Elaine was a vivacious widow in her late 60s. Not a frequent vistor to the practice, she was blessed with reasonably good health, free of the chronic ailments which bring people to the doctor on a regular basis, writes Dr Muiris Houston.
Her passion was dancing, in particular the afternoon "tea" dances which she enjoyed attending with a group of friends. And I suspect if she wasn't so keen on her pastime, she might not have come to see me with this particular complaint.
Elaine was bothered by the recent onset of urinary incontinence which she said only occurred when she danced. The amount of urine which escaped was not large, but whenever she moved suddenly she felt a slight leak of water. It was destroying the enjoyment of her favourite pastime.
It is not often that patients feel able to mention urinary incontinence themselves.
People are generally reluctant to discuss intimate bodily functions, with research showing that less than half of people with the problem have approached a health professional about the condition. And many live with their symptoms for an average of six years before seeking help.
Almost half a million people over the age of 40 in the Republic experience bladder control problems - two in five women and one in four men. The most common symptoms - regardless of the exact cause - are getting up during the night to use the bathroom, having to hurry to reach the toilet on time or losing small amounts of urine when laughing, sneezing, exercising or lifting.
Research has also confirmed Elaine's experience: like her, 33 per cent of people said the complaint made them concerned about doing things away from home, while a quarter said incontinence affected their self-confidence and sometimes made them depressed.
To further explore my suspicion that Elaine had "stress" incontinence I asked her the following questions:
a) Do you leak urine when you cough, sneeze or laugh without having the feeling of wanting to pass urine?
b) Do you leak urine when you run, jump or move suddenly?
She answered yes to both, and also confirmed that the amount of urine which leaked was always small.
The use of the word "stress" in this type of urinary incontinence refers to the physicial stress applied to the bladder and the urethra (the tube which connects the bladder with the outside). It is caused by overstretching or laxity of the supporting structures of the urethra or bladder neck. The most common reason for urinary incontinence in women, it can be caused by pregnancy, a deficiency of the female hormone oestrogen, increasing age, being overweight or a combination of these factors.
Another common type of bladder control problem is "urge" incontinence, which gives rise to an overwhelming need to pass urine, making you rush to the bathroom. This symptom is called urgency, which may be accompanied by frequency - the need to go to the toilet very frequently even though the bladder is not full.
Urge incontinence is caused by a jumpiness or overactivity of the bladder muscle. It is most common in older people and it is worth noting that an enlarged prostate gland can cause this condition in men. It can also be precipitated in both sexes by diuretics (water tablets).
Treatment consists of medication and bladder retraining. Tablets calm the bladder muscle, which relaxes and allows a greater storage of urine. Bladder retraining is very effective. A form of behavioural therapy, it aims to alter the learned behaviour of running to the toilet, a behaviour that leads to a reduction in capacity as the bladder eventually shrinks over time.
BASICALLY, retraining aims to teach the patient to "hold on" for longer periods of time. The time between passing urine is gradually increased until an interval of four hours is gradually achieved. The initial aim of treatment will be guided by the pattern of a bladder diary the patient keeps. While it takes time and effort, retraining reduces incontinence in 75 per cent of patients.
But back to Elaine and the treatment of stress incontinence. As clinical examination did not show up any problem which might require surgery - such as prolapse of the womb or vagina - we agreed to try a conservative approach.
I referred her to a physiotherapist who taught Elaine a series of pelvic floor exercises, which tightened up the musculature around the front and back passages. And I prescribed a local oestrogen cream to help counteract some vaginal atrophy, a common problem in postmenopausal women, which can worsen stress incontinence.
Elaine worked hard at the exercises. When I saw her some months later, she was back dancing with confidence, free of the fear of urinary incontinence.
For further information contact the continence adviser in your local health board or Tirim, the Bladder Control Information Service on tel: 1850-476476.
E-mail Dr Muiris Houston, Medical Correspondent, at mhouston@irish-times.ie, or leave a message on 01-6707711, ext 8511. He regrets he cannot reply to individual medical problems