The latest in surgery for men and women sacral nerve stimulation and artificial urinary sphincters
Innovation does new always mean better?
Technology what does the future of physiotherapy look like?
The little things innovation for surviving bladder cancer
Prolapse after birth injury Should my child be out of nappies? Hidden disabilities Also in this edition
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Welcome to the winter 2025 edition of Bridge Magazine. We have been overwhelmed with the positive response to the return of the printed magazine. Many of our readers have already requested their print copies. Feedback has been that with a physical magazine in their hands, readers find it easier to start up conversations about their continence health with friends and family. This aligns well with this year's theme for World Continence Week, as we shine a spotlight on incontinence and raise awareness of this common condition. With the right support, incontinence can be treated, managed or even cured.
In this edition, we focus on technology and innovation in bladder, bowel and pelvic health. We get the latest from surgeons, physiotherapists and researchers, plus dive into how artificial intelligence (AI) might impact healthcare over the next few years. We talk to two women, Sharon and Julianne, who both experienced incontinence after a birth injury and they share their journeys through diagnosis and surgery. We also talk to Gerry, who overcame bladder cancer, to learn about his experience with incontinence during and after treatment.
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Print ISSN 1836-8107. Online ISSN 1836-8115. Published quarterly by Continence Health Australia (formerly Continence Foundation of Australia) and supported by the Australian Department of Health and Aged Care under the National Continence Program. Medical information: The information in the Bridge Magazine is for general guidance only andnone of the information provided is intended to replacethe advice of a professionalincluding thatof a doctor, continence nurse or continence physiotherapist. Copyright: The Bridge Magazine cannot be reprinted, copied or distributed unless permission is obtained from Continence Health Australia. Images: Unless otherwise indicated, the photographs used in the Bridge Magazine are those of models and bear no resemblance to the story unless specified. Advertising: Continence Health Australia appreciates the support of advertisers in publishing the Bridge Magazine.Advertising conforms to the standards required by Continence Health Australia, but endorsement is in no way implied by the publishing of said material.Continence Health Australia does not make any representations or give any warranties about the accuracy, reliability, completeness or suitability of any advertised products or services. Testimony: Any testimonial, opinion, review, recommendation or lived experience of a product or service published in the Bridge Magazine is not intended to represent the views of, or any guarantee or warranty by, Continence Health Australia, and all Individual results may vary. Liability: To the extent permissible by law, Continence Health Australia will not be liable for any expenses, losses, damages (including indirect or consequential damages) or costs which might be incurred as a result of any of the information contained in the Bridge Magazine being inaccurate or incomplete in any way and for any reason. References: For a list of references for any articles appearing in the Bridge Magazine, please emailmedia@continence.org.au. To become a member of Continence Health Australia: email membership@continence.org.au or Phone 03 8692 8400.
Always looking for the nearest toilet? Let’s shine a light on incontinence.
In many cases, incontinence can be treated, better managed or even cured.
For help and more information about incontinence, call the National Continence Helpline on 1800 33 00 66, for free, confidential advice from a Nurse Continence Specialist. Operates Monday-Friday, 8am-8pm.
Generative artificial intelligence (GenAI) has had a lot of press over the last few years. In this edition, we are discussing technology and innovation, so it is only right we touch on few of the ways you might see artifical intelligence (AI) interacting with your medical treatments in the coming decade.
Note-taking and paperwork. Some doctors and other health professionals are already using AI to help them keep a written record of their consults—saving time on typing notes and allowing them to give the patient their full attention during the appointment. It can also be used for admin tasks and to help organise patient records, picking up human error and alerting them to missing information. If your doctor uses AI to help take notes, they always have to manually check that it is written correctly. Audio recordings are not typically stored and are subject to the same data protection laws as your medical record.
Reading/diagnosing medical scans and results. Research is being done on using AI to read MRI scans, x-rays and ultrasounds, etc. The AI-powered programs can process a huge amount of data in seconds and the theory is that they could save doctors time analysing scans, allowing them to treat more patients and get important results back to them much quicker. Be assured, while AI might suggest a result from a scan or test, it is still the responsibility of the experienced doctor to confirm the diagnosis.
Medical research and drug development. AI can read millions of complex data sets very quickly which gives it the ability to spot patterns which are not always obvious to humans. Because of this it will be a huge asset to medical research. It could lead to earlier diagnosis of diseases, saving patients and healthcare systems money on costly treatments, and cut budgets needed to get new treatments and pharmaceutical drugs to market.
Sharon experienced a life-changing birth injury which resulted in her living with undiagnosed faecal incontinence for a decade. This is her story.
In 1996 Sharon had a very quick birth with her first child who was a large 5.2kg baby. This resulted in a fourth degree tear (the most severe childbirth tear, involving the anal canal and the muscles around the anus that control when you do a poo), severe blood loss, and a life-long problem with faecal incontinence (loss of bowel control). No one explained the implications of her birth injury to her, offered any treatment, or told her about the possible problems she might have in the future.
5% of women have a third or fourth degree tear during their first vaginal birth.
Australian Institute of Health and Welfare
Sharon's son was 18 months old the first time she lost control of her bowels. Over the next 8 years, she visited several different health professionals and was told she had IBS (irritable bowel syndrome). “I never felt wholly satisfied with the diagnosis of IBS, but went with it because that is what I was told,” Sharon explained.
“The incontinence made me very anxious, I was always planning ahead to see where toilets were. I would get no warning that I was about to have an accident.”
It wasn’t until her accidents became worse and more frequent that her husband went with her to the doctors to try and get answers. Luckily for Sharon, there was a locum doctor working who checked if she'd had a rectal exam. In the decade since childbirth, no one had thought to give her a physical exam. The doctor found she had no muscle on one side of her rectum due to her birth injury 10 years earlier and sent her to the specialist to confirm. Sharon had an anal sphincter repair surgery
in 2010 to help her incontinence symptoms. She was told the repair would probably last 7-10 years.
“The anal sphincter repair surgery worked well for a while, but then I was starting to have more frequent accidents at work and in the car and getting very distressed by it. The loss of bowel control was so severe it was starting to impact work, socialising, holidays. I was always having to lie to people around me to cover it up. At this point I hadn’t told my kids, friends or work colleagues.”
By 2018, Sharon had to take time off sick from work because her body didn’t give her enough warning to get to the toilet and she was having frequent faecal accidents at the office which she found very distressing.
“The faecal incontinence ruled my whole life—from where I sat in a restaurant to choosing a seat on the plane for a work trip—I was constantly checking toilets and could never relax,” Sharon told Bridge.
"I think there needs to be a lot more education for young women on pelvic health care, especially before and after birth,"
Sharon tells Bridge.
She was offered a surgery to install a sacral nerve stimulator (SNS) which she decided to trial as opposed to having a stoma (a small opening in your stomach that allows poo to come out directly from the bowel into a bag). “The battery in my SNS will last about 7-10 years before it needs to be replaced. Since my surgery Australia has approved a rechargeable SNS. The sensation of the SNS is similar to a tens machine, but you can’t really feel it. You have a controller to turn it up or down as needed. I wear a MedicAlert 'medical device fitted' bracelet."
Find out more about a sacral nerve stimulators (SNS) on page 12 >>>
!“After having the SNS fitted, I got my life back. Before the surgery the anxiety and despair got the better of me and I couldn’t use my common sense. Despite being a disability nurse and having been around people with incontinence for work, I didn’t feel that I could tell anyone what I was going through or talk to anyone about it," Sharon tells Bridge.
“Since having the SNS surgery I have been loads better at telling people about it. I was always worried about the reaction I would get from people if I told them, but actually I get a very good reaction from women especially."
“BECAUSE MY INCONTINENCE WAS CAUSED BY A FUNCTIONAL PROBLEM, THE SNS HAS PROVIDED EXCELLENT SYMPTOM RELIEF. I HAVE REGAINED CONTROL AND NOW HAVE A LOT MORE NOTICE FROM MY BODY THAT I NEED TO GET TO THE TOILET. I STILL WEAR A PAD BECAUSE I HAVE CONTINUOUS SMALL AMOUNTS OF FAECES LEAKAGE. I WOULD SAY
THE SNS
HAS CUT
MY ACCIDENTS BY ABOUT 60-70%.”
“I think people underestimate how mentally draining incontinence can be, from the minute you wake up to the minute you go to sleep. It impacts your work, social life, relationships. You have to always be prepared when you leave the house and have wipes, pads, spare clothes.”
“Incontinence can happen to anyone and it doesn’t fit what people think having a disability should look like.”
“I think it is hard for people who haven’t experienced it to know how truly debilitating it is. Because you walk around and look okay from the outside, people often give you a funny look if you come out of the disabled toilet after cleaning yourself up and changing your pad. It is one of the many invisible disabilities."
Four years ago, Sharon started a blog about her surgery journey which has now developed into an online support group for people to find out more about SNS surgery and living with faecal incontinence.
Search Sacral Nerve Stimulator - My Journey on Facebook to join Sharon’s online support group
If you always need to know where the nearest toilet is, plan your next trip using the National Public Toilet Map continence.org.au/national-public-toilet-map
“We
have identified over 920 disabilities that can not be easily identified..."
In Australia, 1 in 5 people have some form of disability and 80-85% of these people have a disability that is hidden. That’s roughly 17% of the people around you who may have a non-visible disability that may impact their lives. 'Hidden disability' is a term interchangeable with non-obvious, invisible or non-visible, it simply means that the disability may not be apparent to an observer as there is no obvious indicator.
"Many of these disabilities come with challenges inclusion for millions of Australians, including people someone may need support, more time, help, patience someone needs to be in close proximity to a bathroom
"Many of these disabilities come with challenges that, when met with barriers, prevent full access and inclusion for millions of Australians, including people with continence health conditions. The hidden disability sunflower was designed as a tool to signify that someone may need support, more time, help, patience or understanding because of their non-visible disability,” explains Justin Bruce, Director HD Sunflower Aus/NZ. "The aim is to shift the need to justify a disability by sharing private information, to start a conversation about the individual’s needs. We believe that if someone needs to be in close proximity to a bathroom or to access the nearest disabled toilet, they should be able to do so without explanation."
Living with a hidden disability can make daily life more demanding for many people, but it can be difficult for others to recognise, acknowledge or understand the challenges faced. Wearing the sunflower icon discreetly indicates to staff, colleagues and health professionals that the wearer (or support person with them) has a hidden disability and may need additional help or simply more time.
The hidden disability sunflower program has been in Australia for 5 years and you can buy your sunflower products online (hdsunflower.com/au), this may help you feel confident when using disabled bathrooms, asking where the nearest toilet is, or getting help at the airport with queuing.
Scan the QR code to find out more
"We don't often have one treatment that can address multiple medical conditions in both men and women—but SNS is one of them!"
Urinary or faecal incontinence does not have to rule your life. It can often be treated, better managed, or even cured. There are new and innovative treatments available, as well as the tried and tested methods. From lifestyle changes and physiotherapy, to medications, non-invasive treatments and surgery.
We talked to Dr Bernadette Brown, from Gold Coast Urogynaecology, who specialises in sacral nerve stimulation (SNS)—one of the treatments offered to patients to give them better control over their bladder and/or bowel.
Q: HOW DOES SACRAL NERVE STIMULATION (SNS) WORK?
A: While we do not know exactly HOW it does it, we know that sacral nerve stimulation improves the communication or signals travelling between the brain and the bladder (or brain and the bowel) through stimulation of the S3 nerve root.
Your specialist will usually suggest a test phase (called a basic evaluation or advanced trial, depending on the method used) before proceeding with a full implant. The leads are all placed under x-ray guidance in an operating theatre, and then tested to make sure
Sacral nerve stimulation (also called sacral neuromodulation) is like a pacemaker for your bladder or your bowels. It involves placing a small lead in the lower back along the bladder and bowel nerve (S3 nerve root) which then connects to a battery placed under the skin. The lead sends electric impulses along the nerve—just like a pacemaker sends electric impulses through your heart muscles.
Dr Bernadette Brown, Urogynaecologist
Sacral nerve stimulation can be used in male and female patients who present with:
• Overactive bladders (when you are constantly rushing to the toilet and experiencing bladder leakage before you get there).
• Underactive bladders (when bladders do not empty well enough on their own).
• Bowel symptoms such as bowel (faecal) urgency or accidental bowel leakage (faecal incontinence).
they are placed near the S3 nerve. If your symptoms improve by at least 50% over the trial period (1-2 weeks) then your specialist will discuss proceeding with the permanent implant.
Placing a sacral nerve stimulator is considered a minimally invasive procedure. The basic evaluation placement requires no skin incisions, whereas the full implant will have a small skin incision where the lead is placed, and a skin incision of approximately 7cm for placing the pulse generator.
Once the permanent implant has been inserted, you will usually be seen every few months to trial different programs or settings on the device, to ensure we find the optimal program for your bladder or bowel symptoms. Most of the modern devices have a lifespan of more than 10 years.
Patients often worry that the device and controller will be too complex for them to manage. I can reassure you that you have nothing to worry about here—if you can adjust the channels on your television or make phone calls on your smartphone, you will have no problems.
A: All treatments may have potential side effects so it is important to discuss all these treatments with your specialist to ascertain which will be most suitable for you. Your specialist may recommend further bladder testing procedures such as cystoscopy (a small camera used to look inside your bladder) or urodynamic studies (tests to look at how your bladder and urethra are working).
For overactive bladders, we follow a stepwise treatment approach that involves:
1. Lifestyle modifications such as reducing bladder irritants (caffeine, fizzy drinks and alcohol); as well as bladder training and urge deferral techniques (which aim to reduce urgency and increase time between trips to the toilet). These are undertaken with a pelvic health physiotherapist or a nurse continence specialist.
2. Medications to reduce bladder spasms (such as anticholinergics or B3 agonists). There are other types of nerve stimulator treatments available, such as transcutaneous- or percutaneous tibial nerve stimulation involving the ankle. Finally, we have the option of Botox injections into your bladder to relax it.
3. Sacral nerve stimulation is a highly effective third-line treatment option for overactive bladder symptoms, with more than 85% of patients proceeding with a full implant following the test phase.
Colorectal surgeons treat bowel urgency and accidental bowel leakage. It is important to diagnose the underlying cause of bowel symptoms. Interestingly, both diarrhoea and constipation can lead to bowel urgency and leakage. Your specialist will usually recommend a colonoscopy (a small camera to look in your bowel) if you have not recently had one.
Initial treatment of bowel symptoms will often include:
1. Stool bulking agents such as regular fibre supplements. They may also suggest a trial of loperamide or an anti-diarrhoea medication. Seeing a pelvic health physiotherapist to learn to coordinate pelvic floor muscles may be hugely beneficial.
2. Your specialist may recommend further bowel testing such as endo-anal ultrasound scan and anal manometry. These tests assess the muscle and nerve function of the anal sphincter (the “valve muscle” around the anus) and the lower rectum.
3. Sacral nerve stimulation is a remarkably effective third-line treatment option for bowel urgency and incontinence, with studies suggesting 85% of patients will experience more than 50% improvement in their symptoms following treatment. Up to 40% of patients are cured of bowel leakage.
Q: SINCE APPROVAL FOR USE IN 1994, HOW HAS THE SNS DEVICE CHANGED?
A: The first sacral nerve stimulator device used in Australia was the Medtronic InterStim Therapy. Initially, surgeons had to do an incision over the sacrum (tailbone) and dissect the tissues down to the level of the bone to insert the lead to the S3 foramen. The lead was stitched to the ligaments and fascia (or structures) around the sacrum using a permanent suture to prevent the lead from moving. The first significant advancement of the InterStim in 2003, was the development of a tined lead which is self-anchoring (no need for sutures). The InterStim II device was introduced in 2007 – making the pulse generator 50% smaller than the original InterStim. The InterStim II lasted 5-7 years. In 2021, Medtronic introduced a rechargeable battery to the Australian market. The InterStim X is a non-chargeable battery introduced in 2023, with a battery life of more than 10 years. Axonics joined the Australian SNS market in 2023, they also offer a rechargeable and recharge-free battery option.
The InterStim II device initially allowed MRI scanning of the head and neck only, meaning patients who needed MRI scans of their lower backs, for instance, had to have their SNS devices removed. Now both Axonics and Medtronic devices are fully MRI compatible (when switched to MRI mode), which has made this treatment even more appealing for a greater range of patients.
Q: HOW HAS THE SURGICAL PROCEDURE AND AFTER-CARE DEVELOPED AND CHANGED?
A: The surgical procedure has evolved from an open procedure with full general anesthetic to a minimally invasive procedure. With the modern-day minimally invasive method, some patients may be suitable to have a sedation anaesthetic instead. The minimally
“Urinary and faecal incontinence (bladder and bowel leakage) may be more common than you think, but they are not something you have to live with. If you have either of these symptoms and they are impacting your quality of life, do not wait any longer to talk to your doctor. Chances are there will be a treatment available to improve your symptoms.”
“More than 10% of our patients suffer with bowel symptoms on top of overactive or underactive bladders—so it is wonderful to be able to offer them one treatment that can potentially improve both these highly debilitating conditions.”
invasive technique allows placement of the device, often in less than an hour (but this will depend on your anatomy, previous back surgeries and other spinal conditions). Sacral nerve stimulation can now be done as a day case procedure, but this will depend on your specialist’s usual care.
Q: WHAT QUESTIONS SHOULD PATIENTS BE ASKING THEIR HEALTHCARE TEAM WHEN CONSIDERING SNS?
A: You should make sure that your specialist has discussed all treatment options with you, so that you can make an informed decision about your treatment. Overactive bladder and bowel urgency, as bothersome as they are, are conditions that affect your quality of life (rather than life-threatening conditions). Take your time to make the decision that is right for you.
Ask your specialist which device they will be using. Ask about follow up and how this will be conducted—sacral nerve stimulation is a long-term treatment. Ask what support will be available, both from a medical point of view as well as the device point of view. Ask about your specialist’s experience with sacral nerve stimulation and the outcome of their patients.
Q: HOW DO YOU SEE TREATMENTS FOR INCONTINENCE DEVELOPING OVER THE NEXT 50 YEARS?
A: The success of sacral nerve stimulation has paved the way for testing implantable stimulators on different nerves that supply the pelvic area, including the tibial nerve (nerve in the leg) and the pudendal nerve (nerve in the genitals and anus). These treatments are not yet available in Australia but may offer alternatives to sacral nerve stimulation. Initial studies are very promising.
There is interesting work being done on the bladder biome. Just like the 'gut biome', the bladder biome refers to the normal bacteria that usually live in the bladder (not causing infections). Early evidence suggests that a disruption in this biome may contribute to developing overactive bladder symptoms. Perhaps, in another few years, we will find the 'perfect' bladder biome and be able to replicate this to relieve overactive bladder symptoms.
Q: WHAT ADVICE CAN YOU GIVE PEOPLE WHEN GOING TO THE GP INITIALLY TO TALK ABOUT INCONTINENCE. WHAT SHOULD THEY EXPECT AND WHAT SHOULD THEY BE ASKING FOR?
A: Patients often feel embarrassed when they talk about bladder or bowel symptoms. The first piece of advice I would offer, is try not to be shy when you talk to your doctor. We understand it is a sensitive subject, but the more specific you are about your symptoms, the better we can help you find a solution. Ask for a longer appointment when you go to see your GP—with bladder and bowel conditions, a thorough history and examination takes time, as there are several factors that can contribute to your symptoms.
If your initial therapies or treatments have not had the desired improvement, ask for a second opinion. If your doctor refers you to a specialist, it is important to see the right person. A colorectal surgeon looks after bowel urgency and accidental faecal incontinence. Female patients with urinary incontinence can see a urogynaecologist or a gynaecologist with special interest in urogynaecology. Urologists see male and female patients with urinary incontinence.
Dr
Bernadette Brown
“For urinary and faecal incontinence (bladder and bowel leakage), I have seen time and time again, where pelvic floor physiotherapists have worked their magic and patients have not needed any further treatments.”
If you experience urinary or faecal incontinence get free, confidential advice from a nurse continence specialist. Call the National Continence Helpline 1800 33 00 66 Mon-Fri 8am-8pm AEST.
Gerry* was diagnosed with high-grade bladder cancer in 2022. He received an incorrect course of Intravesical immunotherapy (BCG), which treated the cancer but left him with severe urinary tract bleeding and urinary urge incontinence. This is his story.
NAME: Gerry
FAMILY: Adult children and an unconditionally-loving dog.
OCCUPATION: Healthcare worker.
CONDITION: Bladder cancer.
SYMPTOMS: Severe urinary urge, frequency and blood in urine.
TREATMENT: Intravesical immunotherapy (using BCG).
Trigger warning: suicidal thoughts
After my intravesical immunotherapy using BCG to treat my bladder cancer was administered incorrectly (two acute doses rather than one acute and one maintenance dose), I developed severe urinary tract bleeding and urinary urge incontinence. This meant I was experiencing a sudden and very intense need to wee and often there was only a few seconds between the sensation of needing the toilet and the release of urine. I struggled in my job as a healthcare worker because I was having to go to the toilet sometimes twice an hour. Most of the time I was urinating blood.
I had episodes of urinary urge incontinence (not being able to hold on until I got to the toilet) in the car, in the street and even in a public lift when we were on holidays. I tried wearing the continence aids (pads and pants), but found they were too bulky so you could see them under my clothes. An elderly man caught me urinating on a tree and he started screaming at me. I was worried that he would call the police.
I could not tell my employer that I had bladder cancer because I was worried that they would find a reason to terminate my employment. I could not tell my friends because it was embarrassing. There were times when I felt very alone and I wondered what would happen if I ended my life. My daughter showed me incredible kindness and understanding and helped me through the hard times. She isn’t a nurse, but her compassion has simply changed everything.
h ped me...
I came up with a solution that helped me. It was simple, but it worked. I kept a large plastic bag in the car to cover myself so that I could pull over in a side street and wee in the urine bottle I had hidden under the car seat. I would put the bag on my lap and pretend to be looking through my shopping to find something so I could wee in the bottle without anyone noticing. Innovation does not have to be high tech. Simply carrying a urine bottle and a very large plastic bag in your car can make all the difference.
*name changed for privacy.
Eventually, I resigned from my job as a healthcare worker and now work in an office. I have learned a lot over the last few years of experiencing bladder cancer and incontinence. The most important thing is to accept help. You never know what is out there until you have a look. Sometimes you get help from people you don’t expect. Go your own way. Ask questions, join online support groups like BEAT (beatbladdercanceraustralia. org.au). Be your own best friend and advocate. Remember that your medical professional is obligated to provide informed consent before any treatment. In other words, they are supposed to explain the risks, the benefits and the alternatives. Please, if you feel that you are not being provided with informed consent, ask for a second opinion. Work out what matters to you. Life is a gift. Don’t waste it on people who don’t care about you. Have a reason for getting up in the morning. I firmly believe that life has meaning and purpose when you serve other people. You are important and you do matter. Even when you feel ashamed and embarrassed you have a right to be here. Try to surround yourself with people who care about you.
According to Cancer Council NSW, Immunotherapy is treatment that uses the body’s own natural defences (immune system) to fight disease. Bacillus Calmette-Guérin (BCG) is a vaccine that was originally used to prevent tuberculosis. It can also stimulate a person’s immune system to stop or delay bladder cancer coming back or becoming invasive. It is put directly into the bladder through a catheter. Patients may be asked to change position every 15 minutes so the vaccine washes over the whole bladder. This is usually done as a day procedure in hospital, and each treatment session takes up to 2 hours.
Watch a video from Cancer Council NSW for more information on immunotherapy vimeo.com/220265929
As the bladder fills with wee (urine), it stretches to make room for more wee. When the bladder is about half full you feel the need to go to the toilet. A healthy bladder can hold up to 600mls of wee, so most people can hold on after this initial feeling until it’s convenient to go to the toilet.
People who experience urge incontinence can get a strong feeling to wee (urinate) even when the bladder isn't full. This can occur in both men and women and involves a strong urge to wee, often followed by loss of wee before reaching the toilet. If you experience urge incontinence you may also have the need to wee more frequently. Even if you don’t accidentally lose wee, urgency and frequency can interfere with everyday activities because of the need to keep going to the toilet.
Urge incontinence seems to become more common as we age. Symptoms may get worse at times of stress and can be exacerbated by fluids like tea, coffee, fizzy drinks or alcohol. Urge incontinence (leaking wee) may also occur as a result of constipation, an enlarged prostate gland or simply the result of a long history of poor bladder habits such as going to the toilet before the bladder is full, 'just in case'.
Urge incontinence can be linked to multiple health conditions, including stroke, Parkinson's, multiple sclerosis and other health conditions that interfere with the brain's ability to send messages to the bladder via the spinal cord. These conditions can affect a person's ability to hold and store wee. Pelvic floor (muscles that hold up your organs) dysfunction can also be a factor so your doctor may suggest an assessment with a pelvic floor physiotherapist.
If you or someone you care for are experiencing problems with urgently needing to go to the toilet, call the National Continence Helpline for a free and confidential chat with a continence nurse specialist.
1800 33 00 66 Mon-Fri 8am-8pm AEST
Just like your house and your car, your body needs the occasional check over.
BLADDER SYMPTOMS TO GET CHECKED
• Urgency to rush to the toilet. You can have urgency but no leakage, or have both urgency and leakage.
• Going to the toilet to wee more than 8 times a day.
• Waking more than once in the night to wee.
• Leaking wee when you cough, laugh, sneeze, run or jump. This is known as stress incontinence.
• Leaking wee (urine) without noticing or being able to feel it (insensible bladder leakage) with no stress or urgency.
• Feeling like you can’t get all your wee out when you are on the toilet (incomplete emptying of your bladder).
• Blood in your wee.
Download our Bladder Diary to take to your doctor
BOWEL SYMPTOMS TO GET CHECKED
• Constipation—di culty pooing. Often having hard, lumpy and infrequent bowel actions (less than 3 poos a week).
• Diarrhoea—frequent loose bowel motions (watery poos).
• More than 3 poos a day.
• Poo leakage.
• Constipation with diarrhoea (overflow incontinence), hard poo you can't push out with watery poo leakage.
• Urgency to do a poo or accidents (urgency to have a bowel action that may result in leakage).
• Blood or mucus in your poo.
Download our Bowel Diary to take to your doctor
If you notice any bladder or bowel changes book an appointment with your doctor for a health check. Alternatively you can call the National Continence Helpline 1800 33 00 66 for confidential advice from a nurse continence specialist (8am-8pm AEST Mon-Fri).
Professor Trevor Russell is a physiotherapist and director at the University of Queensland’s RECOVER Injury Research Centre. His area of research focuses on using technology to provide better healthcare to people in remote parts of Australia.
“Our research focuses on delivering healthcare to remote and regional places where people otherwise can’t access it," Professor Russell tells Bridge. "We help educate clinicians on what technology solutions they can add to their practice to increase the geographical distance they are able to support.”
Telehealth using videoconferencing software has been shown to be just as effective as in person appointments for some conditions, and makes physiotherapy more accessible to people in remote areas or people with mobility challenges. It has also been demonstrated that pelvic floor muscle strength can be increased to the same extent via telehealth when compared to in-person care. This leads to better bladder control and better quality of life.
ZOOM / TEAMS and specialised software like eHAB (neorehab.com) is often used for telehealth.
“Research shows that patients are more compliant with their at-home physio exercises after a telehealth appointment. We think this could be because they are taught how to do the exercises in their own home using equipment or props they already have, rather than in a physio gym using equipment they might not have access to at home, which creates a barrier to them doing the exercises.”
3 WAYS TECHNOLOGY IS CHANGING PHYSIOTHERAPY FOR PATIENTS
1. Telehealth via videoconferencing.
2. Mobile apps for accessing treatment plans, recording exercises you complete, and 'gamifying' exercises.
3. Sensors that can provide data to your physiotherapist on things such as muscle tone.
WHAT DOES THE FUTURE LOOK LIKE?
“I think in 10 years time we will see more selfmanagement with mobile apps. Artificial intelligence (AI) could also have a role in analysing the data from the apps and personalising your care."
ARE THERE ANY RISKS?
“Using technology to increase availability of services in remote areas removes the barrier of distance that could prevent patients receiving treatment. But there is a risk of adding other barriers in their place such as someone’s ability to understand and use technology (technology literacy), access to devices (such as smart phone or computer) and access to the internet.”
THERE ARE APPS SUCH AS EASY KEGEL (easykegel.com) which are discreet on your phone screen and remind you to do your pelvic floor exercises.
THE PHYSITRACK APP (physitrack.com/enau/features) is designed for physios to share your exercise program with you. It has written instructions for each exercise as well as instructional videos reminding you how to do it.
For information on accessing incontinence treatment while living remotely or experiencing mobility issues, please call the National Continence Helpline for free and confidential advice.
1800 33 00 66 Mon-Fri 8am-8pm AEST.
A day in the life of someone with a birth injury
Julianne ran athletics at state level, but after giving birth she couldn’t run, jump, cough, or even sneeze without experiencing leakage. She eventually went on to have surgery to repair the injuries she sustained during childbirth. This is her story.
NAME: Julianne
FAMILY: Husband in the military and two young children. I have an au pair who helps to look after my youngest while I am at work.
OCCUPATION: Former military, now senior program management role for a major consultancy firm.
CONDITION: Prolapse resulting from a birth injury.
SYMPTOMS: Constipation, diarrhoea, urinary leakage.
TREATMENT: Pelvic health physiotherapy, surgery.
Prior to childbirth, I would exercise most days, regularly running 5km with bursts of sprinting. I also worked out at the gym focusing on building strength and enjoyed landscaping my garden—often lifting bags of soil as needed. Prior to joining the Army, I was in the best fitness of my life—doing stair runs, sit-ups and push-ups to meet the basic entry standards.
During my pregnancy, I attended bi-weekly specialist pregnancy fitness classes with a pelvic health physiotherapist in Brisbane, which focused on our core and pelvic floor strength. Throughout my life, my mother had regularly described the prolapse issues she faced after delivering me and how it had impacted her. I shared these concerns with my obstetrician who dismissed them.
my bleeding. There were no details recorded in my
I was induced for the birth of my first child. I received an epidural after around 4 hours. After a relatively short first stage of labour (8 hours for a first-time mother), I was instructed to start pushing. I didn’t get much guidance from either the midwives or the doctor on pushing and breathing (something I learnt about from my very different second birth experience). After 45-minutes of pushing, my obstetrician declared that my daughter was stuck and in distress, and that they needed to use the vacuum to extract her. The doctor said they would need to perform an episiotomy (a cut to the perineum—the area between the vaginal opening and the anus—to allow them to insert the vacuum). Three pulls of the vacuum were used on me before my healthy daughter was born with an initial AGPAR (birth score out of 10) of 8, which increased to 9 at the five-minute interval. She certainly didn’t exhibit any signs of having been in distress. Following her delivery, I suffered a significant haemorrhage. The quantities were not recorded, but it was enough for me to go into a state of shock and required medication to help stop my bleeding. There were no details recorded in my post birth report—but I believe I had a third-degree tear from the vaccum (tear that involves a partial tear of the muscles around the anus that control when you do a poo), which was stitched in the birth suite. I struggled
to walk for around 24-30 hours following the birth and couldn’t sit comfortably for around 4 weeks.
Around 4 weeks after the birth, I felt significant ‘heaviness’ above my vagina and inside my pelvis which I reported to my obstetrician. She dismissed it as ‘still healing and recovering’ and didn’t conduct an internal assessment to determine if there were any issues. Again—I didn’t realise this should have been routinely performed until the birth of my second child. Currently, there is no Australian guideline requiring an internal assessment following a vaginal delivery—however ‘best practice’ recommends it. When I was 6-weeks post-partum I saw a pelvic health physiotherapist who cleared me for exercise, and suggested I continue my pelvic floor exercises.
When I eventually felt like I had recovered enough to go for a run, I leaked with every step I took. I tried stopping and starting again, but the leaking continued. The next time I went to the bathroom before I left, but I had the same result. I increased my pelvic floor exercises but it made no difference. I had also noticed if I sneezed or coughed I would leak. I didn’t really talk to anyone about it because I assumed it was normal, especially as I was still less than 12-months post-partum.
When my daughter was 2, we took her to a trampoline centre. With every bounce I took, I leaked. I spent more time in the bathroom than with my daughter that day. I eventually sat on the side watching her, and realised my problem was more severe than I wanted to live with.
I spoke to my GP and he referred me to a pelvic health physiotherapist. There, they gave me an internal assessment and informed me that I had a prolapse with 2 options—wear a pessary (supportive device inserted into the vagina) and/or more pelvic floor exercises. I opted for more exercises, but I knew they weren’t making a difference.
Fast forward another 2 years and we were being sent to the USA for my husband’s work. Whilst there, I gave birth to my second, and last, child. My birth was a breeze compared to my first, with no tears. My doctor gave me clear direction on how to correlate my pushes with my breathing, and I was in control of my epidural through a button—I could still feel my legs and walked from the birth suite to my room after delivery.
Pictured: Julianne and Family
“ON THE OUTSIDE I WAS A FIT, HEALTHY YOUNG WOMAN—BUT MY INSIDES WERE BETRAYING ME. I NEVER EXPECTED THAT GIVING BIRTH WOULD IMPACT MY ABILITY TO REGULARLY EXERCISE.”
‘rectocele’–terms I had never even heard before. Which meant I had a prolapse of the bladder into the vagina and prolapse of the rectum (or lower bowel) into the vagina. It was the first time I had been diagnosed with a rectocele and it made so much sense—it explained why I had constantly struggled with either diarrhoea or constipation. She referred me to a urogynaecologist who did a range of internal assessments as well as advanced 3D imaging. He was able to show me that my muscles had torn from the pelvis and were struggling to hold up my internal organs. I was shocked; partially because of the severity of the diagnosis but also that this hadn’t been detected or even examined before. Why hadn’t this been checked in Australia? Why didn’t the doctor check this before my second delivery?
His explanations were detailed, but also simple. I had 2 options, a pessary or surgery. If I didn't have surgery, I would likely have a complete prolapse within 10 years and my symptoms would increase. He explained that the surgery was still relatively new—he had pioneered it and had been performing it for several years—but
At my 6-week check up my doctor did a full internal exam and identified a ‘cystocele’ and CONTINUED
because of this there was no data to indicate long-term success. The process of repairing and restitching my muscles would be performed robotically and laparoscopically (through small incisions with cameras to guide the surgeon), the most minimally invasive. However, it was considered major surgery and initial recovery would require 6-8 weeks of rest and support, and full healing would take 6 to 9 months. We carefully reviewed the risks and benefits. I did as much research as possible—joining various forums of women that had undergone similar pelvic floor repair or removal of their uterus. Some of the posts were worrying. Some surgeries had failed. Others complained of extreme tightness at the vaginal entrance, making intimacy more challenging. All wrote how difficult the recovery was, it was certainly daunting. As the surgery date crept closer, I began to prepare myself as much as possible.
TheIt has now been 9 months since my surgery and I am just beginning to get back into exercise. So far I don’t experience any leakage when I run. I am probably being overly cautious, but want to give my body adequate time to heal internally.
Because prolapse and incontinence involve sharing such personal information, women haven’t discussed it in the past and medical professionals don’t seem to have a full awareness or regard for it. Until now, it has
There are many treatments for prolapse and incontinence, of which surgery is one. The technology has come a long way and is now able to be performed through small skin incisions with robotics which makes it less invasive with a shorter healing time.
Robotic-assisted uterosacral colpopexy: repositioning of the pelvic organs which have dropped down and are pressing on the vagina.
Perineorrhaphy: repair of damage to the area between the vagina and anus (perineum).
Urethropexy: repair for stress urinary incontinence (loss of wee with coughing, sneezing, exercise) where the urethra (wee tube) is elevated and given extra support with stitches to reposition it.
Laparoscopic paravaginal defect repair: repair of anterior (or front) vaginal wall used to treat cystoceles where the vagina and support tissues are stitched back to the usual positions.
Levator ani repair: repair of the levator ani, a group of muscles that make up the largest part of the pelvic floor. This surgery involves stitching it back in place in the pelvis.
Cystoscopy: often performed at the end of the surgery to check no damage to the bladder has occurred during the procedure.
essentially been a ‘silent’ issue. One of the most positive outcomes of the internet and low-cost connectivity around the world is the connection of women of all ages and nationalities in online forums. Being able to type and share our experiences provides some aspect of anonymity, and with that, less shame. It is allowing women from Europe, Australia, Asia and the Americas to connect, question and understand their births and birthing injuries. I strongly feel that women should be given information at the time of their birth, or upon discharge, of their right to make an official complaint. I hope that through advocacy and awareness, that others can better learn and prepare and hopefully avoid some of the issues I have faced.
"In sharing the intimate details of my experience I hope to provide other women with the courage and insight to question more and expect more from their medical treatment, especially before and after giving birth."
Professor Eric Chung works in the AndroUrology Centre for urinary, sexual and reproductive excellence and is Professor of Surgery at the University of Queensland (Brisbane) and the Macquarie University Hospital (Sydney). He has authored more than 200 peer-reviewed papers and book chapters.
Prof Eric Chung, Urologist and Professor of Surgery
We talk to urologist, Professor Eric Chung, about innovation and technology in continence health. He specialises in the artificial urinary sphincter which can help both men and women experiencing trouble controlling their urine (wee). It involves a surgical procedure to implant the device and can be life changing for people with severe bladder symptoms.
Q: WHAT IS AN ARTIFICIAL URINARY SPHINCTER (AUS) AND WHICH SYMPTOMS CAN IT TREAT?
A: An artificial urinary sphincter is a device that mimics the natural urinary sphincter (muscles in the body that control the flow of urine) to provide urinary continence. It is offered for those with moderate to severe urinary incontinence (more than 4-5 pads per day or greater
than 500 ml/24hr pad when weighed). It is considered the gold standard treatment for male stress urinary incontinence, radiation-induced incontinence, and those who have persistent or recurrent incontinence following male sling surgery (insertion of mesh-like surgical tape to reinforce your bladder where it joins the urethra which is the tube that allows urine to exit out of your penis). Although more common in men, these devices can also be used in women.
Q: HOW DOES AUS WORK?
A: When working well, your urinary natural sphincter is closed tight most of the time, and you relax it to urinate. The AUS works in the same way, the cuff part of the device is tight around your urethra until you want to go to the toilet, then you use a pump in your scrotum or labia to relax the cuff and let the wee out. It prevents leaks and accidents in your day-to-day life.
Q: WHAT ARE THE RISKS, BENEFITS AND ALTERNATIVES?
A: The benefit is that the patient will be dry and is able to resume and enjoy day-to-day activities without wearing a continence pad. Any surgery can have risks and these include cuff erosion or movement, recurrence of incontinence and damage to other surrounding structures (such as the urethra where your wee comes out). The male sling is effective for those with mild to moderate incontinence and those without radiation damage. Otherwise, the patient would have to consider continence pads, a penile clamp or an indwelling urinary catheter into the bladder.
Q: HOW HAS THE AUS CHANGED SINCE IT WAS INTRODUCED 50 YEARS AGO?
A: The device is more robust now with higher durability and mechanical reliability. Advances in scientific technology and surgical techniques have enhanced the clinical outcomes and patient satisfaction rates. The usual mechanical life span is around 7-10 years.
Q: HOW HAS THE SURGICAL PROCEDURE AND AFTER-CARE CHANGED?
A: We see streamlining of the surgery and enhanced postoperative care. The patient usually stays 1 night (instead of 2 nights) in the hospital, and the device can be activated ready to use after 4 weeks (previously
6 weeks postoperatively). There are new surgical techniques to deal with complex patients such as those with radiation-related incontinence, existing penile prosthesis implant, redo incontinent surgery cases, patients who need to perform self-catheterisation (regularly insert a catheter to empty their bladder), and females with stress urinary incontinence.
Q: WHAT QUESTIONS SHOULD PATIENTS ASK THEIR UROLOGISTS WHEN CONSIDERING AN AUS?
A: Patients should choose a urologist who has completed formal training in prosthetic urology and can handle complex reconstructive cases. It is important to find a urologist who is regarded as an expert surgeon in this field. Remember, the first operation is the most critical to ensure success and avoid complications.
Q: ARE THERE ANY INNOVATIONS AND NEW TREATMENTS BEING DEVELOPED IN UROLOGY?
A: Yes, there are other novel AUS-like devices in the market now, with research into the role of an electronic AUS device. As we learn more about male incontinence, we realise quality of life is important for these patients, and that wearing a pad is not the solution. Patients should be encouraged to seek an effective (and more permanent) solution and strive to be pad-free!
“The evidence now says you should aim to start toilet training between 18 months and 2.5 years for optimum results,” says Kerry. “For daytime toilet readiness the timing is down to the parents to make the call, but for toilet training at night children should take the lead when they are ready." Children may not be be dry overnight until they are 5-7 years old. Although some children may achieve nighttime bladder control earlier.
We spoke to Associate Professor Bernadette Richards from The University of Queensland Medical School about what new and innovative treatments in medicine really mean for patients.
“Patients often hear 'innovative' and think it means better. But that is not always the case," Assoc Prof Richards tells Bridge. "Depending on the risk involved in a new treatment, how invasive it is, and if it is reversible, the older tried-and-tested treatments are sometimes better for the individual.”
“Recently my research has been around consent for innovation in treatments. I want to empower patients to ask questions and unpack what they are being offered before making decisions.”
“With new treatments and innovations in medicine there might not always be a lot of information around the risks versus the benefits. Your doctor's experience with the new treatment may be limited, and they may only be learning the pros and cons with each patient. This is not a reason to avoid new treatments, but it is a reason to ask questions and health professionals have to be open and transparent and try to articulate the known and potential risks involved. Patients can consent to the unknown, but the reality of unknown risks and benefits must be made clear to them. The trust patients place in their doctors depends upon open communication. Whether a patient consents to innovative treatment will depend on the medical treatment being discussed and the patient's tolerance of risk.”
Associate Professor Ethics and Professionalism
QUESTIONS TO ASK YOUR HEALTHCARE PROVIDER ABOUT YOUR TREATMENT:
Is it better or just new?
What does it o er that older treatments don’t?
Have you done this procedure before?
What is your personal experience of results so far?
What do your know about the risks?
How many patients have already had it and were they in Australia?
Can it be reversed/removed if unsuccessful?
If part of a clinical trial, what continued care and access to the treatment will I receive after the end of the trial?
WHAT TO EXPECT WHEN YOU CALL THE HELPLINE
Your call will be answered by one of our nurse continence specialists who will listen to your story without judgement and offer confidential advice.
No question is too big or too small. The Nurse Continence Specialist is able to give you advice on how to improve and manage the continence problem, give details of local clinics, funding and product advice, including where to get product samples. The nurse can explain what to talk to your GP about and tests that may be needed. They can help you describe the problems you are having using medical terminology, which can be useful when explaining your symptoms to other health professionals.
Topics people call the helpline about include, but are not limited to:
1. Prevention and management of incontinence (loss of bladder and bowel control).
2. Women's health – bladder or bowel issues from pregnancy, childbirth, pelvic floor dysfunction, prolapse and/or menopause.
3. Men's health – prostate, pelvic floor, after dribble.
4. Children's health – toilet training, bedwetting, day wetting, soiling, constipation.
5. Bladder or bowel issues from medical conditions such as diabetes, dementia, and Parkinson's Disease.
6. Funding schemes including CAPS and NDIS.
7. Continence product advice.
Anyone! You can call the helpline if you are experiencing incontinence, are caring for someone living with incontinence, or you are a health professional calling for advice about a patient. Health professionals can also call and arrange for the helpline staff to contact one of their patients.
For free advice call the National Continence Helpline on 1800 33 00 66 (8am-8pm AEST) to speak to a nurse continence specialist.
SHARE YOUR STORY
If you have a story to share about your experience calling the helpline for advice on your bladder or bowel health, please get in touch. Readers value reading other people's lived experience.
Email Managing Editor, Sarah Tayler media@continence.org.au to share your journey.
Continence Health Australia, formerly known as the Continence Foundation of Australia, is the not-for-profit lead body for promoting bladder and bowel control health. Our aim is continence health for people of all ages in Australia. Listed below are some of the ways we can help you, whether you are experiencing incontinence, caring for someone who is, or a health professional.
NATIONAL CONTINENCE HELPLINE
Call for free, confidential advice from a nurse continence specialist. Average wait time less than 60 seconds. 1800 33 00 66 (Mon-Fri 8am-8pm AEST).
SERVICE DIRECTORY
Our website has information on all things incontinence including an interactive map where you can search for health providers across Australia. Visit: continence.org. au/get-help/continence-service-providers.
RESOURCES/ PATIENT HANDOUTS
Available from continence.org.au/get-help/resources, download and print at home or order a professionallyprinted copy for free.
EDUCATION COURSES
For health professionals, aged care workers and fitness professionals. continencelearning.com pelvicfloorfirst.org.au continencesupportnow.com
CONTINENCE CONSUMER NETWORK
The Continence Consumer Network is a group of over 100 people with lived experience of incontinence, carers or people with an interest in continence health. They share their experiences to make sure our work is person-centred and reflects the community's needs. Join the Continence Consumer Network: continence. org.au/partnering-people-experience-incontinenceand-their-carers.
MEMBERSHIP
Become a member of Continence Health Australia via our website.
EVENTS
We host events throughout the year for both people experiencing incontinence and continence education for health professionals.
BRIDGE MAGAZINE
Free quarterly magazine about bladder and bowel health, available in print and online.
VISIT OUR WEBSITE TO FIND OUT MORE CONTINENCE.ORG.AU
Speak with a Nurse Continence Specialist for free, confidential advice. Bladder and bowel control issues can be manageable and treatable.
1 in 4 Australians experience bladder or bowel leakage. Take the first step toward feeling more confident and in control. Call the National Continence Helpline: 1800 33 00 66
