As women age, their bodies experience changes that can significantly affect their quality of life. While some of these changes are well-recognized and openly discussed, feelings of secrecy and discomfort are associated with one of the biggest areas of change: urinary and pelvic health.
Elodi Dielubanza, MD, associate surgeon in the Division of Urology at Brigham and Women’s Hospital, is seeking to normalize disorders of the female urinary tract and pelvic floor. Her goal is to educate women on what to expect as they age and how milestones like childbirth can affect their urinary and pelvic health. She also wants to help patients restore their normal daily function through surgery, medications and, often, physical therapy (PT) and behavior modification.
Incontinence Causing Women to Withdraw From Life
According to Dr. Dielubanza, incontinence is one of the most common pelvic health problems among women in all age groups. Women who have been pregnant and given birth are at particularly high risk. Incontinence can cause women to withdraw from activities they once enjoyed and is associated with work absenteeism and decreases in job productivity. In elderly women, incontinence is considered a risk factor for nursing home admissions.
“Although incontinence can significantly impact a woman’s daily functioning and quality of life, historically, it has not received a lot of focus,” Dr. Dielubanza says. “Many women have the impression that pelvic health issues like incontinence are rare, and they find these issues embarrassing to discuss, leading to a paucity of open conversation and reticence to see a physician.”
Surgery Is Not the Only Option
Dr. Dielubanza, a surgeon, is quick to point out that surgery is just one of several options open to women with incontinence and frequently recommends managing symptoms with nonsurgical approaches, including pessaries, bladder support tampons and pelvic floor PT. She encourages patients to become empowered and choose the type of therapy that best fits their goals and lifestyle.
“Many women don’t understand what the pelvic floor is and how it functions,” she says. “They may not know the extent to which pelvic floor complaints like incontinence, pain or discomfort with intimacy can be addressed through specialized pelvic floor PT.”
At the Brigham, pelvic floor PT for incontinence focuses on helping women recognize the muscles, nerves and support structures that control the urinary tract and how to use their own functional and muscular control to improve symptoms.
In addition to PT, Dr. Dielubanza often prescribes behavior modification strategies to help women cope with incontinence. She starts by having patients take stock of their dietary and fluid intake as well as their medications, all of which can have an impact on urinary control and voiding habits.
“Several common medications used to treat high blood pressure have a diuretic effect, which increases urine production and can challenge the body’s storage capacity,” she says. “Some patients taking these medications still have high levels of fluid intake and therefore may not receive the intended diuretic effect. Or high fluid intake may compound the diuretic effect of medication, which can further complicate urinary control.”
According to Dr. Dielubanza, behavior modification strategies are especially helpful for older patients and those with comorbid conditions like diabetes, which can cause women to lose bladder sensation or awareness of optimal voiding times. Such behavior modification strategies include timed voiding, cuing for patients with memory loss and working on toileting practices in memory care settings.
When Surgery Is the Best Choice
Dr. Dielubanza and her Brigham colleagues offer a range of surgical interventions for incontinence. For patients with stress incontinence, the aim of surgery is to provide support for the urethra and bladder neck, so the bladder doesn’t leak upon increased abdominal pressure.
One surgical option for stress incontinence involves injection of urethral bulking agents into the sub-urethral tissue to provide support through coaptation of the urethra walls. The surgery, which uses a cystoscope, can be done under local anesthesia or sedation with no incisions needed. Another option is sling surgery using either synthetic mesh grafts or autologous grafts of the patient’s own tissue.
For urgency incontinence, the Brigham offers minimally invasive Botox® injections as well as office-based tibial nerve stimulation that optimizes bladder storage by targeting nerve fibers that send messages to the bladder. The nerve stimulation—covered by most insurance as a third-line therapy for overactive bladder—is conducted over 10–12 sessions and has been shown to provide months of symptom improvement.
The Brigham also offers an implantable nerve stimulation device, which works like a pacemaker for the bladder, regulating abnormal bladder signals that lead to poor bladder control. Placed near the tailbone, it provides steady, non-painful electrical stimulus to assist with nerve signaling. The device is also used for control of fecal incontinence and for women who have trouble emptying their bladder.
A Resource for Non-Urology Colleagues
Dr. Dielubanza, who also treats pelvic floor conditions such as pelvic organ prolapse, acts as a resource to colleagues throughout the Brigham, educating primary physicians on female pelvic health options. In addition to her close work with the Brigham’s pelvic floor PT colleagues, she collaborates with colleagues in pain management, gynecology and gastrointestinal medicine.
“There’s a lot of overlap in female pelvic health. It’s important for everyone to understand that the pelvis is more than a home for reproduction,” she says. “One of our greatest strengths at the Brigham is that we’re organized into interdisciplinary teams, where individual team members think about similar or connected problems in different ways. We are accustomed to coming together as a team to care for patients and offer them options that fit their health status and their goals.”