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Urinary incontinence

It is not clear exactly how many people have urinary incontinence, as many people are too embarrassed to report their condition. In general, urinary incontinence affects three times as many women as men and becomes more common with increasing age.

Common types of urinary incontinence

Stress incontinence 
Stress incontinence is urinary leakage which occurs with physical activities such as running, walking, exercising or laughing and sneezing.

Urge incontinence 
Urge incontinence, or overactive bladder syndrome, occurs when urine leaks soon after a sudden and very intense need to pass urine. The need to pass urine is often triggered by a sudden change of position, sound of running water or cold weather. There are often only a few seconds between the need to urinate and the release of urine. Women are unable to hold on or delay going to the toilet.

Mixed incontinence 
Mixed incontinence occurs when symptoms of both stress incontinence and urge incontinence are present. For example, a woman may leak urine on coughing or sneezing, and also experience very intense urges to pass urine.


Overflow Incontinence Also called chronic urinary retention, occurs when the bladder cannot completely empty itself. This causes the bladder to swell above its usual size.  If someone has overflow incontinence, they may pass small trickles of urine very often. It may also feel as though the bladder is never fully empty and cannot be emptied, even when trying to do so.

Causes

Urinary incontinence occurs when the normal process of storing and passing urine is disrupted. This can happen for a number of reasons.

  • Vaginal birth. Giving birth vaginally may be associated with stress incontinence.
  • Heavier birth weight. Having a child or children who was/were heavier than normal.
  • Number of children. Giving birth to a high number of children.
  • Family history. There may be a genetic link to urinary incontinence, particularly stress incontinence.
  • Increasing age. Urinary incontinence becomes more common on reaching middle age and is most common in women over 70 years of age.

Causes of stress incontinence



The urethra may not be able to stay closed if the pelvic floor muscles are weak or damaged. Any sudden extra pressure on the bladder, such as laughing, sneezing, can then cause urine to leak out of the urethra.

Stress incontinence occurs when the pressure in the bladder, as it fills with urine, becomes so great that the urethra is unable to stay closed.  

Causes of urge incontinence


This urgent and frequent need to pass urine is caused by contractions of the muscles in the bladder wall, known as the detrusor muscles. The detrusor muscles relax to allow the bladder to fill with urine, than contract when going to the toilet to let the urine out.

Sometimes the detrusor muscles contract too often, creating an urgent need to go to the toilet. This is called detrusor overactivity.

Diagnosis

Bladder diary
Diagnosis can be assisted with the use of a frequency/volume chart (bladder diary). This is a simple and practical method of obtaining objective quantification of fluid intake, functional bladder capacity and voiding (urine emptying) behaviour. Frequency and times of voiding, voided volumes and leakage episodes (day and night) are all recorded for at least 24 hours and typically 3 days.

Bladder ultrasound scan
An ultrasound scan of the bladder can show how much urine is left in the bladder after urinating.

Urodynamic test

  • Comprises a group of tests to check the function of the bladder and urethra.


Treatment of Urinary Incontinence

NICE - Stress Incontinence
Urodynamics
Surgical Tratment of Urinary Incontinence
Tension Free Vaginal Tape (TVT)
Bladder Neck Bulking Injections
Relax trial (Detrusor instability & Botox)

Medical Treatments for Urinary Incontinence

Conservative measures for treating urinary incontinence should always be tried first & include:

Simple changes to lifestyle e.g.,

  • Reducing caffeine intake. Caffeine is found in tea, coffee and cola. It increases the amount of urine that the body produces.
  • Drinking 1-1.5 litres (six to eight glasses) of fluid a day. Drinking too much or too little can cause symptoms that affect the lower urinary tract (bladder and urethra).
  • Losing weight, if overweight.

Pelvic floor muscle training

Weak or damaged pelvic floor muscles can cause urinary incontinence, so strengthening these muscles through exercise is often one of the first treatments recommended, whether the patient has stress, urge or mixed incontinence.

The pelvic floor muscles surround the bladder and urethra (the tube that carries urine from the bladder to outside the body). 

Bladder training

In urge incontinence, one of the first treatments offered is bladder training. Bladder training may also be combined with pelvic floor training if the patient has stress incontinence or mixed urinary incontinence.

Bladder training involves learning  to increase the length of time between feeling the need to urinate and passing urine. The course usually lasts for six weeks.

Medication for urge incontinence

If bladder retraining alone does not produce sufficient improvement, then anticholinergics can be tried e.g., solifenacin, tolterodine oxybutynin and fesoterodine. 

The amount of improvement varies from person to person. There may be fewer toilet trips, fewer urine leaks, and less urgency. However, it is uncommon for these symptoms to disappear completely with medication alone. A common plan is to try a course of medication for a month or so. If this is helpful, the patient may be advised to continue for up to six months and then stop the medication, to see how symptoms are without medication. The symptoms may return after finishing a course of medication. However, if a course of medication is combined with bladder training, the long-term outlook is often better and the symptoms are less likely to return when medication is stopped.

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 side-effects can include dry eyes, constipation and blurred vision. However, there are differences between these medicines and an individual patient may find that, if one medicine causes troublesome side-effects, switching to an alternative one may suit better.

Hormonal preparations

For women after the menopause, topical treatment with oestrogen (via a pessary or cream) may have a positive effect on incontinence. This is used in women who have vaginal atrophy, a condition that caused by lack of oestrogen, leading to vaginal dryness, itching or discomfort. The urgent and frequent need to pass urine, may also be a symptom of vaginal atrophy. Therefore, treating vaginal atrophy with oestrogen cream can sometimes relieve these symptoms.





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