Women and Urinary incontinence

It is generally thought that between 10-12% of women regularly experience urinary incontinence with the incidence being far higher in some groups. The most common form of urinary incontinence amongst women is stress urinary incontinence. This is followed by urge incontinence, and many women experience both forms of incontinence with a mixture of symptoms.

Diagnostic Assessment

When a woman presents with reported symptoms of urinary incontinence it is most important to rule out other pathology before making a diagnosis of stress urinary incontinence (SUI), urge incontinence (UUI), or mixed incontinence. This should involve a medical history including any head, neck or back injury, relevant conditions e.g. diabetes, sports activity, parity, family history and both urinary symptom analysis and physical examination.

Symptom analysis includes reported episodes and nature of incontinence. Urinary analysis to test for bladder or urinary tract infection and to exclude haematuria should always be undertaken. If feasible, direct her to fill out a urinary diary to document both time and amount of voiding, and the volume and nature of her fluid intake.

Physical examination should rule out constipation, prolapse, masses or tumours, fistulae and damage from pregnancy, childbirth or previous surgery or injury. Neurological symptoms and mental state should be assessed in case of head trauma, multiple sclerosis, Parkinson’s disease, Alzheimer’s, etc.

Finally, an assessment of quality of life, mobility and toilet access may be applied to determine need for treatment.

Stress Urinary Incontinence

Stress urinary incontinence describes the complaint of involuntary leakage of urine on effort or exertion, or on sneezing or coughing. This may be a small amount, but it can sometimes be significant.

Treatment alternatives

Lifestyle

Review lifestyle for food and fluid intake, weight reduction and smoking. Overweight people have a greater tendency to stress incontinence because of increased abdominal pressure. Smokers cough more, which can result in an increased incidence of leakage.

  • Do not drink too much or too little. Reducing fluid intake to decrease urine may produce further irritation of the bladder and promote infection.
  • Avoid caffeine and fizzy drinks, which may irritate the bladder, as may alcohol.
  • Review current medication for interaction or iatrogenic effects.

Pelvic Floor Muscle Exercise

The generally accepted first treatment for stress incontinence is pelvic floor muscle exercise, to improve bladder support and closure pressure of the urethra. Referral to a physiotherapist is the most effective way of ensuring that the exercises are being done correctly and so give the best chance for success. Physical examination will help determine the status of the pelvic floor muscles and so allow the physiotherapist to advise on a personalized exercise regime.

Biofeedback and electrical stimulation aid in the execution of pelvic floor muscle exercise for both men and women and ideally should be recommended by a physiotherapist or continence professional.

Medical devices

Absorbent incontinence products designed specifically for urinary incontinence are the most popular products amongst patients, to protect against urine leakage. There are both disposable and reusable products and although all products are not alike, many are developed to a high technological standard and provide the user with flexibility and ease of use. Patients may use several different types of pads or pants depending on their daily needs. There are pads and pants developed for specific purposes, which can be slim and unobtrusive for day use or substantial enough to contain heavy leakage.Continence advisers can give the best guidance on what to use and local continence organisations can help with consumer issues.

Other products for urine collection and inhibiting urine flow may also be used to contain leakage in certain circumstances. Catheters may be used as a temporary measure, after surgery, or as a long term solution. Catheters may be intermittent or indwelling and are connected either to a drainage bag held on the person or to a valve which allows the catheter to be emptied in a vessel on a regular basis. Indwelling suprapubertal catheters may be surgically introduced through the abdomen rather than via the urethra. Patients or carers may be trained to change and clean these.

Pharmacological and surgical interventions (under certain conditions)

Pharmacological intervention

New agents are available which aid in stress incontinence. These are called dual noradrenaline/serotonin reuptake inhibitors and are available in selected European markets. Studies have suggested that the best results are achieved if these are used in association with pelvic floor muscle exercises.

Surgical intervention

A urologist or urogynaecologist can advise on all the available surgical procedures for stress urinary incontinence. There are both open procedures and day procedures as well as the use of bulking agents. For most patients, surgery for stress incontinence should be considered as tertiary care after conservative and pharmacological interventions have not produced the desired result.

Urge Incontinence

Urge incontinence or overactive bladder refers to the overactivity of the detrusor muscle of the bladder that creates an increased urgency, with little or no warning, and often accompanied by leakage of urine. In severe cases, the volume of leakage can be large. Urinary frequency (more than eight times per day) and nocturia (one or more per night) may also occur.

Treatment alternatives

Lifestyle

Make getting to the toilet as easy as possible. This may involve special adaptations to the patients living area. A raised toilet seat, handrails, commodes in the bedroom, all may aid in helping the patient, as may easily opened clothes if manual dexterity is a problem.

Bladder Retraining

Bladder retraining is a behavioural technique designed to increase the capacity of the bladder and decrease the frequency of urination. Over time, the bladder becomes less irritable and able to cope with larger volumes of urine. A urinary diary is the first step in assessing urge incontinence and setting up a course of bladder retraining.

Pelvic Foor Muscle Exercise

Pelvic floor muscle exercise is most successful with stress incontinence and mixed incontinence, but may be of value to those with urge incontinence, to strengthen the musculature and minimalise or eliminate leakage. Biofeedback and electrical stimulation aid in the execution of pelvic floor muscle exercise and ideally should be recommended by a physiotherapist or continence professional.

Medical devices

Some women experience sudden involuntary urine loss and choose to wear an absorbent incontinence product when they are in at-risk situations. There are several styles and shapes of pads and pants which suit varying amounts of leakage. There are both disposable and reusable products available and an experienced continence advisor who can direct the patient to the most appropriate form of protection which is designed to absorb urine rather than a sanitary towel which is designed to absorb blood.

Other products for urine collection and inhibiting urine flow may also be used to contain leakage under certain circumstances. Catheters may be used as a temporary measure, after surgery, or as a long term solution. Catheters may be intermittent or indwelling and are connected either to a drainage bag held on the person or to a valve which allows the catheter to be emptied in a vessel on a regular basis. Indwelling suprapubertal catheters may be surgically introduced through the abdomen rather than via the urethra. Patients or carers may be trained to change and clean these.

Pharmacological and surgical interventions (under certain conditions)

Anitmuscarinics and anticholinergics may be prescribed for detrusor muscle overactivity. Surgical intervention for urge incontinence without stress incontinence symptoms is rare.

MIXED INCONTINENCE

With mixed incontinence, the symptoms of stress urinary incontinence co-exist with those of urge incontinence. According to the most recent guidelines for the International Committee on Incontinence, it is recommended to treat the predominant symptom first.

OTHER FORMS OF INCONTINENCE

There are other forms of incontinence which may not fall into the above categories.

  • Giggle incontinence: A form of incontinence generally experienced in youth, but may continue into adulthood. Urination triggered by laughter, result of instable detrusor muscles and may be hereditary.
  • Functional incontinence: The inability to reach the toilet to urinate either due to disability (physical or mental) or infirmity.