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Incontinence

Millions of women experience involuntary loss of urine called
Urinary tract (039.gif)urinary incontinence (UI). Some women may only lose a few
drops of urine while running or coughing whilst others may
feel a strong, sudden urge just before losing a large amount of urine.
Many women experience both symptoms. UI symptoms can vary from being slightly bothersome to totally debilitating. For some women, the risk of public embarrassment keeps them from enjoying many activities with their family and friends. Urine loss can also occur during sexual activity and cause tremendous emotional distress.

Older women experience UI more often than younger women. Your doctor or nurse can help you find a solution. No single treatment works for everyone, but many women can find improvement without surgery.

Incontinence occurs because of problems with muscles and nerves that help to hold or release urine. The body stores urine—water and wastes removed by the kidneys—in the bladder, a balloon-like organ. The bladder connects to the urethra, the tube through
which urine leaves the body.

Bladder (040.gif)

During urination muscles in the wall of the bladder contract, forcing urine out of the bladder and into the urethra. At the same time, sphincter muscles surrounding the urethra relax, letting urine pass out of the body. Incontinence will occur if your bladder muscles suddenly contract or the sphincter muscles are not strong enough to hold back urine. Urine may escape with less pressure than usual if the muscles are damaged, causing a change in the position of the bladder. Obesity, which is associated with increased abdominal pressure, can worsen incontinence. Fortunately, weight loss can reduce its severity.

The Types of Urinary Incontinence

Stress

 

Leakage of small amounts of urine during physical movement (coughing, sneezing, exercising).

Urge

 

Leakage of large amounts of urine at unexpected times, including during sleep.

Overactive Bladder

 

Urinary frequency and urgency, with or without urge incontinence.

Mixed

 

Usually the occurrence of stress and urge incontinence together.

Stress Incontinence: Coughing, sneezing and running can put pressure on the bladder causing a leak - this is termed stress incontinence. Physical changes resulting from pregnancy, childbirth and menopause are contributory factors. This type of incontinence is common in women and, in many cases, can be treated by physiotherapy alone, or a combination of physiotherapy and surgery.

The pelvic floor muscles, the vagina, and ligaments support your bladder. If these structures weaken, your bladder can move downward, pushing slightly out of the bottom of the pelvis toward the vagina. This prevents muscles that ordinarily force the urethra shut from squeezing as tightly as they should. As a result, urine can leak into the urethra during moments of physical stress. Stress incontinence also occurs if the squeezing muscles weaken.

Stress incontinence can worsen during the week before your menstrual period. At that time, lowered estrogen levels might lead to lower muscular pressure around the urethra, increasing chances of leakage. The incidence of stress incontinence increases following menopause.

Urge Incontinence: If you lose urine for no apparent reason after suddenly feeling the need or urge to urinate, you may have urge incontinence. A common cause of urge incontinence is inappropriate bladder contractions. Urge incontinence can mean that your bladder empties during sleep, after drinking a small amount of water, or when you touch water or hear it running (as when washing dishes or hearing someone else taking a shower). Certain fluids and medications can worsen this condition.

Overactive Bladder: Overactive bladder occurs when abnormal nerves send signals to the bladder at the wrong time, causing its muscles to squeeze without warning. Passing urine up to seven times a day is normal for many women, but women with overactive bladder may find that they must urinate even more frequently.
Specifically, the symptoms of overactive bladder include

  • urinary frequency—bothersome urination eight or more times a day or two or more times at night
  • urinary urgency—the sudden, strong need to urinate immediately
  • urge incontinence—leakage or gushing of urine that follows a sudden, strong urge
  • nocturia—awaking at night to urinate

Mixed Incontinence: Stress and urge incontinence often occur together in women. Combinations of incontinence—and this combination in particular—are sometimes referred to as mixed incontinence. Most women don’t have pure stress or urge incontinence, and many studies show that mixed incontinence is the most common type of urine loss in women.

How is incontinence evaluated?

The first step toward relief is to see a doctor who has experience treating incontinence to learn what type you have. To diagnose the problem, your doctor will first ask about symptoms and medical history. Your pattern of voiding and urine leakage may suggest the type of incontinence you have. Your doctor will physically examine you for signs of medical conditions causing incontinence, including treatable blockages from bowel or pelvic growths. In addition, weakness of the pelvic floor leading to incontinence may cause a condition called prolapse, where the vagina or bladder begins to protrude out of your body. This condition is also important to diagnose at the time of an evaluation.

Your doctor will test your urine for infection and sugar and may also recommend other tests:

  • Urinalysis and urine culture—Laboratory technicians test your urine for evidence of infection, urinary stones, or other contributing causes.
  • Ultrasound—This test uses sound waves to create an image of the kidneys, ureters, bladder, and urethra.
  • Cystoscopy—The doctor inserts a thin tube with a tiny camera in the urethra to see inside the urethra and bladder.
  • Urodynamics—Various techniques measure pressure in the bladder and the flow of urine.

How is incontinence treated?

Behavioural Remedies: Bladder Retraining and Kegel Exercises: By looking at your bladder diary, the doctor may see a pattern and suggest making it a point to use the bathroom at regular timed intervals, a habit called timed voiding. As you gain control, you can extend the time between scheduled trips to the bathroom. Behavioural treatment also includes Kegel exercises to strengthen the muscles that help hold in urine.

How do you do Kegel exercises?: The first step is to find the right muscles. One way to find them is to imagine that you are sitting on a marble and want to pick up the marble with your vagina. Imagine sucking or drawing the marble into your vagina. Practice this with the physiotherapist who will teach you the right technique. Pull in the pelvic muscles and hold for a count of three. Then relax for a count of three. Work up to three sets of 10 repeats. Start doing your pelvic muscle exercises lying down. This is the easiest position to do them in because the muscles do not need to work against gravity. When your muscles get stronger, do your exercises sitting or standing. Working against gravity is like adding more weight.
Be patient as most people do notice an improvement after a few weeks.
Diagram of two bladders, one with weak pelvic muscles and one with strong pelvic muscles.  The bladder on the left has weak pelvic muscles that fail to keep the urethra closed, so urine escapes.  Labels point to the bladder neck, weak pelvic muscles, urethral sphincter, and urethra.  The bladder on the right has strong pelvic muscles that keep the urethra closed, so no urine can escape.  Labels point to the bladder neck, strong pelvic muscles, and urethra.
Figure 3. Front view of bladder. Weak pelvic muscles allow urine leakage (left). Strong pelvic muscles keep the urethra closed (right).

Medicines for Overactive Bladder: If you have an overactive bladder, your doctor may prescribe a medicine to block the nerve signals that cause frequent urination and urgency.

Several medicines from a class of drugs called anticholinergics can help relax bladder muscles and prevent bladder spasms. Their most common side effect is dry mouth, although larger doses may cause blurred vision, constipation, a faster heartbeat, and flushing. Other side effects include drowsiness, confusion, or memory loss. If you have glaucoma, ask your ophthalmologist if these drugs are safe for you.

Biofeedback: Biofeedback uses measuring devices to help you become aware of your body’s functioning. By using electronic devices or diaries to track when your bladder and urethral muscles contract, you can gain control over these muscles. Biofeedback can supplement pelvic muscle exercises and electrical stimulation to relieve stress and urge incontinence.

Neuromodulation:
For urge incontinence not responding to behavioural treatments or drugs, stimulation of nerves to the bladder leaving the spine can be effective in some patients. Neuromodulation is the name of this therapy.

Vaginal Devices for Stress Incontinence:
One of the reasons for stress incontinence may be weak pelvic muscles, the muscles that hold the bladder in place and hold urine inside. A pessary is a stiff ring that a doctor or nurse inserts into the vagina, where it presses against the wall of the vagina and the nearby urethra. The pressure helps reposition the urethra, leading to less stress leakage. If you use a pessary, you should watch for possible vaginal and urinary tract infections and see your doctor regularly.

Injections for Stress Incontinence:
A variety of bulking agents, such as collagen are available for injection near the urinary sphincter. The doctor injects the bulking agent into tissues around the bladder neck and urethra to make the tissues thicker and close the bladder opening to reduce stress incontinence. Over time, the body may slowly eliminate certain bulking agents, so you will need repeat injections.

Surgery for Stress Incontinence: In some women, the bladder can move out of its normal position, especially following childbirth. Surgeons have developed different techniques for supporting the bladder back to its normal position. The three main types of surgery are sling procedures and anterior repairs with buttress, the former being by far the more effective.

Midurethral slings are newer procedures that you can have on a day case basis. These procedures use synthetic mesh materials that the surgeon places midway along the urethra. The two general types of midurethral slings are retropubic slings, such as the transvaginal tapes (TVT), and transobturator slings (TOT). The surgeon makes small incisions behind the pubic bone or just by the sides of the vaginal opening as well as a small incision in the vagina. The surgeon uses specially designed needles to position a synthetic tape under the urethra. The surgeon pulls the ends of the tape through the incisions and adjusts them to provide the right amount of support to the urethra.

If you have pelvic prolapse, your surgeon may recommend an anti-incontinence procedure with a prolapse repair and possibly a hysterectomy.

Side view diagrams of three female bladders after different types of continence surgery.  The diagram on the left shows a bladder held in place by sutures that form a supportive web for the bladder.  Labels point to the bladder, bladder neck, pubic bone, sutures, and urethra.  The diagram in the middle shows a bladder held in place by a ribbon-like sling that wraps around the bladder neck.  Labels point to the bladder, bladder neck, pubic bone, sling material, and urethra.  The diagram on the right shows a bladder held in place by a tape material wrapped around the bladder neck with tape ends emerging through incisions in the groin.  Labels point to the bladder, bladder neck, tape ends, pubic bone, transobturator tape, and urethra.

Figure 4. Side view. Supporting sutures in place following retropubic or transvaginal suspension (left). Sling in place, secured to the pubic bone (center). The ends of the transobturator tape supporting the urethra are pulled through incisions in the groin to achieve the right amount of support (right). The tape ends are removed when the incisions are closed.

Overall, 86 percent of women with a sling said they were satisfied with their results at 2 years. The main risks are a) difficulty passing water, infection and tape erosion. A small number may have bladder injury or numbness/pain in the groin. For more information, please visit www.uitn.net.

Talk with your doctor about whether surgery will help your condition and what type of surgery is best for you. The procedure you choose may depend on your own preferences or on your surgeon’s experience. Ask what you should expect after the procedure.

Other Helpful Hints

Many women manage urinary incontinence with menstrual pads that catch slight leakage during activities such as exercising. Also, many people find they can reduce incontinence by restricting certain liquids, such as coffee, tea, and alcohol.

Finally, many women are afraid to mention their problem. They may have urinary incontinence that can improve with treatment but remain silent sufferers and resort to wearing absorbent undergarments, or nappies. This practice is unfortunate, because nappies can lead to diminished self-esteem, as well as skin irritation and sores. If you are relying on nappies to manage your incontinence, you and your family should discuss with your doctor the possible effectiveness of treatments such as timed voiding and pelvic muscle exercises.

Points to Remember

  • Urinary incontinence is common in women.
  • All types of urinary incontinence are treatable.
  • Incontinence is treatable at all ages.
  • You need not be embarrassed by incontinence.

Further help and information

The Bladder and Bowel Foundation
(formerly Incontact and the Continence Foundation)
SATRA Innovation Park, Rockingham Road, Kettering, Northants, NN16 9JH
Nurse helpline: 0845 345 0165
Counsellor helpline: 0870 770 3246
General enquiries: 01536 533255
Web: www.bladderandbowelfoundation.org

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