Incontinence in Women
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Incontinence is defined as an involuntary loss of urine that's enough to cause a social or hygiene concern. It is about 4 times more common in women than in men. By the age of 75, at least 16% of women experience some incontinence, but younger women can also be affected.
Urine is produced by the kidneys and collected in the bladder, which expands like a balloon as the volume increases. When full, the bladder empties to the outside through the urethra. Most people need to pass water every 3-4 hours during the day and up to once or twice in the night. For normal urination, the muscular wall of the bladder has to contract at the same time as a valve mechanism at the outlet of the bladder relaxes. Most incontinence in adults results from problems with one or other of these processes and are responsible for most incontinence in women.
- Stress incontinence – causes urine to leak when there is an increase in pressure from within the abdomen such as when coughing, sneezing, laughing or carrying heavy weights etc. It develops when the normal control mechanism for keeping the outlet of the bladder closed is weakened. This can happen when the urethra moves out of the normal position (prolapses), as it can when the pelvic floor muscles are weakened. Stress incontinence is much more common in women than men and can be triggered by childbirth, hysterectomy and the menopause. Other causes include constipation.
- Urge incontinence – There is a desperate urge to pass frequent, small amounts of urine. This is caused by the muscle of bladder wall – known as the detrusor muscle– being overactive. This means it contracts to squeeze out urine before the bladder is completely full. Urge incontinence can also be caused by a bladder infection. Diabetes can cause excessive production of urine and very frequent trips to the toilet.
- Mixed incontinence- Some women get both urge and stress incontinence. The two may or may not be linked.
- Overflow incontinence – This happens when the amount of urine held by the bladder builds up to the point where the bladder can no longer expand. It can be caused by an obstruction in urinary tract or damage to the nerves that supply the bladder.
Other causes of incontinence:
- Medication – Some drugs for blood pressure (particularly alpha-blockers such as prazosin and doxazosin) and muscle relaxants like diazepam can cause incontinence.
- Problems with the urinary system – fistulas (abnormal openings between the ureter, urethra or bladder and into the uterus or vagina) and bladder stones.
Anyone who passes urine accidentally – e.g. when they cough, have a full bladder or just leaks for no reason, has incontinence. Although many people try to manage on their own – often because it's a source of embarrassment, medical advice should be sought sooner rather than later as help is available.
What will the doctor want to know?
The GP will probably ask about the following things:
- The length of time incontinence has been a problem
- The time of day leakage occurs
- Whether there is any pain passing urine
- The number of times urine is passed in 24 hours
- Whether coughing, sneezing, etc. causes a leak
- If you have an urgent need to go, or go frequently
- Whether any medications are being used
- If the problem is getting worse
- What effect it is having on the person's life
To make it easier to answer these questions, it's a good idea to keep a note of the amount of urine passed, the time of day and whether leakage occurred (a frequency/volume diary) for 7 days before the consultation.
The doctor will probably carry out a physical examination. This may include:
- Examination of the abdomen to feel the bladder
- Checking for leakage on coughing
- Testing the sensation around the bridge of skin between the vagina and anus (the perineal area)
- A pelvic examination to check the vagina, and the size of the cervix, and uterus, ovaries and bladder.
A sample of urine (mid-stream urine, or MSU) is examined for signs of infection, bladder stone or other abnormalities.
A urodynamic assessment may be carried out by a urologist or a uro-gynaecologist – doctors who specialises in urinary problems. A catheter (fine tube) is passed into the bladder to fill it with sterile fluid. The pressure inside the bladder and flow and volume of urine are measured during urination and the amount of urine left in the bladder is assessed.
In ambulatory urodynamics, the urinary system is monitored 'on the move', with catheters connected to a portable computer.
- Lifestyle – Cutting down what you drink can actually make the problem worse because it increases the chances of infection. But caffeine-based drinks should be avoided as they can irritate the bladder. Smoking can also be an irritant and should also be avoided. Try to include lots of fibre, such as fruit, vegetables and whole grain cereals, in the diet to avoid constipation.
- Bladder training techniques – This is useful for an overactive bladder and urge incontinence. The bladder is emptied at set intervals, and the time between intervals is gradually increased. Protective pads and suitable clothing – this can help leaks less embarrassing. Special products are available from pharmacists.
- Pelvic floor exercises (Kegel exercises) – These are useful for mild to moderate stress 6 and urge incontinence7. Exercises involve contracting the muscles that start and stop the urine flow.
- Biofeedback – A variation of pelvic floor exercises, this uses sensors that indicate when the correct pelvic floor muscles are being contracted. This helps the person do the exercises more effectively.
- Vaginal cones – These can be bought as a set from certain pharmacies. A cone is held in the vagina for increasing periods of time, and helps to strengthen the pelvic floor muscles. As the muscles improve, a heavier cone can be used.
Your GP or hospital doctor should be able to refer you to a specialist for further advice.
Four main drugs are used – oxybutynin, flavoxate and tolterodine and newer drugs, trospium chloride and propiverine. They all work by making the detrusor muscles less likely to contract involuntarily.
There are some common but usually not serious side effects, which can include dry mouth, constipation, blurred vision and drowsiness. Tolterodine, trospium chloride and propiverine may have fewer side-effects than the other drugs.
- Imipramine and amitriptyline, which are drugs also used in depression, are used for urge incontinence and for night-time bedwetting, even for people who are not depressed. This type of (tricyclic) antidepressant, may also cause side-effects such as dry mouth and blurred vision.
- Hormone replacement therapy (HRT) may be useful in menopausal women with overactive bladders or mixed incontinence.
Surgery is sometimes needed for moderate to severe stress incontinence. The aim is to support the bladder neck and urethra. A number of different procedures are available. Typically, the longer, more complex operations have the greatest effect but can involve a stay of 5 days in hospital.
Less invasive sling procedures may be suitable, although their long term effectiveness is less well proven. A sling made of muscle, fibrous tissue or synthetic material, is looped under the urethra and attached to the pubic bone or the abdominal wall.
The Continence Foundation
National Kidney and Urologic Diseases Information Clearinghouse
American Foundation for Urologic Disease
National Womens Health Information Center
National Association for Continence
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