Urinary incontinence is a condition that affects both sexes, although it is twice as common in women and becomes more common with age
Urinary incontinence is the unintentional passing of urine. It is a very common problem and is thought to affect millions of people worldwide.
Urinary incontinence is a condition that affects both sexes, although it is twice as common in women and becomes more common with age.
The bladder stores urine and is supported by the muscles of the pelvic floor. The urethra is the tube that runs from the bladder to outside the body. Some of the pelvic floor muscle wraps around the urethra to help keep it closed until you need to pass urine. When the bladder is full a signal is sent to the brain. The brain then tells the pelvic floor muscles to relax to open the urethra and the muscles around the bladder (detrusor muscle) to contract and push the urine out. Urinary incontinence can occur if there is a problem in any part of this mechanism.
The symptoms depend on the type of the incontinence. The two most common types of urinary incontinence are responsible for 90% of cases:
It is possible to have a mixture of stress and urge incontinence.
Stress incontinence is usually the result of weakened or damaged muscles used to prevent urination, such as the pelvic floor muscles and the urethral sphincter.
Causes of a weakened sphincter and pelvic floor muscles could include:
Urge incontinence is usually the result of over activity of the detrusor muscles, which control the bladder.
Reasons for the detrusor muscles contracting too often may not be clear, but could include:
Most incontinence is a result of stress or urge incontinence or sometimes a combination of both.
Risk factors that increase the chances of urinary incontinence developing include:
Other less common causes include:
Stress incontinence occurs when urine leaks from the bladder under sudden extra pressure e.g. coughing. Other activities could include sneezing, laughing, heavy lifting and exercise. Usually small amounts of urine are passed, although if your bladder is very full large volumes may be passed involuntarily.
In urge incontinence you feel a sudden and very intense need to pass urine and you are unable to delay going to the toilet. A sudden change in position or the sound of running water may trigger the need to pass urine. Urine may also be leaked during sex, particularly when you reach orgasm. With urge incontinence you may get up several times during the night to urinate and may pass urine frequently in the day.
In mixed incontinence you may experience a combination of the above symptoms e.g. leakage of urine when sneezing but also experiencing extreme urges to urinate.
Overactive Bladder syndrome (OAB) is similar to urge incontinence in terms of urgency and frequency in passing urine. However many people with OAB do not experience incontinence.
If you have any symptoms of urinary incontinence, see your GP so the type of problem can be determined.
Your GP (General Practitioner) will take a careful history to make an assessment. He/she will want to determine:
Your GP will suggest keeping a bladder diary over a 2-3 day period, recording times you pass urine and all episodes of incontinence/leakage. Episodes of urgency should also be recorded. The diary should include how much fluid and the type of fluid consumed.
Tests and Investigations:
•Urine sample dipstick testing - to check for signs of infection.
•Physical examination- to assess the pelvic organs, vaginal tissues and feel the bladder.
•Bladder ultrasound scan- to determine if the bladder is emptying fully or if there is residual urine.
Following this, a referral may be made to a specialist who will perform additional tests:
Most cases of incontinence can be simply treated. Urinary incontinence is no longer a condition with which women have to suffer in silence. There are plenty of options available and most treatments do not involve any surgery at all.
Treatment depends on the type of incontinence you have.
Conservative treatments are tried first:
Thereafter medication and surgical measures can be considered.
Lifestyle changes include – decreasing caffeine consumption, maintaining a health body weight and keeping fluid consumption to 1- 1,5 litres per day (too much or too little can affect the urinary tract).
Pelvic floor muscle training – your GP may refer you to a specialised nurse or physiotherapist so they can assess the strength of the pelvic floor muscles and prescribe an exercise program.
Exercises should be performed regularly – doing a minimum of 8 contractions 3 times a day for at least 3 months
Studies from around the world show that conservative treatment, such as pelvic floor muscle training can improve stress or mixed urinary incontinence in women by two-thirds.
Additional techniques may be used with pelvic floor training to increase their efficiency:
Vaginal Cones- Weighted cones are inserted into the vagina and muscle tone is increased by holding them in place for a given length of time. You can then progress to the next cone which weighs more.
Biofeedback- this can help to monitor the progress of pelvic floor exercises . A small probe in the vagina or external electrodes provide feedback to a pressure meter. Some studies have shown that this may not improve the incontinence but some women find the feedback motivating.
Electrical stimulation – through a small probe in the vagina can help strengthen the muscles further while performing the exercises
Bladder training –
This is useful in urge incontinence. If you have stress or mixed incontinence bladder training can be prescribed in conjunction with pelvic floor muscles strengthening. Bladder training involves slowly increasing the length of time between feeling the need to pass urine and emptying the bladder. Keeping an accurate bladder diary is important in bladder training. This course of treatment usually lasts for about 6 weeks.
A variety of medications can be used for the different types of incontinence. Medications can have side effects and need to be monitored. Your GP would need to assess which medication was appropriate and safe to use taking into consideration your medical history.
If other treatments are not successful surgery may be considered. If you plan to have children this will affect your decision as the strain and physical pressure increase in pregnancy and childbirth may cause surgical treatments to fail. Many women therefore wait until they have completed their families before having incontinence surgery.
Sling procedures – an incision is made in the abdomen and a sling is insterted to support the bladder. The sling can be made from tissue elsewhere in the body and in the long term can be an effective solution for stress incontinence.
Colposuspension – can be used for stress incontinence. Stitches are placed through the bladder to hold up the bladder neck. This can be done through a large abdominal incision or laparoscopically through smaller abdominal incisions. A specialised surgeon is required for the laparoscopic approach hence the National Institute for Clinical Excellence (NICE) does not recommend this approach as a routine procedure.
Urethral Bulking - a substance is injected into the walls of the urethra. This is done in order to increase the size of the urethral walls and therefore allows the urethra to stay closed with more force. You may require repeat injections as the efficacy wears off over time. This option is less invasive but less effective in the long term than other surgical procedures.
Tape procedures – are used for stress incontinence. A piece of tape is inserted behind the urethra trough a small incision in the vagina. This tape provides the urethra with support. There are two techniques used with various pros, cons and risks associated.
Botulinum toxin A (Botox) - injections into the bladder muscle can be used to treat urge incontinence and overactive bladder syndrome (OAB).
The incontinence may improve after the injections, but you may not be able to pass urine normally, so you will need to insert a catheter (a thin, flexible tube) to drain the urine from your bladder.
Botox is not currently licensed to treat urge incontinence or OAB, so you should be made aware of any risks. The long-term effects of this treatment are not yet known, but it may be of benefit when other treatments have not worked.
Sacral and posterior tibial nerve stimulation, augmentation cystoplasty (making the bladder larger) and urinary diversion (the tubes running to the bladder from the kidneys are redirected outside of the body).
In some types of incontinence catheterisation may be needed. This can be done as:
Used to empty the bladder at regular intervals and so reduce overflow incontinence (also known as chronic urinary retention).
A continence adviser will teach you how to place a catheter through your urethra and into the bladder. Your urine will flow out of your bladder, through the catheter and into the toilet. It can also be used as a short term treatment for some types of incontinence to rest or re-train the bladder.
Long term catheterisation:
In some cases, a longer, indwelling, soft rubber tube sits inside the urethra and bladder with a bag attached to continuously drain the bladder. Long term catheterisation is only used in specific cases and usually when other treatments have not been successful. It also may be used temporarily after abdominal surgery to rest the bladder after an operation.
There are several changes that women could consider making to their everyday lifestyle to help prevent bladder incontinence.
Diet- include plenty of fresh fruit, fibre, vegetables and wholegrain cereals in the diet to avoid constipation.
Hydration- drink 6-8 glasses of liquid (1-1,5 litres) every day to keep the bladder flushed and working efficiently. If you pass a lot of urine during the night you should drink less in the hours preceding bed time, provided you keep your total consumption of fluid the same.
Alcohol and Caffeine- reduce the intake of alcohol and caffeine such as tea, coffee and cola, as alcohol and caffeine dehydrate the body and force the kidneys to produce more urine which irritates the bladder.
Exercise- keeping active helps prevent obesity and strengthens muscles. If you are pregnant it is important to keep the pelvic floor muscles exercised daily.
“Not sure when it first started but it was just the odd leak when I coughed or laughed. This continually increased and I could feel myself leaking when I was walking the dog. I was very self-conscious of the fact I was leaking and would worry that people could smell urine on me. The more I leaked the more often I went to the toilet, I would just go sometimes for the sake of going it was getting that bad.
I always wore a panty liner but was finding this becoming more wet and had to change half way through the day.
When these started to become wetter throughout the day I began to get worried so I made an appointment at the doctors. The doctor suggested that I should try doing pelvic floor exercises. Well I tried and believed I was doing the right thing only the leaking was becoming worse so I advanced to lady’s pads for leaks.
I love to swim and on our last holiday I was just unable to sit by the pool in a swimsuit so I would get changed, then hurry to the pool and swim and then change because I just couldn't go without a pad. There were times when I have had to change my clothing or woke in the morning to find a wet patch in the bed because the pad has become so wet.
The doctor referred me to the hospital and arranged for me to see a physiotherapist at the Continence and Urology Clinic. I couldn’t believe that I was suffering from incontinence as I was only 50, and thought that this is something older people suffer from. I went to the hospital where they checked how much my bladder held and how much I was leaking and due to the weakness of the muscle around the bladder I was informed that an operation would be necessary.
Whilst waiting for the operation I attended physio where they told me how to do pelvic floor exercises correctly. I had to do flow charts showing what my fluid intake was and how often I went to the toilet and how much urine I was passing. I was told that I was drinking too much coffee which can cause irritation to the bladder and I should consider trying more fruit juice and water or if I did want coffee to change to decaffeinated.
Finally I was given my operation date for January. The operation went well, friends that came to see me couldn’t believe that I'd been to hospital as I looked so well. The difference has been incredible and even more noticeable because I have recently had a bad cold and had no leakage at all.
I have felt really great since the operation - I was told it would take about 6 - 12 weeks for recovery and 4 weeks before driving again.
It's taken a few weeks but I now don't have to go to the toilet so often. The operation has been 100% successful as far as I am concerned".
Urinary incontinence is no longer a condition with which you have to suffer in silence. The sooner you speak to a GP about your particular experience, the sooner a solution can be found. There are plenty of options available which will almost certainly improve your quality of life and most treatments do not involve any surgery at all.
If you would like to tell us your story so we can help and inform other women; there is more information available HERE
This interview was recorded in February 2009.
Welcome to Wellbeing of Women’s health podcast. 1 in 3 women in the UK will have a problem with incontinence at some point in the adult lives. This is a particularly high statistic and is the reason why this month we will be focussing on bladder conditions and in particular incontinence and cystitis.
We are joined by medical expert Suzy Elneil, a Consultant in Urogynaecology and Reconstructive Pelvic Floor surgery. Suzy has helped many women who have suffered with severe bladder conditions and is here to explain what we can do to prevent getting a bladder condition ourselves.
Thank you so much for joining me today, for a topic which, really, many people don’t want to talk about. Why if the statistic is so high are people so embarrassed to talk about incontinence?
Well, incontinence is a problem that for many many years has been really a social taboo subject, mainly because nobody wants to admit to leaking in public or discussing it openly to friends and family. It is an embarrassment, it is a condition which socially deprives many patients and many women will tell you that it affects their working life, their home life, their family life, their social life, their exercise, in fact every aspect of their life and many will not want other people to know about it because they associate it with getting old and actually being in, well, not having control of their body and so it’s something many people do not wish to admit to.
And can you explain what incontinence is exactly and why it happens?
Well, urinary incontinence is a problem that affects the bladder and what happens is that the bladder fails to function in a normal way. The main role of the bladder is to store urine and then under voluntary control, that is when you are ready to go to the toilet, it should empty. However, this whole mechanism is quite intricate and requires in place support muscles, it requires an intact bladder, and intact pipe coming out of the bladder or urethra and an intact neurological system to make it work. If any of these are damaged for any reason, then the bladder doesn’t work properly and you leak urine and it’s not a condition that is always easy to predict because there are certain situations which make it worse but when it happens it can be quite debilitating.
Now, there are different types of incontinence aren’t there? I understand that stress incontinence is the most common. What causes that particularly and what are the symptoms?
Well, stress incontinence is a condition where the bladder neck support of the whole system is compromised and the typical example is in women who have had babies. During the childbirth process there is slight damage to the structures in place and as a result the bladder neck prolapses slightly and therefore if you cough or sneeze or laugh or indeed just walk fast, the bladder is unable to hold onto the urine and the urine comes out. It is a very common problem, so much so, that in antenatal classes patients are always advised to do physiotherapy in order to try and prevent it happening in pregnancy and after childbirth so that’s the commonest form of incontinence that we see.
There is another condition known as an overactive bladder or urge incontinence or some people will give it a different term such as urgency incontinence or detrusor overactivity where the problem doesn’t lie with the support mechanism and structures of the bladder, the urethra, but in fact in the bladder muscle itself. The bladder muscle for some reason becomes hyperactive and in the process does not relax appropriately when the bladder is filling with urine. As a consequence, the bladder muscle will contract and you’ll have no control over this and you will passively leak. A lot of women will say they get a sudden feeling of urgency but by the time they get to the toilet they’ve already leaked. So this is another distressing form of incontinence.
So how can the doctor actually diagnose which type of incontinence you are suffering from?
The diagnosis is really based on taking a very good history. We do, do quite a lot of fancy tests but actually taking a very good history helps you a great deal. So if a patient says, I only leak when I jump or if I’m catching a bus or climbing the stairs then there is a strong possibility that the problem she has is stress incontinence. Whereas the patient who says to you, I was sitting at the table having my dinner with my family or I was sitting in front of the television and suddenly I felt myself wet, that’s a different form and we think that’s probably likely to be urge incontinence. So this is sort of a broad view of how they can present but generally a good history will give you an idea of the condition.
Now, many women think that incontinence is untreatable or can’t be cured. Is this true?
No, a lot of incontinence actually is treatable and this is the sad fact that a lot of women think nobody can do anything about it anyway so I’ll just put up with it now perhaps one of the stories I find the saddest is a lady I met in her eighties in a special continence forum group who had been incontinent for over twenty years and was just using pads and special underwear and she had it in her head that incontinence was not only part of aging but that there was no alternative but to use pads and to wear these special continence form of underwear and it was quite a remarkable feat to encourage her to come in and be investigated and she was able to go onto medication and was pad free for the first time in over twenty years so there is this misconception that if you’re old you’re going to get it, if you get it the only option may be interventional surgery which is not the case and therefore a lot of women would prefer not to even discuss it. So it’s really avoiding the medical profession, the nursing profession, the physiotherapists because a lot of women feel they can’t get any help.
You just said that there is this perception that incontinence is something only old people will get, is it something that young people can totally forget about and not worry about?
Not at all, there are a lot of studies that have shown, that young women, in particular women in university who have been part of big surveys and studies actually admit to incontinence on occasion. And some people will tell you that actually it happens when they are about to have their period and immediately during their period time suddenly they find it very difficult to hold onto their urine. Others will tell you that when they do high impact sports they leak, and these are young, fit women who have not had children, who have not had any damage to their pelvic floor and yet they are still having similar problems to women later on in life. So age is not really a factor, it is true that the older you get the more likelihood you are going to have a problem but it does not mean that if you are in your teens or twenties you may not get incontinence. It affects women of all age groups.
So what advice can you give to help prevent incontinence?
Well, if you look at some of the work that has been done in the Netherlands in particular, they actually start young girls on pelvic floor physiotherapy exercises from puberty onwards and it’s become part of their psyche. So pelvic floor physiotherapy not only helps stress incontinence but it helps all other forms of incontinence. By strengthening the support structures of the bladder then chances are you will prevent getting significant incontinence. You may have a little leak every now and then but it will certainly be better than what you would have had, had you not done the profalactic, as it were, treatment.
What about women who already suffer from incontinence, is there anything they can do?
I always come back to very basic things. Working out what you drink, for instance, we all like our cup of coffee or tea in the morning but caffeine is a fairly nasty substance to the bladder. It can make the bladder become more urgent and frequent for a lot of women so just generally changing products to decaffeinated products for instance. Reducing the amount of drink that you take in, that doesn’t mean you become thirsty but if you are drinking 4-5 litres of fluid a day maybe reducing it down to 3 litres a day would make a difference to the frequency, the urgency and the loss of urine. And of course, physiotherapy is always helpful and I would usually recommend that women seek the help of a women’s health physiotherapist who are dedicated specialists to the pelvic floor.
That’s great advice, thank you very much.
Welcome back. Cystitis is another common bladder condition affecting 1.7 million women in the UK each year.
Suzy, what is cystitis and why are women more likely to get it than men?
Well, the actual definition of cystitis is an inflammatory process in the bladder but commonly women believe it is an infection in the bladder. We tend to sort of separate an infection by calling it a urinary tract infection and cystitis is generally a symptom of a sense of frequency so a lot of women are going to the toilet quite a lot, they have urgency, an uncontrollable urgency so often they will leak as well and often it’s also associated with a degree of pain or discomfort or a feeling of pressure in the vagina. So, it’s a sort of a complex of symptoms but it’s much more common in women than in men for a specific reason. It is believed the shorter urethra, that is the pipe coming out of the bladder, actually predisposes women to more infection than it does to men. Also, the closeness of the urethra to the peri-anal or anal region also increases the risk of getting an infection or an inflammatory response in the bladder. So there is the anatomy that is a feature and then of course with all the problems that women get following childbirth or if they’ve had any sexual intercourse and so on, all of that also affects the urethra directly and therefore affects the bladder. So there are lots of reasons why women can get cystitis and at different phases of our life you are more likely to get it than at other phases of your life.
And are there different types of cystitis or is it just one common condition?
Well, you can have a cystitis without infection, so you can have an acute cystitis where there is a bacteria present so you can have a chronic cystitis where the bacterial presence is not picked up but you have still got the symptoms. You can have what is known as acute or chronic cystitis, you have an underlying problem but intermittently you get an acute infection on top of it. You can have a condition which is known as interstitial cystitis but that’s a whole other ball game. So there’s a whole group or host of diseases that you can suffer in that region which are of an inflammatory nature.
And is there one general treatment for cystitis as a whole or would each of those require their own separate treatments?
Generally, very simple measures would be increasing the amount of fluid you take at a time, it helps to flush out the system and a substantial proportion of women will actually respond to something as simple as that. In some women where it has become more of a chronic state, we sometimes recommend they take cranberry juice extract in the form of powder that you can get in the form of sachets from your nearest chemist or tablets from various shops and that helps to reduce the stickiness of the bacteria to the surface of the lining of the bladder and therefore reduce the chance of you getting the infective cystitis or an acute or chronic state. So there are a few measures you can take. The other things that I usually recommend are simple things such as washing after you pass urine so you reduce the bacterial load on the skin and therefore the susceptibility of getting an infection and also after passing a motion, cleaning the whole of that area with water and gently cleaning it up so that also reduces the chances of getting an infection. So there are lots of very simple measures you can institute that can reduce your chance of getting an infection.
What about drinking pure cranberry juice, does that actually make a difference?
Well, there’s a theory that pure cranberry juice is the answer for a lot of women but pure cranberry juice invariably to make it drinkable usually has quite a lot of sugar. It is quite a tart drink so it depends on the juice but the common commercial available cranberry products often have quite a large amount of sugar and sugar is very attractive to bacteria so the jury is really out as to whether cranberry juice per se is the answer or whether one should really stick to the cranberry juice extract preparations because they are much more likely to have a beneficial effect.
I read somewhere that the type of underwear you wear can make a difference, is that true?
There is a theory that with the advent of the thong, a few years ago now, that this actually contributed to an increase in urinary problems because of the urethra being crushed with the way the undergarment is worn because there is a significant pulling effect so there isn’t a supportive effect per se, there’s actually a pulling and crushing effect on the urethra. So one of the suggestions was that women who wear thongs and had problems like this should discard them and go back to wearing those old supportive pants.
There’s also a perception that you can catch cystitis from using public loos is that true, or is that something that’s become a bit of an old wives tale?
I think it’s one of those things that, as you well know with many women when they go into a public facility, they find it very difficult to sit down on a toilet and so on so, and so they’ll tend to hover over the toilet but in fact sometimes, hovering over a toilet seat may not be appropriate because the splash back is quite a problem for some women. I do think it is an old wives tale, it’s unlikely you’ll get it but a lot of women never the less will probably still avoid a public toilet if they can and try hard not to sit on the seat.
So is there anything you can do to try and prevent getting cystitis in the first place or is it one of those things that will affect you at some stage in your life?
I think there’s no doubt that every woman at some point in her life will get one or two attacks of cystitis. The easiest thing is just to maintain a healthy diet, drink plenty of fluids and in particular water based drinks. Making sure that after you use the toilet to use some sort of water facility to help cleanse the area and generally that will prevent you from getting cystitis.
And finally, what advice would you give to someone suffering from a bladder condition whatever it may be?
I think you can always start off with very simple things, such as if your symptoms are things like frequency and urgency, you can monitor what you drink and what you actually drink, that in itself is very helpful. Once you’ve looked at that you can then consider alternatives such as changing your habits and trying to make sure you can hold on as long as you can. Testing your, what we call the mid-stream urine test which a lot of women were taught which is hold onto your pelvic floor as you’re passing urine and see if you can stop the urine flow. So practising your own form as it were, of physiotherapy, all of those are preventative strategies. But after a certain point it is very difficult to get the response you wish and it is at that stage you probably ought to seek help. You need to chat to your GP and see what advice they can give to you locally and a lot of GP practices are affiliated with physiotherapy practices so they can get you seen locally by your physiotherapist and I would normally suggest a period of at least six months of active physiotherapy and if then you still have a problem then it is a good idea to go and see a specialist and fortunately in the UK, there is a whole host of colleagues who work in urogynaecology and reconstructive pelvic floor surgery who will be happy to see you, assess you and then offer you other forms of therapy which could include medication which a lot of people get surprised about because they don’t always believe a tablet could make such a difference but that’s maybe all that they need and very rarely you may need some form of surgery and often it is minimal surgery. It’s not like the old days when you needed to have big, open operations. A lot of the surgery is what we call day case procedures and many patients will be up and out and back to normal working life within a week. So, it’s not as bad as people think now, it’s much, much better, so try it on your own first, if it doesn’t work, have a chat with your local GP and physiotherapist and if after that you feel you need to come further then come and see us at the hospitals and we’ll see what we can do to help you.
That’s great, thank you very, very much
It’s been very insightful and I’m sure it’s helped lots of women out there who’ve had lots of questions on their minds so thank you.
You’re welcome Ali, it’s a pleasure.
Seldom talked about and often believed to be an incurable condition, incontinence dominates some women's lives but this needn't be the case.
Discover the truth behind some of the myths surrounding this topic.
Incontinence is a “natural” part of ageing
It is not by any means a ‘natural’ part of ageing, incontinence can affect women of all ages but is commonly associated with ageing.
People who are healthy and in good physical shape do not become incontinent
Incontinence is affected by several factors, including childbirth, ageing, surgery; so good health helps but does not exclude one becoming incontinent.
I’m too old to do anything about incontinence
You are never too old, the oldest woman I have treated is 91 years old.
Women who haven't had vaginal births don't have to worry about incontinence
Pregnancy alone with or without caesarean births can still lead to incontinence.
Incontinence can’t be cured
Yes it can, often using simple interventions.
To find out about our research follow these links:
Page last updated January 2013