Ambika*, a young teacher, dreaded returning to her job after maternity leave. Her inability to stop the continuous dribble of urine she was experiencing worried her. She had not been too concerned when she first became aware of the constant trickle, thinking it would go away after some time. Her mother too assured her that it was a common occurrence for women after deliveries, and that it would get better. But almost three months later, the problem persisted, and it perturbed her. Priya, another patient, experienced intense pain while passing urine, and she needed to urinate frequently. This was later diagnosed as a bladder stone; imagine the surprise of the surgeon who found a T-shaped stone - a migrated copper T that had perforated the bladder and caused havoc in the bag designed by nature to hold only watery waste matter.
Such diagnostic difficulties arise because women's gynaecological and urological organs share a close relationship anatomically and physiologically. Any disorder affecting one may give rise to symptoms in the other, complicating the diagnosis. The pelvic floor (the lower area of the pelvic region) of women is made up of tissues, muscles and bones that keep the urinary and reproductive organs in place. Pregnancy and childbirth stretch these to the maximum, and improper care during this crucial period results in loosening of the natural support, leading to prolapse of the organs fitted just above. Uncontrolled loss of urine or faeces, sexual dysfunction, descent of uterus, and protrusion of the bladder and rectum, are some of the manifestations of urogynaecological ailments.
Professor N Rajamaheshwari, Head of the Department of Urogynaecology in Kasturba Gandhi Hospital, Chennai, the only hospital in India to have an exclusive centre devoted to urogynaecological ailments, says, "Urinary problems among women are common in our society, even though they are not openly discussed. So far, a comprehensive study to ascertain the exact prevalence of such conditions in India has not been conducted. Conservative estimates suggest that almost half the women over the age of 35 in our country are plagued by urogynaecological problems arising due to childbirth injury, gynaecological factors or ageing. This indicates that while almost 30 million women in our country seek treatment for such problems, at least 180 million women could be suffering silently," she says.
In 1997, the Kasturba Gandhi Hospital carried out an observational study of 1,062 women in the age group of 20 to 70 attending various outpatient departments of the hospital. The study found that almost 80 per cent of them had some kind of urinary complaint. Prolapse or sliding down of the uterus, bladder, rectum and vault are common urogynaecological disorders, though incontinence is by far the most widespread urinary disturbance encountered by women, Rajamaheshwari explains.
Latha found herself laughing less because she found that every time she laughed or coughed she had a leakage, and this terrified her. "My social life suffered as a result." She also had to contend with the constant odour and dampness. Keerthi, on the other hand, always empties her bladder before going out and makes it a point to locate a toilet at every place she visits so that she can make a dash when she feels the urge. Both have different types of incontinence; Latha has stress incontinence, while Keerthi suffers from urge incontinence.
Incontinence may arise due to many reasons, says Rajamaheshwari, "Stress incontinence, overactive bladder, fistula, chronic retention, neurological dysfunctions, constipation, urinary tract infection, even anxiety could be the root cause of this embarrassing problem. It is necessary to diagnose the underlying problem and give appropriate treatment." Many of these conditions can be easily rectified with medications and exercise, though some may require surgical intervention. Stress incontinence is the involuntary leakage of urine while lifting weights, laughing, coughing or sneezing. In the Kasturba Gandhi Hospital study, almost 58 per cent of women were found to suffer from stress incontinence. The sliding down of the bladder and urethra or a defect in the sphincter mechanism of the urethra are the most likely causes, though it can also occur due to an overactive bladder. Overactive bladders result from obstruction to the urinary outflow tract or from a missing link in the brain-bladder communications. These are treatable conditions, confirms Rajamaheshwari.
Fistula, another urogynaecological ailment, is caused by an abnormal connection between the bladder and vagina, or between the vagina and rectum. This gives rise to continuous urinary/faecal leakage. Obstructed, prolonged labour, forceps delivery, surgery, crude abortion practices, radiation injury, infection or foreign bodies are some of the causative factors for the development of fistula. This anomalous passage can arise at any age as a consequence of childbirth complications or pelvic surgeries.
Greater awareness and quality of medical care has brought the number of delivery-related fistula cases down. Rajamaheshwari cites statistics compiled by her in two five-year segments during the course of her practice, "In the period from 1993-98, 76 per cent of fistula cases could be traced to childbirth, while it dropped to 55 per cent in the period 2000-05." According to her, even though the numbers fell from earlier years, the fact that it is occurring at all in such high numbers during normal delivery is quite disturbing. A further cause for concern is that the majority of women suffering from fistula are young; almost 69 per cent of patients seen by her are less than 30 years of age.
Better care and knowledge can decrease the incidence of such problems to a great extent, feels Rajamaheshwari. Women must also get into the habit of doing pelvic floor exercises right from their teenage years to keep the pelvic muscles strong. "Women do not have to endure and suffer in misery; they need to realise the availability of specialised treatments for these embarrassing problems." (Women's Feature Service)
