If your pee starts to leak, even a little, it is NOT normal. Many women are unaware that this could be a potentially serious problem, but one that can be treated.
“If you ask your female friends whether a leaky bladder is normal, they’ll say yes. Women think that after childbirth, it’s normal to leak when they cough and sneeze. It is not!
“To be able to hold your urine when you cough and sneeze is not a privilege, it is normal. Sadly, women still don’t know where to seek help,” says consultant obstetrician and gynaecologist Dr Hoo Mei Lin.
Being Asian, we are also embarrassed about revealing this problem unless our doctor broaches the subject first.
Says Dr Hoo: “People normally don’t come and tell me until something is hanging between their legs or they’re having frequent toilet runs or when the problem is starting to impact their life. When that happens, the situation is already very serious.
“Unfortunately, many healthcare professionals also think leaking is a normal part of ageing and believe women should bear with a little bit of urine escaping – it is devastating!”
Incontinence usually stems from weak pelvic floor muscles. These muscles help support the pelvic organs, which comprise the bladder and bowel in men, and bladder, bowel and uterus in women. The weakening is most commonly caused by pregnancy.
Other factors include childbirth, surgery, obesity, menopause, ageing, excessive straining from constipation or chronic coughing. Often, women perceive symptoms such as incontinence, sexual dysfunction and stubborn belly fat to be separate problems, but in most cases, they are caused by weakened pelvic floor muscles.
Statistics from the Continence Foundation Malaysia show that urinary incontinence affects 200 million people worldwide, with one in four women over the age of 18 experiencing episodes of leaking urine involuntarily.
“Everybody thinks childbirth is the biggest culprit, but it’s not. It’s actually pregnancy. Every woman you talk to will have some form of incontinence during her pregnancy. From the time you’re pregnant, your pelvic floor is pressured. It’s like putting something heavy on a hammock – it will sag.
“The same goes for our stomach muscles. It’s like a balloon – when you first blow it up, everything is tight. Then when you let all the air out, it gets saggy. The same goes for the pelvic floor. If you don’t strengthen it (after pregnancy), it will never go back to what it was,” says Dr Hoo.
The exercise principle of “if you don’t use it, you lose it” also applies to the pelvic floor muscles.
She adds, “Your risk increases with childbirth, and a caesarean section will not save you from pelvic organ problems and incontinence. Not getting pregnant may save you, but then again, if you are not blessed with good genetic muscle make-up, you can still get it.”
Recognising the problem
Dr Hoo recalls a horrifying story about a healthy 80-year-old patient who came to consult her, complaining of something that was coming out between her legs.
“When I examined her, every-thing had fallen out. She had procedentia or a severe grade four prolapse of the uterus (where the cervix projects from the vaginal opening). She thought it was normal! Imagine having a baby’s head between your legs – that was how bad it was,” she recollects, still shocked at the encounter.
The patient had to be referred to a urogynaecologist for surgery. Urinary incontinence can happen at an earlier age, although it’s usually a progressive condition that tends to get worse around the time menopause occurs.
“Once you hit menopause, oestrogen levels drop, the skin starts sagging, muscles start getting weaker and that’s when things start to manifest itself. It’s a gradual process.
“The muscle tone down there is the same as muscle tone everywhere else, so if you’re not genetically blessed with good muscle tone, then it is unfortunate,” says Dr Hoo, who is also a fertility specialist.
She advises women to be aware and able to recognise that there is a problem and discuss it with their doctor, who can then teach them to strengthen their pelvic floor muscles by doing Kegel exercises.
She says, “Pelvic floor exercises are notoriously difficult to teach! I could spend half an hour with the patient and she still wouldn’t get it. One of the old ways of teaching it was to ask a woman to put two fingers inside her vagina and squeeze or kemut them.
“If you feel your fingers being squeezed, then it is being done correctly. But many Malaysian women don’t even know where their vagina is! So, for me to tell them to put their fingers inside it is an alien concept. They’re very shy.”
Once you know how to engage these muscles, the exercises become easy and can be performed anywhere, without anyone knowing. However, it’s also advisable to strengthen the abdominal and back muscles as well. Note that just having strong abdominal muscles doesn’t help the pelvic floor muscles.
Ideally, women should start doing pelvic floor exercises before they embark on pregnancy. One can get incontinence from the very first pregnancy, especially if you’re not blessed with good muscle tone or are obese. Not knowing what to do, these women resort to wearing pads.
Unless you have nerve issues, paralysis or spinal cord injuries, you should be able to hold your pee at all times.
“But we’re not telling you to hold your pee continually. The bladder can only hold so much liquid and if you hold too much for too long, there will come a point when the bladder cannot contract.
“These women will have overflow incontinence where they will go to the toilet very often and the pee comes out bit by bit because the bladder cannot empty all at once. This is not normal. They will also get frequent infections,” says Dr Hoo.
A chronic cough or a huge tumour sitting inside the pelvic area can cause a bit of prolapse and also manifest itself as incontinence.
“In these instances, you need to get rid of the problem or it will persist. “So, it’s important to identify what is causing the pelvic floor collapse.
“In fact, a chronic cough will impede your treatment because you’re putting constant pressure on those muscles, so the treatment will not work,” she points out, adding that lifting heavy weights can contribute to weakening pelvic floor muscles, but is not a risk factor for incontinence.
Devices to the rescue
To test the strength of your pelvic floor muscles, try stopping your pee when the stream is strong. Difficult? Then consider this option. With technology, many devices are available to help you identify and train the correct muscles.
Unlike doing crunches, which you can correct by looking into the mirror or having a personal trainer next to you, working internal muscles is difficult. Locally, there is a US Food and Drug Administration-approved pelvic trainer gadget that gives positive biofeedback and is easy to use with the right guidance.
“This gadget is inserted into the vagina and will vibrate if you’re using the right muscles, which are not the buttocks, thighs or abdominals. The squeeze should feel like lifting up and sucking in, not pushing out.
“When there is no vibration, there are two possible scenarios: you’re not activating the right muscle or the muscle is just too weak to trigger a vibration,” explains Teoh Huiyi, co-founder of Vibrance Pelvic Care Centre.
Our muscles forget how to activate after a long lay-off. Here, the training gadget assists you to get back on track in the privacy of your home without the need for a human coach. All it takes is three times a day, six minutes every time.
“As long as the patient has control over her muscles (this excludes stroke patients), she can do it. On average and depending on the severity of the problem, you’ll see improvements within three months,” says Teoh.
Dr Hoo feels that pelvic care is still in its infancy in Malaysia, even though it tremendously improves a woman’s health and sex life.
“Whether there is a cure depends on the grade of muscle collapse. The exercises may not be 100% effective, but it will help you avoid surgery. Remember that even after surgery, you need to work on the muscles.
“Before all these devices and exercises came about, we couldn’t really help women with minimal symptoms, even though it was bad enough that they had to wear pads. When your problem is not bad enough to have surgery, it’s so defeating to hear your doctor say, ‘Just come back when you’re bad’.
“No woman should live like that. Leaking is not going to kill you, but it reduces your quality of life. And within our lifetime, we’re going to see that it’s not how long you can live, but how long you can live well.
“Pelvic care and health may not be about staying alive, but they are part of living well,” she concludes.