Nursing home patients, young moms, soldiers returning home from Afghanistan, middle-aged guys who have trouble peeing and prostate cancer survivors?

The answer of course is a medical condition that never kills unless one dies of embarrassment. It is incontinence – the equal opportunity affliction that affects millions of individuals and results in billions of dollars of expense every year, much of it unreimbursed by insurance.

There are countless reports on all aspects of incontinence – much of them a bit confusing but what is clear is that incontinence to a varying degree affects up to more than 10 percent of young women, 50 percent of middle aged women and up to 80 percent of elderly females and is the main reason for nursing home admission in many cases.

Incontinence, whether it be urge, stress or mixed is as much an esthetic problem as a medical condition though absolutely it is both. As we all know esthetic treatments are rarely reimbursed by insurance unless it is the result of trauma or a medical condition. Similarly much of incontinence management is self-pay.

The common pathway that often leads to incontinence is a weak pelvic floor. A variety of conditions that may overcome a once healthy pelvic floor include trauma, surgery, drugs, pregnancy (parity/vaginal delivery), malignancy, neurologic disorders and the usual list of suspects including medications, poor nutrition and fluid management, alcohol and smoking, obesity (high BMI) and poor fitness.

The bottom line, regardless of the stressors: Incontinence does not need to be a natural part of aging!

Restoring a healthy pelvic floor can reduce a wide variety of issues from incontinence (both urinary and fecal) to sexual dysfunction. Yet in spite of many treatment options it is a growing problem.

Let’s look at some important numbers as reported by NHANES (The 2005 – 2006 National Health and Nutrition Survey). The prevalence of pelvic floor dysfunction shows a dramatic rise over life span with a rate of almost 10 percent in the 20 – 39 age group growing to about 50 percent in middle age and 75 percent in the 80+ age group.

Population data shows an aging population, as the baby boomers progress in life. This assures that the rate of pelvic floor dysfunction will continue to grow with the aging population.

By 2040 the over 80-age group will have ballooned to over 16 percent of the population. By 2050 over 40 million women will be affected by pelvic floor dysfunction. If you add to this the complications of prostate surgery, the problems returning soldiers are having as well as adverse drug events related to the continuing problem of over prescribing drugs with urinary side effects one can see the numbers are impressive.

With a problem this big that affects quality of life so dramatically one would think that dramatic new therapies are developing around every corner. The truth be told up until recently most of the pelvic floor rehabilitation could be described as “same old same old”. Recently more drugs and surgery options are getting in the mix but these are higher risk treatments.

All treatment should start with the least invasive modalities available and should include lifestyle modification!

After incontinence products (pads - $2000/year) what have we had – who has not heard of Kegel exercises? This now ancient form of treatment involves a women squeezing her pelvic floor muscles for 10 - 15 minutes 3 times a day 7 days a week for essentially forever. Once the exercises are discontinued the incontinence issue likely will return. I was recently at a national meeting and asked a specialist who was all about Kegels what her data looked like after one year. She was hard pressed to answer since it is difficult to keep people doing these exercises for more than a year. The Kegel protocols have been souped up a bit by adding biofeedback to help women define the muscle groups that are the focus of Kegels.

Let it be said that Kegels can help if one is religious in their commitment to doing them. Vaginal cones, pessery products and bladder training are adjuncts to this non-invasive treatment approach.

Medications are a next step (keep in mind stopping a medication that could be troubling the urinary tract may be the most important thing you can do) If you insist on giving a drug be prepared for a poor response rate and plenty of side effects (constipation, diarrhea, hot flashes, agitation and shaky sensations among others). In many studies of drug efficacy it is not uncommon to see as many people stopping drugs because of side effects as benefit from them. Responses vary dramatically.

Drugs really should not be used in the elderly, the cardiac or hypertensive patient, patients with renal disease and women who are pregnant or breastfeeding.

Neuromodulation represents a next step up in the non- invasive treatments. There are a number of electrical stimulating devices on the market that all require various probes inserted into the pelvic area, implantable devices or peripheral nerve (posterior tibial) stimulation in the physician office and the administration of an electrical impulse that causes a muscle contraction. The patient must disrobe to accommodate placement of the electrodes. One of the problems with this treatment lies in the complexity of the neuromuscular make up of the pelvic floor. An external electrical stimulus produces a very ineffective muscle contraction usually with only a feeble 1 – 2 centimeters of penetration by the impulse. It’s not surprising that only modest responses are the norm.

EXMI (Extracorporeal Magnetic Innervation). The ability to induce muscle contractions is not limited to applying an electrical impulse through the skin or mucosa.

Nerve stimulation may be accomplished by way of passing a strong magnetic impulse through the pelvis stimulating pelvic nerves. This generates a normal neural impulse that travels via the neuromuscular junction into the pelvic floor muscles producing a contraction that matches exactly the patient’s natural muscular activity. This is critical because of the complexity and asymmetry of the pelvic muscles. The EXMI contractions reproduce the best potential contractions of a Kegel but much more frequent and effective than Kegels. EXMI does not release any electrical impulse into the body and the magnetic wave has no known side effects. The contraindications are as for a CAT scan (including pregnancy).

The patient sets fully clothed on the EXMI treatment chair for 22 minutes. A series of 6 to 29 treatments depending on the diagnosis and stage of the incontinence has resulted in a durable response of 30 to 100 percent lasting from months up to 2 – 3 years.

This treatment was FDA approved in 1998 in part because the research leading up to patent approval demonstrated dramatically greater muscle contractions than that produced by electrical stimulation.

EXMI has been in use around the world for over a decade. It is now being reintroduced into the United States in conjunction with Dr. Michael Jordan’s work in Munich Germany. A recent German study showed a 67 percent improvement in post prostatectomy incontinence patients who failed conventional pelvic floor rehabilitation and did not want more surgery.

This represents the spectrum of non-invasive incontinence therapies. Surgery remains a possibility in select cases but most patients should have the benefit of non-invasive therapy before surgery. If surgery is considered a much more complex workup should be undertaken to determine the suitability of surgery.

The guiding principles in managing incontinence include getting a good diagnosis, which can be made with a good patient history supported by a bladder diary and a simple relevant physical exam. A UA to rule out infection as an immediate cause is mandatory. If you are seeing young soldiers returning from rigorous tours be sure to enquire of them about incontinence. It is not something young guys like to talk about but it is relevant to their care.

The American Urologic Association and the Urology Care Foundation have many items on-line such as a bladder diary to support the workup of your patient.

John G. Langdon, M.D., FACP is the chief medical strategist for New Wave Biosciences, Inc. For over 40 years he has held leadership positions in clinical (Internal Medicine), academic and socioeconomic medical institutions. New Wave Biosciences is a medical device support team that partners with innovative developers of new medical technologies that have the potential to be major assets in healthcare and the practice of medicine. Dr. Langdon’s e-mail is jlangdon@newwavebio.com