Urinary incontinence

By , 21 August 2013

Urinary incontinence

 

 

What is urinary incontinence?

 

Urinary incontinence, or just “incontinence”, is the involuntary leakage of urine from the bladder.(1)  

This leakage may significantly impact a woman’s confidence in her personal, professional, and social life, and reduce her overall quality of life.  Unfortunately, incontinence is often portrayed as being a normal part of aging, and so many women suffer with symptoms without seeking expert help.  Fortunately, however, several treatment options exist and these are generally very effective. 

 

How common is incontinence?

As with prolapse, the precise proportion of women who experience incontinence is not known, because many women with symptoms do not seek medical attention.  However, incontinence probably affects up one in three women at some time in their lives, making it a very common condition.(2)

 

What causes incontinence?

As your kidneys produce urine, it passes through small tubes to the urinary bladder, where it is stored until you find a convenient time to empty your bladder.  The bladder has a muscular wall, which must relax in order to fill properly, and contracts to help drain the bladder.  The tube that drains the bladder to the outside (the urethra) also has a muscular part to help keep urine inside the bladder.  When your bladder fills to a certain level, you feel the need to pass urine; when you choose to pass urine the urethra relaxes, the bladder contracts, and the urine flows to the outside.(1)  In addition, the upper urethra is supported by tissues of the pelvic floor; normally, increased pressure (for example, from coughing, laughing or sneezing) compresses the urethra against the vaginal wall, assisting in preventing bladder leakage.

Incontinence may result when one or more of these mechanisms do not work properly.
 

Stress incontinence is leakage that occurs when increased pressure in the abdomen (“stress” from coughing, laughing, etc.) overwhelms the closure mechanisms of the urethra.  It occurs without the bladder contracting, and may be due to problems with the urethra itself or, more commonly, from pelvic floor weakness that causes the urethra to be more mobile and not compressed against the vaginal wall.  This pelvic floor weakness has similar causes to pelvic organ prolapse.  Stress incontinence is the most common cause of incontinence in younger women.
 

Urge incontinence is leakage of urine associated with a sudden need to pass urine.(3)  It is thought to be due to overactivity of the bladder wall muscle (“overactive bladder”).  It may be caused by irritation of the bladder by infection, nicotine (cigarette smoking), caffeine, or dietary factors (see bladder irritants).  In many cases, a specific cause may not be found.
 

Mixed incontinence is considered when women have symptoms of both stress and urge incontinence.
 

Overflow incontinence occurs when poor bladder emptying causes the bladder to become overfull and dribble almost continuously.4  It may be due to blockage of normal bladder draining (for example, due to severe prolapse), or incomplete emptying of the bladder (for example, due to medications).  It is uncommon.

 

What are the symptoms of incontinence?

Although suggestive, the types of symptoms a woman may have do not necessarily predict the type or cause of her incontinence.  However, common symptoms include:

  • Leakage of urine with coughing, sneezing, laughing, jogging, lifting, or sexual intercourse

  • The sudden urge to empty the bladder, sometimes with leakage on the way to the bathroom

  • Pain with urinating, or relieved after emptying the bladder

  • The need to wear pads or tissue in the underwear to catch urine

  • Symptoms of prolapse

  • Unfortunately, embarrassment and loss of self-esteem are also common symptoms

 

How is incontinence diagnosed?

If you have urinary incontinence, the type may be suggested by a history or questionnaire, and pelvic examination by your doctor.  A test for urine/bladder infection and, although cumbersome, a “bladder diary” (a log of symptoms, fluid intake and bladder emptying) are also useful.  In addition, specialised testing of the bladder and urethra, called urodynamics, is sometimes required to make a diagnosis.

 

Can incontinence be prevented?

Symptoms of incontinence may be reduced by:

  • Avoiding heavy lifting or straining

  • Reducing the total volume of fluid you drink, especially before bed

  • Reducing dietary intake of known bladder irritants

  • Ceasing cigarette smoking

  • Losing weight if you are overweight

  • Discuss your regular medications with your doctor, to determine if any could potentially be making your symptoms worse (there may be alternatives)

  • Pelvic floor exercises: these strengthen the muscles that help control urine flow, and are best taught by a qualified physiotherapist with special training in women’s pelvic floor rehabilitation

 

How is incontinence treated?

Treatment options depend on the type of incontinence you may have, and include specialised physiotherapy with bladder retraining, medications, electrical therapy, continence pessaries, or surgery. 
 

Pelvic floor rehabilitation exercises (also called “Kegel” exercises) may be recommended by your doctor.  These aim to strengthen the muscles of your pelvic floor and may improve symptoms of incontinence, and improve the degree of any associated prolapse.  Although instructive aids can easily be found on the internet or in pamphlets, many gynaecologists would suggest that best results are seen when these exercises are taught and monitored by a qualified physiotherapist with special training in women’s pelvic floor rehabilitation.  I have established professional relationships with, and can recommend, particular physiotherapists who excel in this area.
 

Bladder retraining is used to treat urge and mixed incontinence, and involves developing  good bladder habit by progressively increasing the time between trips to the toilet so that, ultimately, you determine when you go to the toilet – not your bladder.  Relaxation techniques help to treat the intervening urgency symptoms.5  Bladder retraining can be very successful, especially when undertaken with the expertise of a specially-trained physiotherapist or continence therapist.  Keeping a bladder diary is useful to assess progress.
 

Electrical therapy involves either the monitoring of electrical signals from your pelvic floor to help physiotherapists tailor your treatment, or the delivery of gentle electrical stimulation to improve pelvic floor function.(1)  This technique is generally supervised by specially-trained physiotherapists.
 

There are some medications available that can improve the symptoms of urge incontinence by “calming down” overactive bladder muscles.  Side effects of these medications may include a dry mouth and constipation, and these may be bothersome enough to limit their use.  Ideally, these medications can be used in conjunction with bladder retraining programs to assist in their success, with the aim of eventually weaning these medications whilst maintaining a good bladder habit.  In addition, the use of oestrogen replacement therapy, in the form of a cream applied inside the vagina, has been shown to improve symptoms of urinary incontinence (stress and urge) in women after menopause.  However, oestrogen replacement in the form of tablets appears to worsen symptoms of incontinence, and the improvement seen with oestrogen creams is less dramatic than the improvement seen with pelvic floor rehabilitation.(6)   
 

Vaginal pessaries are small devices that are inserted inside a woman’s vagina to support the walls, usually to reduce the symptoms of prolapse.  They come in different shapes and sizes, and a few are specially designed to treat stress incontinence.  These work by compressing the urethra against the back of the pubic bone, thereby increasing the resistance to flow in the urethra to prevent leakage.  Continence pessaries are useful alternatives for women who do not want surgery, or who may be unfit for surgery due to other medical conditions.  These are generally shaped like a large tampon, and require removal before sexual intercourse.(7)
 

Surgery is highly effective for treating stress incontinence, but usually ineffective for urge incontinence.  Surgery aims to limit the mobility of the urethra during episodes of increased abdominal pressure (such as coughing or laughing).  Several surgical techniques are available, including minimally-invasive, “day surgical” procedures, which involve inserting a small piece of mesh as a “sling” underneath the urethra.  These procedures are effective in up to 90% of women, even after 10 years since surgery.(8)  If indicated, I will discuss with you the most suitable surgical technique, depending on your particular condition and situation.
 

References

  1. RANZCOG. Urinary incontinence: a guide for women. 1st ed. Melbourne: Mi-tec Medical Publishing; 2005.
  2. Luber KM. The definition, prevalence, and risk factors for stress urinary incontinence.  Rev Urol.  2004; 6 Suppl 3:S3-9.
  3. Patient information: urinary incontinence (The Basics). In: Basow DS, (Ed). UpToDate. Waltham, MA, 2013.
  4. DuBeau CE. Clinical presentation and diagnosis of urinary incontinence. In: Basow DS, (Ed). UpToDate. Waltham, MA, 2013.
  5. DuBeau CE. Treatment of urinary incontinence. In: Basow DS, (Ed). UpToDate. Waltham, MA, 2013.
  6. Cody JD, Jacobs ML, Richardson K, Moehrer B, Hextall A. Oestrogen therapy for urinary incontinence in post-menopausal women.  Cochrane Database Syst Rev.  2012; 10:CD001405.
  7. Clemons JL. Vaginal pessary treatment of prolapse and incontinence. In: Basow DS, (Ed). UpToDate. Waltham, MA, 2013.
  8. Nilsson CG, Palva K, Rezapour M, Falconer C. Eleven years prospective follow-up of the tension-free vaginal tape procedure for treatment of stress urinary incontinence.  Int Urogynecol J Pelvic Floor Dysfunct.  2008; 19(8):1043-7.
     

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Urinary incontinence
 

About Dr David Moore

Urinary incontinence

David is a Fellow of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, and undertook his specialist training in Queensland.  He is highly skilled in the management of complex and high-risk pregnancies, and has special training in minimally-invasive surgery, endometriosis, pelvic floor and incontinence surgery.  David has completed a Master of Reproductive Medicine and is skilled in the assessment and management of fertility problems, and can offer the full range of assisted reproductive treatments.  He is a Senior Lecturer with The University of Queensland Medical School, and has published both medical journal and textbook contributions.

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