Dealing with urinary incontinence.

Some women find there’s a leak of urine when they laugh or cough.  Some men and women know where every public convenience is in the places they visit and don’t like going to new places because they can’t be sure where the toilets are.

If this sounds like you then this article is going to look at what incontinence is and how it can be treated.

Incontinence, especially in women is common.  It’s estimated that about 20% of women suffer with incontinence, but that figure is probably an underestimate as many women are too embarrassed to talk to their doctor about it.

We’ll look at drug treatments so note that all medications have a drug name and a brand name.  There are some examples of both the drug and brand names here.  (The brand names are shown with a Capital Letter and often in brackets after the drug name.)

Understanding your anatomy.

emedicinehealth.com

The pelvic floor muscles stretch like a hammock from the pubic bone at the front to the spine at the back.  The bowel, a woman’s vagina and the urethra (tube the urine travels down as it exits the body) all pass through it.  The picture demonstrates a woman’s anatomy here.

You control when you choose to have a pee and the brain and spinal cord send messages down the nerves to the bladder, which is a muscular bag.

Normally when you cough, sneeze, laugh or exercise etc, the brain tells the pelvic floor muscles to tighten them so there’s no leakage.  However if the muscles are weak or the bladder muscle is irritated, they can’t do their job.

It’s when something goes wrong with the mechanics of the system, or the nerve messages that control the mechanics, that problems can occur.

Stress Incontinence.

  • Leaking a small amount of urine when you laugh, cough, jump etc, when you haven’t had the sensation that you need to go to the toilet, is probably stress incontinence.
  • Leakage may also occur during sex, usually during penetration.
  • Stress incontinence is caused by weak pelvic floor muscles.  They can become overstretched during pregnancy and childbirth, obesity or gynae operations.  And like any muscle that’s out of shape, they won’t work effectively.

Treating Stress Incontinence.

Treatments for stress incontinence have improved a lot in recent years.

1. The first course of action is to start pelvic floor exercises (Kegel exercises – see below) as soon as you suspect you have a problem, so that you get on the road to putting it right.  The effectiveness of these exercises can be improved by using a specially designed, weighted cone, which is put into the vagina.

Squeezing against this and increasing the weight as you get better at it, increases the muscle strength.  Practising this pelvic floor workout for about 4 months will show the greatest rewards.  To help you maintain the dedication to this, remember there’s an added bonus: many women report an improvement in sensation and enjoyment with their sex lives!

Kegel exercises:

  1. Sit with the legs apart and close the front and back passages as if ‘zipping’ them up inside.
  2. Hold for the count of 4 and then relax slowly.
  3. Repeat 4 times each hour.
  4. Consider doing these after passing urine.

You can increase the exercises after 3 months by

  • repeating steps 1 and 2 above – close the front passage and count to 4 then release.

2. Older medications for stress incontinence had a lot of side effects but are good for mild incontinence. Examples are oxybutynin (Ditropan, Gelnique), tolterodine (Detrol,)darifenacin (Enablex),solifenacin (Vesicare).  Their side effects include: dry mouth, and less commonly constipation, heartburn, blurry vision, rapid heartbeat (tachycardia), flushed skin, urinary retention and cognitive side effects, such as impaired memory and confusion.

A newer drug called Yentreve is available on prescription and is effective for more severe stress incontinence.  It takes a couple of weeks to show an improvement but women who have seen their doctors and are taking it report a greatly improved quality of life.

There are several surgical treatments for stress incontinence, such as injections into the muscles that close the urethra, using stitches to improve the suspension of the pelvic floor ‘hammock’ or using an artificial fibre to create a sling to support the urethra.

Urge Incontinence.

If you feel a sudden need to pee and often leak urine you probably suffer from urge incontinence.  This leak is usually a greater volume than with stress incontinence.

Urge incontinence is also called an irritable or oversensitive bladder.  The bladder doesn’t fill properly and this can be caused by infection or small particles in the urine which irritate the bladder, or even by emotion.  This irritation causes the bladder muscle to contract, squeezing its contents so that you feel that you want to pass urine.

The bladder may also be ‘unstable’ which means its muscles squeeze at the wrong time and this causes the feeling of the urgent need to pee and leakage.  If you have an unstable bladder you may have leakage during orgasm.

The causes of urge incontinence include problems with the nerves sending the wrong messages to the bladder or vice versa.  This can happen in neurological disorders such as Parkinson’s Disease, multiple sclerosis, after a stroke and spinal cord injury or from nerve damage in diabetes or surgery.  In many cases the cause isn’t known and it’s called idiopathic urge incontinence.

Other causes might be a side effect from a diuretic (water pill) or meds with caffeine in them, urinary infection, tumours in the bladder, enlarged prostate, or pregnancy or a recent delivery.

Treating urge incontinence.

  • Your doctor may ask you to keep a ‘bladder diary’ for a few days so that she can determine how often you’re going to the toilet and how much urine you’re passing each time.  She may ask you to increase the time between trips to the toilet so that the bladder can be re-trained.
  • There are drug treatments Cystin, Ditropam, Lyrinel XL, Detrusitrol which can be effective in stopping the bladder spasms, and again surgery is used in the most severe cases.

Incontinence isn’t an inevitable part of the ageing process for women (or men) and the problems of childbirth or weight gain can be reversed.

More about the overactive bladder here.

Mixed incontinence.

A combination of stress incontinence and urge incontinence is called ‘mixed incontinence’ so you could have symptoms of both types.

Look at this table to see which type you may have:

Stress or Urge Incontinence or Both?

Question

Stress incontinence

Urge incontinence

Mixed

Do you need to pass urine more than 6 times a day? Sometimes Yes No
Do you need to go to toilet in the night? No Most nights Most nights
Do you have to hurry to get to the toilet in time? No Yes Yes
Do you leak when laughing, sneezing etc? Yes No Yes
How much do you leak? Small amounts Larger amounts Large
Do you have to strain to pass urine or does it hurt when you do? No Yes (pain-  sensory urge incontinence might mean an infection) No
When did this start? After vaginal childbirth/gynae surgery Anytime After vaginal childbirth/gynae op
Do you have a feeling of needing to pass urine? Yes, but leak when there is no feeling to pass urine Yes strong need Yes

Overflow incontinence

Overflow incontinence is less common than urge and stress incontinence and more common in men.

It happens when there is something blocking the outflow of urine and this stops the bladder emptying properly.  A small amount of urine is left in the bladder after you pee; this is called urinary retention.

Pressure builds up behind the obstruction and some urine may leak past the obstruction occasionally and escapes, giving you this incontinence.

An enlarged prostate gland in men is a common cause of overflow incontinence and this can be treated by drugs which shrink the prostate or by surgically removing it.

In women finding the cause can be more complicated and your doctor may refer you for a cystoscopy, where a specialist will look into the urethra and bladder with a special camera.  This will help to determine the cause of the blockage and therefore its treatment.

Functional incontinence is the name doctors give incontinence that happens when there is no problem with the nerves or the mechanics of the urinary system itself.  This might happen if you were unable to get to the toilet in time because of poor mobility or incontinence during a seizure.

Tests for incontinence.

It can take a lot of courage to talk to your doctor as we said at the top of the page, and many people put of asking for help for years.  If it helps to see a doctor of the same sex as you then ask at the surgery, but remember s/he will have seen and heard of this problem before.  And you’ll be glad you asked for help.

The doctor will want to determine the type of incontinence you have and will do this by:

  • Asking about your personal, family and medical history.
  • Performing a urinalysis at the surgery – dipping a specially formulated wand into a urine sample to test for abnormalities.
  • Examining you internally to see if there are prolapses or an enlarged prostate that might be causing the problem.

S/he may then refer you to s urologist or urogynaecologist for further testing.  These other tests may include:

  • Doing a test for residual urine.  This tells the doctor how much urine is left in the bladder after you’ve been to the toilet and is done either by an ultrasound scan or by passing a small catheter into the bladder to drain the urine.
  • Urodynamic studies test the urine flow and are often done if surgery is thought to be a treatment option.

What can you do to help yourself?

Here are some measures that you can take to help reduce or manage your incontinence:

  • Drink normal amounts of fluid – up to 2 litres a day but more if the weather is hot or you have been exercising.  Drinking a lot will also mean you pass a lot of urine, but don’t restrict how much you drink as this can make you dehydrated and make the urine more concentrated which irritates the lining of the bladder.
  • Avoid drinks with caffeine in them – such as tea, coffee, colas and chocolate drinks – as this can make urge incontinence worse.
  • Lose weight if you need to.  Research has shown that incontinence in overweight women can be improved by modest (5-10% of the body’s weight) loss.
  • Avoid constipation.  This can stop the bladder emptying properly.
  • Get into a good toilet habit.  Go to pass urine when you need to rather than holding on or going ‘just in case’.  It’s normal to go to the toilet every 3-4 hours, depending on how much you’re drinking, your activity and the temperature of the day.
  • Look here for advice on continence aids.

See more on incontinence from patient.co.uk.

If you’re worried about your symptoms or medical problem but don’t want to seek professional help because you feel embarrassed, silly or that it’s your fault, read this page now:  How to talk to a doctor about an embarrassing problem.

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