The bladder usually stores urine until you choose to empty it. Urinary incontinence is the inability to hold your urine until you get to a toilet.
Condition – Incontinence
What is urinary incontinence?
Urinary incontinence can happen to people at any age. About 1 in 3 women and 1 in 10 men are affected in Australia – it is estimated about 2 million Australians suffer from incontinence. The problem is even worse amongst nursing home residents of whom 40-60% are affected.
Although incontinence is not a life-threatening problem, it is a social one. It can be very embarrassing for those who suffer from it, altering confidence and social behaviour.
What are the symptoms?
There are different types of incontinence, although the main symptom will be the same – leakage of urine at a socially inappropriate time.
Urge incontinence is when your bladder contracts when you do not wish it to do so. You may have the feeling that you want to urinate, but cannot delay the bladder’s “urge” to empty. This means that you may not always get to the toilet on time.
When you cough or sneeze, the pressure inside your abdomen increases. This puts pressure on the muscles controlling the release of urine from your bladder. When these muscles are weak, you may leak urine when you cough, laugh, sneeze or even while you are walking. This is stress incontinence. It occurs mostly in women, and is thought to be due to the stretching of these muscles from childbirth or aging – though this is not necessarily the case. Weight can also be a factor. In men, stress incontinence is usually associated with surgery or other trauma in this area.
This is usually a combination of urge and stress incontinence.
If the bladder is allowed to become too full, usually due to bladder weakness or a blocked urethra, the pressure in the bladder can become so great that urine overflows into the urethra, leading to continuous leaking of urine. As an enlarged prostate is one of the most common causes of a blocked urethra, overflow incontinence affects more men than women. Aside from an enlarged prostate, people with diabetes, heavy alcohol users, and others with decreased nerve function are also at risk.
What causes incontinence?
In order to understand what causes incontinence, it helps if you understand a little of the normal function of the urinary tract.
The main mechanism of continence is the urinary sphincter. In women this is supported by the pelvic floor muscles and some surrounding ligaments. These as a group take the pressure of abdominal straining or the filling bladder and prevent urinary leakage. In men, the mechanism has the additional presence of the prostate and its supports, which add extra sphincter elements, whilst not directly affecting continence themselves. Disruption or interference with any of these normal mechanisms in men or women can result in incontinence.
Common causes of incontinence include:
- Thinning of the skin in the vagina & urethra – occurs especially after menopause.
- The enlarged prostate or prostatic surgery.
- Weak pelvic floor muscles
- Certain drugs or medications
- Urinary tract infection (UTI or cystitis)
- Neurological diseases eg Parkinson’s disease or stroke
How does the doctor diagnose it?
In order to manage your incontinence properly, the doctor must first establish what type of incontinence you have. The doctor will first take a history from you to find out the pattern of your incontinence, past medical history, medications etc. The doctor may also ask you to keep a diary of your toilet trips etc. The physical examination usually consists of an assessment of your nerves and an examination of your abdomen, rectum, genitals, and pelvis. The doctor may also ask you to cough forcefully, to see if there is any urine loss, which would suggest stress incontinence.
The doctor will examine your urine to see if there is a medical condition that might be causing your incontinence. For example, bacteria in your urine could suggest infection, glucose in your urine may indicate diabetes.
If your incontinence has not got better after initial diagnosis and treatment, you may be sent to a urologist who will perform other tests to obtain a more detailed evaluation view of the lower urinary tract to decide a new treatment plan.
Post-void residual volume (PRV)
To do this test, you will be asked to urinate. This will help to identify hesitancy, straining, or interrupted flow. The doctor will then measure how much urine is left in your bladder after you have finished urinating.
This is also called cystometry and is a way of looking more closely at the bladder and urethra, and how they work. It measures pressure and volume of fluid in the bladder during filling, storage and urination.You will first have to empty your bladder as much as possible.
A thin plastic tube (catheter) is then inserted into the urethra until it reaches the bladder. Measurements are taken of residual urine volume (amount remaining in the bladder after urination) and bladder pressure. Depending on the type of test being performed, the bladder is then gradually filled with water, saline solution, carbon dioxide gas or a dye solution for x-ray analysis.
You will be asked to describe sensations during filling, including temperature sensations and when the first feeling of bladder fullness occurs. Once the bladder is completely full, you will be asked to begin urinating. Pressure and volume measurements are taken again including flow rate and flow pressure.
A cystoscopy (a small camera inserted into your urethra) may be performed if urodynamic testing does not provide all the answers, or if you are experiencing new symptoms (e.g., cystitis, pain), or if urinalysis reveals a disease process. Cystoscopy allows the doctor to see the lining of the bladder.
X-rays and ultrasound may also be used to look more closely at your urinary tract system.
Treatment – Incontinence
If the cause of the incontinence is something simple, such as infection, the problem will go awat as soon as the underlying problem in treated, for example, with antibiotics. If there is no treatable underlying cause, treatment will be focused on the incontinence itself.
- Non-medical management
- Tension-free Vaginal Tape (TVT)
- Autologous fascial sling
- Periurethral Bulking agents
- Advance®/Virtue Male Sling
- Artificial Urinary Sphincters
There are several things patients can do to help improve continence.
- Caffeine-related drinks such as tea and coffee, alcohol, antidepressants, antihistamines, and cough-cold preparations should be avoided as they can all increase urine production, putting a strain on the bladder.
- Pelvic floor exercises to strengthen the pelvic muscles should be performed daily.
- Stop-start urination should be practiced (urinate, stop, wait a few seconds, urinate again).
- Eat fruits, vegetables, and whole grains daily to prevent constipation.
- Retrain the bladder (try and urinate only every 3 to 6 hours).
- Stop smoking (nicotine irritates the bladder).
- Pelvic muscle exercises (PFE’s) – help strengthen pelvic floor muscles (the muscles at the entrance to the urethra) and sphincter muscles (the muscles at the neck of the bladder) and help ease the symptoms of stress incontinence.
- Electrical stimulation may also be used to help strengthen pelvic muscles in the treatment of stress and/or urge incontinence.
- Biofeedback uses various techniques to increase the patient’s awareness of bladder and sphincter muscle function. Together with pelvic muscle exercises and/or electrical stimulation, biofeedback can help relieve stress and/or urge incontinence.
- Timed or planned urination involves keeping a record of urination and leakage. Knowing when you normally urinate helps you to plan your urination in advance. This could help prevent leakage, which might otherwise occur in cases of urge or overflow incontinence.
- Bladder training involves the use of both biofeedback and muscle conditioning, to change the bladder’s schedule for holding and emptying urine. (This is for treatment of urge or overflow incontinence).
There are various medications that can:
- Tighten sphincter muscles, to prevent leakage of urine
- Relax muscles, to allow more efficient emptying of the bladder during urination (eg Minipress; Flomax)
- Relax the bladder muscle to decrease urgency and frequency (eg Ditropan; Detrusitol; Vesicare, Betmiga)
- Hormone replacement therapy may relieve stress incontinence through its effect on muscle function
If you have stress incontinence the following two treatments may be offered to you. Both of these methods work on the principle of applying pressure around the urethra, so that urine is less likely to leak out:
- A stiff ring called a pessary can be inserted into the vagina to press against the wall of the vagina and the urethra which lies next to it. This is more appropriate if there is any prolapse or descent of the front wall of the vagina.
- Implants of collagen or artificial inert materials (eg Macroplastique, Bulkamid) can be injected into the area around the urethra, to add bulk and help compress the urethra.
- For cases of overflow incontinence, perhaps caused by muscle or nerve damage, and where exercises are unlikely to help, catheterisation is an option.
- Catheterisation is when a thin tube is inserted through the urethra and into the bladder.
- The tube is kept in place, and the bladder is emptied through the tube into a bag.
Surgery is indicated for those who have suboptimal or failed conservative measures.
The colposuspension was the most common operation to treat stress incontinence in women. This is a major operation where you will have a general anaesthetic. The bladder neck is lifted and stitched to a nearby ligament. This helps to stop leaks from the bladder. This procedure has a success rate of between 50% and 70%.
There are two versions of this operation. Open colposuspension gives better long-term success rates, but involves making a large cut in the abdomen. Laparoscopic colposuspension (sometimes called keyhole surgery) needs a smaller cut to do the operation, but its success rate is not as good.
Another type of surgery for women with stress incontinence is tension-free vaginal tape (TVT). This operation has been around for 20 years or more and has proved to be a very reliable form of surgical treatment for stress incontinence.
The operation is relatively simple and can be done as an overnight or even day surgery case procedure. Tape is inserted through a small vaginal incision and two tiny suprapubic incisions – it runs between the vagina and the urethra, lifting the middle of the urethra. This support can reduce the effect of sudden abdominal stress, which is the cause of stress incontinence.
There are a number of variations of the TVT Procedure now available, all of which seem to be reliable, safe and involve short recovery times. They are now often collectively called – mid-urethral sling procedures.
Autologous fascial Sling
For more complicated cases or those that are adverse to synthetic materials, using the patient’s own tissue to create a sling from the rectus fascia or the tensor fascia lata is a suitable alternative, although the morbidity is slightly higher. Generally in hospital stay for 1 to 2 nights is required.
Incontinence in men has become a more frequent occurrence in recent times, mainly as a side effect of radical surgery for cancer. Whilst male incontinence is not often severe, it can be annoying and require treatment.
The Advance® sling uses a mesh, very similar to the tape used in females, to provide support for the disrupted pelvic floor and so regain continence.
It is anchored around the obturator pelvic bone and has proved to be safe, reliable and has revolutionised the treatment of male incontinence. The Virtue sling has four sling arms and has additional compression with the prepubic arms for further support.
Artificial sphincters (AUS) are probably the gold standard in returning continence to men and women who have failed or are not suitable for lesser alternatives.
This system involves the surgical placement of an inflatable cuff around the urethra to take the place of the sphincter. A small pump mechanism is used to work the device, which has proved to be a reliable means by which to achieve continence when all other measures seem to have failed.
A number of protective devices can help to manage accidental urination, including the following:
- Bed pads
- Combination pad-pant systems
- Full-length absorbent undergarments
- Male incontinence drip collectors
- Underwear liners (pads, guards, shields, inserts)
If you use absorbent pads, they should be applied correctly and changed often to prevent skin irritation and urinary tract infection.