Urinary incontinence

Urinary incontinence is defined as loss of bladder control. This results in the involuntary leakage of urine. This is an extremely common problem for women, but is often not diagnosed or treated as women are too embarrassed to discuss it with their doctor.

There are several types of incontinence but the commonest two types in women are:

Stress Incontinence

Stress incontinence occurs when any activity such as coughing, sneezing or laughing causes increased pressure on the bladder. It can also be severe enough to happen without any of the above triggers. It is the most common type of incontinence.

Stress incontinence is most commonly associated with pregnancy and childbirth, and advancing age, particularly in post menopausal women. It can be caused by weakness in the pelvic floor muscles, or by a prolapsing downwards of the neck of the bladder.

Women usually report that they leak urine involuntarily if they cough, sneeze or exercise while their bladder is in any way full. This can range in volume from a few drops to a large amount. There is no warning or element of urgency to urinate.

Treatment of Stress Incontinence

Approximately 70% of all stress incontinence can be greatly improved using pelvic floor exercises (PFE). These can be done by the patient themselves, as long as they are familiar with the muscles that need to be strengthened. A consultation with a physiotherapist experienced in this are can be very useful to help the patient identify the muscles to be targeted.

 

Pelvic Floor Exercises:

Pelvic floor exercises (PFE), also known as Kegel exercises help strengthen the muscles that support the bladder, uterus, and bowels. Strengthening these muscles greatly reduces the risk of urine leakage.

To do Kegel exercises, pretend you are trying to stop the flow of urine or trying not to pass wind. When you do this, you are contracting the muscles of the pelvic floor. While doing these exercises, try not to move your leg, buttock, or abdominal muscles. In fact, no one should be able to tell that you are doing Kegel exercises.

Kegel exercises should be done daily, five times a day. Each time you contract the muscles of the pelvic floor, hold for a slow count of five and then relax. Repeat this 10 times for one set of Kegels.

Ring pessaries:

These are plastic devices inserted by your doctor in to the top of the vagina. The ring pessary helps keep the neck of the bladder in place and can reduce the extent of stress incontinence. Ring pessaries are usually used in older women who have a prolapse of the bladder, and who prefer not to opt for surgery.

Surgery:

Surgery may be necessary in some cases when more conservative treatments have failed. The commonest procedure performed inn Ireland at present is the TVT procedure (Tension-free vaginal tape). This procedure is considered to be quite minor surgery, with a small incision done only through the vagina. A small ribbon-like strip is inserted as a sling to support the bladder neck. It is successful in reducing or curing stress incontinence in 95% of patients, and post-operative recovery is usually within a few days.

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Urge incontinence

Urge incontinence is defined as the involuntary loss of urine preceded by a sudden desire to pass urine. This type of incontinence is often referred to as overactive bladder or detrusor instability (detrusor is the name of the bladder muscle).

Urge incontinence is usually associated with a pattern of both daytime and nighttime urinary frequency and urgency.

This type of incontinence is the second most common type, after stress incontinence. It can occur at any age, but often starts in early adult life, and is more common in women than men.

The causes of urge incontinence are poorly understood. It happens when the muscle in the bladder becomes irritated and contracts more frequently than normal. In a normal healthy bladder, the bladder fills slowly with a constant trickle of urine from the kidneys. Only when the bladder is reasonably full does the bladder start to contract and the message reaches the brain that the bladder needs to be emptied. With urge incontinence the bladder muscle contracts too early before it actually needs to be emptied. This leads to an increase in frequency of urinating, and in the case of incontinence reduces your control over when you pass urine. Certain factors worsen this, such as caffeine in tea, coffee and cola drinks, and alcohol. Stress is also known to worsen it.

It is important to rule out infection when you initially attend your doctor, as a bladder infection can mimic the symptoms of urge incontinence.

Treatment of urge incontinence

General measures

  • Limit fluid intake to a maximum of 1000ml fluid per day.
  • Avoid caffeine-containing drinks
  • Avoid alcohol
  • Stop drinking fluids after 6pm
  • Losing weight if you are overweight will reduce the severity of your symptoms.

Bladder training (sometimes called 'bladder drill')

The aim is to slowly stretch the bladder so that it can hold larger and larger volumes of urine. In time, the bladder muscle should become less overactive and you should become more in control of your bladder. This means that more time can elapse between feeling the desire to pass urine and having to get to a toilet. Leaks of urine are then less likely.

You will need to keep a diary. On the diary make a note of the times you pass urine, and the amount (volume) that you pass each time. Also make a note of the times you leak urine (are incontinent).

When you first start the diary, go to the toilet as usual for 2-3 days at first. This is to get a baseline idea of how often you go to the toilet and how much urine you normally pass. If you have an overactive bladder you may be going to the toilet every hour or so, and only passing less than 100-200 ml each time. This will be recorded on the diary.

After the 2-3 days of finding your 'baseline', the aim is then to 'hold on' for as long as possible before you go to the toilet. This will seem difficult at first. For example, it you normally go to the toilet every hour, it may seem quite a struggle to last one hour and five minutes between toilet trips. When trying to hold on, try distracting yourself.

With time it should become easier as the bladder becomes used to holding larger amounts of urine. The idea is to gradually extend the time between toilet trips and to train your bladder to stretch more easily. It may take several weeks, but the aim is to pass urine only 5-6 times in 24 hours (about every 3-4 hours). Also, each time you pass urine you should pass much more than your baseline diary readings. (On average, people without an overactive bladder normally pass 250-350 ml each time they go to the toilet.) After several months you may find that you just get the normal feelings of needing the toilet which you can easily put off for a reasonable time until it is convenient to go.

Medication

If there is not enough improvement with bladder training alone, certain medicines in the class of drugs called antimuscarinics (also called anticholinergics) may help. They include: oxybutynin (Ditropan), tolterodine (Detrusitol), trospium chloride(Sanctura), propiverine (Detrunorm), and solifenacin (Vesitirim). They work by blocking certain nerve impulses to the bladder which 'relaxes' the bladder muscle and so increases the bladder capacity.

Medication may improve symptoms further in some cases, but it is uncommon for symptoms to go completely with medication alone. A common plan is to try a course of medication for a month or so. If it is helpful, you may be advised to continue for up to six months or so and then stop the medication to see how symptoms are without the medication. Symptoms may return after you finish a course of medication. However, if you combine a course of medication with bladder training, the long-term outlook may be better and symptoms may be less likely to return when you stop the medication. So, it is best if the medication is used in combination with the bladder training.

Side-effects are quite common with these medicines, but are often minor and tolerable. The most common is a dry mouth, and simply having frequent sips of water may counter this. Other common side-effects include dry eyes, constipation and blurred vision. However, the medicines have differences, and you may find that if one medicine causes troublesome side-effects, a switch to a different one may suit you better

Pelvic floor exercises

Many people have a mixture of urge incontinence and stress incontinence. Pelvic floor exercises are the main treatment for stress incontinence. It is not clear if pelvic floor exercises help if you just have urge incontinence without stress incontinence. However, pelvic floor exercises may help if you are doing bladder training.

Surgery

If the above treatments are not successful, surgery is sometimes suggested to treat urge incontinence.

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