Female Incontinence

What is Incontinence?

Incontinence is the involuntary leakage of urine. This is a very prevalent condition affecting women.

How prevalent is this problem?

The prevalence of urinary continence raises from about 16% at the age of 30 to 50-84% in elderly patients in long term care facilities. At any age, this is more common in females than in males.

What are the types of urinary incontinence?

1. Urge incontinence: This is the leakage of urine accompanied by uncontrollable desire to pass urine. This is usually caused by over activity or irritation of the bladder caused by different conditions. Over active bladder is diagnosed after other conditions causing such symptoms are ruled out. These conditions may include: infection, inflammation, stones and bladder tumours. For further information on over active bladder please click over active bladder.

2. Stress urinary incontinence: This is involuntary leakage of urine during situations of increased pressure in the abdomen caused by coughing, sneezing, laughing, effort and excretion. This is due to the weakness of the muscles that support the bladder in position. These muscles are located in the lower part of the pelvis and are called pelvic floor muscles. These muscles are damaged or weakened by pregnancy and childbirth.

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However, the stress incontinence usually does not manifest until well into the 40’s even though the weakness would have occurred much earlier in life due to pregnancy and childbirth. This is because of the progressive weakening of the body’s supporting tissue called collagen, which tends to occur during the late 40’s for a woman when she goes into menopause.

3. Mixed Incontinence: This is the combination of both stress and urge incontinence and the combination could be to varying levels. Usually it is the leakage of urine during coughing and straining associated with severe urgency (uncontrollable desire to pass urine) or urge incontinence.

4. Functional incontinence which is the inability to hold urine due to reasons other than any problems in the urinary tract or any neurological conditions. This usually occurs in conditions of delirium, psychiatric disorders, urinary infections and reduced mobility.

What should I do if I think I have any of these types of incontinence?
The first thing to do is to consult with your doctor to look for the correctable temporary cause of these leakages and also to find out what type of incontinence you have. The treatment depends of the type of incontinence. As mentioned above, sometimes the different types of incontinence can be present in one person (called mixed incontinence).
What tests will I have?

Urine Tests: Your doctor may do tests to rule out any other significant conditions that might affect your bladder and may present with incontinence. This could start with a simple urine test (urine dipstick test) or lab tests by microscopy. This will show if there is any blood cells, white cells or any other abnormal cells or substances (like glucose, proteins and nitrites) which could indicate the presence of various diseases.

Bladder Diary: You doctor may ask you to fill out a bladder diary (frequency volume chart). This is a very useful tool to document the volume of urine you pass and also the timing of urination indicating the presence or absence of any leakages. Usually this is done over a three day period which will give your doctor a clear idea about the severity and the nature of your problem. This chart or diary is very useful to diagnosis some disease conditions which might result in excessive volume of urine production.

Specialist Investigations: If you doctor finds any substances like blood in the urine by testing, he/she may refer you to a urologist. A urologist may carry out special tests as listed below:

  • Cystoscopy – this is an examination of the bladder through an endoscope and a camera. This helps to rule out any significant conditions like tumours or stones in the bladder and also any other abnormalities in the bladder.
  • Urodynamics – this is a specialised test to assess the function of the bladder. This includes passing a fine tube through the urethra into the bladder and another fine tube through the anus into the lower part of the bowel. These fine tubes will have electronic pressure sensors (transducers). With these too very fine tubes in place, when the bladder is filled with water and these fine lines will measure the pressures inside the bladder, as well as in the abdomen. This will help your urologist to diagnose the type of problems you may have in your bladder. You may be asked to cough and/or strain during this test to measure at what pressure you leak. This is the diagnostic test which is done prior to consideration of any invasive surgical treatment for incontinence.

How is incontinence treated?

The treatment of incontinence is entirely dependent on the type of incontinence, as indicated below:

Urge Incontinence

The treatment of urge incontinence is commenced once the diagnosis is confirmed. Once the diagnosis of over active bladder is conformed, this is treated by lifestyle changes, bladder retraining and pelvic floor exercises to control the urgency.

Medical treatment

A certain group of medications called antimuscarinics are also helpful to slow down the bladder and reduce the urgency. However the bladder retraining is the mainstay of the treatment. This means to increase the intervals between the visits to the toilet to pass urine. This can be done gradually from the current state by small increments of one-half hour to achieve a maximum of three to four hours between the times of urination.

Surgical treatment

If the conservative treatment options fail, the surgical treatment options would be: Overactive Bladder Surgical Treatment Options:

  • Injection of Botox into in the bladder
  • Sacral neuromodulation
  • Posterior tibial nerve stimulation

Stress Incontinence:

The treatment of stress incontinence is mainly by increasing the resistance at the urethra or support the urethra by different means. Conservatively, it is done by regular pelvic floor exercises to strengthen the pelvic floor muscle thereby increasing the resistance at the level of the urethra and reduce or prevent the leakages associated with coughing and straining.

How can I perform pelvic floor exercises?

To do the pelvic floor muscle exercise, the first thing to do is to identify these muscles. These are the muscles that you would be contracting to stop breaking wind or stop urinating. You will need to contract those muscles in sets of 10 - 20 many times a day achieving a total of 60 – 80 contractions per day. Once you have mastered the ability to contract these muscles you could contract and sustain for a few seconds and release which is called ‘slow contractions’ and to contract and release quickly called ‘fast contractions’. If you could achieve this level of contractions and maintain 60-80 contractions per day you are likely to see improvement in your stress incontinence. After mastering the ability to contract these muscles, at your voluntary control you may contract your pelvic floor muscles before the situations of vulnerability like coughing, laughing and straining. What you would do in the situation (for example just before a cough) is to pull your pelvic floor muscles up by contracting them and cough (or sneeze or laugh) which could avoid the situations of leakage. This is called KNACK manoeuvre.

What treatment will I receive if I am unable to get enough improve with pelvic floor exercises (rehabilitation)?

If you continue to have bothersome leakage after sufficient pelvic floor exercises your urologist would give you an option for surgical treatment for stress urinary incontinence. He or she is likely to carry out the Urodynamics test. The surgical treatment options are:

Insertion of tension free vaginal tapes or mid urethral slings (these are the slings which are inserted to support the mid part of the urethra and increase the resistance at the level of the urethra and cure or prevent stress leaks) or a procedure called colpo-suspension. The slings used can be synthetic slings or natural slings (made from tissue in your body – tissue taken from the side of the thigh or sheath covering the long muscle in the abdomen). However, now days are artificial slings made from polytetrafluoroethylene (PTFE) is used.

These tapes can be inserted in two ways:

Retro pubic (tapes are inserted from behind the urethra and they loop around the urethra and come behind the pubis).

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  • Transobturator tape are inserted from the inner part of the upper most thigh and stretch across to the other side just behind the urethra parallel to the front wall of the vagina.
  • In general the success rates of both types of tapes are relatively the same. The retro-pubic tapes have slightly higher success rates those they have slightly increased complications of bladder injury during the insertion of the tapes and also slightly higher rate of having to use a catheter to empty the bladder following the tape operation. Transobturator tapes have a slightly reduced risk of causing obstruction of the urethra requiring subluxation. For further details about tension free vaginal tapes please click here.

Mixed Incontinence

In patients suffering with mixed urinary incontinence, the predominant condition will be treated first. Usually one would start with conservative treatment which would include bladder retaining, lifestyle changes, pelvic floor exercises and also treatment with medication which can all be done at the same time. When we proceed to the invasive treatment the most bothersome problem will be treated first.

Functional Incontinence

Treatment of functional incontinence depends on the underlying problem. If someone is leaking because of dementia or delirium they have to be taken to the toilet regularly by clock before they start to leak. If someone is leaking due to immobilisation they could be offered ways of managing it by using a long term catheter.

Other Methods of Treating Incontinence

If patients are not suitable for medical or surgical treatment of incontinence or if they fail such treatments the final result would be to use containment products like pads or resort to an indwelling long term catheter.

What types of catheters are available?
If one resorts to a long term indwelling catheter, particularly for women, it would be preferable to have suprapubic catheter. This is catheter which is inserted through a lower part of the abdomen directly into the bladder. The advantage of this type of catheter is that it does not carry the problem of the catheter coming through the urethra and it is easy to maintain hygiene and care for the catheter. It also reduces the risk of damage to the urethra that can happen with a urethral catheter, especially in women, if they decide to have a long term catheter. Of course suprapubic catheter is done by a surgical procedure which includes the complications of requiring an anaesthetic and bleeding, infection or injury to other organs like the bowel and blood vessels at the time of the procedure.

 

Click here to download Vaginal Sling (Tapes) operations for Stress Urinary Incontinence Information for patients