a woman goes to the gym or out for a jog.</p>
<p>Vaginal support pessaries can be effective for <a href="https://www.continence.org.au/who-it-affects/women/prolapse">prolapse</a> (a type of hernia or weakness of the vaginal walls and ligaments that allow the uterus, bladder, or bowel to descend to or beyond the vaginal opening). If successfully fitted, pessaries can help <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004010.pub4/full">60% to 70%</a> of women with these problems. There is improvement in the feeling of a vaginal bulge or tissue protrusion, improvement in bladder emptying and bladder leakage and urgency, sexual frequency and satisfaction. About 50% of women who have a vaginal birth will have some prolapse and up to <a href="https://journals.lww.com/greenjournal/Fulltext/2014/06000/Lifetime_Risk_of_Stress_Urinary_Incontinence_or.9.aspx">20%</a> will go on to have surgery during their lifetime.</p>
<p>Pelvic floor muscle training in the early stages can improve symptoms as can vaginal estrogen in women after menopause. A <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2876320/">pessary</a> can be an alternative to surgery or used while women are delaying (such as in between pregnancies) or waiting to have surgery.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/478487/original/file-20220810-7093-8xw795.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="diagram of pessary and prolapse" src="https://images.theconversation.com/files/478487/original/file-20220810-7093-8xw795.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/478487/original/file-20220810-7093-8xw795.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=233&fit=crop&dpr=1 600w, https://images.theconversation.com/files/478487/original/file-20220810-7093-8xw795.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=233&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/478487/original/file-20220810-7093-8xw795.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=233&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/478487/original/file-20220810-7093-8xw795.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=293&fit=crop&dpr=1 754w, https://images.theconversation.com/files/478487/original/file-20220810-7093-8xw795.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=293&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/478487/original/file-20220810-7093-8xw795.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=293&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">One example of a pessary and how it can be fitted to help prolapse.</span>
<span class="attribution"><a class="source" href="https://image.shutterstock.com/image-vector/pelvic-floor-prolapse-type-uterine-600w-1484216528.jpg">Shutterstock</a></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-you-shouldnt-make-a-habit-of-doing-a-just-in-case-wee-and-dont-tell-your-kids-to-either-167628">Why you shouldn't make a habit of doing a 'just in case' wee — and don't tell your kids to either</a>
</strong>
</em>
</p>
<hr>
<h2>The downside</h2>
<p>Pessary use can have a downside too. Side effects may include vaginal discharge or odour or vaginal bleeding. These side effects generally occur after many months or years of continuous use and contribute to discontinuation. </p>
<p>An <a href="https://pubmed-ncbi-nlm-nih-gov.monash.idm.oclc.org/19906018/">Australian study</a> reported only 14% women continued long term use of pessaries mainly due to these side effects and the need for long term maintenance. </p>
<p>But a pessary can “buy time”. Theoretically, pessary use can help prevent worsening of prolapse.</p>
<p>A pessary for longer wear is usually fitted in clinic. Generally, all gynaecologists are trained to fit a pessary as are specialised pelvic floor physiotherapists and continence nurse specialists. Women often require a trial of more than one size or type to find the “best fit”. Sometimes a pessary can’t be fitted, is uncomfortable or falls out. This can occur when the vaginal length is short after previous prolapse surgery or hysterectomy, the vagina has a wide opening or the muscles are very weak.</p>
<p>Support pessaries can be self-managed by women who are willing to do this regularly in the same way they might manage a tampon, menstrual cup, or diaphragm contraceptive device. Sexually active women may choose to remove the pessary prior to intercourse; however, this is not essential for all types. </p>
<p>If not self-managed, pessary follow up is needed every six to 12 months, when the device is removed, cleaned, and reinserted or a new one inserted. </p>
<p>There are rare but serious complications like fistula (an opening between vagina and bowel or bladder) and impaction where an anaesthetic or surgery is required to remove the pessary.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1368924473479598082"}"></div></p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/playing-games-with-your-pelvic-floor-could-be-a-useful-exercise-for-urinary-incontinence-182431">Playing games with your pelvic floor could be a useful exercise for urinary incontinence</a>
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</em>
</p>
<hr>
<h2>Some future models</h2>
<p>Recently, there is some research and development occurring in adding <a href="https://www.medicaldesignbriefs.com/component/content/article/mdb/pub/features/applications/40042">personalised</a> or “smart” capabilities to the vaginal support pessary such as electrical stimulation therapy or pressure biofeedback such as <a href="https://www.ncbi.nlm.nih.gov/books/NBK565181/">already exists</a> for pelvic floor training devices.</p>
<p>Acceptance of pessaries is variable and often related to prior knowledge and appropriate <a href="https://pubmed-ncbi-nlm-nih-gov.monash.idm.oclc.org/26829346/">counselling</a>. </p>
<p>There is a lack of knowledge and awareness regarding how common pelvic organ prolapse and urinary incontinence are. We often hear women express embarrassment, shame or fear but many suffer in silence. The main barrier to seeking treatment is the perception that prolapse or incontinence are inevitable parts of childbirth and ageing.</p>
<p>Prolapse and urinary incontinence can have a negative impact on a woman’s physical, <a href="https://www.researchgate.net/profile/Javier-Pizarro-Berdichevsky/publication/301795538_Association_between_pelvic_floor_disorder_symptoms_and_QoL_scores_with_depressive_symptoms_among_pelvic_organ_prolapse_patients/links/59dd6741aca272b698e19388/Association-between-pelvic-floor-disorder-symptoms-and-QoL-scores-with-depressive-symptoms-among-pelvic-organ-prolapse-patients.pdf">emotional and social wellbeing</a>. Women experiencing any pelvic floor dysfunction can speak to their GPs, gynaecologists, or <a href="https://www.ugsa.com.au/home">urogynaecologists</a> (gynaecologists specialised in management of prolapse and incontinence). </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-is-pelvic-organ-prolapse-9097">Explainer: what is pelvic organ prolapse?</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/187083/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anna Rosamilia is Clinical Associate Investigator for studies receiving funding from NHMRC, Past research grants from Boston Scientific, American Medical Systems. Astellas. She has had an expert witness role. None of this funding is related to pessaries.
She is affiliated with and member of International Urogynecological Association, Urogynaecological Association of Australia, Continence Foundation of Australia and International Continence Society.</span></em></p><p class="fine-print"><em><span>Mugdha Kulkarni is a member of International Urogynecological Association & Urogynaecological Association of Australia.
</span></em></p>They are rarely talked about but vaginal pessaries can give women freedom and security if they have prolapse or urinary incontinence.Anna Rosamilia, Adjunct associate professor and urogynaecology & pelvic reconstructive surgery, Head Pelvic Floor Unit at Monash Health, Monash UniversityMugdha Kulkarni, Consultant Urogynaecologist, Pelvic Floor Unit, Monash HealthLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1844512022-06-28T02:00:42Z2022-06-28T02:00:42ZMen have pelvic floors too – and can benefit when they exercise them regularly<figure><img src="https://images.theconversation.com/files/469907/original/file-20220621-22-zu5l9t.jpg?ixlib=rb-1.1.0&rect=13%2C41%2C4580%2C3021&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://image.shutterstock.com/image-photo/sick-man-prostate-cancer-premature-600w-791204665.jpg">Shutterstock</a></span></figcaption></figure><p>“Kegels” and pelvic floor exercises are usually associated with “women’s business” – think pregnancy, childbirth, and menopause. But men have pelvic floors too. </p>
<p>Just like women, at various times in their lives men can benefit from training their pelvic floors to address a variety of health concerns. About 30% of men visiting the doctor have <a href="https://www.continence.org.au/incontinence/who-it-affects/men">urinary incontinence</a>, or bladder leakage, but a large majority don’t bring it up. Around 15% of men also experience faecal incontinence, or bowel leakage, and take longer to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4069320/">seek help</a> for it compared to women. </p>
<p>The pelvic floor muscles are also involved in sexual function. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1324914/">Erectile dysfunction</a> affects around 10% of healthy men, and up to almost 40% of men with chronic health conditions, and can be associated with pelvic floor issues.</p>
<p>People sometimes assume these problems are just a normal part of ageing; but common doesn’t mean inevitable. There is often much improvement to be had with some simple strategies – including pelvic floor rehabilitation. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1536587745195343872"}"></div></p>
<h2>Pelvic floor dysfunction in men is really common</h2>
<p>Though pelvic floor problems are <a href="https://obgyn.onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2000.tb11669.x">more common in women</a>, one in eight men <a href="https://choose.physio/your-lifestage/adults/mens-health">have issues</a> with their pelvic floor, bladder or bowel. </p>
<p>The pelvic floor is a group of muscles lining the base of the pelvis. For men, this <a href="https://www.continence.org.au/who-it-affects/men/male-pelvic-floor-muscles">supports</a> the bladder, prostate gland and bowel. It is essential in maintaining core stability, bladder and bowel control, and for erectile function and sexual satisfaction. </p>
<p>Most men have little reason to think about their pelvic floor for the majority of their lives, until something goes wrong medically (in comparison to women, who tend to be introduced to pelvic floor exercises much younger, often in the context of pregnancy and childbirth). </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/469908/original/file-20220621-25-eny4r6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="couple look affectionate in bed" src="https://images.theconversation.com/files/469908/original/file-20220621-25-eny4r6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/469908/original/file-20220621-25-eny4r6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/469908/original/file-20220621-25-eny4r6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/469908/original/file-20220621-25-eny4r6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/469908/original/file-20220621-25-eny4r6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/469908/original/file-20220621-25-eny4r6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/469908/original/file-20220621-25-eny4r6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Working on your pelvic floor strength might even improve your sex life.</span>
<span class="attribution"><a class="source" href="https://image.shutterstock.com/image-photo/happy-asian-senior-couple-having-600w-1684173169.jpg">Shutterstock</a></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/playing-games-with-your-pelvic-floor-could-be-a-useful-exercise-for-urinary-incontinence-182431">Playing games with your pelvic floor could be a useful exercise for urinary incontinence</a>
</strong>
</em>
</p>
<hr>
<h2>Why it happens</h2>
<p><a href="https://www.continence.org.au/who-it-affects/men/male-pelvic-floor-muscles">Risk factors</a> for incontinence and pelvic floor problems in men include ageing, prostate issues, pelvic surgery, bowel issues including constipation, chronic coughing, frequent heavy lifting, and being overweight. </p>
<p>Prostate cancer affects up to 15% of men and is the <a href="https://www.wcrf.org/cancer-trends/worldwide-cancer-data/">second most common cancer</a> in men (and fourth most common cancer overall). </p>
<p>The largest source of pelvic floor physiotherapy referrals for men tends to be in the context of prostate surgery. This is because surgery on the prostate gland (which sits very close to the base of the bladder) causes trauma to the nearby structures and nerves that maintain bladder control and erectile function. </p>
<p>However, we know that training the pelvic floor early (starting pre-operatively) means post-operative side effects like incontinence <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7471070/">resolve more quickly</a>. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/prostate-cancer-linked-to-bacteria-raising-hope-of-new-test-and-treatment-181542">Prostate cancer linked to bacteria, raising hope of new test and treatment</a>
</strong>
</em>
</p>
<hr>
<h2>How can men exercise their pelvic floors?</h2>
<p>To engage the pelvic floor, the sensation should feel like a squeeze, lift and relax of the muscles running between the pubic bone, tailbone, and sit bones. Some popular cues include visualising: </p>
<ul>
<li> stopping urine mid-flow (but <a href="https://www.wellandgood.com/im-a-pelvic-floor-therapist-and-this-is-why-you-shouldnt-stop-your-flow-mid-pee/">not actually doing this</a>)</li>
<li> holding in wind</li>
<li> retracting the penis/testicles</li>
<li> pulling the perineum (skin between the genitals and back passage) away from your underwear.</li>
</ul>
<p>It is important to ensure that the abdominal, gluteal (buttock) and thigh muscles stay relaxed, with breathing maintained throughout. </p>
<p>Exercises can be performed in any position, and if done right, should be able to be done inconspicuously (even when there are other people around!). But it’s quite common to find the exercises difficult to do without some coaching. </p>
<p>Working with a health professional such as a <a href="https://choose.physio/find-a-physio">pelvic floor physiotherapist</a> may be beneficial. Physiotherapists trained in men’s health and pelvic floor conditions will teach clients how to perform exercises correctly. Often they do this with biofeedback devices such as real-time ultrasound imaging that can help identify the right muscles to use and refine technique. </p>
<p>Not all pelvic floor problems require more strengthening. Optimal muscle function requires good strength, but also correct timing, co-ordination and relaxation. </p>
<p>A pelvic floor that is too tight can be problematic, for both men and women, and can contribute to symptoms of pelvic or genital pain, sexual dysfunction, urinary issues including overactive bladder, and bowel problems. </p>
<p>Your specific concerns will inform the way in which your physio might prescribe exercises, but good targets to aim for are to be able to: </p>
<ol>
<li>turn the pelvic floor on and off 10 times in 10 seconds</li>
<li>strongly hold 10 seconds, repeated 10 times</li>
<li>maintain an easy hold for 1 minute.</li>
</ol>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1537925051722309637"}"></div></p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/technology-for-incontinence-hasnt-developed-that-much-since-ancient-egyptian-times-98349">Technology for incontinence hasn't developed that much since ancient Egyptian times</a>
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</em>
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<hr>
<h2>If I don’t have pelvic floor problems, do I need to do exercises?</h2>
<p>Like a good gym program keeps you in optimal physical health and helps stave off injuries, it stands to reason that a regular pelvic floor training routine might serve to combat the likelihood of bladder, bowel and erectile dysfunction. However, the literature is scarce for preventative use in asymptomatic men.</p>
<p>Knowing where your pelvic floor is and how to exercise it properly can never be a bad thing – and training might even have some happy side effects, like <a href="https://link.springer.com/article/10.1007/s11934-013-0358-1">reduced waking in the night</a> with the need to urinate, reduced dribbling post-urination, better bowel emptying, and improved sexual satisfaction. </p>
<p>If you are unsure whether pelvic floor exercises are suitable for you or if you’re doing them properly, check in with a trusted health professional.</p><img src="https://counter.theconversation.com/content/184451/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mischa Bongers is the Founder and Principal Physiotherapist at Pelvic Fix Physiotherapy. She is affiliated with CQUniversity as a Sessional Lecturer, Curtin University as a Physiotherapy Clinical Supervisor, and Queensland Health as a Senior Women's Health Physiotherapist. </span></em></p>Knowing where your pelvic floor is and how to exercise it properly can help male incontinence – and might even have some happy side effects.Mischa Bongers, Sessional Lecturer, CQUniversity AustraliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1824312022-05-30T04:29:14Z2022-05-30T04:29:14ZPlaying games with your pelvic floor could be a useful exercise for urinary incontinence<figure><img src="https://images.theconversation.com/files/463238/original/file-20220516-12-amac5z.jpg?ixlib=rb-1.1.0&rect=32%2C49%2C5458%2C3598&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://image.shutterstock.com/image-photo/girl-synchronizes-kegel-trainer-application-600w-1840517470.jpg">Shutterstock</a></span></figcaption></figure><p>Many of us have heard of “<a href="https://www.mayoclinic.org/healthy-lifestyle/womens-health/in-depth/kegel-exercises/art-20045283">Kegels</a>” or pelvic floor exercises, and probably have a vague sense we should be doing more of them. For many women, our social media news feeds are full of ads for the latest gizmos and gadgets for exercising our pelvic floors. There are brands with game-like apps including <a href="https://au.perifit.co/">Perifit</a> and <a href="https://www.elvie.com/shop/elvie-trainer">Elvie</a>, and there are <a href="https://www.health.com/condition/sexual-health/kegel-balls">Kegel balls</a> for sale too. </p>
<p>As technology advances and the need for pelvic floor rehabilitation after pregnancy, childbirth and menopause continues, the demand for innovation in these devices has increased. Then there is the global pandemic that has restricted access to face-to-face medical treatment – prompting many of us to take our health into our own hands.</p>
<p>But what exactly are these devices used for, and do they actually work? The short answer: pelvic floor strengthening; and, it depends.</p>
<h2>4 things the pelvic floor does and why it often fails</h2>
<p>The pelvic floor is a group of muscles that run from our pubic bone to tailbone, and between our sit-bones, lining the base of our pelvis. Contrary to popular belief, you don’t have to lie on the floor to exercise your pelvic floor. </p>
<p>The role of the pelvic floor muscles is to: </p>
<ol>
<li> keep all our organs (bladder, uterus, bowel) inside the pelvis</li>
<li> keep the sphincters to our bladder and bowel closed (until we’re ready to relax them on the toilet)</li>
<li> provide sexual sensation</li>
<li> work together with other deep core muscles to help with trunk stability. </li>
</ol>
<p>The pelvic floor doesn’t always work the way it’s meant to. Bladder leakage (also known as <a href="https://theconversation.com/urinary-incontinence-can-be-a-problem-for-women-of-all-ages-but-there-is-a-cure-49365">urinary incontinence</a>) and pelvic organ prolapse are common pelvic floor complaints for women of all ages. </p>
<p>About <a href="https://www.continence.org.au/incontinence/who-it-affects/women/pregnancy-and-childbirth">one in three women will experience urinary incontinence</a> at some point in our lives, especially if we’ve had a baby. Other risk factors include repetitive heavy lifting, straining due to constipation, carrying extra weight, pelvic surgery, and hormonal changes. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/463244/original/file-20220516-26-41ie2i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="doctor points to muscles sitting within the human pelvic bones" src="https://images.theconversation.com/files/463244/original/file-20220516-26-41ie2i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/463244/original/file-20220516-26-41ie2i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/463244/original/file-20220516-26-41ie2i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/463244/original/file-20220516-26-41ie2i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/463244/original/file-20220516-26-41ie2i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/463244/original/file-20220516-26-41ie2i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/463244/original/file-20220516-26-41ie2i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The pelvic floor helps hold organs inside the pelvis.</span>
<span class="attribution"><a class="source" href="https://image.shutterstock.com/image-photo/doctor-gynecologist-showing-layout-female-600w-2122502321.jpg">Shutterstock</a></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/are-kegel-exercises-actually-good-for-you-111747">'Are Kegel exercises actually good for you?'</a>
</strong>
</em>
</p>
<hr>
<h2>Getting the pelvic floor into shape</h2>
<p>Pelvic floor muscle training is recommended as the first line of treatment for incontinence and prolapse, along with lifestyle changes such as healthy bladder and bowel habits, good general fitness, and weight management. </p>
<p><a href="https://choose.physio/find-a-physio">Pelvic floor physiotherapists</a> are health professionals specially trained to give you individualised advice for your pelvic floor symptoms based on an assessment and your circumstances. They will likely recommend daily exercises that may include rapid contractions of the pelvic floor muscles, coordination tasks and longer holds.</p>
<p>Those who have trouble sticking to the prescribed exercises, or who don’t have access to a suitable physio for geographical or financial reasons, may be interested in trying biofeedback devices. These devices and their associated apps are designed to give you more information on how and when to do your exercises, remind you to do them, and help you to stick with the program. </p>
<p>Maintaining motivation can be tough. Research shows it usually takes at least 6–12 weeks of regular pelvic floor training <a href="https://www.tandfonline.com/doi/abs/10.1080/j.0001-6349.2004.00559.x">to see results</a> (just like visiting the gym, we can’t build muscle overnight). </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/463235/original/file-20220516-12-vcls9f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="bright pink shapes with long handles" src="https://images.theconversation.com/files/463235/original/file-20220516-12-vcls9f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/463235/original/file-20220516-12-vcls9f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/463235/original/file-20220516-12-vcls9f.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/463235/original/file-20220516-12-vcls9f.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/463235/original/file-20220516-12-vcls9f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/463235/original/file-20220516-12-vcls9f.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/463235/original/file-20220516-12-vcls9f.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">There are many types of pelvic floor trainers on the market.</span>
<span class="attribution"><a class="source" href="https://image.shutterstock.com/image-photo/kegel-trainer-latex-vaginal-vibrator-600w-1800284818.jpg">Shutterstock</a></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/urinary-incontinence-can-be-a-problem-for-women-of-all-ages-but-there-is-a-cure-49365">Urinary incontinence can be a problem for women of all ages, but there is a cure</a>
</strong>
</em>
</p>
<hr>
<h2>Do pelvic floor biofeedback devices work?</h2>
<p>There’s some evidence to suggest pelvic floor <a href="https://bmcnurs.biomedcentral.com/articles/10.1186/s12912-022-00812-6">reminder apps</a> and <a href="https://www.sciencedirect.com/science/article/abs/pii/S0031940610612643">biofeedback devices</a> can be helpful for improving pelvic floor function and bladder control. This might be <a href="https://www.sciencedirect.com/science/article/abs/pii/S0090429502021258">superior to pelvic floor exercises alone</a>. Then again, it <a href="https://www.sciencedirect.com/science/article/abs/pii/S0029784402021609">might not make a difference</a>. </p>
<p>Some women <a href="https://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.665355">do not find the use of technology helpful</a> for pelvic floor training. Barriers can include connectivity or set-up issues, need for privacy, tech being distracting, and price. Insertable devices also require caution for use, as most are not appropriate during pregnancy, within the first six weeks after having a baby or pelvic surgery, or when there is unexplained bleeding, pain or active infection. If in doubt, it’s always best to consult your medical provider.</p>
<p>The benefits of pelvic floor trainers with game-like apps that sync with an inserted device include:</p>
<ul>
<li>giving real-time feedback on the screen for pelvic floor performance and <a href="https://onlinelibrary.wiley.com/doi/abs/10.1002/nau.24439?fbclid=IwAR1XhK4xlsLgiYTbjkf3VnbGTfHKXNXYT5iBmxhmFL9IONGlWnvKzoD9n0U">correct technique</a> </li>
<li>allowing women to <a href="https://link.springer.com/article/10.1007/s00192-021-04981-x?fbclid=IwAR06JPIZ8SywUS-14Wmr_IfEJW56eea2m1eJuA14dHOKwironUEWmceNeU8">work with their physio remotely</a> </li>
<li>measuring and tracking strength, endurance and coordination improvements over time</li>
<li>providing reminder prompts via phone notifications to complete workouts</li>
<li>adjusting the workout difficulty of each session based on how the body is responding (this accounts for time-of-day fluctuations and fatigue) </li>
<li>entertaining the user with a variety of games and tasks, making them more likely to stick with their pelvic floor program!</li>
</ul>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/463240/original/file-20220516-20-9dz6w6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="woman lying on exercise mats" src="https://images.theconversation.com/files/463240/original/file-20220516-20-9dz6w6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/463240/original/file-20220516-20-9dz6w6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/463240/original/file-20220516-20-9dz6w6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/463240/original/file-20220516-20-9dz6w6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/463240/original/file-20220516-20-9dz6w6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/463240/original/file-20220516-20-9dz6w6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/463240/original/file-20220516-20-9dz6w6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">You do not have to do pelvic floor exercises lying down – or with special equipment.</span>
<span class="attribution"><a class="source" href="https://image.shutterstock.com/image-photo/group-young-pregnant-women-lying-600w-1809776566.jpg">Shutterstock</a></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-you-shouldnt-make-a-habit-of-doing-a-just-in-case-wee-and-dont-tell-your-kids-to-either-167628">Why you shouldn't make a habit of doing a 'just in case' wee — and don't tell your kids to either</a>
</strong>
</em>
</p>
<hr>
<h2>The bottom line</h2>
<p>The evidence definitively supports pelvic floor exercises for incontinence and prolapse, and this is <a href="https://pubmed.ncbi.nlm.nih.gov/25233622/">best done</a> with the support of a suitably trained professional such as a pelvic floor physiotherapist. </p>
<p>While early research looks promising, the evidence for commercially marketed pelvic floor feedback devices has <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6852158/">not yet caught up</a> to their hype. But if you are keen to try a pelvic floor biofeedback device or app to improve pelvic floor tone for better bladder control, prolapse symptoms, or sexual function – then go for it (especially if your specialist physio agrees). </p>
<p>After all, the best kind of pelvic floor exercise regime is the one you’ll stick with. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1404967700686835714"}"></div></p><img src="https://counter.theconversation.com/content/182431/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span><a href="mailto:m.bongers@cqu.edu.au">m.bongers@cqu.edu.au</a> is the Founder and Principal Physiotherapist at Pelvic Fix Physiotherapy. She is affiliated with CQUniversity as a Sessional Lecturer, Curtin University as a Physiotherapy Clinical Supervisor, and Queensland Health as a Senior Women's Health Physiotherapist. </span></em></p>Social media is awash with ads for interactive games and devices to strengthen the pelvic floor. But do they work?Mischa Bongers, Sessional Lecturer, CQUniversity AustraliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1097152019-04-25T21:51:12Z2019-04-25T21:51:12ZPain during sex? Incontinence or constipation? You might benefit from pelvic floor physiotherapy<figure><img src="https://images.theconversation.com/files/267435/original/file-20190403-177175-4fvomr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Up to 20 per cent of women have pain during sexual intercourse and up to 40 per cent have issues with bladder control. Physiotherapy can help. </span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>“How did I not know this was a pelvic floor issue? Why didn’t my doctor send me here sooner? Do you have other patients with problems like mine?”</p>
<p>As a physiotherapist, I hear these questions again and again, from people of all ages and genders, who are <a href="https://www.penguinrandomhouse.com/books/558308/a-headache-in-the-pelvis-by-david-wise-phd-and-rodney-anderson-md/9781524762049/">struggling with issues related to the urinary system, sexual function and the lower digestive tract</a>.</p>
<p>Adrian is one example. A 35 year-old active cyclist and successful professional, he has a nagging pain in the private parts that just won’t go away. It is interfering with his sporting activities and ruining his sex life. Pressure from the bicycle seat, the ambitious effort to cycle 100 kilometres in record time, and the stress from a crazy week at work have all resulted in pelvic floor muscle tension and <a href="https://uroweb.org/wp-content/uploads/26-Chronic-Pelvic-Pain_LR.pdf">chronic pelvic pain</a>. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/267437/original/file-20190403-177187-9x2544.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/267437/original/file-20190403-177187-9x2544.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/267437/original/file-20190403-177187-9x2544.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/267437/original/file-20190403-177187-9x2544.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/267437/original/file-20190403-177187-9x2544.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/267437/original/file-20190403-177187-9x2544.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/267437/original/file-20190403-177187-9x2544.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Pelvic floor issues can affect anyone.</span>
<span class="attribution"><span class="source">(Unsplash/JaneSundried)</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Then there’s Lisa, a 63 year-old woman who is ready to become involved in a new relationship. In her search for a companion, she explores online dating and begins to realize that sex may be involved sooner than later. She worries that she may not be ready, physically, not having had sex for quite a few years, and wonders what she could do to improve her vaginal comfort and physical confidence.</p>
<p>These patients, and many others, did not know that a physiotherapist could help them. In my role as a clinician and as course co-ordinator for pelvic floor rehabilitation at <a href="https://www.mcgill.ca/spot/">McGill University’s School of Physical and Occupational Therapy</a>, I see a huge lack of awareness of the impact that physiotherapy can have on the lives of people suffering these very personal conditions.</p>
<p>From pain during sexual intercourse to urinary incontinence after surgery for prostate cancer, to anal incontinence after pregnancy, physiotherapy can help. </p>
<h2>Pain during sexual intercourse</h2>
<p>Up to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5969816/">20 per cent of women have pain during sexual intercourse</a>. This is a surprising statistic, especially when it predominantly includes active women in their twenties and thirties, who may believe that there is something psychologically wrong with them when all of the gynaecological tests come up negative.</p>
<p>Vestibulodynia, an invisible hypersensitivity at the entrance to the vagina, is considered the<a href="https://www.ncbi.nlm.nih.gov/pubmed/27080365"> most common cause of sexual pain in pre-menopausal women</a>. It can be treated in physiotherapy.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/270823/original/file-20190424-121228-12czx1a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/270823/original/file-20190424-121228-12czx1a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/270823/original/file-20190424-121228-12czx1a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/270823/original/file-20190424-121228-12czx1a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/270823/original/file-20190424-121228-12czx1a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/270823/original/file-20190424-121228-12czx1a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/270823/original/file-20190424-121228-12czx1a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Pelvic floor physiotherapy can help reduce pain during sexual intercourse.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>The pelvic floor muscles span the private area under the pelvis. They are responsible not only for helping to control the passage of urine, stool and gas, but also for allowing comfort and pleasure during sex.</p>
<p>These muscles also support the pelvic organs and help with balance and stability. It is important to be able to contract and to relax these muscles. <a href="https://www.sciencedirect.com/topics/medicine-and-dentistry/kegel-exercise">Pelvic floor exercises train the muscles for the desired result</a>, and are sometimes referred to as “targeted” Kegels.</p>
<p>In <a href="https://www.issm.info/sexual-health-qa/what-is-pelvic-floor-physical-therapy/">pelvic floor physiotherapy</a>, patients learn exercises, and they may receive manual treatments, biofeedback and/or electrical stimulation. Biofeedback displays pelvic floor activity on a computer screen, making it easier to contract and relax muscles that are usually hidden from view. Electrical stimulation causes a pain-free muscle contraction, with the goal of improving the ability to contract and relax naturally. </p>
<p>Research supports the <a href="https://doi.org/10.1002/14651858.CD005654.pub4">use of physiotherapy</a> in the treatment of <a href="https://doi.org/10.1002/14651858.CD003882.pub4">a variety of pelvic disorders</a>. A team approach is ideal, and, depending upon the condition, may involve collaboration with general practitioners, urologists, gynaecologists, sex therapists and others.</p>
<h2>Prostate, pregnancy and potty</h2>
<p>After surgery for prostate cancer, <a href="https://dx.doi.org/10.5152%2Ftud.2014.222014">up to 40 per cent of men experience problems with urinary incontinence</a>. Pelvic floor physiotherapy teaches men different strategies to control leakage. Men can even consult prior to surgery, in order to prepare. </p>
<p>Women experience an array of pelvic floor issues during and after pregnancy. It is important to mention that <a href="https://www.ncbi.nlm.nih.gov/pubmed/9740521">many women who have had a third or fourth degree tear during delivery will experience issues with anal incontinence later in life</a>.</p>
<p>Some countries systematically refer these patients for preventative physiotherapy and some centres in Canada are now beginning to follow suit.</p>
<p>More than 40 per cent of women also have issues with bladder control. Patients with <a href="https://doi.org/10.1016/j.jogc.2017.11.027">stress urinary incontinence</a> and those with <a href="https://www.cua.org/themes/web/assets/files/4586_v3.pdf">an overactive bladder</a> can experience significant improvement in physiotherapy.</p>
<p>Physiotherapy is considered first-line intervention for <a href="http://www.canadiancontinence.ca/EN/">both types of incontinence</a> by the <a href="https://www.ics.org">International Continence Society</a>, the <a href="https://www.cua.org/en">Canadian Urological Association</a> and the <a href="https://uroweb.org">European Association of Urology</a>. </p>
<p>Constipation is another issue that may be caused by the inability to relax the muscles of the pelvic floor and anal sphincter at the appropriate time. Physiotherapists can work to improve “defecation dynamics” and provide suggestions for lifestyle changes. </p>
<p>In children, constipation may lead to soiling or overflow incontinence. Children may also be seen for <a href="https://doi.org/10.1053/j.gastro.2016.02.015">urinary disorders</a>.</p>
<h2>A co-ordinated physiotherapy plan</h2>
<p>The internet has been instrumental in enabling patients to learn about embarrassing or taboo subjects in the privacy of their own homes, and has led many to seek out physiotherapy as a viable treatment option for pelvic conditions.</p>
<p>Patients consulting for pelvic floor issues learn how the bladder functions, how the pelvic floor muscles can be involved in constipation, what causes the muscles to be such culprits in pelvic pain and how new brain research supports a bio-psycho-social approach for the management of their problems. They find an ally in the physiotherapist, who supports them and directs them towards the improvement of their condition.</p>
<p>A step-by-step coordinated physiotherapy plan is a key element in the interdisciplinary management of patients with disorders related to the pelvic floor.</p><img src="https://counter.theconversation.com/content/109715/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Claudia Brown is co-owner of Physiothérapie Uro-Santé, a company aimed at teaching physiotherapists about pelvic floor physiotherapy. She is also owner and manager of a group of private physiotherapy clinics that offer pelvic floor physiotherapy in the Montreal area, including Physiothérapie Polyclinique Cabrini and La Clinique de Physiothérapie Concorde.</span></em></p>A step-by- step coordinated physiotherapy plan is key for patients with disorders related to the pelvic floor.Claudia Brown, Assistant Professor, School of Physical and Occupational Therapy, McGill UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/983492018-07-30T16:07:42Z2018-07-30T16:07:42ZTechnology for incontinence hasn’t developed that much since ancient Egyptian times<figure><img src="https://images.theconversation.com/files/228599/original/file-20180720-142411-1tceemj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/closeup-young-sick-woman-hands-holding-704812942">Voyagerix/Shutterstock.com</a></span></figcaption></figure><p>Today’s healthcare is full of technology that would seem like science fiction to our grandparents. But this is far from true in every area: some remain woefully neglected by innovation. Hop in a time machine back to ancient Egypt and you would find recognisable examples of the absorbent pads and catheters which are still a mainstay in the management of incontinence today.</p>
<p>The earliest known reference to an absorbent pad dates from 4th-century Egypt: the female scientist <a href="https://www.jstor.org/stable/2975600">Hypatia</a> is recorded as having thrown her menstrual rag at a student to ward off his infatuation with her. The pad remained a homemade “product” for many centuries until the 19th century, when manufactured versions of reuseable “antiseptic cotton for absorbing discharges” could be purchased from pharmacies. Disposable pads, first produced by Kotex in 1920, were in widespread use by the late 1930s. Since then, the only major innovation in their design has been the introduction of <a href="https://www.sciencedirect.com/science/article/pii/S2090123213000969">super absorbent polymers</a> in the 1980s, which have dramatically improved absorbency. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/228597/original/file-20180720-142408-14vitiw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/228597/original/file-20180720-142408-14vitiw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=1566&fit=crop&dpr=1 600w, https://images.theconversation.com/files/228597/original/file-20180720-142408-14vitiw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=1566&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/228597/original/file-20180720-142408-14vitiw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=1566&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/228597/original/file-20180720-142408-14vitiw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1967&fit=crop&dpr=1 754w, https://images.theconversation.com/files/228597/original/file-20180720-142408-14vitiw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1967&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/228597/original/file-20180720-142408-14vitiw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1967&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Silver catheter.</span>
<span class="attribution"><a class="source" href="https://wellcomecollection.org/works/ehqvfsjp?query=catheter">Wellcome Collection</a></span>
</figcaption>
</figure>
<p>Again, we can thank the Egyptians for the first records of devices like catheters. These were made of bronze, reeds, straws or curled-up palm leaves that would be inserted into the urethra to drain the bladder. Various versions, mostly made of silver, appeared over the following centuries, but these were predominately rigid devices only suitable for intermittent use until the <a href="https://en.wikipedia.org/wiki/Foley_catheter">Foley catheter</a> was invented in 1929, which provided a solution for long-term use. Despite many drawbacks, such as an increased likelihood of developing urinary tract infections, Frederic Foley’s flexible design is still the most commonly used type of <a href="https://www.nhs.uk/conditions/urinary-catheters/types/#indwelling-urinary-catheters">indwelling</a> catheter worldwide.</p>
<p>Research into this area has long been stagnant, perhaps stalled by the persistent <a href="https://doi.org/10.12968/gasn.2014.12.1.16">stigma</a> surrounding this health condition. Potential researchers who are either unaware of the <a href="https://doi.org/10.1177/0954411918784073">diverse challenges</a> of incontinence, unwilling to battle for traditionally limited funding in this area, or unable to jump the many <a href="https://doi.org/10.1007/s10439-014-1104-7">barriers</a> necessary to translate research advances into clinical benefit. But finally, there are some promising technological developments in continence care.</p>
<h2>Incontinence today</h2>
<p>These are needed. Incontinence is a subject people usually feel too embarrassed to talk about, one they sometimes ridicule, and one the research community rarely considers. Yet such is its impact and prevalence that overlooking it will cost us at economic, societal and personal levels.</p>
<p>We know that <a href="https://doi.org/10.1016/S0020-7292(03)">urinary incontinence</a> effects on average around 28% of females and 10% of males worldwide, while a study in the US in 2009 showed that around 8% of adults endure <a href="https://doi.org/10.1053/j.gastro.2009.04.054">faecal incontinence</a>. Prevalence increases with age but the condition doesn’t only affect adults; about 10% of <a href="http://dx.doi.org/10.1136/adc.2006.098335">school-aged children</a> experience urinary incontinence and about 4% faecal incontinence. Together these conditions account for more than <a href="https://doi.org/10.1111/j.1464-410X.2004.04810.x">2% of the total UK healthcare budget</a> and urinary incontinence alone <a href="https://doi.org/10.1016/S0029-7844(01)01464-8">cost the US</a> over US$16 billion in 1995.</p>
<p>Living with incontinence long term can lead to social isolation and psychological issues, damaging well-being and creating a vicious cycle of care need. In <a href="https://theconversation.com/why-we-need-to-talk-about-incontinence-86080">low and middle-income countries</a> the burden is magnified by <a href="http://eprints.whiterose.ac.uk/131482/">limited access to affordable aids</a> such as fluid absorbing materials or catheters and the need for products that do not increase the strain on municipal waste disposal. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/228598/original/file-20180720-142417-h7nw4w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/228598/original/file-20180720-142417-h7nw4w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/228598/original/file-20180720-142417-h7nw4w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/228598/original/file-20180720-142417-h7nw4w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/228598/original/file-20180720-142417-h7nw4w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/228598/original/file-20180720-142417-h7nw4w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/228598/original/file-20180720-142417-h7nw4w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A urine bag (Foley catheter).</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/urine-bag-pee-beside-bed-hospital-103952396?src=Uq2PNkx5GpaGYvD9jD7azg-1-79">Suphatthra olovedog/Shutterstock.com</a></span>
</figcaption>
</figure>
<h2>Addressing the problem</h2>
<p>While many people today are able to deal with their condition independently, they often resort to using homemade solutions because they are plagued by feeling unable to control their condition <a href="https://theconversation.com/solving-the-toilet-shortage-needs-a-bottom-up-approach-20202">to the level society expects</a>. </p>
<p>Meanwhile, technological care has long been at a standstill. For example, the design of stoma and catheter systems have remained fundamentally unchanged since their introduction. This means that the invasive procedures, poor tolerance and infection issues that characterise them continue to obstruct individual’s daily lives and strain our healthcare systems. </p>
<p>On top of this, little has been done to address diversity. Appropriate provision for different groups, such as school aged children and young adults, remains comparatively scant. Continence pads are the popular choice despite their issues of bulk, noise, efficacy and disposal – they continue to be tolerated simply because better alternatives haven’t been developed. </p>
<p>Faecal incontinence is especially challenging, and here the shortfall runs much deeper. Pads have always been designed primarily for urine so their capacity for containment of faecal matter is profoundly lacking. While anal plugs can be useful, they can’t cope with major episodes. To top it all, nothing really tackles people’s anxiety over smell.</p>
<h2>Promising options</h2>
<p>But there is <a href="http://events.imeche.org/ViewEvent?code=CON6475">growing recognition</a> and action among scientists to develop new technology for continence care. A number of organisations recently collaborated to publish a white paper on <a href="https://doi.org/10.1177/0954411918784073">continence technologies</a>, with the aim of inspiring and guiding new engineering science research. Our paper highlights that there is a wealth of opportunity for innovation spanning basic science, materials and coatings, bioengineering, informatics and smart systems. </p>
<p>For instance, tissue engineering provides opportunities for new procedures to repair damaged bladder or pelvic musculature, and <a href="https://www.bbc.co.uk/news/uk-northern-ireland-31737679">new bioengineered coating technologies</a> are beginning to impact on previously stagnant areas such as catheter performance. In basic science, <a href="https://doi.org/10.1016/B978-0-12-374248-3.00002-1">neuromodulation</a> seeks to directly target the nerve pathways which control continence.</p>
<p>Meanwhile, the remarkable advancements in smart technology are ripe for creative application. Such technologies could, for example, be used to create a new generation of <a href="http://agiledata.org/">agile</a> and personalised data handling software systems which could transform how incontinence is managed and diagnosed. This might make procedures such as <a href="https://doi.org/10.1046/j.1365-2648.2000.01627.x">urodynamics</a> and <a href="http://dx.doi.org/10.1097/MPG.0000000000001595">anorectal manometry</a> less invasive, an exemplary improvement that <a href="http://dx.doi.org/10.1136/bmjopen-2016-015544">undeserved groups such as young adults</a> would benefit from greatly.</p>
<p>Genuine change will require sustained effort and support. Addressing this situation requires <a href="http://www.imeche.org/policy-and-press/reports/detail/incontinence-engineering-innovation-to-enhance-quality-of-life">attention</a> from government, industry, academia and healthcare bodies equally. The main thing everyone else can do to help is <a href="https://theconversation.com/why-we-need-to-talk-about-incontinence-86080">discuss incontinence more openly</a> so that stigma is addressed through awareness and education.</p>
<hr>
<p><em>This piece was written with input from <a href="http://impress-network.com/team/sarah-king/">Sarah King</a>, research manager at IMPRESS, an initiative which aims to encourage more engineers and scientists to work on researching new technologies for incontinence. She is co-author on the <a href="https://doi.org/10.1177/0954411918784073">white paper on continence technologies</a>.</em></p><img src="https://counter.theconversation.com/content/98349/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Pete Culmer receives funding from EPSRC (EP/N027345/1) and the NIHR.</span></em></p>The persistent stigma surrounding incontinence has paralysed today’s inventive minds.Pete Culmer, Associate Professor in Surgical Technologies, University of LeedsLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/954442018-06-14T20:38:33Z2018-06-14T20:38:33ZShould all women do pelvic floor exercises? We asked five experts<figure><img src="https://images.theconversation.com/files/216067/original/file-20180424-94149-16edwtn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Doing them properly is key. </span> <span class="attribution"><span class="source">from www.shutterstock.com</span></span></figcaption></figure><p><a href="https://www.continence.org.au/pages/key-statistics.html">Over a third</a> of Australian women suffer from urinary incontinence, and it’s estimated at least <a href="https://womhealth.org.au/conditions-and-treatments/genital-prolapse-fact-sheet">half of women</a> who’ve had more than one child have some degree of genital prolapse. </p>
<p>Pelvic floor disorders affect many women, and <a href="https://www.thewomens.org.au/health-information/pregnancy-and-birth/a-healthy-pregnancy/the-pelvic-floor">health professionals often recommend</a> exercising the pelvic floor muscles in order to keep them strong to reduce symptoms and prevent disorder.</p>
<p>We asked five experts if all women should be exercising these muscles regularly. </p>
<h2>Five out of five experts said yes</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/216058/original/file-20180424-94145-1s8b3qo.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/216058/original/file-20180424-94145-1s8b3qo.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=99&fit=crop&dpr=1 600w, https://images.theconversation.com/files/216058/original/file-20180424-94145-1s8b3qo.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=99&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/216058/original/file-20180424-94145-1s8b3qo.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=99&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/216058/original/file-20180424-94145-1s8b3qo.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=125&fit=crop&dpr=1 754w, https://images.theconversation.com/files/216058/original/file-20180424-94145-1s8b3qo.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=125&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/216058/original/file-20180424-94145-1s8b3qo.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=125&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
</figcaption>
</figure>
<p><strong><em>Here are their detailed responses:</em></strong></p>
<p><iframe id="tc-infographic-265" class="tc-infographic" height="400px" src="https://cdn.theconversation.com/infographics/265/a8d28f39b496b1a291906a67fa31edf2fbe09e89/site/index.html" width="100%" style="border: none" frameborder="0"></iframe></p>
<hr>
<p><em>If you have a “yes or no” health question you’d like posed to Five Experts, email your suggestion to: alexandra.hansen@theconversation.edu.au</em></p>
<hr>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/210303/original/file-20180314-113452-h7un11.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/210303/original/file-20180314-113452-h7un11.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/210303/original/file-20180314-113452-h7un11.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/210303/original/file-20180314-113452-h7un11.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/210303/original/file-20180314-113452-h7un11.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/210303/original/file-20180314-113452-h7un11.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/210303/original/file-20180314-113452-h7un11.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption"></span>
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<p><em>Disclosures: Hannah Dahlen has received funding from the NHMRC and ARC. Victoria Salmon receives funding from the UK National Institute for Health Research (NIHR). The views and opinions expressed in this article are those of the authors and do not necessarily reflect those of the NIHR, NHS or the Department of Health.</em></p><img src="https://counter.theconversation.com/content/95444/count.gif" alt="The Conversation" width="1" height="1" />
If you haven’t had kids you probably haven’t given much thought to your pelvic floor muscles. But 5 out of 5 experts say all women should regularly exercise them.Alexandra Hansen, Deputy Editor and Chief of Staff, The Conversation AUNZLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/939552018-05-23T02:52:38Z2018-05-23T02:52:38ZWhen you’re sick, the support you’ll get may depend on the ‘worth’ of your disease<figure><img src="https://images.theconversation.com/files/212751/original/file-20180331-189810-1cjsl9q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Diseases low on the hierarchy of prestige are often difficult to diagnose and treat.</span> <span class="attribution"><a class="source" href="https://pixabay.com/en/care-diagnose-disease-health-3031259/">Pixabay</a></span></figcaption></figure><p>The name of an illness can affect the level of care a person receives. Cancer sufferers experiencing fear and uncertainty may have access to <a href="https://canceraustralia.gov.au/clinical-best-practice/multidisciplinary-care">cancer care centres</a>. Donations and bequests enable these centres to offer everything from accessible parking, to wig and beauty services, to comprehensive clinical care. </p>
<p>A person with arthritis, on the other hand, may have little access to public services. For instance, there is only one <a href="https://arthritisaustralia.com.au/nurses-the-key-to-caring-for-arthritis-17-october-2017/">rheumatology nurse</a> for every 45,000 people living with rheumatoid arthritis. </p>
<p>While suffering can be severe across all diseases, access to care is uneven. The hierarchy that determines how little or how much support is available for an illness is known as “disease prestige”. </p>
<p>The idea was introduced in the 1940s and since then a <a href="https://today.mims.com/a-case-of-hierarchy-in-medical-conditions-and-specialities">number of researchers</a> have tried to classify diseases on a <a href="http://www.abc.net.au/radionational/programs/lifematters/is-there-a-social-hierarchy-for-diseases/9421840">hierarchy of prestige</a>. The higher a disease is on this hierarchy, the more resources and community support available for its sufferers. The lower a disease, the less resources.</p>
<p>Generally, high-prestige diseases are treated with technically sophisticated procedures, occur in the upper part of the body and often affect young people. Heart disease and childhood cancer are examples.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/217449/original/file-20180503-153895-g1pbus.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/217449/original/file-20180503-153895-g1pbus.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=3344&fit=crop&dpr=1 600w, https://images.theconversation.com/files/217449/original/file-20180503-153895-g1pbus.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=3344&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/217449/original/file-20180503-153895-g1pbus.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=3344&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/217449/original/file-20180503-153895-g1pbus.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=4203&fit=crop&dpr=1 754w, https://images.theconversation.com/files/217449/original/file-20180503-153895-g1pbus.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=4203&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/217449/original/file-20180503-153895-g1pbus.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=4203&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Author provided.</span>
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<p>Low-prestige diseases tend to be vague and difficult to diagnose and treat. Many carry shame and stigma, or are thought to be the “fault” of the sufferer. Examples include urinary incontinence, schizophrenia and liver disease.</p>
<h2>Urinary incontinence</h2>
<p>Urinary incontinence describes any accidental or involuntary loss of urine from the bladder. It ranges in severity from “just a small leak” to complete loss of bladder control and can seriously <a href="https://theconversation.com/urinary-incontinence-it-doesnt-have-to-be-a-secret-shame-7869">affect a person’s well-being</a>. Urinary incontinence affects <a href="https://www.continence.org.au/pages/key-statistics.html">13% of men and 37% of women</a>. It particularly affects people after surgery (such as hysterectomy or prostate cancer surgery) and women after childbirth. </p>
<p>Incontinence can be treated and managed. In many cases it can also be cured, but only a third of people who experience incontinence will <a href="https://www.continence.org.au/pages/key-statistics.html">discuss their condition</a> with a health professional. Like many people with embarrassing conditions, people who have <a href="https://theconversation.com/urinary-incontinence-it-doesnt-have-to-be-a-secret-shame-7869">urinary incontinence</a> may keep it secret due to shame. </p>
<p><strong><em>Read more: <a href="https://theconversation.com/urinary-incontinence-it-doesnt-have-to-be-a-secret-shame-7869">Urinary incontinence: it doesn’t have to be a secret shame</a></em></strong> </p>
<p>Despite the fact this condition is common and can be disabling, there is little investment in care. In 2010, the health system invested around <a href="https://www.continence.org.au/data/files/Access_economics_report/dae_incontinence_report__19_april_2011.pdf">A$270 million</a> in urinary incontinence. The remainder of the <a href="https://www.continence.org.au/data/files/Access_economics_report/dae_incontinence_report__19_april_2011.pdf">A$67 billion</a> impact of this disease fell on patients and carers. </p>
<p>Disease champions have targeted such discrepancy in different ways. The <a href="https://www.continence.org.au/">Incontinence Foundation</a>, for instance, has used comedians to promote its cause in the <a href="https://www.continence.org.au/news.php/537/laugh-without-leaking-can-comedy-cure-incontinence">“Laugh without Leaking”</a> campaign.</p>
<h2>Schizophrenia</h2>
<p>As we move down the hierarchy, we’re more likely to strike diseases with stigma, such as mental illness. <a href="https://www.sane.org/mental-health-and-illness/facts-and-guides/schizophrenia">Schizophrenia</a> is an illness that disrupts the functioning of the human mind. It causes intense episodes of psychosis, involving delusions and hallucinations, and longer periods of reduced motivation and functioning. </p>
<p>The <a href="https://www.mifa.org.au/images/Documents/Wellways/164829%20Understanding%20Schizophrenia.pdf">causes are not clear</a>, but are probably due to a combination of genetic, psychological and social factors. Schizophrenia <a href="https://www.sane.org/mental-health-and-illness/facts-and-guides/schizophrenia">affects 1% of the population</a> and often begins in adolescence. Despite the fact schizophrenia is common in the community, it is <a href="https://www.sane.org/mental-health-and-illness/facts-and-guides/reducing-stigma#introduction">poorly understood and often feared</a>. </p>
<p>Patients with mental illnesses often <a href="https://www.sane.org/mental-health-and-illness/facts-and-guides/reducing-stigma#what-is-stigma">avoid disclosing their illness</a> because of active discrimination in the workplace, at home or in institutions, such as <a href="https://www.beyondblue.org.au/about-us/about-our-work/discrimination-in-insurance">insurance companies</a>. Unfortunately, people with schizophrenia can also experience <a href="https://ama.com.au/ausmed/mental-health-stigma">significant stigma from health professionals</a> and can have poor health outcomes with <a href="https://www.livingwithschizophreniauk.org/advice-sheets/physical-health-schizophrenia/">early death from physical illness</a>. </p>
<p>American academic and schizophrenia sufferer <a href="https://www.ted.com/talks/elyn_saks_seeing_mental_illness">Elyn Saks</a> and other high-profile people living with schizophrenia are addressing the stigma, but progress is slow.</p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/f6CILJA110Y?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Elyn Saks shares her experiences with schizophrenia in this TED talk. Source: YouTube.</span></figcaption>
</figure>
<p>We can understand the impact of disease prestige for diseases like schizophrenia by looking at fundraising. The <a href="https://www.pinkribbon.com.au/">Pink Ribbon campaign</a> for breast cancer has raised an average <a href="https://www.pinkribbon.com.au/about-us/about-cancer-council/">A$6 million per year</a>. In contrast, schizophrenia, which causes about half the <a href="https://www.aihw.gov.au/reports-statistics/health-conditions-disability-deaths/burden-of-disease/overview">burden of disease</a> of breast cancer, raised A$100,000 last year through <a href="https://www.sane.org/images/Annual_Reports/2016-SANE-Australia-signed-financials.pdf">SANE Australia</a>. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/mood-and-personality-disorders-are-often-misconceived-heres-what-you-need-to-know-94971">Mood and personality disorders are often misconceived: here's what you need to know</a>
</strong>
</em>
</p>
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<h2>Liver disease</h2>
<p>Stigmatised diseases include those that could be influenced by a person’s behaviour, such as <a href="https://www.mycause.com.au/charity/2026/AustralianLiverFoundation">cirrhosis of the liver</a>. Cirrhosis is a type of liver scarring which can be caused by excessive alcohol consumption, hepatitis B and C (which can be the result of sexual transmission or drug use), and fatty liver, common in obesity and diabetes. Stigma stops the majority of people living with viral hepatitis enjoying <a href="https://www.hepatitisaustralia.com/">the quality of life they deserve</a>. </p>
<p>However, liver disease can also <a href="http://www.liverkids.org.au/">occur in children</a>. Liver transplant is the only treatment available for children with severe acute liver failure or chronic end-stage liver disease, certain metabolic diseases and some liver cancers. In 2012, there were more than <a href="http://cart.gesa.org.au/membes/files/Resources/Deloitte_Report_FINAL_06032013.pdf">6 million Australians</a> living with liver disease and more than <a href="http://cart.gesa.org.au/membes/files/Resources/Deloitte_Report_FINAL_06032013.pdf">7,000 deaths</a> due to liver disease in Australia. However, Commonwealth research funding is low.</p>
<h2>Research funding</h2>
<p>Research funding from Commonwealth sources, such as the <a href="https://www.nhmrc.gov.au/grants-funding/research-funding-statistics-and-data">National Health and Medical Research Council</a> (NHMRC), follows the disease prestige hierarchy. <a href="https://www.aihw.gov.au/reports-statistics/health-conditions-disability-deaths/burden-of-disease/overview">Burden of disease</a> can be measured in <a href="http://www.who.int/healthinfo/global_burden_disease/metrics_daly/en/">DALYs</a> (Disease Adjusted Life Years), a way of quantifying the <a href="https://www.aihw.gov.au/reports/burden-of-disease/abds-impact-and-causes-of-illness-death-2011">healthy years lost to disease</a>. </p>
<iframe src="https://datawrapper.dwcdn.net/MRARt/3/" scrolling="no" frameborder="0" allowtransparency="true" width="100%" height="405"></iframe>
<p>If we compare the research investment across the national health priorities, we see each year of healthy life lost attracts different levels of investment, depending on the disease involved. The Medical Research Future Fund may <a href="http://health.gov.au/internet/main/publishing.nsf/Content/medical-research-future-fund-budget-2017-factsheets">extend this discrepancy</a>, with almost half of its initial investments being earmarked for cancer research. </p>
<iframe src="https://datawrapper.dwcdn.net/txwhE/5/" scrolling="no" frameborder="0" allowtransparency="true" width="100%" height="405"></iframe>
<p>The following graph shows the National Health Priority diseases, as <a href="https://www.nhmrc.gov.au/grants-funding/research-funding-statistics-and-data">reported by the NHMRC</a>, and maps the research investment per DALY. We have calculated the investment for the low-prestige diseases by searching for <a href="https://www.nhmrc.gov.au/grants-funding/research-funding-statistics-and-data">grants allocated from 2010-2016</a> that mention liver disease, schizophrenia or urinary incontinence. </p>
<iframe src="https://datawrapper.dwcdn.net/3tdbr/1/" scrolling="no" frameborder="0" allowtransparency="true" width="100%" height="406"></iframe>
<p>As a community, we should aim to reduce suffering across the hierarchy of disease prestige. We need to consider issues of justice and equity, not only across populations, but also between diseases. When we raise money for health care, we need to consider who funding supports and who it does not. We also need to create clinical, educational and research priorities that recognise the complexities of funding the breadth of illness that occurs in the community.</p><img src="https://counter.theconversation.com/content/93955/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Louise Stone does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>In the hierarchy of diseases, those suffering from ‘high prestige’ diseases benefit from strong community and clinical support, while others are left in the dark.Louise Stone, Clinical Associate Professor, ANU Medical School, Australian National UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/944032018-04-04T08:10:29Z2018-04-04T08:10:29ZNot all vaginal implants are a problem and treating them the same puts many women at risk<figure><img src="https://images.theconversation.com/files/213103/original/file-20180404-189830-7ufdlf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Around on in five women might need surgical treatment for prolapse or urinary incontinence.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>Last week, a <a href="https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/MeshImplants">Senate Committee</a> investigating the impacts of “transvaginal mesh implants” on women in Australia handed down its report, with 13 recommendations. The implants are medical devices surgically inserted to prevent prolapse and urinary incontinence - conditions that affect many women over their lifetime, with around 20% <a href="https://www.ncbi.nlm.nih.gov/pubmed/24807341">requiring surgical</a> treatment.</p>
<p>The inquiry was the result of many <a href="http://www.abc.net.au/news/2017-05-31/more-women-mesh-implant-side-effects-than-thought-experts-say/8572840">women coming forward</a> reporting <a href="http://www.abc.net.au/news/2017-05-31/how-a-vaginal-mesh-implant-destroyed-maessens-life/8573878">serious side effects</a>, such as chronic pain and trouble walking, after vaginal mesh surgery. Recommendations included that these medical devices are to be used only “as a last resort”, that each mesh implant be registered, patient counselling and decision-making, surgeon training and better reporting of adverse events. </p>
<p>Proposals to improve outcomes for patients by implementing stricter standards in training, audit, research and monitoring of medical implants are welcome. However, the Senate has lumped together incontinence and prolapse devices, considering them all to be “transvaginal meshes”. </p>
<p>Only the prolapse devices are problematic, while those used for incontinence are safe and evidence-based procedures. Conflating the two confuses women and may lead them to seek snake-oil type treatments that have no evidence base, and can be risky.</p>
<h2>Different devices</h2>
<p>Prolapse is when pelvic organs – such as the bladder, bowel or uterus (womb) – fall through the vagina. Stress urinary incontinence is involuntary urine leakage with activity such as sport, coughing or even walking. Both conditions are types of pelvic floor dysfunction, but the surgery and medical devices used to treat them are different.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/urinary-incontinence-can-be-a-problem-for-women-of-all-ages-but-there-is-a-cure-49365">Urinary incontinence can be a problem for women of all ages, but there is a cure</a>
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</em>
</p>
<hr>
<p>Despite many <a href="https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/MeshImplants/Submissions">submissions to the inquiry</a> from clinical bodies, the Senate committee has been unable to distinguish between midurethral mesh slings (used for urinary incontinence) and transvaginal mesh (used for prolapse). The first is a mesh tape placed under the urethra like a sling for support. The second are sheets of mesh placed under the bladder, or in front of the bowel, to stop prolapse and prevent recurrence.</p>
<p>Midurethral slings in Australia have been associated with complaints in around equal numbers to mesh used for prolapse, but proportionately most problems have been seen with prolapse. This is because an estimated 120,000 sling operations have <a href="https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/MeshImplants">been performed</a>, compared to only around 30,000 prolapse mesh procedures.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/213106/original/file-20180404-189798-kzkowr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/213106/original/file-20180404-189798-kzkowr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/213106/original/file-20180404-189798-kzkowr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/213106/original/file-20180404-189798-kzkowr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/213106/original/file-20180404-189798-kzkowr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/213106/original/file-20180404-189798-kzkowr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/213106/original/file-20180404-189798-kzkowr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/213106/original/file-20180404-189798-kzkowr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Many women who had mesh surgery for pelvic prolapse have experienced significant pain, bladder injury and incontinence.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>There is <a href="https://theconversation.com/common-surgery-for-vaginal-prolapse-can-lead-to-complications-review-shows-54559">still clinical uncertainty</a> and insufficient data on indications for use and best practice when it comes to the mesh used to treat vaginal prolapse. A <a href="http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD012079/abstract">review of several studies</a> found that the artificially grafted mesh had more problems than benefits, and the women who underwent the operation had high rates of needing repeat surgery due to mesh exposure, bladder injury and urinary incontinence.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/common-surgery-for-vaginal-prolapse-can-lead-to-complications-review-shows-54559">Common surgery for vaginal prolapse can lead to complications, review shows</a>
</strong>
</em>
</p>
<hr>
<p>Midurethral slings, however, have an <a href="https://www.ncbi.nlm.nih.gov/pubmed/26130017">excellent track record</a> and are the <a href="https://www.ncbi.nlm.nih.gov/pubmed/23563892">most researched incontinence procedure</a> in history. Midurethral slings have been recognised by every national and international medical or regulatory organisation as the treatment of choice for stress urinary incontinence in patients who have failed conservative management, such as pelvic floor exercises.</p>
<h2>There are riskier procedures</h2>
<p>The Senate also tasked the Australian Commission on Quality and Safety in Health Care with carrying out many of its recommendations. The commission recently <a href="https://www.safetyandquality.gov.au/our-work/transvaginal-mesh/status-of-commission-guidance-february-2018/">published guidelines</a> for hospital credentialing of surgeons to perform transvaginal mesh procedures for urinary incontinence and prolapse. </p>
<p>Along with many sensible recommendations on training and audit, the commission determined that surgeons needed to perform:</p>
<blockquote>
<p>a minimum of ten surgeries for stress urinary incontinence (either mesh or non-mesh) each year. </p>
</blockquote>
<p>This is not ten midurethral slings – the procedure for which the whole guideline was designed – but any surgery for stress incontinence.</p>
<p>There is no requirement from the commission that such procedures have proven efficacy and safety. This means that, in theory, a completely non evidence-based treatment such as vaginal laser could be claimed as a continence procedure. Vaginal laser is essentially a cosmetic laser treatment, for which there is absolutely no scientific data for any effect in patients with urinary incontinence.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/vaginal-mesh-controversy-shows-collective-failure-of-the-tga-and-australias-specialists-78605">Vaginal mesh controversy shows collective failure of the TGA and Australia's specialists</a>
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</em>
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<hr>
<p>Along with the Senate’s recommendation that mesh be used as a “last resort”, this suggests patients should be offered less effective procedures, such as an <a href="http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD003881.pub4/abstract">injection therapy</a>, or <a href="http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD001755.pub2/abstract">big abdominal operations</a>, with <a href="https://www.ncbi.nlm.nih.gov/pubmed/28479203">more complications</a> and no better efficacy, simply because they don’t involve mesh.</p>
<p>We have already seen a <a href="https://obgyn.onlinelibrary.wiley.com/doi/10.1111/ajo.12445">reduction in continence surgery</a> over the last several years, which could be related to adverse mesh publicity. This has not been replaced by an increase in conservative management. Rather Australian women are now continuing to suffer with their incontinence. And there is a risk they will turn to expensive “snake oil” treatments, such as <a href="https://splinternews.com/vaginal-rejuvenation-stem-cell-therapy-is-probably-bogu-1793859971">vaginal rejuvenation therapy</a>.</p>
<p>We anticipate further patient anxiety and poor outcomes if the system doesn’t guarantee patients receive evidence-based care. We have the data on midurethral slings so we can’t compromise access to the safest and most effective surgical treatment for their stress incontinence.</p><img src="https://counter.theconversation.com/content/94403/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jennifer King is the Chair of the UroGynaecological Society of Australasia.</span></em></p>Mesh surgery for urinary incontinence is effective and extensively studied, while the mesh used in pelvic prolapse is problematic. But the Senate has conflated the two, which will confuse women.Jennifer King, Honorary Clinical Lecturer, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/911912018-02-14T12:03:05Z2018-02-14T12:03:05ZIncontinence affects more than 200m people worldwide, so why isn’t more being done to find a cure?<figure><img src="https://images.theconversation.com/files/205276/original/file-20180207-74482-i0y468.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/success?src=QgLs1Y_X6daOlftRSDWL3w-1-96">Shutterstock</a></span></figcaption></figure><p>For a chronic health condition that causes shame and misery for countless people and costs billions, urinary incontinence keeps a low profile. </p>
<p>Media reports about chronic health conditions appear with alarming regularity, but it is rare to read about the debilitating impact of the involuntary leakage of urine. Nevertheless, urinary incontinence is a condition which, next to Alzheimer’s or strokes, is reported as most negatively affecting “<a href="https://www.ncbi.nlm.nih.gov/pubmed/14608795">health-related quality of life</a>”.</p>
<p>The reasons for this are not too hard to fathom. Urinary incontinence, of course, elicits some embarrassment. And there also seems to be a feeling this is a low priority condition: urinary incontinence does not directly bear up against the terrible impacts of life threatening conditions and illnesses. </p>
<p>But to those who suffer urinary incontinence, it can be a tragedy. This condition is often associated with shame, loss of self-confidence, and low quality of life. It is a condition that increases with older age – approximately <a href="https://www.ncbi.nlm.nih.gov/pubmed/21105895">half of nursing home residents</a> suffer from urinary incontinence.</p>
<p>The financial cost to society is also great. The total cost of urinary incontinence in the US is estimated to exceed US$80 billion by 2020, according to one <a href="https://www.ncbi.nlm.nih.gov/pubmed/24456314">report</a>. <a href="https://www.ncbi.nlm.nih.gov/pubmed/18268289">Another study</a> shows that the treatment costs associated with incontinence in general exceeds those connected to treating pneumonia, influenza and breast cancer. </p>
<h2>Talking about incontinence</h2>
<p>In a collaboration between Lund University in Sweden and Leeds University in the UK, we recently began looking at this subject as part of a <a href="https://www.vbe.lu.se">wider research project</a> on decision making among health experts. </p>
<p>We reviewed the literature on preventions and treatments and interviewed five experts working in this field in Sweden. Three key findings emerged: a general lack of awareness about the condition, a lack of research on its treatments, and challenges around implementation of the research. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/205282/original/file-20180207-74487-1bnbty0.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/205282/original/file-20180207-74487-1bnbty0.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/205282/original/file-20180207-74487-1bnbty0.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/205282/original/file-20180207-74487-1bnbty0.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/205282/original/file-20180207-74487-1bnbty0.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/205282/original/file-20180207-74487-1bnbty0.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/205282/original/file-20180207-74487-1bnbty0.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Your pelvic floor muscles are the muscles you use to control the flow of urine as you urinate.</span>
<span class="attribution"><a class="source" href="https://www.pexels.com/photo/white-ceramic-male-toilet-127726/">Pexels</a></span>
</figcaption>
</figure>
<p>The experts we spoke to all agreed there was a lack of awareness about urinary incontinence among health care professionals. We heard how many in the health care sector did not always recognise patients who experience problems with urinary incontinence – perhaps because the affliction is considered to be a low priority. And it often didn’t occur to doctors to ask about urinary incontinence at all. </p>
<p>One of the experts we interviewed said:</p>
<blockquote>
<p>Maybe 90% of those with urinary incontinence are managed in primary care, but they are given very little attention.</p>
</blockquote>
<p>And another expert added:</p>
<blockquote>
<p>Finding these patients isn’t easy … Health care providers often say that, no we don’t have any patients with urinary incontinence and then they see that yes, they do…</p>
</blockquote>
<h2>Bladder issues</h2>
<p>Urinary incontinence seems to be especially neglected among the elderly. <a href="https://www.rcplondon.ac.uk/file/nacc-full-organisational-and-clinical-report-national-audit-continence-care-2010">The National Audit for Continence Care</a> found that in primary and emergency care settings in the UK, older people were less likely to have a record of incontinence, despite the fact that the condition becomes more common with age. </p>
<p>Our second key finding was that there is an alarming lack of research into treatments for urinary incontinence. Our interviewees noted that urinary incontinence was simply not an attractive area for study. One expert told us:</p>
<blockquote>
<p>Who does a study on how many times you should help an elderly person to empty the bladder in order to minimise leakage?</p>
</blockquote>
<p>Instead, <a href="http://www.cochrane.org/search/site?f%5B0%5D=im_field_terms_cochrane_library%3A51632">most researchers</a> seem more interested in understanding surgical and pharmaceutical treatments. Yet, in practice, the most common treatments for urinary incontinence typically include incontinence pads and behavioural interventions such as toileting programmes or pelvic floor training. </p>
<h2>Lack of research</h2>
<p>While research on the effectiveness of incontinence treatments is sorely lacking, even less is known about the prevention of incontinence. Pelvic floor training, restricting fluid intake and promoting weight loss are all suggested, but there is simply insufficient research to reliably inform practice. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/205285/original/file-20180207-74512-adhue8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/205285/original/file-20180207-74512-adhue8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/205285/original/file-20180207-74512-adhue8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/205285/original/file-20180207-74512-adhue8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/205285/original/file-20180207-74512-adhue8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/205285/original/file-20180207-74512-adhue8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/205285/original/file-20180207-74512-adhue8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Urinary incontinence in women is a common problem.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/success?src=QgLs1Y_X6daOlftRSDWL3w-1-2">Shutterstock</a></span>
</figcaption>
</figure>
<p>While there is some research on toileting programmes and pelvic floor training, it does not provide enough practical guidance about how to implement those strategies, or for how long. One expert explained the impact this can have:</p>
<blockquote>
<p>It is often hard to implement scientific results regarding pelvic training, because the level of detail is too low to actually learn from each other. You need to know how it is done concretely.</p>
</blockquote>
<p>Ultimately, urinary incontinence is a health condition that seriously undermines quality of life. And informed, sensible discussion and dedicated research could go a long way towards raising its profile and ultimately, improving the lives of millions. </p>
<p>But for this to happen, people need to start talking about incontinence. We cannot be shy about a condition that is likely to affect many of us at some point in our lives.</p><img src="https://counter.theconversation.com/content/91191/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Annika Wallin receives funding from Riksbankens Jubileumsfond (The Swedish foundation for Humanities and Social Sciences) </span></em></p><p class="fine-print"><em><span>Nils-Eric Sahlin receives funding from Riksbankens Jubileumsfond (The Swedish foundation for Humanities and Social Sciences).</span></em></p><p class="fine-print"><em><span>Wändi Bruine de Bruin receives funding from Riksbankens Jubileumsfond (The Swedish foundation for Humanities and Social Sciences) </span></em></p>The shame of incontinence and why no one wants to talk about it.Annika Wallin, Associate professor in Cognitive Science, Lund UniversityNils-Eric Sahlin, Professor, Lund UniversityWändi Bruine de Bruin, University Leadership Chair in Behavioural Decision Making, University of LeedsLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/860802017-11-16T11:57:45Z2017-11-16T11:57:45ZWhy we need to talk about incontinence<figure><img src="https://images.theconversation.com/files/191215/original/file-20171020-13936-1jy9u2x.JPG?ixlib=rb-1.1.0&rect=30%2C1056%2C3971%2C1913&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Claire Scott/Cranfield University</span>, <span class="license">Author provided</span></span></figcaption></figure><p>We rarely hear or speak about incontinence. But the <a href="https://www.ncbi.nlm.nih.gov/pubmed/20025020">condition</a> – the involuntary loss of urine or faecal matter – is frighteningly common. </p>
<p>Incontinence does not know wealth divides. It brings profound personal and socio-economic consequences across the income spectrum and around the world. <a href="https://www.ncbi.nlm.nih.gov/pubmed/19410574">Best estimates</a> reveal that about 8% of adults experience faecal incontinence, increasing to 15% for those over 70 years. Urinary incontinence is even more prevalent, affecting approximately <a href="https://www.ncbi.nlm.nih.gov/pubmed/14499979">24% of men and 53% of women</a> (the condition is more prevalent in women due to strong causative links with childbirth). It is <a href="https://www.ncbi.nlm.nih.gov/pubmed/20617303">equally prevalent in lower income countries</a>. </p>
<p>Incontinence is a symptom which can have <a href="http://www.ics.org/public/factsheets">many underlying causes</a>. It can result from a weakened pelvic floor (often resulting from childbirth), obstetric fistula, cancer, bladder or bowel dysfunction, emotional distress and many other conditions. And it can be traumatising regardless of where you call home. Many cultures consider incontinence to be a taboo topic, not to be spoken about in polite conversation:</p>
<blockquote>
<p>For the majority of my 34 years I’ve kept my daily accidents a secret. Even as a four year old I remember hiding my dirty underwear from my parents.</p>
</blockquote>
<p>This experience, recounted by a person experiencing faecal incontinence in the UK (to our colleagues in the <a href="http://impress-network.com/">IMPRESS Network</a>) is typical, and reveals that the condition affects all ages. Equally, a recent study in <a href="http://impress-network.com/wp-content/uploads/2017/10/Claire-Scott-Thesis-Incontinence-in-Zambia-1.pdf">Zambia</a>, conducted by a Cranfield University researcher, revealed that incontinence is sometimes considered a “curse”, particularly when it is not linked to an obvious causative “trauma” or illness. This results in the condition being more stigmatised for women (as childbirth is perceived as “natural” and not traumatic or an illness).</p>
<p>A similar study in Pakistan, conducted by the London School of Tropical Hygiene and Medicine (but not yet published) asked those experiencing incontinence to take photographs of people and objects that represented their experience. A common theme was photographs portraying the isolation they feel. Often they are excluded from their community, particularly if they are unable to bathe often enough to manage odour.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/194560/original/file-20171114-27573-1qr5ny.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/194560/original/file-20171114-27573-1qr5ny.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=420&fit=crop&dpr=1 600w, https://images.theconversation.com/files/194560/original/file-20171114-27573-1qr5ny.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=420&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/194560/original/file-20171114-27573-1qr5ny.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=420&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/194560/original/file-20171114-27573-1qr5ny.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=528&fit=crop&dpr=1 754w, https://images.theconversation.com/files/194560/original/file-20171114-27573-1qr5ny.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=528&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/194560/original/file-20171114-27573-1qr5ny.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=528&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Incontinence can lead to ostracism and loneliness.</span>
<span class="attribution"><span class="source">De Visu/Shutterstock.com</span></span>
</figcaption>
</figure>
<h2>What is normal?</h2>
<p>In both low and high resource contexts, there is confusion around what is “normal” when it comes to continence-related conditions, particularly those caused by <a href="https://theconversation.com/pelvic-floor-training-in-pregnancy-could-help-prevent-the-need-for-barbaric-vaginal-mesh-surgery-76440">childbirth</a> and ageing. </p>
<p>People are often unaware, for example, that appropriate medical intervention could treat or better manage the condition. This can be compounded by non-specialist healthcare professionals dismissing the condition. One British patient we have worked with reported visiting several doctors over a 30-year period before undergoing surgery that has dramatically reduced her urinary incontinence symptoms. She told us: “It has really improved my quality of life.”</p>
<p>But in locations where traditional healers are common, rural Zambia for example, those who experience incontinence (and recognise it as a health issue) may choose to visit such healers, who have not undergone medical training. If these healers are unable to address their concerns, people often simply “give up” on treating the condition at all, preferring to manage it privately and not visit a trained medical practitioner.</p>
<h2>Access is important</h2>
<p>In high income countries, primary treatment of incontinence includes pharmaceutical, surgical and lifestyle modifying interventions. Where the condition cannot be fully treated, management strategies are dominated by disposable products including catheters, colostomy bags and absorbent pads. This can have a severe impact on everyday life, bringing worries about where the nearest public toilet will be and making even short outings stressful, requiring extensive planning. This is exacerbated when those experiencing incontinence are also <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3980491/">homeless</a>. </p>
<p>For those with internet access, Google Maps now allows users in some Indian cities to <a href="https://www.guidingtech.com/63154/google-maps-public-toilet-locator-india/">find their nearest public toilet</a>. Extending this facility worldwide would transform lives.</p>
<p>In low income contexts and in <a href="http://www.sphereproject.org/resources/sphere-essentials/">emergencies</a>, those with incontinence often cannot afford treatment or expensive management products (or appropriate infrastructure is not there to deliver it). The previously mentioned studies in <a href="http://impress-network.com/wp-content/uploads/2017/10/Claire-Scott-Thesis-Incontinence-in-Zambia-1.pdf">Zambia</a> and Pakistan both highlighted an affordability issue for those experiencing incontinence, but not necessarily of specialised incontinence aids such as catheters and colostomy bags. Rather, the primary issue was the unaffordability of the soap they required to wash themselves, their reusable pads and their surroundings. Disposable options are often not even a consideration due to their exorbitant cost.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/194561/original/file-20171114-27616-112ec0x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/194561/original/file-20171114-27616-112ec0x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=420&fit=crop&dpr=1 600w, https://images.theconversation.com/files/194561/original/file-20171114-27616-112ec0x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=420&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/194561/original/file-20171114-27616-112ec0x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=420&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/194561/original/file-20171114-27616-112ec0x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=528&fit=crop&dpr=1 754w, https://images.theconversation.com/files/194561/original/file-20171114-27616-112ec0x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=528&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/194561/original/file-20171114-27616-112ec0x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=528&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Not being able to afford washing powder entrenches stigma around incontinence.</span>
<span class="attribution"><span class="source">Laboko/Shutterstock.com</span></span>
</figcaption>
</figure>
<h2>A complex issue</h2>
<p><a href="http://www.un.org/sustainabledevelopment/blog/2016/01/sanitation-becomes-separate-un-human-right-in-enhanced-fight-against-infection/">Sanitation is a human right</a>. How can we ensure that it is realised for everyone, including those experiencing incontinence? </p>
<p>Incontinence is treated and managed in a variety of ways around the world. But it is never as simple as installing a technology, selling a product or delivering an intervention. Even the most basic of management measures require supply chains, infrastructure and policies. Even where these are in place, affordability and a reluctance to seek medical help can result in many suffering quietly, often tagged with a stigma of being “smelly” or “cursed”.</p>
<p>So perhaps the heart of the challenge, and the solution to better tackling incontinence, lies in raising awareness and understanding. Through <a href="http://www.bladderandboweluk.co.uk/">education</a>, <a href="https://www.ncbi.nlm.nih.gov/pubmed/26555779">public discussion</a>, <a href="http://www.telegraph.co.uk/health-fitness/body/kate-winslet-has-opened-the-floodgates-literally-how-to-cope-wit/">media coverage</a>, better <a href="http://www.bradforddistrictsccg.nhs.uk/news/lets-talk-about-incontinence/">recognition in healthcare</a> and even <a href="http://www.theguardian.com/healthcare-network/2017/aug/10/why-wrote-comedy-show-incontinence-edinburgh-fringe">comedy</a>, we can tackle stigma and reduce social barriers to appropriate healthcare. Furthermore, education can help transform the current burden of postpartum urinary incontinence through better awareness of preventative measures such as <a href="http://www.cochrane.org/CD007471/INCONT_pelvic-floor-muscle-training-for-prevention-and-treatment-of-urinary-and-faecal-incontinence-in-pregnant-women-and-women-who-have-recently-given-birth">pelvic floor training during pregnancy</a>.</p>
<p>We all urinate and defecate every day. <a href="https://data.unicef.org/topic/water-and-sanitation/sanitation/">Two thirds of us</a> have some basic sanitation system that we rely on to help us manage this, and don’t often think about what would happen if we didn’t have such access. But, undoubtedly, there have been instances where you, or someone you care for, has needed to “go” and hasn’t reached these facilities in time. Remembering the inconvenience, perhaps even embarrassment, of these experiences highlights why we need to be more open to discussing incontinence and developing management methods that allow everyone to live happy, productive and healthy lives.</p><img src="https://counter.theconversation.com/content/86080/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dani J Barrington is Editor-in-Chief of Engineers Without Borders, Australia's Journal of Humanitarian Engineering. This article grew out of conversations between Dani and Pete with Zara Ansari (Masters student, London School of Hygiene and Tropical Medicine), Claire Scott (Masters student, Cranfield University) and Sarah House (independent consultant) following a side event that they facilitated together at the WEDC 2017 Conference.
</span></em></p><p class="fine-print"><em><span>Pete Culmer receives funding from UK research councils – EPSRC and the UK National Institute of Health Research (NIHR). He is a member of the iMechE Biomedical Engineering Association.</span></em></p>Incontinence is frighteningly common.Dani Barrington, Lecturer in Water, Sanitation and Health, University of LeedsPete Culmer, Associate Professor in Surgical Technologies, University of LeedsLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/786052017-06-06T19:21:24Z2017-06-06T19:21:24ZVaginal mesh controversy shows collective failure of the TGA and Australia’s specialists<figure><img src="https://images.theconversation.com/files/172197/original/file-20170605-20608-1x1wfgp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Hundreds of women have complained of adverse reactions from transvaginal mesh implants.</span> <span class="attribution"><a class="source" href="https://unsplash.com/search/older-women?photo=_EKlFRXUuvg">Anna Noack/Unsplash</a></span></figcaption></figure><p>Australian women are coming forward with <a href="http://www.abc.net.au/news/2017-05-31/how-a-vaginal-mesh-implant-destroyed-maessens-life/8573878">stories of the negative impacts on their lives of transvaginal mesh implants</a>, medical devices surgically inserted to prevent pelvic organ prolapse. </p>
<p>A recent <a href="http://www.abc.net.au/news/2017-05-31/more-women-mesh-implant-side-effects-than-thought-experts-say/8572840">Australian consumer group</a> survey reported more than 700 women said they had a mesh implant that had caused adverse effects. These included incontinence, severe chronic pain, problems walking, painful intercourse and even marriage breakdown. In the United Kingdom, hundreds of women are <a href="http://www.bbc.com/news/health-39567240">taking legal action</a> against the National Health Service and the makers of mesh implants. </p>
<p>The <a href="http://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/MeshImplants">Senate is conducting an inquiry</a> into transvaginal mesh implants in Australia. The questions the inquiry aims to answer include why there is no accurate record of how many meshes have been inserted in Australia, and how we can guarantee safer introduction of new products in future.</p>
<p>So, how did we get to a place where hundreds of Australian women have allegedly had this surgery leading to lifelong complications? </p>
<h2>A history of transvaginal mesh</h2>
<p>The pelvic floor is a group of muscles in the pelvic area that support the bladder, vagina and rectum. About 50% of women who have had children <a href="http://www.ajog.org/article/S0002-9378(00)53840-X/abstract">experience pelvic floor dysfunction</a>. As many as 20% <a href="https://www.ncbi.nlm.nih.gov/pubmed/24807341">will require surgery</a> for these conditions.</p>
<p>Pelvic floor dysfunction includes prolapse (falling through) of pelvic organs, such as the bladder, bowel or uterus (womb), through the vagina. It also includes stress urinary incontinence, which is involuntary urine leakage with activity such as sport, coughing or even walking.</p>
<p>The surgery and the medical devices used differ between these two conditions.</p>
<p><strong>Stress incontinence</strong></p>
<p>In the late 1990s, <a href="https://www.ncbi.nlm.nih.gov/pubmed/7618052">an innovative treatment</a> for stress incontinence was introduced. This involved a <a href="https://www.thewomens.org.au/health-information/continence-information/urinary-incontinence/">permanent synthetic sling, called a mid-urethral sling</a>, placed under the urethra (the tube through which urine travels from the bladder) to give it support. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/172196/original/file-20170605-20575-160pays.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/172196/original/file-20170605-20575-160pays.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/172196/original/file-20170605-20575-160pays.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/172196/original/file-20170605-20575-160pays.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/172196/original/file-20170605-20575-160pays.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/172196/original/file-20170605-20575-160pays.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/172196/original/file-20170605-20575-160pays.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/172196/original/file-20170605-20575-160pays.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The mid-urethral sling is placed under the urethra for support.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>By 2002, the mid-urethral sling became the most frequently performed incontinence surgery in Australia. This was <a href="https://www.ncbi.nlm.nih.gov/pubmed/12114234">because doctors saw</a> the procedure was equivalent to, or better than, alternative procedures. The blood loss and operating time were less and recovery times were shorter than older procedures. </p>
<p>This clinical experience was later <a href="https://www.ncbi.nlm.nih.gov/pubmed/14981369">confirmed in large trials</a>. But while we waited for the results of these, which were published from 2004 onward, many women gained from a highly effective and safe operation, demonstrating the benefits of the innovation.</p>
<p><strong>Pelvic organ prolapse</strong></p>
<p>Traditional surgery for pelvic organ prolapse involved repairing the torn connective tissue with sutures. This was called vaginal repair. Unfortunately, this <a href="https://www.ncbi.nlm.nih.gov/pubmed/9083302">surgery was associated</a> with a <a href="http://www.ajog.org/article/S0002-9378(01)99389-5/abstract">high rate of the prolapse</a> recurring.</p>
<p>Following the success of the sling tape in stress incontinence, and of mesh use for hernias, doctors and manufactures looked to <a href="http://www.ejog.org/article/S0301-2115(00)00341-9/abstract">introduce a mesh</a> product to treat vaginal prolapse. This involved sheets of mesh being placed under the bladder, or in front of the bowel, to stop prolapse and prevent recurrence.</p>
<p>The <a href="https://www.ebs.tga.gov.au/servlet/xmlmillr6?dbid=ebs/PublicHTML/pdfStore.nsf&docid=2349C2AAB6E8898ECA2577DD0001C16B&agid=(PrintDetailsPublic)&actionid=1">Therapeutic Goods Association (TGA)</a> approved a variety of transvaginal mesh kits for pelvic organ prolapse from 2003. As with the mid-urethral sling four years earlier, little supporting data on the safety and efficacy of these kits was initially available. </p>
<p>Due to a lack of detail in the Medicare codes used to record the surgeries, we are unable to accurately determine how many women underwent surgery. I estimate that around 150,000 tapes for stress urinary incontinence and between 30,000 and 40,000 transvaginal meshes for pelvic organ prolapse have been performed to date.</p>
<h2>Problems with vaginal mesh</h2>
<p>Since the introduction of transvaginal mesh, long-term trials and <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD012079/abstract">reviews have demonstrated</a> it has some advantages over traditional vaginal repair. These include reduced symptoms of prolapse and need to operate again. But the mesh kits also have disadvantages. </p>
<p>The mesh rubs or <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD012079/abstrac">becomes exposed in the vagina</a> in as many as 14% of cases. For some women, the exposure has no symptoms, but others experience bleeding, discomfort and painful intercourse. </p>
<p>At least half of the women in the studies reviewed needed surgery to treat the exposed mesh and sew over the vaginal tissue. The surgical correction is relatively straightforward and is generally successful. </p>
<p>Another problem is <a href="http://www.ajog.org/article/S0002-9378(10)02270-2/abstract">vaginal and groin pain</a>, which affects 3-4% of women. Sometimes multiple surgeries are required to remove large portions of the mesh. The pain <a href="https://www.ncbi.nlm.nih.gov/pubmed/26506159">persists in as many as 25% of women</a>, even after mesh excision, and may become chronic and disabling. Some find it difficult to maintain employment and intimate relationships. </p>
<h2>What regulatory bodies did</h2>
<p>Following reports of these complications, the <a href="https://www.fda.gov/downloads/medicaldevices/safety/alertsandnotices/ucm262760.pdf">US Food and Drug Administration</a> (FDA) <a href="http://www.mdedge.com/obgmanagement/article/63461/fda-alert-transvaginal-placement-surgical-mesh-carries-serious-risks">issued alerts</a> in 2008 and 2011 that the mesh carried serious risks. Many transvaginal mesh kits were voluntarily removed from the market. Most doctors in Australia stopped using the mesh for prolapse from 2012.</p>
<p>While the evidence of the benefits of the mid-urethral sling for urinary incontinence is overwhelming, <a href="http://journals.lww.com/co-urology/Abstract/2004/11000/Trans_obturator_tape_procedure____inside_out_or.3.aspx">some changes to the tapes</a> were introduced from 2005 to decrease adverse events. The TGA approved these new mini-slings (or obturator slings) and specialists used these without evidence confirming whether they were safer or more effective than the traditional mid-urethral sling.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/172354/original/file-20170606-16849-6hfs7h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/172354/original/file-20170606-16849-6hfs7h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/172354/original/file-20170606-16849-6hfs7h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/172354/original/file-20170606-16849-6hfs7h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/172354/original/file-20170606-16849-6hfs7h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/172354/original/file-20170606-16849-6hfs7h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/172354/original/file-20170606-16849-6hfs7h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/172354/original/file-20170606-16849-6hfs7h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Disabling vaginal and groin pain can be a complication of vaginal mesh implants.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>In 2015, an <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006375.pub3/abstract">extensive Cochrane review</a> showed 2-3% of women developed significant groin pain after surgery with the obturator slings. It also showed the obturator slings were not as effective as the traditional slings at the five-year mark. But the obturator slings were quicker to perform and had less bladder injury than the traditional mid-urethtral slings. </p>
<p>In 2016, specialist groups such as the Urogynaecology Society of Australia and the Australian College of Obstetricians and Gynaecologists undertook <a href="http://www.ugsa.org.au/data/MUS_Presentations/3.UGSA_MUS_SUI_treatment_Read-Only.pdf?COLLCC=3602805463&">educational courses and later issued statements</a> cautioning doctors about using the new slings.</p>
<p>Many of the affected women have asked how procedures could be performed on them when the full benefit-to-risk profile of the intervention was not yet known. It can be argued doctors wanted to provide new and better options. But, in hindsight, innovation and patient safety could have been far more closely aligned. </p>
<p>This could have been achieved if both the TGA and the specialists themselves had more thoroughly evaluated transvaginal meshes by ensuring these were used under the oversight of medical ethics committees. The well-established practice of performing large trials under the guidance of an ethics committee encourages innovation while ensuring patients are properly informed of the possible benefits and risks of the innovation. </p>
<p>While some Australian hospitals took this precautionary step, the fact it did not happen uniformly is a collective failure of both the TGA and specialists. </p>
<h2>Next steps</h2>
<p>The Senate review will evaluate how sponsoring manufacturers interact with doctors performing surgical interventions, and how the broader medical community and public are educated about new interventions. </p>
<p>It is hoped the inquiry will inform the general community, doctors and industry of a clear and transparent pathway that balances the need for innovation and the responsibility for protecting patients.</p>
<p>Finally, while waiting on the inquiry’s deliberations, women should remain confident mid-urethral slings used for stress incontinence are an excellent intervention. Those undergoing prolapse surgery should also be reassured that highly trained specialists will carefully evaluate and perform surgery without the need for transvaginal mesh. </p>
<p>Those affected by ongoing complications associated with transvaginal mesh can be reassured Australian specialists are leaders in the management of these problems. Not only were we among the first in the world to report large trials that evaluated transvaginal mesh, we’ve also reported on the safety, technique and efficacy of mesh-removal procedures for vaginal pain in peer-reviewed publications.</p>
<p>We are fully supportive of the women who have experienced complications of transvaginal mesh. We look forward to working collaboratively at a national and local level, under the auspices of the Senate enquiry, to ensure we learn from the mistakes made when introducing transvaginal mesh into clinical practice. </p>
<hr>
<p><em>Further information is available on the websites of the <a href="https://www.ranzcog.edu.au/Womens-Health/Patient-Information-Guides">College of Obstetricians and Gynaecology</a> (RANZCOG) and the <a href="http://www.ugsa.org.au/pages/patient-information.html">Urogynaecology Society of Australia</a> (UGSA).</em></p><img src="https://counter.theconversation.com/content/78605/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christopher Maher does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Regulatory bodies approved some medical devices to treat pelvic organ prolapse and urinary incontinence before having data to prove their safety and efficacy.Christopher Maher, Associate Professor, Urogynaecology Royal Brisbane and Women's and Wesley Hospitals Brisbane, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/604502016-07-04T20:09:45Z2016-07-04T20:09:45ZCaught short: we need to talk about public toilets<p>We don’t tend to talk about toilets much, even though we all use them. Yet not only do public toilets meet our voiding needs when we go out, but they are the site for many underlying social processes and behaviours, especially those related to gender roles. They also represent unspoken boundaries between public and private (eyes front! Avoid noises! Wash hands!). </p>
<p>The lack of attention to public toilets means we know very little about how they meet local needs and social participation in Australia. </p>
<p>We do know that a lack of public toilets can result in social isolation and create difficulties for daily life (particularly for the large proportion of the population with continence issues), such as shopping for food and even going to work. Wider consequences are <a href="http://www.sciencedirect.com/science/article/pii/S0002937812020650">low self-esteem, depression and loneliness</a>.</p>
<h2>Meeting the need to go</h2>
<p>From a purely physical needs perspective, nearly five million Australians have <a href="http://www.continence.org.au">bladder or bowel control problems</a>. This means many can’t confidently leave their homes unless they know toilets will be available. </p>
<p>People who have to plan their activities or schedules around their toileting needs are frequent users of public toilets. They include the elderly, parents with small children, people with certain disabilities, people with a range of medical conditions, and workers whose jobs involve driving (and these groups are not mutually exclusive). </p>
<p>Inability to find or use toilets when outside the home also has implications for bladder, bowel or kidney health when people are <a href="http://www.huffingtonpost.ca/2012/02/27/holding-your-pee-health-_n_1299435.html">forced to “hold on”</a>, or can result in embarrassing accidents. Incontinence has a profound effect on people’s social and psychological wellbeing.</p>
<p>A <a href="http://www.ageuk.org.uk/documents/en-gb/for-professionals/research/nowhere%20to%20go%20public%20toilet%20provision%20(2007_pro.pdf?dtrk=true)">2006 survey in the UK</a> found that 82% of respondents felt that public toilet provision in their areas did not meet their needs. More than half agreed that the lack of public toilets stopped them from going out as often as they would like. </p>
<p>Despite this need, the number of available public toilet facilities in the UK <a href="http://www.materialworldblog.com/2011/05/everybody-goes-designing-age-friendly-public-toilet-solutions/">halved</a> between 1999 and 2008. </p>
<p>Population ageing means more people will <a href="https://www.nia.nih.gov/health/publication/urinary-incontinence">eventually experience incontinence</a> or take medication that means they <a href="http://www.rightdiagnosis.com/symptoms/frequent_urination/side-effects.htm">need to go more often</a>. Older people may also simply find it harder to get on and off the toilet, or even reach it in time. </p>
<h2>Barriers to use</h2>
<p>Ironically, current innovations in public toilet design may not be suitable for an ageing population. Research has found that older people perceive self-cleaning toilets as <a href="http://s3.amazonaws.com/academia.edu.documents/30865968/WP_Shanghai_26_10.pdf?AWSAccessKeyId=AKIAJ56TQJRTWSMTNPEA&Expires=1466053254&Signature=hIUkGt9edXIdbk0BEnZYBAvT2SM%3D&response-content-disposition=inline%3B%20filename%3DDesign_for_togetherness.pdf#page=135">unfamiliar and difficult to use</a>. </p>
<p>Many other people may also <a href="http://www.nytimes.com/2009/12/11/nyregion/11toilet.html?_r=0">avoid self-cleaning public toilets</a>. The reasons include fears of being locked in, the doors opening or water squirting before the user is ready, wet surfaces, or being unable to see who might be waiting outside. </p>
<p><a href="http://www.abc.net.au/rampup/articles/2014/02/05/3938645.htm">People with disabilities</a> face additional problems. For a start, toilets designated for the disabled are often locked (to prevent others from using them for undesirable purposes). Users must first request permission or a key to gain access.</p>
<p>The average toilet cubicle does not provide enough space for people with disabilities (or aged persons) or, for those who have carers, for a carer to assist them. Very few public toilets have <a href="http://changingplaces.org.au/">hoists or changing tables for adults</a>. Sometimes they must <a href="https://www.youtube.com/watch?v=Zadt8ufDikA">lie on the floor of a toilet block</a>, which obviously is neither private nor hygienic. If carers are of the opposite gender, entering a public toilet can be awkward. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/Zadt8ufDikA?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Having a disability is hard enough without the design of public toilets making it worse.</span></figcaption>
</figure>
<h2>A right to better toilet facilities</h2>
<p>As a result of these problems, many people with disabilities are forced to go home to attend to their toileting needs. This is a major disruption to their education, employment or socialising. </p>
<p>All these problems mean that some people with disabilities must restrict their fluid and food intake so as to avoid needing a toilet while outside the home. That’s a serious infraction of human rights.</p>
<p>The online <a href="https://toiletmap.gov.au/">National Toilet Map</a> tells us where public toilets are. What it does not tell us is:</p>
<ul>
<li><p>whether there are enough public toilets</p></li>
<li><p>how well the pattern of distribution meets the needs of the local population</p></li>
<li><p>how the availability, cleanliness, maintenance, design and other uses of public toilets influence people’s daily life. </p></li>
</ul>
<p>Providing public toilets is <a href="https://www.legislation.sa.gov.au/lz/c/a/local%20government%20act%201999/current/1999.62.un.pdf">not a legislative requirement for local governments</a>. In fact, most don’t have dedicated public toilet policies beyond basic aspects of design and costs of maintenance and vandalism. Research by the author has found one result of this is <a href="http://aurin.org.au/projects/data-hubs/public-toilets-distribution-in-south-australia/">socioeconomic inequality in where public toilets are provided</a>.</p>
<p>Issues for all age groups and genders are hygiene, information (about location), lighting, cleanliness, maintenance and cubicle design. The presence of “sharps” disposal boxes, for example, can have a negative impact on ordinary public toilet users who are forced to share the space with people with a drug habit. </p>
<p>The inclusive design of a public toilet is not just a matter of “getting the specifications right”. How do the multiple uses of public toilets affect people’s toileting patterns and consequently their use of public spaces? </p>
<p>Without understanding how the wide range of prospective users actually use public toilets, costly design responses may exclude rather than include.</p><img src="https://counter.theconversation.com/content/60450/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lisel O'Dwyer received research funding for the spatial analysis of public toilets from AURIN at the University of Melbourne. </span></em></p>Millions of people need to be confident that suitable public toilets will be available when they leave their homes. A shortage of such facilities is a serious problem for an ageing population.Lisel O'Dwyer, Senior Researcher, Social and Policy Studies, Flinders UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/545592016-02-15T01:04:17Z2016-02-15T01:04:17ZCommon surgery for vaginal prolapse can lead to complications, review shows<figure><img src="https://images.theconversation.com/files/111399/original/image-20160214-29185-amzlt6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Up to 50% of women who have had children will experience vaginal prolapse.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/66755335@N05/8111915024/in/photolist-dmPFHS-dF56PQ-gegfYd-nVU3jH-dEW4MZ-87xcdG-b37PjH-bDdZ8Y-cj65y7-5QHiz8-d3EWjC-9TBQjo-p2M6nW-dmJoDR-bUcf6T-nmnsC1-anMwLJ-ayFGbU-ekhPNB-95DjwF-28WN7t-gYaUsz-awHapT-7BMHff-b75wx2-oAhMcz-oKggBK-bufSMv-q21rjM-64sk4i-iR91VW-65dbY9-mbgzEP-524rqU-9eQyGf-bwJwYr-cUDD1J-7tvqAy-jU42nb-66GvKg-cEjFPY-8qaDwD-8skPjh-czgKM1-czgJPN-bXuYXA-74oKyv-6qm1AL-6CGC4k-c14Z8b"> Geneva Vanderzeil apairandasparediy.com/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>A common surgery to treat vaginal prolapse using an artificially grafted mesh has more problems than benefits, <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD012079/abstract">our Cochrane review</a> has found. Women who underwent the operation had high rates of needing repeat surgery due to mesh exposure, bladder injury and urinary incontinence.</p>
<p>A vaginal prolapse occurs when the walls of the vagina become weak and collapse inwards. Women can feel a lump or bulge low in their vagina, which is exacerbated at times of physical activity. The debilitating condition <a href="http://www.oxfordgynaecology.com/Conditions/Uterine-Prolapse.aspx">affects up to 50%</a> of women who have had children. </p>
<p>We evaluated the safety and success of inserting mesh through the vagina (transvaginal) with that of traditional surgery that repairs damaged tissue. The aim was to provide clarity in a long-standing controversy over vaginal prolapse treatment.</p>
<p>Complications following transvaginal mesh surgery have led to <a href="http://www.drugwatch.com/transvaginal-mesh/verdict-settlement/">lawsuits in the United States</a> and to Scotland’s health minister temporarily <a href="http://www.bbc.com/news/uk-scotland-scotland-politics-27884794">suspending the technique</a> in 2014 pending safety investigations.</p>
<p>We analysed evidence from 37 randomised trials in 4,032 women and found 12% of those who had mesh inserted suffered from the mesh being exposed in the vagina. This can cause vaginal bleeding, pain, painful intercourse and penile scratching or bleeding in the male partner. </p>
<p>While 7% more women who had transvaginal mesh surgery compared to a native tissue repair reported successful resolution of prolapse, one in 12 of these needed repeat surgery for mesh exposure.</p>
<p>Newer transvaginal mesh products available in Australia haven’t been rigorously evaluated despite being on the market for at least five years. We advise clinicians ensure women understand this uncertainty, as well as the proven complications, before undergoing the interventions. </p>
<h2>Pelvic organ prolapse</h2>
<p>Overweight women, those with a family history of the condition or who chronically strain, by coughing, constipation or heavy lifting, are at increased risk of vaginal prolapse.</p>
<p>Women with the condition can experience incomplete emptying of their bladder or bowel and feel very negatively about their body, which impacts sexual function. </p>
<p>As many as 10% to 20% of women with vaginal prolapse <a href="http://www.ncbi.nlm.nih.gov/pubmed/24807341">will need surgery</a>. </p>
<p>Until the early 2000s, surgeons used different techniques to treat prolapse involving stitching the damaged tissues surrounding the vagina. These remain relatively successful, but <a href="http://www.ncbi.nlm.nih.gov/pubmed/9083302">rates of recurrent prolapse</a> of up to 30% have been reported. </p>
<p>Following successes incontinence surgeons have had <a href="http://www.ncbi.nlm.nih.gov/pubmed/12114234">using tapes</a> to support the urethra like a sling and others using mesh in hernia repair, gynaecology surgeons adopted the use of the net-like mesh to support the vagina. </p>
<p>The technique took off and in 2010, transvaginal mesh operations <a href="http://www.ajog.org/article/S0002-9378(15)00153-2/abstract">accounted for nearly 25%</a> of prolapse interventions in some countries.</p>
<h2>The controversy</h2>
<p>In the last few years, <a href="https://www.researchgate.net/publication/227343100_Vaginal_invagination_Definition_clinical_presentation_and_surgical_management">increasing complaints from women</a> who had undergone transvaginal mesh surgery have raised questions about the safety of the procedure. The problems included vaginal pain, painful intercourse and vaginal bleeding, secondary to the mesh rubbing or becoming exposed in the vagina. </p>
<p>Although there has been insufficient evidence as to the frequency of the complications, as well as no consensus on the best approach to treat the condition, regulatory authorities in several countries took some action. </p>
<p>In 2012, the United States Food and Drug Administration (FDA) <a href="http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/MedicalDevicesAdvisoryCommittee/ObstetricsandGynecologyDevices/UCM271769.pdf">reclassified transvaginal mesh</a> as a high-risk device that demands a higher level of evaluation of new products. Existing mesh devices were also required to report greater comparative data to determine their efficacy and safety. To date, these evaluations have not been published.</p>
<p>The Medicines and Healthcare products Regulatory Authority (MHRA) in Britain <a href="https://www.gov.uk/government/publications/vaginal-mesh-working-group-interim-report">recently reported</a> “a strong disparity between the types of experience patients are reporting and the published evidence” relating to transvaginal mesh. The MHRA recommended regulatory changes including improvements to the informed consent process. </p>
<p>A <a href="https://www.gov.uk/government/publications/vaginal-mesh-working-group-interim-report">Scottish report</a> stated they “remained concerned regarding the safety and efficacy of the transvaginal meshes”. </p>
<p>In Australia, the Therapeutic Goods Administration (TGA) formed the <a href="https://www.tga.gov.au/behind-news/review-urogynaecological-surgical-mesh-implants">Urogynaecological Devices Working Group</a> to advise on this issue. Due to concerns over the lack of definitive data, the group is reassessing clinical evidence for each transvaginal mesh product to ensure it complies with the TGA’s requirements for safety and performance. These evaluations are ongoing. </p>
<p>It is concerning also that many of the mesh products already evaluated were voluntarily withdrawn from use in 2011 to be replaced with newer, lightweight transvaginal permanent meshes. These have yet to be evaluated but remain in use. </p>
<h2>What we found</h2>
<p>Our research aimed to offer women and health professionals the evidence to make better informed choices about surgical treatment. </p>
<p>We found transvaginal mesh surgery had benefits. It reduced the risk that women would be aware of the vaginal bulge from 18% in those who had traditional repairs to 12% in those who had mesh repairs, one to three years following the surgery. </p>
<p>The rate of repeat operations for prolapse following transvaginal permanent mesh repair (1-3%) was also lower compared to traditional repairs (3%). </p>
<p>But some problems were reported with transvaginal mesh. The average rate for repeat operations for prolapse, urinary incontinence, or mesh exposure after mesh repair, was 11% compared with around 5% in women who had a traditional tissue repair. </p>
<p>Permanent mesh surgery was also associated with higher rates of bladder injury than traditional tissue repair and higher rates of urinary incontinence with activity after the surgery.</p>
<p>And, as already mentioned, one in 12 women experienced unpleasant symptoms from mesh complications.</p>
<p>Clinicians and women should be aware that the benefits of transvaginal mesh as compared to traditional repairs should be carefully weighed against the complications. </p>
<p>Gynaecologists should be wary of adopting innovations that have not been fully evaluated by clinical trials. Our patients deserve better studies and, in the absence of evidence, better advice.</p><img src="https://counter.theconversation.com/content/54559/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christopher Maher is Chair of the Urogynaecological Society of Australasia . </span></em></p>A common operation to treat vaginal prolapse using an artificially grafted mesh has women needing repeat surgery due to mesh exposure, and suffering from bladder injury and urinary incontinence.Christopher Maher, Associate Professor, Urogynaecology Royal Brisbane and Women's and Wesley Hospitals Brisbane , The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/493652016-02-11T19:01:30Z2016-02-11T19:01:30ZUrinary incontinence can be a problem for women of all ages, but there is a cure<figure><img src="https://images.theconversation.com/files/109586/original/image-20160129-27156-le0h63.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Urinary incontinence is often seen as a degrading condition and women can feel too ashamed to seek help.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p><em>This article is part of our series examining women’s hidden health conditions. You can read about endometriosis, menopause and other pieces in the series <a href="https://theconversation.com/au/topics/womens-health-series">here</a>.</em></p>
<hr>
<p>Urinary incontinence is urine leakage from a loss of bladder control that mainly affects women after childbirth. But it can happen to anyone. Around <a href="http://www.continence.org.au/pages/key-statistics.html">37% of Australian women</a> have some form of the condition compared to 13% of Australian men.</p>
<p>Mild incontinence is <a href="http://onlinelibrary.wiley.com/doi/10.1002/(SICI)1520-6777(1999)18:6%3C567::AID-NAU7%3E3.0.CO;2-F/abstract">the most common form</a>, affecting about two out of three sufferers. This is where small amounts of urine leak out onto clothing a few times a week and require a light pad or pantyliner to catch the flow. </p>
<p>Moderate to severe incontinence is less common and affects about a third of sufferers. Women need to use a specific incontinence pad (with absorbent gel) and change it more than once or twice daily. This might not be enough though, and they may get accidental wetting through to their clothing even if using the pad.</p>
<p>Whatever form it takes, <a href="http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=6442455815">the impact of incontinence</a> can be debilitating and women are often too embarrassed to seek help from their doctor. This is unfortunate as there is more likelihood of a cure for those who receive treatment at an earlier point.</p>
<h2>Stress and urge incontinence</h2>
<p>There are <a href="http://www.medicalobserver.com.au/medical-news/female-urinary-incontinence">two main forms of urinary incontinence</a>: stress incontinence and urge incontinence. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/110551/original/image-20160208-18303-ygfcrw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/110551/original/image-20160208-18303-ygfcrw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=462&fit=crop&dpr=1 600w, https://images.theconversation.com/files/110551/original/image-20160208-18303-ygfcrw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=462&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/110551/original/image-20160208-18303-ygfcrw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=462&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/110551/original/image-20160208-18303-ygfcrw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=581&fit=crop&dpr=1 754w, https://images.theconversation.com/files/110551/original/image-20160208-18303-ygfcrw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=581&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/110551/original/image-20160208-18303-ygfcrw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=581&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A urethra is like a hose.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/aboutamy/9393569695/in/photolist-fj5v1c-oP3Dyz-dFeJuJ-euAJrh-u1XZbc-87sDPW-87sDYY-ejHu9E-CyG8VV-brQmQ9-bQXhyT-4zD86w-3kDmhH-6sVPNv-6qsCeC-feetQ-6GiGDD-6qsCtY-8znEb9-6tfyr2-6zYu1t-6zYtEF-6qaaSK-AHq7JC-rJG7n4-3kDkup-7pSaM-7QVd9S-6gdkBM-Ha6vs-4xxAXw-om5m7i-87EWG3-7jE2oQ-b3cg3R-7YSN8X-c9aPVj-4SoZ7b-bL3xu4-dgMWHL-91RmJq-4Ftxuo-nC9ecZ-87m66u-tQo36f-84iNCt-bwfnjh-wxwyB8-bCMxkg-pQYPHR">Amy Stanley/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>In stress incontinence, urine leaks out during coughing, sneezing, laughing, or exercising. People with this condition have weak pelvic muscles around the urethra, which are overwhelmed during times of physical stress. </p>
<p><a href="http://www.ncbi.nlm.nih.gov/pubmed/8041527">About 28% of young women</a> who engage in high-impact sports - such as gymnastics, basketball and tennis - develop stress incontinence.</p>
<p>The second form, urge incontinence, is a desperate need to go to the toilet due to spasms in the bladder muscle. Sometimes this results in leaking. People often go to the toilet more than eight times a day, and get up to go more than once at night.</p>
<p>There’s another form called overflow incontinence, which is actually more common in men who have an enlarged prostate gland. It partly blocks the urethra so a pool of residual urine builds up in the bladder and leaks out when capacity overflows. </p>
<p>The problem is rare in women and happens when the bladder has <a href="https://jeanhailes.org.au/health-a-z/bladder-bowel/prolapse-bladder-weakness">prolapsed or dropped down</a> into the vagina. This can block off the urethra, leading to incomplete emptying with overflow leakage.</p>
<h2>Incontinence across the ages</h2>
<p>Women are more prone to incontinence because their urethra is very short (only 4 cm) while the male’s is quite long (11 cm). If you imagine a garden hose, the shorter it is, the more likely water from the tap is to leak out. In a longer hose, the tap water might stop flowing before it reaches the end.</p>
<p>About a third of women <a href="http://www.alswh.org.au/who-is-involved/students/9-who-is-involved/28-dr-pauline-chiarelli-s-studies">who have had children</a> suffer from incontinence at some point. Adolescent girls and older children also experience urine leakage, mainly in the case of bed wetting. This is due to an overactive bladder and <a href="http://www.ncbi.nlm.nih.gov/pubmed/8944518">affects about 4%</a> of children between five and 12.</p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/109584/original/image-20160129-27180-14khbp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/109584/original/image-20160129-27180-14khbp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/109584/original/image-20160129-27180-14khbp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=441&fit=crop&dpr=1 600w, https://images.theconversation.com/files/109584/original/image-20160129-27180-14khbp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=441&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/109584/original/image-20160129-27180-14khbp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=441&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/109584/original/image-20160129-27180-14khbp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=554&fit=crop&dpr=1 754w, https://images.theconversation.com/files/109584/original/image-20160129-27180-14khbp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=554&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/109584/original/image-20160129-27180-14khbp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=554&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Weak pelvic muscles around the urethra can lead to stress incontinence.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>Bed wetting gradually declines during adolescence, but urge and stress <a href="http://www.ncbi.nlm.nih.gov/pubmed/22704114">incontinence persist</a> in up to 10% of women. Incontinence then becomes more common after menopause as women <a href="https://jeanhailes.org.au/health-a-z/bladder-bowel/prolapse-bladder-weakness">produce less oestrogen</a> which weakens ligaments and pelvic floor muscles supporting the urethra. </p>
<p>Obesity <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2866035/">increases the likelihood</a> of incontinence too, as abdominal fat puts pressure on pelvic floor muscles. Likewise, constipation and repeated straining to pass a bowel motion weakens these muscles, <a href="http://www.ncbi.nlm.nih.gov/pubmed/20346050">increasing the risk</a>. </p>
<p>Other factors influencing incontinence include urinary tract infection, which is <a href="http://www.ncbi.nlm.nih.gov/pubmed/18238968">known to worsen</a> its prevalence and severity. Anxiety also contributes to symptoms with studies showing 28% to 32% of women with <a href="http://www.ncbi.nlm.nih.gov/pubmed/22068320">urge incontinence</a>, and 22% with stress incontinence, suffer from anxiety.</p>
<h2>Treatment options</h2>
<p>Urinary incontinence implies lack of control which leads to feelings of shame and reluctance to seek help. As one <a href="http://www.ncbi.nlm.nih.gov/pubmed/15621220">study showed</a> 55% of women who wore pads for incontinence had not consulted a general practitioner in 12 months. </p>
<p>This is unfortunate as treatment options have advanced enormously in the last 20 years. If a patient seeks treatment when leakage is mild, it’s much more likely <a href="http://www.ncbi.nlm.nih.gov/pubmed/12955342">to be successful</a>. The more severe the incontinence, the more difficult and expensive it is to treat.</p>
<p>First-line therapy for stress incontinence is pelvic floor muscle training by a specialist continence physiotherapist, which doesn’t require a doctor’s referral. This has a 65% likelihood of cure for mild, and <a href="http://www.ncbi.nlm.nih.gov/pubmed/12842055">35% for moderate, incontinence</a> with no side effects or risk.</p>
<p>If this doesn’t work, there are two kinds of <a href="http://link.springer.com/article/10.1007/s00192-007-0519-1">vaginal ring pessaries</a> available to support the urethra. These are particularly useful for women who only leak with active sports or gym classes.</p>
<iframe src="https://datawrapper.dwcdn.net/Oy0vk/2/" frameborder="0" allowtransparency="true" allowfullscreen="allowfullscreen" webkitallowfullscreen="webkitallowfullscreen" mozallowfullscreen="mozallowfullscreen" oallowfullscreen="oallowfullscreen" msallowfullscreen="msallowfullscreen" width="100%" height="300"></iframe>
<p>The final option is to have an operation. The most widely performed is one where a mesh tape is placed under the urethra like a sling for support. About 93% of women <a href="http://www.ncbi.nlm.nih.gov/pubmed/10426241">are found to be</a> cured three years after having the surgery and it shows good long-term results.</p>
<p>For urge incontinence, first-line therapy is training to increase bladder capacity. <a href="http://www.australianprescriber.com/magazine/29/1/22/4">A tablet or patch</a> that reduces bladder spasms is prescribed alongside training for at least three to six months.</p>
<p>Urge incontinence after menopause is treated with vaginal oestrogen cream that helps <a href="http://www.ncbi.nlm.nih.gov/pubmed/23076892">strengthen the urethra</a> and enhance bladder capacity. </p>
<p>About 40% of women who don’t respond to these are found to <a href="http://www.ncbi.nlm.nih.gov/pubmed/24844724">have a low grade infection</a> of the bladder, known as cystitis. More treatment options are being developed for this. For instance, a <a href="http://www.anzctr.org.au/TrialSearch.aspx?searchTxt=12613000285752&isBasic=True">randomised trial is currently underway</a> exploring bladder-specific antibiotics together with a muscle spasm reduction tablet for urinary incontinence. </p>
<p>No woman should have to suffer urinary incontinence in silence or shame. The above treatments are not difficult, but they require a professional to steadily work through the options to find the right cure for each woman.</p>
<p><em>Specialist continence physiotherapists can be found at the <a href="https://www.physiotherapy.asn.au">Australian Physiotherapy Association’s</a> website and at the <a href="http://www.continence.org.au">Continence Foundation of Australia’s</a> website.</em></p><img src="https://counter.theconversation.com/content/49365/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kate Moore receives funding from the NHMRC, the Bupa Research Foundation and the Australian Bladder Foundation.</span></em></p>Women with urinary incontinence are often too embarrassed to seek help from their doctor. But there is more likelihood of a cure for those who receive treatment at an earlier point.Kate Moore, Professor, Obstetrics and Gynaecology and Head of Department of Urogynaecology, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/209772013-12-09T14:39:25Z2013-12-09T14:39:25ZRegular pelvic floor exercises help a very common problem<figure><img src="https://images.theconversation.com/files/37148/original/s8rbkpjt-1386339721.jpg?ixlib=rb-1.1.0&rect=1%2C3%2C1022%2C680&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">And hold.</span> <span class="attribution"><span class="source">Relaxing Music</span></span></figcaption></figure><p>Women who have had children are often advised to do exercises to tighten their pelvic floor muscles. The <a href="http://www.nhs.uk/chq/Pages/1063.aspx?CategoryID=52&SubCategoryID=146#close">muscles run</a> from the pubic bone at the front of your body towards the back and help support your bladder and control when you urinate.</p>
<p>As you get older, these muscles can also weaken, and pelvic organ prolapse is a common disorder. This is when the bladder, womb or bowel moves downwards from its normal position because the muscles or ligaments aren’t supporting it as they should. It can lead to pain, discomfort and less enjoyment in life. Problems with the bladder – both difficulty passing urine or incontinence – the bowel and having sex can be embarrassing and debilitating. Prolapse and bladder problems often co-exist but they aren’t always related.</p>
<p>We don’t know the exact number of women with prolapse. This is because women don’t always come forward because they are embarrassed, but also because studies measure prolapse in different ways – some record symptoms, others actually measure how far your anatomy has dropped from its normal position but which may not always be accompanied by symptoms. </p>
<p>According to <a href="http://www.ncbi.nlm.nih.gov/pubmed/12066091">one large study</a> about 40% of women older than 50 had some degree of prolapse when examined. About 11% of women undergo surgery for urinary incontinence or prolapse in their lifetime, <a href="http://www.ncbi.nlm.nih.gov/pubmed/9083302">and 7%</a> for prolapse alone. In England, <a href="http://www.hscic.gov.uk/hes">about 29,000</a> prolapse repairs were done between 2010 and 2011, at a cost of around £60m.</p>
<p>All of this suggests that the problem is common – but there are things that can be done to help. Pelvic floor exercises have been recommended but evidence of their effectiveness has been limited. But a study we carried out with 447 women suggested that women reported fewer symptoms at six and 12 months if they had been involved in a personalised programme of pelvic floor muscle training than if they had been in the control group.</p>
<h2>Pelvic floor muscles exercises</h2>
<p>You can pull in your pelvic floor muscles by pretending to hold in your wee or stop yourself passing wind. Once located, the muscles can be trained by regularly doing a series of long and short holds. For example, you might squeeze these muscles slowly ten times in a row, then do ten fast squeezes.</p>
<p>The exercises can be built up over time, and in our study we aimed for women to achieve ten long muscle holds for ten seconds, and up to 50 fast contractions three times per day. It does take some time to start to see the effect, but after a couple of months they did start to feel a difference.</p>
<p>Consulting a professional, such as a pelvic floor physiotherapist, as well as giving you the correct exercises, can also help you understand more about the anatomy and function of pelvic floor muscles and the types of prolapse, and offer support. They will perform an internal assessment of the muscles to ensure correct exercise technique and provide an individualised exercise programme.</p>
<h2>Risky business</h2>
<p>There are a number of reasons why women develop a pelvic organ prolapse. The main one is childbirth, which is associated with a higher risk of prolapse in later life. The more children you deliver, the greater the risk. Other obstetric factors could also play a part. Caesarean sections, for example, might be protective compared to vaginal delivery, while the use of instruments such as forceps during the delivery may increase risk. </p>
<p>Women can also have a genetic predisposition to prolapse, and heavy lifting or a physically strenuous occupation can contribute.</p>
<p>Treatments for prolapse include surgery and conservative (non-surgical) management, which includes the pelvic floor exercises, lifestyle changes (such as weight loss), and vaginal pessaries (a support device worn inside the vagina to push the prolapse up to restore normal anatomy).</p>
<p>Choice of treatment depends on the severity of the prolapse and its symptoms, and the woman’s general health and preferences. Conservative treatment is generally considered for women with a mild degree of prolapse, those who wish to have more children, the frail or those unwilling to undergo surgery. These therapies are less expensive, carry lower risk and don’t stop you having further treatment such as surgery later on. It is also the main form of management used to help women with this condition. </p>
<p>While we reported better results for women who’d done exercises in a follow up after a year, we still don’t know whether in the longer term it prevents women from having to go on to surgical procedures. What we do know is how common prolapse is and what could help. It really is nothing to be embarrassed about. </p><img src="https://counter.theconversation.com/content/20977/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Suzanne Hagen receives funding from the Chief Scientist Office, Scottish Government Health Directorates.</span></em></p>Women who have had children are often advised to do exercises to tighten their pelvic floor muscles. The muscles run from the pubic bone at the front of your body towards the back and help support your…Suzanne Hagen, Programme Director in Nursing and Midwifery, Glasgow Caledonian UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/90972012-09-11T01:38:27Z2012-09-11T01:38:27ZExplainer: what is pelvic organ prolapse?<figure><img src="https://images.theconversation.com/files/15315/original/y34qg4vf-1347327330.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Little is known about pelvic organ prolapse because its symptoms are incredibly embarrassing for women.</span> <span class="attribution"><span class="source">Meghana Kulkarni</span></span></figcaption></figure><p>Millions of Australian women experience a pelvic organ prolapse, but they suffer in silence. This hidden epidemic is a well-kept secret and few people in the rest of the community know anything about the condition.</p>
<p>One in four Australian women have one or more symptoms of pelvic organ prolapse. The most common one is urinary incontinence. Half of all women over 50 who’ve had children will suffer urinary incontinence, mainly because of pelvic organ prolapse. Considering these statistics, three generations of women in a family may potentially be affected at any given time – the new mum, her mum and her grandmother.</p>
<h2>What is it?</h2>
<p>Pelvic organ prolapse is when the muscles and ligaments supporting a woman’s pelvic organs weaken and the organs (bladder, bowel and or uterus) in the area slip out of place (or prolapse) into the vagina. The major cause is vaginal birth, but ageing, heavy lifting, chronic constipation, chronic asthma and obesity exacerbate it. Giving birth by caesarean section doesn’t prevent pelvic organ prolapse or urinary incontinence because pregnancy itself is a major contributor.</p>
<p>Pelvic organ prolapse results from damage to the three support structures of the pelvic organs – the suspensory ligaments, pelvic floor muscles and fibromuscular tissue surrounding the vaginal walls. These support structures are injured by overstretching during pregnancy and tearing during the birthing process. </p>
<p>The nerves that enable the muscles to function can also be damaged in these processes. And using forceps during delivery, prolonged second-stage labour, large infant birth weight and episiotomy (cut to assist delivery) all contribute to the injury sustained during the birthing process as well.</p>
<p>The main symptoms of pelvic organ prolapse are urinary and bowel incontinence, sexual problems and an uncomfortable feeling of bulging in the vaginal area. These symptoms may be experienced during pregnancy, following childbirth or may only manifest many years later, particularly after menopause.</p>
<h2>A secret shame</h2>
<p>The reason so little is known about pelvic organ prolapse in the community is that these symptoms are incredibly embarrassing for women.</p>
<p>No one likes losing control of their bodily functions or discussing it with friends, let alone talking to the general public about it via the media. But the impact of incontinence on the quality of life and daily functioning can be severe. Indeed, it’s comparable to the effects of having a stroke or dementia.</p>
<p>Women suffer anxiety about not being able to get to a toilet when needed, or coughing or sneezing and wetting themselves in public. This can easily lead to social isolation as they retreat from everyday activities to the safety of their own home. (The advent of the smart phone has made life a little easier with “loo locator” applications.)</p>
<h2>Prevention and treatment</h2>
<p>Preventive measures include daily pelvic floor exercises and treatment can range from the use of a pessary (a device inserted into the vagina to support the uterus) to reconstructive surgical repair operations that provide support to vaginal walls, damaged pelvic floor muscles and over-stretched ligaments in more severe cases.</p>
<p>An Australian <a href="http://www.ncbi.nlm.nih.gov/pubmed/20966694">study showed</a> 19% of women in the general population have a lifetime risk of having surgery for pelvic organ prolapse or incontinence. Up to one third of these women will have subsequent operations because of failed surgery.</p>
<p>To improve outcomes, meshes similar to those used in hernia operations have been adapted for repairing damage leading to pelvic organ prolapse. These provide improved support for pelvic organs but they’ve introduced a new set of problems – infection, exposure of the mesh into the vaginal wall, bladder or bowel and shrinkage of the mesh causing pain and painful sex. And they can require another operation to correct. Some companies have recently withdrawn their product from the market because of these unacceptable complications.</p>
<p>Non-permanent biological collagen-containing materials have also been used for pelvic organ prolapse surgery, but these often fail due to their degradation by normal body processes and repeat surgery is required. And, while permanent or non-permanent meshes provide structural support to the pelvic organs, they don’t repair the support structures damaged during pregnancy and childbirth or block the ageing process.</p>
<h2>Steps in a promising direction</h2>
<p>My research group is currently working with urogynaecologists and scientists at CSIRO to develop a tissue-engineering approach to repair the vaginal wall tissues damaged by processes leading to pelvic organ prolapse. Our work focuses on using a woman’s own mesenchymal stem cells (a type of adult stem cell found in bone marrow, fat, and in the uterine lining, which is known as endometrium). Endometrium is a highly regenerative tissue that grows each month and is shed at menstruation.</p>
<p>Mesenchymal stem cells can produce connective tissues cells – fat, bone, cartilage, smooth muscle, and tendon – and have healing properties when transplanted into the human body. They promote blood vessel growth and tissue repair, reduce inflammation, prevent excessive fibrosis, and promote adult stem cells in the body to proliferate and produce new tissue. All these processes help repair injured tissues.</p>
<p>Combining endometrial mesenchymal stem cells with new mesh materials to treat pelvic organ prolapse has the potential to regenerate damaged pelvic tissues and provide a more durable solution for the condition. It’s currently being tested in pre-clinical animal models and is most likely about five years away from being generally available.</p>
<p>This condition should not be suffered in silence and the more awareness raised about this common, but invisible problem, the sooner there will be better solutions available for women. </p><img src="https://counter.theconversation.com/content/9097/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Caroline Gargett receives funding from the National Health and Medical Research Council, The CASS Foundation and Monash IVF Research & Education Foundation, and has previously received funding from Australian Stem Cell Centre, Royal Australian and New Zealand College of Obstetricians and Gynaecologists and a variety of philanthropic organisations.</span></em></p>Millions of Australian women experience a pelvic organ prolapse, but they suffer in silence. This hidden epidemic is a well-kept secret and few people in the rest of the community know anything about the…Caroline Gargett, Deputy Director of The Ritchie Centre and head of Women's Health Theme at Monash Institute of Medical Research, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/78692012-06-26T01:43:26Z2012-06-26T01:43:26ZUrinary incontinence: it doesn’t have to be a secret shame<figure><img src="https://images.theconversation.com/files/12167/original/73xc25nm-1340607551.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Most women are too embarrassed to talk about urinary incontinence – even to a doctor.</span> <span class="attribution"><span class="source">gogoloopie/Flickr</span></span></figcaption></figure><p>Urinary incontinence, or the uncontrolled leakage of urine, is a common problem among women: it affects almost one in two women at some time in their life. It’s understandably a condition most women are too embarrassed to talk about and, unfortunately, health professionals often assume that if a woman doesn’t raise the issue, then it’s not a problem. </p>
<p>As a consequence, urinary incontinence often goes untreated and substantially affects women’s well-being and quality of life. But it doesn’t have to be that way. Affected women should tell their doctor about their incontinence symptoms as a variety of treatments are available.</p>
<p>Urinary incontinence can occur in three different patterns. Stress-only incontinence is the uncontrolled loss of urine when coughing, sneezing, laughing, bending over or during exercise. The urge-only type is uncontrolled loss due to an overwhelming urge to pass urine so that the person cannot reach the toilet in time. And a woman who experiences both of these types of uncontrolled leakage of urine is said to have mixed urinary incontinence. </p>
<p>Different types of incontinence are more common in different age groups. The stress-only variety, for instance, is most common in women between the ages of 35 and 45. Risk factors include having had at least one child and also being obese. </p>
<p>The mixed pattern of urinary incontinence is generally seen in women aged 45 and over. Its risk factors are being either overweight or obese and having had a hysterectomy. Urge-only urinary incontinence is most common in elderly women and the main risk factor is simply ageing. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/12156/original/nyqdd4pm-1340603924.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/12156/original/nyqdd4pm-1340603924.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=430&fit=crop&dpr=1 600w, https://images.theconversation.com/files/12156/original/nyqdd4pm-1340603924.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=430&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/12156/original/nyqdd4pm-1340603924.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=430&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/12156/original/nyqdd4pm-1340603924.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=541&fit=crop&dpr=1 754w, https://images.theconversation.com/files/12156/original/nyqdd4pm-1340603924.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=541&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/12156/original/nyqdd4pm-1340603924.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=541&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Stress-only incontinence can occur when coughing, sneezing, laughing, bending over or during exercise.</span>
<span class="attribution"><span class="source">Mait Juriado/Flickr</span></span>
</figcaption>
</figure>
<p>Other specific causes of incontinence include infection of the urinary tract, stones in the bladder, some neurological conditions and certain medications. In most cases, it is not caused by any of these conditions, but related to pregnancy, obesity or ageing as described above.</p>
<p>Incontinence can have a marked impact on a woman’s life. Not infrequently, women have to make major adjustments to their everyday lives to accommodate their symptoms. They do this by planning their activities around access to a toilet, wearing incontinence pads or avoiding activities they know will result in urinary leakage.</p>
<p>There are treatments for incontinence so it’s important that women with persistent symptoms discuss them with their doctor. Tests are often done to eliminate the possibility of a specific cause.</p>
<p>These are likely to include:</p>
<ul>
<li>Urinalysis: this checks the pH (acidity or alkalinity) of your urine and whether there are any traces of glucose, protein or blood in it.<br></li>
<li>Urine micro and culture: this is to check if you have an infection of the urinary tract.<br></li>
<li>Your doctor may suggest a blood test to check your blood glucose level (to exclude diabetes) and your kidney function.<br></li>
</ul>
<p>Sometimes a bladder diary is helpful. This involves keeping a diary over a few days of every time you need to urinate and how often and how much you drink. It’s important not to restrict fluid intake to avoid having to pass urine, as that may cause dehydration.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/12157/original/ztrgxz6r-1340603968.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/12157/original/ztrgxz6r-1340603968.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/12157/original/ztrgxz6r-1340603968.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/12157/original/ztrgxz6r-1340603968.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/12157/original/ztrgxz6r-1340603968.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/12157/original/ztrgxz6r-1340603968.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/12157/original/ztrgxz6r-1340603968.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Urge-only incontinence is most common in elderly women and occurs simply from ageing.</span>
<span class="attribution"><span class="source">Borya/Flickr</span></span>
</figcaption>
</figure>
<p>Sometimes, more specialised tests are needed.</p>
<p>Treatment of urinary incontinence often involves doing pelvic floor exercises. Pelvic floor is the name for the muscles that hold the bladder, uterus and vagina and bowel in the correct positions. </p>
<p>Other measures include bladder retraining, often taught by a physiotherapist, weight loss (if needed), avoiding irritants such as drinks containing caffeine (they increase the urge to urinate), and measures to prevent urinary tract infections. </p>
<p>There are a variety of drug treatments available for the specific types of urinary incontinence, as well as a range of specialised surgical procedures, which can be performed, if needed, with good outcomes. In some women, a combination of pelvic floor exercises or bladder retraining and weight loss will be enough to significantly reduce incontinence.</p>
<p>Urinary incontinence can be socially embarrassing and prevent women from participating in a range of activities. Those experiencing symptoms should really seek help, so that their problem can be treated and not be a secret shame holding them back anymore. </p>
<p>Further information is available from the <a href="http://www.continence.org.au/">Continence Foundation</a> and the <a href="http://womenshealth.med.monash.edu.au">Monash Women’s Health Research Program</a>.</p><img src="https://counter.theconversation.com/content/7869/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Susan Davis receives funding from NHMRC Australia and the Bupa Health Foundation. She is also the recipient of research support from Biosante USA and in the last year has also received support from Bayer Schering. She is a consultant to Biosante USA, Trimel Pharm Canada, Bayer Schering and has been a consultant to Warner Chilcott..</span></em></p>Urinary incontinence, or the uncontrolled leakage of urine, is a common problem among women: it affects almost one in two women at some time in their life. It’s understandably a condition most women are…Susan Davis, Chair of Women's Health, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.