What and Why?
For those affected by it, inability to hold water or stop anal seepage reliably is one of the most distressing features of ageing. It affects about one woman in every five and by no means all of them are elderly. Far fewer men are bothered with this until old age — they tend instead to have the opposite problem.
The reasons for this are basically mechanical. Men and women both have a cage of bone between their hips which supports the contents of their pelvis and lower abdomen quite effectively, but it is incomplete right underneath, exactly where it matters most. Both sexes need a hole about 5cm across to allow their bowels to empty (see Constipation). In women it is twice that size, large enough for a baby to be born through. Ten centimetres is a long way to bridge with muscle alone without it sagging, which is how the trouble starts.
The muscles concerned form the vagina, which slants upwards and backwards and is slung like a hammock between attachments on the bony cage. The bladder sits directly on top of this hammock. It is shaped like a filter funnel running down into the urinary pipe or urethra, and depends on a loop of muscle around its neck to shut off the flow of urine when you want to hold it. If your vagina sags the funnel neck sags with it and the muscle loop is stretched out of shape. To begin with it just works more slowly, but later in life it may become too stretched and feeble to work at all. By that time your bladder may swell down into your vagina and pout enough for you to feel it — one form of prolapse.
The gradual progress of this weakening usually starts with giving birth to one or more children, after which you may not for various reasons have succeeded in re-toning the muscles completely. In your thirties and forties you may only notice, very occasionally at first, that you accidentally let out a little urine by coughing, sneezing or laughing — and only then if your bladder is full to start with. However, unless you act on this early sign of trouble, matters get gradually worse. Leakages are provoked more and more easily until they become an unacceptable limitation on your every-day life and you are forced to overcome your embarrassment and discuss it with your doctor. By then he may feel that the best option is surgery to shorten the muscle sling and repair any prolapse — a fairly major operation without any definite guarantee of success.
There is unfortunately little incentive to overcome your embarrassment before you reach this extreme stage, because your doctor’s advice may well be to wait until it does! Few doctors are aware how much function you can regain by patient practice, partly because the results are disappointing unless you are prepared to work hard. Drugs have very little to offer because the feeble muscles cannot respond to them any more than to your commands, and drugs tend also to make emptying your bladder more difficult. So most women hang on hopefully, dreading further decline but not knowing what they can usefully do about it.
What can I do?
Advice to maintain and maximise health
1. Exercises: At the very first indication of trouble, start practising. You need to learn the trick of stopping your urine in mid-stream. You do not have to do this only while urinating but can make a habit of it at any time — waiting for a bus, washing up, standing in check-out queues. Tighten and relax the muscles of your vagina and anus repeatedly until you feel the response getting stronger and brisker.
2. Every morning during your bathroom routine take a cold Sitz bath. This consist of sitting in four inches of cold water for about thirty seconds, or long enough to get through the initial shock to the creeping, tingling sensation that could be hot or cold. This tones up the circulation, nerves and muscles around your vagina and makes the exercise (item 1) easier. The effects are cumulative, so keep it up day after day.
3. During pregnancy learn to relax your pelvic muscles well to let the baby’s head through easily. Paradoxically this helps you restore their tone afterwards because they bruise and tear less during birth. Resume your Sitz baths as soon after birth as you can and take seriously the postnatal exercises taught you by your midwife or physiotherapist.
4. Physiotherapy: If you have difficulty doing all this on your own, the best person to ask for help is a physiotherapist. She can not only train you expertly but also help you with gentle electrical stimulation to the unresponsive muscles. Once they have strengthened a little you should be able to progress on your own.
5. If you have a hysterectomy for any reason your vagina may start to sag a few years afterwards, so take these measures seriously right from the start - do not wait for signs of failure or weakening.
6. Surgery: If things are already seriously out of hand you may need an operation anyway. That will remove the accumulated effects of the weakness but it will be up to you to prevent it from happening again. There is no escaping those exercises, I’m afraid!
7. After your menopause the tissues of your vagina may get thinner and be less well maintained by your circulation. This is one case in which oestrogen or progesterone cream, applied into your vagina about once a month, may be a safe and acceptable form of medical treatment which will help you to prevent leakages from developing. You should ask your doctor about this if you think it may apply to you.