Urinary incontinence

Urinary incontinence, also sometimes called bladder leakage or bladder control problems, is when you accidently leak urine or lose control of your bladder. Some people have just an occasional, small leak during certain activities, but others have more significant bladder leaks that can cause self-consciousness to the point they avoid going out.

Urinary incontinence is very common and affects women more often than men. It becomes more common with age, but isn’t a routine part of ageing and should not be thought of as such.

See your doctor if you have any unexpected leakage, to work out the underlying cause. Don’t be embarrassed or reluctant to talk about problems with urinary incontinence - it is a treatable condition, so talk to your doctor about what can be done.

Symptoms

Symptoms vary according to the type of incontinence you have. Severity also varies from light bladder leakage to complete loss of bladder control.

You may experience increased frequency (needing to go more often than usual to pass small amounts of urine) or urgency (feelings of a strong and sudden desire to urinate and sometimes being unable to hold on).

Having to pass urine several times during the night is known as nocturia.

Many people simply find that they leak urine (often just a small amount - sometimes called light bladder leakage) with certain activities including exercise or even just when laughing or coughing.

Some people have the feeling of not having emptied the bladder even though they've just urinated. They may also experience difficulty starting to urinate (hesitancy), weak urine flow and dribbling. These problems are common in men who have an enlarged prostate.

Causes of urinary incontinence

Your bladder is a balloon-like organ that expands to hold about 450 mL of urine. It can usually hold urine comfortably for about 2-5 hours. Muscles called sphincters stop the urine from leaking by closing tightly around the neck of the bladder. Your pelvic floor (muscles, ligaments and tissue that help support the bladder from below - like a sling) also helps with bladder control.

When you urinate, the bladder muscles tighten to squeeze urine out of the bladder and the sphincter muscles relax to release urine through a tube called the urethra. Urinary incontinence may occur when illness or injury interfere with either part of this process - storing urine or passing it (voiding).

Any one of the following factors may be involved in urinary incontinence.

  • An infection of the urinary tract (urinary tract infection - UTI, or bladder infection) can irritate your bladder and lead to temporary urinary incontinence. Many people with UTIs complain of frequently needing to urinate, and urgency, which can result in bladder leakage.
  • Ongoing (chronic) constipation can impact bladder function by affecting the nerves and muscles near the bladder.
  • Pelvic floor muscle weakness, which commonly affects women who have been pregnant and women who have gone through menopause. Being overweight can also contribute. Many women with a prolapsed uterus experience urinary incontinence.
  • An enlarged prostate in men. Because the urethra (the tube that the bladder empties through) passes through the prostate in men, an enlarged prostate can cause problems with bladder emptying and leakage.
  • Use of certain medicines such as diuretics, muscle relaxants and sedatives.
  • Damage to the nerves that control bladder function. This may be through surgery of the pelvic area, conditions such as multiple sclerosis, Parkinson’s disease, a stroke, or spinal cord injury.
  • Having diabetes also increases your risk of developing urinary incontinence. So does smoking.
  • Physical limitations that affect mobility and ability to reach the toilet in time, for example, having arthritis.

The different types of urinary incontinence

There are several types of urinary incontinence, and you can have more than one type (mixed incontinence). The most common types of urinary incontinence in women are stress and urge incontinence. Men are more likely to have voiding dysfunction.

Urge incontinence

Urgency is the feeling of urgently needing to go to the toilet at once. Urge incontinence is when you have this feeling with a sudden loss of urine. Urge incontinence is also associated with frequency (needing to wee frequently) and nocturia (needing to wee several times at night).

It is caused by overactive contractions of the bladder. In many cases it is due to detrusor instability (primary overactivity of the bladder muscle) and no other cause is found.

Stress incontinence

Stress incontinence usually causes light leakage and is due to weakness of the pelvic floor muscles or urinary sphincter muscle. Leaks usually happen when you cough, laugh, sneeze or exercise.

Stress incontinence is the most common type of incontinence in women. Men may also get stress incontinence, especially those who have had prostate surgery.

Voiding dysfunction

Voiding dysfunction is when an obstruction or weakening in the bladder muscle stops the bladder from emptying completely.

Voiding dysfunction is often caused by bladder outlet obstruction (eg. due to enlarged prostate). In addition to bladder leaks, symptoms can include difficulty starting urinating, weak stream, stop-start stream, needing to strain to urinate and dribbling at the end of urination.

A blocked outflow tract can also cause overflow incontinence. This is when when the bladder becomes overfull (called urinary retention) and does not sense that it is full, causing urine to leak out in small amounts intermittently. Problems with the nerves to the bladder (e.g. spinal injury) can also cause overflow incontinence.

Functional incontinence

People with loss of memory may not be able to remember where the toilet is or what it’s for, or those people with poor mobility may not be able to get there in time. This is known as functional incontinence.

Tests and diagnosis

To get a good picture of your symptoms, you should keep a symptom diary. Include how often you need to empty your bladder, about how much urine you pass (large or small amounts), and how often you leak. You should also record how much water and other fluids you drink.

Your doctor will want to know whether you notice leaks:

  • when you are doing certain activities (walking, exercising, lifting, coughing, sneezing, laughing);
  • when you have an urgent need to empty your bladder; and/or
  • at other times.

Following a physical examination, your doctor will probably ask for a urine sample (to check for infection). They may suggest a bladder ultrasound (to see if your bladder is emptying properly) or blood tests to rule out other problems.

Another test that can evaluate bladder function in women is called a urodynamics bladder test. This test measures how well your bladder can hold and release urine. The test takes about half an hour and is not painful, but can be uncomfortable.

You may also be referred to a physiotherapist who specialises in pelvic floor function or a continence advisor.

Men needing specialist assessment and treatment may be referred to a urologist (specialist in the urinary tract); and women may be referred to a uro-gynaecologist (specialist in women’s bladder problems).

What is the treatment for urinary incontinence?

The type of treatment suitable for you will depend upon the type of urinary incontinence you have and its severity. Any underlying illnesses that are causing or contributing to bladder leakage should also be treated. Sometimes a combination of treatments may be recommended.

Treatments are often effective in improving symptoms and quality of life, but urinary incontinence is not always completely cured. Many people have some degree of ongoing leakage.

Lifestyle adjustments and self-help tips for urinary incontinence can help relieve symptoms, and are often the first treatment suggested. Other treatment options include pelvic floor muscle exercises, bladder retraining, medicines, and surgery.

Pelvic floor muscle rehabilitation

Pelvic floor muscle exercises (also sometimes called Kegel exercises) help strengthen the muscles that support the bladder. Your doctor or a specialist physiotherapist can teach you how to do these exercises.

Some people find it hard to know whether they are using the right muscles. Biofeedback is a way of learning to localise your pelvic floor muscles and exercise them. It uses electronic or mechanical instruments (e.g. small weights that you insert into the vagina) to give feedback.

Functional electrical stimulation is a treatment that uses an electrical impulse to stimulate and strengthen the nerves and muscles of the pelvic floor. The current is applied via a probe that is temporarily inserted in the vagina or rectum. Having the probe inserted may feel uncomfortable, but this treatment should not be painful.

Bladder retraining

Bladder retraining can be used to treat urge and stress incontinence. It involves retraining your bladder so that it can hold urine for longer. Techniques may include postponement and distraction, which can help if you frequently get the urge to go. Some people benefit from having scheduled times to urinate rather than waiting for the urge to go.

People with bladder outlet obstruction can try ‘double voiding’, which involves urinating and then trying again after a few minutes to try to make sure the bladder is completely empty.

Training your bladder is a gradual process and takes time. A specialist physiotherapist or continence nurse can help develop a personalised bladder training programme for you.

Medicines for urinary incontinence

There are several medicines that can help in the treatment of different types of urinary incontinence. As always, the benefits of medications need to be weighed against the possible side effects. In the case of urinary incontinence, benefits are often modest at best, and side effects can be problematic.

Oestrogen cream or vaginal tablets may help treat stress incontinence in women who have been through menopause.

Medications to relax an overactive bladder in people with urge incontinence include oxybutynin (brand name Ditropan, Oxytrol skin patches) and tolterodine (brand name Detrusitol). Newer medicines include darifenacin (brand name Enablex) and solifenacin (brand name Vesicare) - these newer medicines may have fewer side effects.

Mirabegron (brand name Betmiga) is another medicine that can be used to treat urge incontinence. It relaxes the bladder and increases the amount of urine that the bladder can hold.

Tricyclic antidepressant medicines may also be helpful in treating stress incontinence in women.

Injections of botulinum toxin type A (brand name Botox) into the bladder wall can also be used to treat an overactive bladder. The injections are given during a procedure called a cystoscopy, where a thin, flexible tube with a camera on the end is inserted into the bladder via the urethra. The inside of the bladder can be viewed and the injection given while you are under sedation.

There are also medicines that can be used to treat voiding dysfunction in men with urinary symptoms due to prostate enlargement.

Surgery to treat urinary incontinence

Surgical options and procedures for stress incontinence may be offered to people whose symptoms have not improved with other treatments. You should always ask your doctor or surgeon about the long term outcomes of any procedures that are recommended.

Options for women include:

  • Injections of urethral bulking agents into the neck of your bladder to make it tighter and stronger.
  • A mid-urethral sling (MUS) procedure, which is the most common type of surgery done for stress incontinence in women. It involves inserting a strip of surgical mesh/tape to support the bladder neck or urethra and prevent the leakage of urine. The procedure can be done in several different ways - your surgeon will discuss the best option for you, as well as the risks and side effects, including possible complications from surgical mesh.
  • Rectus fascial bladder neck sling - a procedure that uses a small amount of your own body tissue (part of the rectus fascia - tissue that covers your abdominal muscles) to create a sling to support your bladder.
  • Colposuspension - a procedure that lifts up the bladder neck and changes its position to prevent urine leakage.

Surgical options for men include:

  • Male sling procedures, which involve supporting the urethra with a sling to prevent urine leakage in men with stress incontinence.
  • Implanting an artificial urinary sphincter (a fluid-filled ring that is placed around the bladder neck to help keep the sphincter muscle closed).
  • Various surgical treatments used to treat prostate enlargement and associated urinary incontinence.

Other treatments

Women with bladder leakages due to either urge or stress incontinence can sometimes be treated with vaginal devices, such as anti-incontinence pessaries. These devices, which are inserted into the vagina and worn during the day, help support the bladder neck.

Neuromodulation is a treatment that involves stimulating certain nerves that are involved in bladder control. The nerves can be stimulated with small electric impulses via electrodes placed on the surface of the skin or via an implantable device. Neuromodulation can help relax the bladder and improve the strength and sensitivity of pelvic floor muscles.

Some studies have found that doing yoga may help improve bladder leakage.

Products for people with bladder leakage

If you have light bladder leakage you may just need a little extra protection in case of leakage. Women can wear panty liners, pads or special absorbent underwear to keep dry and comfortable. There are also products available specifically for men.

Some people with significant bladder leakage may choose to use pads rather than take medicines or have surgery. This may be the case in older people with several other health problems that would make medications and/or surgery risky. Absorbent products may also be needed if treatments have not completely stopped bladder leakages.

People who cannot effectively empty their bladders may need to regularly use a urinary catheter to drain the bladder. A continence advisor can teach you (or your carer) how to insert the catheter (a flexible, narrow tube) to drain the bladder.

Prevention

Maintaining a healthy weight, not smoking and getting plenty of physical activity all help prevent problems with urinary incontinence. Having a healthy diet with plenty of dietary fibre is also important.

Doing pelvic floor muscle exercises also helps prevent bladder leakage.

It’s also important to listen to your body. Empty your bladder when your body tells you it’s time. Women should sit on the toilet rather than hover, because that helps fully relax the bladder and allows it to empty completely.

Support for people with incontinence

There is support available for people with urinary incontinence. The Continence Foundation of Australia offers an online support group, as well as advice and information from continence nurse advisors. There is also a National Continence Helpline (Phone: 1800 33 00 66) for people with incontinence and their carers. Ask your doctor for local information that will suit your needs.

References

1. Management of urinary incontinence in adults. Aust Prescr 2014;37:10-13. DOI: 10.18773/austprescr.2014.003 https://www.nps.org.au/australian-prescriber/articles/management-of-urinary-incontinence-in-adults (accessed Oct 2018).
2. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice, 9th edition. 13. Urinary incontinence. https://www.racgp.org.au/your-practice/guidelines/redbook/13-urinary-incontinence/ (accessed Oct 2018).
3. BMJ Best Practice. Urinary incontinence in women (updated 4 Sep 2018). https://bestpractice.bmj.com (accessed Oct 2018).
4. Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). Use of mesh for the surgical treatment of vaginal prolapse and urinary incontinence (29 Oct 2017). https://www.ranzcog.edu.au/news/Use-of-mesh-for-the-surgical-treatment-of-vaginal (accessed Oct 2018).
5. Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). Position statement on midurethral slings (May 2017; amended Jan 2018). https://www.ranzcog.edu.au/getattachment/Statements-Guidelines/Gynaecology/Midurethral-Slings,-Position-Statement-(C-Gyn-32)/Position-statement-on-midurethral-slings-(C-Gyn-32)-Jan18.pdf?lang=en-AU&ext=.pdf (accessed Oct 2018).
6. Chung E, Katz DJ, Love C. Adult male stress and urge urinary incontinence - a review of pathophysiology and treatment strategies for voiding dysfunction in men. AFP 2017;46(9):661-6. https://www.racgp.org.au/afp/2017/september/adult-male-stress-and-urge-urinary-incontinence/ (accessed Oct 2018).
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