Urinary Incontinence

There are many causes of urinary incontinence. The causes listed immediately below are often temporary and once they are treated the incontinence is relieved. These include

• Urinary tract infection
• Constipation
• Certain medications
• Increased dietary intake of caffeine, alcohol, artificial sweeteners and carbonated beverages

However, it may also be noted that some causes of urinary incontinence are not temporary and they are listed below. The treatment for these differs based on what causes the condition. However all of these conditions, if not cured, can be improved.

• Pelvic floor muscle weakness
• Weakness of the bladder and/or the sphincter muscles
• Overactive or under active bladder muscles
• Decreases in certain hormones, especially oestrogen
• Neurological disorders (e.g. Multiple Sclerosis, Parkinson’s disease)

Incontinence can be classified into different types. These are:

1. Urge Incontinence

Urge incontinence occurs when the individual feels a sudden and strong desire to void urine and cannot delay the bladder’s “urge” to empty. This results in them not being able to reach the restroom in time. Sometimes, this is called overactive bladder (OAB). This condition can occur in women due to a bladder muscle that becomes overactive.

2. Stress Incontinence

Stress incontinence is the involuntary loss of urine due to an increase in “belly pressure.” This can occur with coughing, sneezing, laughing or lifting something heavy. (The leakage can vary from a few drops to more than a cup). This is the most common type of urinary incontinence in women.

Some women may experience Stress incontinence during menopause due to their bodies producing less of a hormone called oestrogen. This hormone is needed to preserve the integrity of urethra after passing urine.

3. Overflow incontinence

Overflow incontinence occurs because the bladder becomes overfilled and urine leaks due to the inability of the bladder to hold any more urine. This condition is mainly due to neurological disorders. There may be other reasons such as:
4. Mixed Incontinence

• The blockage of the urethra due to a full bladder or the prolapse of pelvic organs
• Damage to bladder control nerves, the urethral sphincter or pelvic floor muscles
• Medical conditions such as diabetes, multiple sclerosis, stroke or Parkinson’s disease
• The use of some medications that can interfere with bladder function

Mixed incontinence is when an individual experiences a combination of incontinence types. Most commonly, women will present with both stress and urge continence.

5. Fistula related Incontinence

Fistula incontinence occurs when there is an abnormal connection between two organs. This happens most frequently with the connections formed between the bladder or urethra and the vagina. It is an uncommon condition in developed countries. However, it can occur after surgical trauma, obstetric trauma, pelvic cancer or pelvic radiation therapy. The following symptoms may be experienced:

• Continuous urine leakage
• Leakage with coughing, sneezing, or a rise in abdominal pressure
• Uncontrollable leakage

Some or all of the following tests are used to confirm the existence of urinary incontinence:

MSU

Mid-stream urine testing (MSU) is used to check for bladder infection (cystitis). Urine is collected midstream in a sterile container and tested for possible infection. If an infection is present then appropriate antibiotics are administered to manage the type of infection. Often, antibiotics are started before the test results are available especially if the symptoms present are highly suggestive of a bladder infection.

Bladder Diary

Many urinary problems develop over a long period of time. A bladder diary takes a period of 2 - 3 days and records the fluid intake, time and volume of urine voided, number of leakages, the amount leaked and the activity during which the leak was experienced and whether there was an urge. This can be very helpful for the doctor to determine the exact cause of your incontinence. You can find a sample of a bladder diary here.

One hour pad test

The one hour pad test is used to measure the loss of urine and can be performed at home. It involves weighing a pad, wearing the pad and performing a series of activities that can induce a leakage. At the end of the tests the weight of the pad is recorded again to determine how much urine has been leaked. Any type of pad can be used. First measure the initial weight of the pad in a plastic bag and at the conclusion of the test record the weight of the pad in a plastic bag again. You can find a template to record your results here.

Dye test

This test is used as an outpatient if there is any suspicion of a fistula causing the incontinence. In this test, the doctor will insert 3 small swabs inside the vagina and then fill the bladder with a non toxic dye. You will then be asked to walk around for half an hour. At the end, the doctor will remove the swabs one by one to check for any dye staining in the swabs. If there is a fistula, the dye will escape through it and stain the swab.

Urodynamics

Urodynamics is a way of testing the functions and behaviours of the bladder and urethra. It requires the placement of a very small tube in the bladder and another tube in either the vagina or rectum. Sterile fluid is then used to fill the bladder so that the behaviour of the bladder as it is getting filled can be determined. This type of testing should not be painful. The catheters are very small and an anaesthetic gel may be used if it is required.

Cystoscopy

Cystoscopy is a method of looking inside the bladder. A numbing gel is applied in the urethra and a small telescope is passed into the bladder. Sterile fluid is then used to fill the bladder and the doctor can see inside making sure there are no abnormalities.

The treatment of urinary incontinence depends on the type of incontinence and the severity of it. The various modalities available for treatment are lifestyle changes, bladder retraining, physiotherapy or medications and surgery.

Lifestyle changes:

The following lifestyle changes may be of help for some women.
Bladder retraining:

• Drink 6-8 cups (2 litres) of fluids a day. More than this is excessive.
• Avoid drinking anything within 2 hours of going to bed.
• Limit caffeine intake to 3 cups per day or switch to decaffeinated if the urgency or frequency is bad
• Avoid ‘just in case’ visits to the toilet
• No straining or ‘hovering’ over the toilet. Lean forwards when passing water with feet flat on the floor and elbows resting on knees
• Limit alcohol intake
• Ensure good bowel habits all your life. Avoid constipation by following a healthy diet.

The aim of this training is to increase the duration between the voids and also to increase the bladder capacity. This is done by delaying the urge to void using urge control techniques like perineal pressure, sitting down, pelvic floor muscle squeezing and toe curling. Dr. Kannan will be able to discuss this further with you.

Pelvic floor muscle exercise:

This helps to strengthen the pelvic floor muscles that surround your bladder, urethra and anus. You will be asked to squeeze these muscles as if you are trying to stop flatus passing through or passing urine. You should try and hold this contraction for 10 seconds. You may not be able to do the 10 seconds straightaway but you should be able to gradually increase the time. You should relax the muscles completely after each contraction. If you do 10 contractions at a time for 4 times a day, you will see the improvement in about 4 – 6 weeks. If you have difficulty identifying the correct muscles or unsure about how to do it, you may need to see a physiotherapist. Your doctor should be able to refer you to a physiotherapist.

Medications are useful to manage certain types of incontinence such as urge incontinence. Medications act by controlling the over active bladder muscles thereby reducing the urgency and frequency. They also have some side effects like dry mouth, dry eyes, and constipation. Dr. Kannan should be able to discuss the suitability of the medications with you.

Most women will see improvement after corrective surgery. There are two major types of surgical options available namely urethral slings and colposuspension. A surgical incision can be made in the abdomen or vagina either by an open method or by using minimally invasive techniques such as laparsocopy to perform corrective surgery. Dr. Kannan will consider several factors such as your age, lifestyle, possiblity of hysterectomy, pressence of other relevant medical history or conditions and your general health among other things to determine which surgical approach is right for you.

Some of the surgical options involve the use of several types of slings. Each have their own advantages and disadvantages. No one sling is suitable for everyone. Some of the slings available are Tension free Vaginal Tape (TVT), transobturator sling (Monarc), and minisling (Miniarc and Miniarc Precise).

Where necessary, Dr. Kannan will also be able to combine surgical procedures to produce the best results. For example, it is often possible to correct a pelvic floor related problem while performing a procedure to fix a stress urinary incontinence.

While surgery is an option for some types of incontinence like stress urinary incontinence, not all women are suitable for surgery and Dr. Kannan should be able to discuss this with you.

Bulking agents – This is used for women with a weak urethra. A substance is injected into the urethra to make it bulkier and stronger. This minimises the leakage of urine.

REMEMBER – Urinary incontinence is a common problem and is easily treatable most of the times. Do not hesitate to seek help.