Stress Incontinence & Travel Health

FJ Vol 20, No 22
Nov 17-30/06

My lola has been complaining of leaking ihi when she coughs, laughs, or sneezes. She is too embarrassed to see the doctor. Why is this happening, and what can she do?

Stress incontinence (the loss of urine due to an increase in pressure in the tummy) is more common in women. Weakness in the pelvis muscles (eg due to childbirth, abdominal obesity--overweight in the tummy) and thinning of the bladder and vaginal muscles and tissues from the decrease in estrogen after menopause are often contributing factors. Urge incontinence is leakage due to inability to delay peeing when an urge is felt. Causes include bladder wall hyperactivity and neurological disorders such as Parkinson’s Disease and stroke. Overflow incontinence involves leakage due to an over-distended bladder usually from blocked urine outlet (eg. enlarged prostate) or neurological causes (eg. multiple sclerosis, diabetes affecting the nerves). Functional incontinence is caused by the inability to get to a toilet such as due to physical constraints (eg restricted mobility), mental factors (eg. dementia, depression), and environmental barriers (eg. distance to toilet, positioning).

Her doctor should rule out problems like a urinary tract infection or a problem with the nerves controlling the bladder muscles. Some things she can do include: decreasing caffeine intake; addressing any bowel problems like constipation; limiting fluid intake—1.5-2 L/d is considered appropriate; losing weight; quitting smoking; watching high-impact physical activities; avoiding some types of medications (check with her doctor) like diuretics, some blood pressure and depression drugs, and alcohol; and improving mobility & accessibility to toilets. When secondary causes have been ruled out or treated, she can try pelvic floor muscle training (aka Kegels): do a minimum of 30-45 pelvic floor muscle contractions (goal of 10 seconds for each contraction); done in 2 or 3 sets; may take 6-8 weeks to see results. To contract the pelvic floor muscle, instruct her to pee, and while she’s peeing, she should squeeze her pelvic muscles to stop the flow of pee. Biofeedback and/or electrical stimulation therapy can teach her to isolate and control these muscles if she is not having any luck. If the problem is severe, her doc might refer her to a gynecologist/urologist who could confirm the diagnosis + possibly book her for surgery. Another option is wearing pads/ “Depends” to catch the leak. Depending on the cause, there are some medications her doctor can prescribe to help manage her symptoms. There are different treatments available for men who have difficulty with stress incontinence after having prostate surgery—check with their urologist.

My family is going to the Philippines for Christmas. What do we need to do ahead of time?

According to the Health Canada (http://www.hc-sc.gc.ca/iyh-vsv/life-vie/travel-voyage_e.html) and WRHA websites (http://www.wrha.mb.ca/community/travel/manual_countries.php), Canadians traveling internationally should contact their doctor or a travel clinic 6-8 weeks before traveling, regardless of where they are going, to have their risk assessed. Based on your current health, travel itinerary and previous immunization history, your doctor can determine what immunizations and/or preventive medication you may need, as well as advise you on how you can avoid disease risks.

By far the most common complaint while traveling is diarrhea. This is usually caused by the differences in water purity. Travelers may have diarrhea if they drink the local water or food prepared with local water in these countries.
You can also be at risk for a number of childhood illnesses (Diphtheria, Tetanus, Polio, Measles, Mumps, Rubella) when you travel, especially if you have not been immunized against them or haven’t kept your immunizations up to date. In countries where sanitary conditions are poor, immunizations may be recommended—there is a higher risk of hepatitis A (immunization recommended for all travelers) and typhoid in the Philippines. Depending on your travel activities and the local disease situation, you may need to be immunized against Meningitis, Japanese encephalitis (depending on degree of exposure), European tick-borne encephalitis, Hepatitis B (higher risk), Rabies (higher risk). Depending on where you are traveling, you may also be at risk of Malaria (caused by infected mosquito bites in many tropical countries; rural areas only, except no risk in Manila and province of Bohol, Catanduanes and Cebu), Yellow fever (caused by infected mosquito bites in Central Africa and South America; if traveling from an endemic zone and > 1 yr of age), Dengue fever (caused by infected mosquito bites in many tropical countries), Schistosomiasis (caused by a parasite in fresh water in the Carribean, South America, Africa, the Middle East and Southeast Asia). You are also at a higher risk of tuberculosis that is resistant to many drugs we use to treat it. As well, some sexually transmitted diseases, such as HIV/AIDS, are more common in some countries than they are in Canada.

You should also be safety conscious when traveling. Economic conditions in developing countries can cause increased crime rates and tourists are often targeted.
Some tips to help you enjoy safe travel:
_. Make sure all your regular vaccinations are up to date.
_. Before you travel, contact a travel clinic or your doctor six to eight weeks before you go, to allow time for any vaccinations you may need. This is especially true if you are going to tropical areas or developing countries.
_. Arrange for private health insurance while you are away, as your provincial/territorial health insurance may not cover you. Your travel agent can advise you on this.
_. If you are going to an area where malaria is present, it is important that you take anti-malarial medication as prescribed by your doctor.
_. Since anti-malarial medication does not guarantee absolute protection against the disease, preventing mosquito bites is very important. Use mosquito repellents when outside, especially between dusk and dawn. Sleep in well-screened or air conditioned accommodation or use a bed net. Wear trousers and long sleeves at dusk.
_. If you become ill in the first two months to a year after you return, see your doctor immediately and tell her/him that you have visited an area where malaria occurs.
_. To prevent diarrhea, the key principles to remember are: boil it, cook it, peel it or leave it! Always drink purified water or commercially bottled beverages, and pasteurized milk. Avoid ice, salads, re-heated foods, uncooked shellfish, fruit that is not peeled and food from street vendors.
_. Wash your hands often with soap or a sanitizing agent when travelling, especially before eating or drinking.
_. Should you experience diarrhea, be sure to drink plenty of liquids to prevent becoming dehydrated, especially in warm climates.
_. In warmer climates, always use a sunblock with a minimum SPF of 15.
_. To help prevent sexually transmitted diseases, always use a condom if you have sex with someone you meet while travelling.
_. Never share needles to inject intravenous drugs with anyone.
_. Swim in fresh water only if you know it is free of biharzia, the parasites that cause schistosomiasis.
_. Do not walk alone in remote areas, back streets or beaches, where you may be at risk of a personal attack or bag snatching. Valuables should be left at home or deposited in hotel safes. Travellers cheques, cash, passports and tickets should not be carried in bags that can be snatched. It is recommended that you use a body belt.
_. Do not ride in over-crowded vehicles or on motorcycles, especially at night outside of urban areas.
_. If you need medication for an existing medical condition, take enough with you to last during your travel. Make sure the containers are clearly marked and carry a copy of the doctor's prescription with you. Essential medication should be carried in two different pieces of luggage, in case one should get lost or stolen.
_. If your medication requires sterile syringes or needles, carry a doctor's explanation or medical certificate with you. In many countries where drug trafficking is a problem, a traveller found with syringes and without adequate explanation, could be in serious trouble with the police.

Ask Dr. Denise: Gout & STD screening

The Filipino Journal: October 20-November 5 2006 issue; Volume 20, Number 20 p 10
By Denise Koh, BSc (mcl), MD, CCFP

* My dad suffers from gout. What is it, and what can he do to treat it?

Gout is a disease in which uric acid (UA, the normal end product of the breakdown of purines) crystals deposit in body tissues. This causes recurrent attacks of severe joint pain and inflammation, deposits in soft tissues, kidney problems, and kidney stones. Many genetic and environmental factors affect the chain of events that regulate UA formation, transport, and disposal. Any problem in these processes can lead to too much UA in the blood and gout. Filipinos have a predisposition to gout. There is a higher blood level seen in Filipinos living in North America compared with Filipinos living in the Philippines. Filipinos have a limited ability to excrete/remove UA leading to a tendency to high blood UA levels manifested when a diet with a relatively high purine content, such as the usual North American diet, is eaten. Your dad can do several things to control his disease: lose weight, avoid foods high in purines, avoid alcohol (increases production and impairs removal of UA), avoid dehydration (drink lots of water!), and avoid diuretics (“water pills” often used for high blood pressure) if possible. High purine foods include visceral (organ) meats (liver, tripe), sardines, shellfish, turkey, salmon, trout, beans, peas, asparagus, and spinach.


* I have a new sexual partner and was told to get checked for STD’s, even though I feel fine. What is involved in an STD screen, and when should someone get checked?

A common misperception is that no symptoms, means no STI (sexually-transmitted infections). This is far from the truth, and is a huge reason for the continued spread of STIs. Get tested when: you have unprotected (no condom) sex, you have a new partner, you are worried about it, you are experiencing any symptoms such as discharge, pelvic pain/burning, lumps, bumps, sores, unusual vaginal bleeding, or fertility concerns. Many people choose to get tested regularly, such as every 6 months, or with their annual physical exam. A typical screen can include blood tests for HIV (anonymous and requires your consent), Hepatitis B, Syphilis, and Herpes Simplex (although some docs don’t check for herpes because it is so common, and can’t be cured). Gonorrhea and Chlamydia can be checked in two ways: 1) a pee test or 2) a swab. For women, this is a swab of the inside of the cervix (opening of the uterus) requiring the insertion of a speculum typically used in Pap tests. For men, this requires a swab of the urethra/inside the penis. If you are uncomfortable with the swab tests, you can get the pee test instead, keeping in mind that these tests are not as sensitive as the swabs. It’s way better to get tested than not—for treatment and relief from easily treatable infections, management with improved outcome of the non-curable ones, prevention of spread, and peace of mind. Tests for Genital Warts are more specialized and seldom performed (extremely common and difficult to treat), but often a doctor can recognize them on examination. Tests for vaginal infections (not necessarily sexually-transmitted) such as yeast, trichomonas, and bacterial vaginosis are usually reserved for women with symptoms.