What is urinary incontinence?
This means that urine leaks out at times when it shouldn't. It is a common problem affecting many women sometimes several or more times a week. It can be so bad that underwear needs to be changed during the, pads have to be worn to keep dry and daily activities like lifting, dancing or going on long journeys have to be restricted.
Why talk about bladder control?
Women, and some men, have bladder control problems. it is a very common problem affecting women of all ages. In young women, urine leakage can occur after giving birth to a child. Sometimes it occurs after periods stop (menopause) or in older women in their 70s.
Incontinence is not something to be ashamed and affects many women. Urine leakage is not normal and can be successfully treated in the majority of women.
Why do I leak when I cough, exercise, laugh or sneeze?
Activities such as these increase the pressure on the bladder literally forcing urine out of the bladder. Usually, the muscles in the pelvis support the bladder and urethra (water pipe) prevent urine from coming out. These muscles can be weakened by pregnancy, obesity, menopause or an inherited tissue weakness. This is usually known as 'genuine stress incontinence'. Sometimes, the problem is due to a weakness in the wall of the urethra (water pipe) rather than the bladder or urethral support.
Less commonly, coughing, exercise, laughing or sneezing can stimulate the bladder muscle to contract and that causes urine to leak. This is known as Valsalva induced detrusor overactivity
Why do I need to rush to the toilet when I feel the need to pass urine?
Normally, the bladder muscle should contract only when you pass urine. Sometimes, the bladder muscle contracts before it is full and when you would rather not go to the toilet. If you don't reach the toilet on time, you might leak. During the day and night, the urge to pass urine may be overwhelming and so you go to the toilet more than other people. If you don't make it to the toilet on time, incontinence may occur. If the bladder muscle itself is contracting inappropriately, this condition is often known as 'detrusor overactivity'. Sometimes, there are important causes for this problem, but often no specific cause is found.
How does bladder control normally occur?
The bladder is like an expandable bag that holds urine as it fills. When the bladder is full, the pelvic floor relaxes, the bladder muscle ('detrusor') contracts and urine is passed. Urine passes from the bladder through a tube called the urethra (water pipe) to the outside world. Usually, the desire to pass urine occurs when the bladder is almost completely full, but in some people, the bladder muscle (detrusor) contracts far too early. This gives rise to an urgent desire to pass urine that can sometimes be too strong to stop resulting in a leak. This is often called detrusor overactivity. Thus, normal bladder filling occurs with the detrusor (bladder muscle) remaining relaxed and not overactive.
As the bladder becomes full, coughing, lifting and other activities do not usually cause urine leakage because the urethra (water pipe) is supported. The support comes from the pelvic floor, which is a layer of muscle under the bladder. Lack of urethral support results in urine leakage with stressful activities. Urethral support can be improved by pelvic floor exercises, losing weight, drugs and new procedures that can be performed as day cases or with an overnight stay.
For bladder control to be effective, the nervous system has to be working normally.
How do you work out why bladder control is poor and urine leakage occurs?
In the majority of women, the cause is principally either of the two problems listed above ie stress incontinence or detrusor overactivity. It can be difficult to distinguish between the two from symptoms alone, as they can often overlap in 3 in 10 cases.
Symptoms that suggest that detrusor overactivity is present include the sudden urge to pass urine (urgency) that occurs day and night, together with urine leakage that occurs with urgency ('urge incontinence'). Urine is passed frequently and often in large amounts when the strong urge is present.
Stress incontinence usually occurs with activity and the leakage is usually only a few drops only. Urine leakage rarely occurs at night except in the worst cases.
Symptoms and the findings on physical examination can help sometimes. The 'cough test' determines whether leakage occurs on coughing or not. However, often it is difficult to reliably rule out one or other condition. If the symptoms do not resolve after simple help, additional tests are required. These include
- urodynamics (pressure/flow studies): This is a test in which a narrow tube is placed in the bladder and rectum ('backpassage') so that the pressure in each can be recorded.
- ultrasound of the bladder
- frequency/volume chart (voiding diary/log)
What can I do myself to reduce urine leakage?
There are simple things one can do: pelvic floor exercise and lose weight.
Can pelvic floor exercises and physiotherapy help?
Providing the exercises are done, they will help, and they will need to be done for the rest of one's life. They can be performed by oneself or taught with the aid of a physiotherapist. Please see Pelvic Floor Exercises.
They help urinary leakage that occurs due to stress incontinence as well as due to detrusor overactivity (urge incontinence).
There are additional aids that one can use to improve the efficacy of pelvic floor exercises. These include biofeedback machines. Again, these have to be performed regularly like any exercise programme.
Can drugs or medicines help?
For women with stress incontinence, Yentreve or duloxetine is a new drug that helps women by reducing the number of times incontinence occurs. It is not a complete cure, but does make some women better and maybe usefully combined with pelvic floor exercises. The feeling of nausea may occur, but usually ameliorates after the first few weeks. This drug should only be taken on the advice of a doctor who knows your medical history well.
For women with urge incontinence or detrusor overactivity, drugs such as Detrusitol (tolterodine), Lyrinel (oxybutynin), Regurin (trospium), propiverine, or solifenacin may help. To some extent these can give rise to a dry mouth or constipation. These medications should be combined with changes in drinking habits such as reducing caffeine and alcohol consumption.
Aren't there procedures or operations that can help?
It is possible to improve the urethral support that has become weak resulting in stress incontinence. There are three ways that this can be done:
- placing a tape under the urethra to support the urethra when there is stress - TVT or transobturator tape (eg MONARC)
- fixing the bladder in a higher position by stitches placed at an operation (eg Burch colposuspension) - this is the traditional way to treat stress incontinence
- injecting agents to increase the bulk of the urethral wall
Of all these, many prefer the first option nowadays. More is described in the section on transobturator tapes. In some cases, these can improve symptoms of urgency or urge incontinence, but you need to have a careful discussion with your doctor.
What about the new transobturator tapes?
Urinary leakage occurs in part because the support of the urethra is inadequate. A tape or hammock can be placed under the urethra to provide additional support. The number of times urinary leakage occurs is reduced and it is possible to enjoy a better quality of life as a result. You have to come in to hospital for up to 24 hours and normal activities can be resumed after a month or so. More details are on the MONARC page.
To some extent, this problem can also be ameliorated by placing a tape to support the urethra, but a specific operation may be needed to correct this itself. This is usually assessed at the time of investigation of incontinence.