Urinary incontinence in women

You may think that if you have leakage of urine then you just have to put with the problem, and perhaps spend a fortune on pads. This is not generally true.

Decide what type of incontinence you have

It is helpful to work out whether you have stress incontinence or overactive bladder, or both, because they have different treatments. There are some simple questions to ask yourself to find out.

What you can do for stress incontinence

If you have stress incontinence, there is a lot you can do to help yourself:

Check whether you are taking an alpha-blocker for raised blood pressure (hypertension). Alpha-blockers can cause stress incontinence, and your doctor could probably prescribe a different type of blood pressure medication instead.

Lose weight. Being overweight puts stress on your pelvic floor muscles and losing weight can reduce leakage by 60% (Journal of Urology 2005; 174: 190–5).

Cross your legs when you feel a cough or sneeze coming on. This sounds ridiculously simple, but a scientific study found that it helped prevent leakage in 73% of women.

Squeeze before you sneeze. Just before you cough or sneeze, tighten your pelvic floor muscles and hold them tight to prevent leakage.

Strengthen your pelvic floor muscles with pelvic floor exercises or vaginal cones.

Pelvic floor exercises are especially useful for stress incontinence and reduce episodes of leakage by 50%. You may have to do them for a few months before you notice any improvement, so patience is essential. Ideally, these should be taught by a continence adviser as it is easy to do them incorrectly. One advantage is that they are invisible, so you can do them at anytime at bus stops, in the supermarket queue or while talking on the phone! Once you have learnt to tighten your pelvic floor muscles, you can squeeze them and hold when you sneeze, lift or jump. This will protect them from more damage.

Learning pelvic floor exercises

Stand, sit or lie with your knees slightly apart (sitting is easiest). Now imagine that you are trying to stop yourself passing wind from the back passage; to do this, you must tighten the muscles round the back passage. Squeeze and lift those muscles as if you really do have wind: you should be able to feel the muscles move and the skin round the back passage tightening. Your legs and buttocks should not move at all
Next, imagine that you are sitting on the toilet passing urine. Imagine yourself trying to stop the stream of urine (the stop test) really try hard. You will be using the same group of muscles as in the first exercise, but you will find it more difficult
Next time you go to the toilet to pass urine, try the stop test about half way through emptying your bladder. (If the flow of urine speeds up, you are using the wrong muscles.) Once you have stopped the flow of urine, relax and allow the bladder to empty completely. Do not worry if you find you can only slow the stream, and cannot stop it completely

Checking you are contracting the pelvic floor correctly

If you are unsure you are exercising the right muscles, put one or two fingers in the vagina and try the exercise to check. You should feel a gentle squeeze if you are exercising the pelvic floor. A common mistake is to just clench your buttocks and hold your breath; if you can not hold a conversation at the same time, you are doing the exercises wrongly. Counting aloud while you do the exercises will stop you holding your breath. Do not tighten the tummy, thigh or buttock muscles or cross your legs. Only use your pelvic floor muscles
Using a mirror, check that the area between the vagina and back passage moves up and inwards when you contract the muscles
Place your fingertips on the skin between your vagina and back passage. You should feel the inside lift up from your fingertips when you contract your muscles.
Ask your sexual partner if he can feel the muscles squeezing during sexual intercourse.

Using pelvic floor exercises

Stand, sit or lie with your knees slightly apart. Slowly tighten and pull up the pelvic floor muscles as hard as possible. Hold tightened for at least 5 seconds if you can, then relax (slow pull-up). Repeat at least five times. Now pull the muscles up quickly and tightly, then relax immediately (fast pull-up). Repeat at least five times. Do these exercises five slow and five fast at least ten times every day
Suck your thumb at the same time you will find it helps to lift the pelvic floor

Vaginal cones are an easier way of toning up the pelvic floor, though they are not as effective as the exercises. The cones can be bought as a set (Aquaflex) consisting of several different weights with directions for using them. You insert a cone into your vagina and hold it there by contracting the pelvic muscles. The cones have a rounded shape and are comfortable to use. The only problem is that it can be difficult to hold the cone in – a continence adviser can show you how to contract the correct muscles, which is similar to doing the pelvic floor exercises. You should start with the cone that you can hold for 1 minute. By using it twice a day, you will find that you can gradually hold it in for longer and longer. When you can hold it for 15 minutes, progress to the next weight of cone. The aim is to use the heaviest cone in the set for 15 minutes twice a day.

Which is better – pelvic floor exercises or vaginal cones?

A study in Norway (British Medical Journal 1999;318:487–93) gave the following results.

	Some improvement	Almost cured	Completely cured	No effect
Pelvic floor exercises for 6 months	8%	44%	40%	8%
Vaginal cones for 20 minutes/day for 6 months	0%	37%	44%	19%

Support your bladder neck to keep the bladder closed. You may find that simply inserting a large-size (super) tampon before sport of vigorous activity is all you need. (Remember to remove it afterwards.) There are some specially designed vaginal devices that do a similar job, such as Contiguard, Contrelle, Contiform and Introl. Some women find them uncomfortable and they are not effective for everyone. Before buying one, get advice from a continence advisor.

What you can do for an overactive bladder

Does it sting when you pass urine? If so, you probably have cystitis. See your doctor – the urge incontinence will disappear or improve when the infection is treated.

Use mental tricks to take your mind off the urge. For example, concentrate on the mental image of a tight knot in a balloon. Or distract yourself by thinking of as many words as you can beginning with the letter A, and then work your way through the alphabet.
Empty your bladder properly each time you pass urine. Do not hover over the toilet seat. Sit down and bend forward at the waist, and take your time.
The bladder can be retrained to hold larger amounts of urine, so that the muscle does not start to contract until you are ready. This bladder retraining drill (see box below) is tedious but does work, particularly for urge incontinence.
Do pelvic floor exercises. They will not cure the bladder contractions that cause the urge, but stronger pelvic floor muscles will minimize any leakages.
It is natural to think that by cutting the amount you drink, you will have more control and research backs up this idea (Journal of Urology 2005; 174: 1879). However, it could worsen the problem by increasing your susceptibility to irritating bladder infections (cystitis) and encouraging the bladder to empty when it does not contain much urine.
Cut out coffee and strong tea caffeine encourages overactivity of the bladder muscle. Stop smoking nicotine irritates the bladder.
Eat plenty of fresh fruit, vegetables and fibre to avoid constipation, which can press on the bladder and the urethra.

Bladder retraining drill

Bladder retraining is based on passing urine by the clock at regular intervals. If holding on is difficult, distract yourself by watching TV or making a phone call

Days 1 and 2
Start by choosing an interval you feel fairly confident you can achieve, such as 1-2 hours. Continue this for 2 days

Days 3 and 4
Increase the interval between emptying by 15 minutes. Continue with this interval for 2 days

Day 5 onwards
When you are comfortable with the extra 15 minutes, increase it again. As each interval becomes manageable, increase it again

Seeing your doctor or continence advisor

You can ask your doctor for advice or, in the UK, you can get help from a continence adviser. Continence advisers are specially trained nurses or physiotherapists. They are expert at working out what type of incontinence you have and the best way to deal with it. They can teach you how to do pelvic floor exercises properly, and tell you whether it is worth buying aids and devices such as vaginal cones.

Your doctor or continence advisor will also be able to check that you do not have a urinary infection or an unusual type of incontinence. For example, you might have a prolapsed womb that is pressing on the bladder. The doctor may wish to do a vaginal examination, inserting a speculum (like when you have a cervical smear) to check for prolapse of the womb.

If you discuss your problem with your doctor, it is quite likely that your doctor will put you in touch with a continence adviser. But you do not have to go through your doctor you can arrange to see a continence adviser yourself. In the UK, your local Citizens Advice Bureau should be able to give you details, or you can find out more from The Continence Foundation or Incontact.

Things you can do before visiting your doctor or continence adviser. Make a urine chart for a few days before your appointment to record how your bladder is actually behaving. Get a jug (marked in millilitres or fluid ounces) one that you can easily pass urine into and use it to measure how much urine you pass on each occasion. Note down the time and the volume on a chart. Also make a record of the occasions when leakage occurs. You can print off a chart from the National Kidney and Urologic Diseases Information Clearinghouse website.

Be prepared for questions: your doctor or continence adviser may ask you some of the following, so you might want to think about the answers in advance.

What medicines are you taking? Take a list with you, and include medicines you buy over the counter?, as well as prescription medicines.
When did you start having bladder trouble?
If you have had the menopause, when did your periods stop?
Have you had any operations?
Do you have any pain or burning feeling when you pass urine?
Do you often have a really strong urge to pass urine immediately?
Do you leak when you cough or sneeze?
How do you cope? Do you sometimes wear a sanitary pad because you are worried about leakage?
How is the problem affecting your life? Do you avoid going out or doing certain activities because of bladder control problems? Are you always on the lookout for the nearest toilet?

What your doctor can do. Your doctor or continence advisor may suggest any of the following options.
Medication for stress incontinence. If your main problem is stress incontinence, there is now a specialist medication, Duloxetine, which is taken twice daily. Duloxetine halves the number of leakage episodes, and 1 in 10 women taking it becomes completely dry. Nausea is the most common side effect (British Journal of Obstetrics and Gynaecology 2004;111:249–57). Other side effects include dry mouth, fatigue and constipation. There have been concerns (but no proof) that it could lead to suicidal thoughts either during treatment or if it is suddenly stopped (Current Problems in Pharmacovigilance 2006; 31: 2).

Another new medication, solifenacin (see below), may also help stress incontinence, though its main use is for overactive bladder.

Medicines for overactive bladder. If you have an overactive bladder, there are some drugs you can get from your doctor that may help. However, all these drugs have side effects some make you less alert, so you have to be careful about driving or operating dangerous machinery while taking them. The medication may take some time to work, so persist with it.

The most common medications for overactive bladder are oxybutynin and tolterodine. These drugs are very similar and work in the same way, by calming the bladder muscle. Their side effects are dry mouth, constipation and blurring of vision. Doctors now usually prescribe extended-release types of these drugs, which you need to take only once a day and which are less likely to have side effects. Extended-release tolterodine seems to have slightly fewer side effects than extended-release oxybutynin (Mayo Clinic Proceedings 2003;78:687–95). Oxybutynin is also available as a skin patch; this has fewer side effects than the tablet form, but some people are allergic to the active patch.

Darifenacin and solifenacin are newer medications to calm bladder muscle. They are taken once daily. Their main side effects are dry mouth and constipation. It is not yet clear whether they are better than the older medications (though a study has shown solifenacin to be more effective than tolterodine). Typically, someone with 16 episodes of incontinence/week would have only 7 episodes/week while taking darifenacin (Drug and Therapeutics Bulletin 2007;45:448). One benefit of darifenacin is that it does not cause confusion in elderly people, which can occur with some bladder-calming drugs.
Propiverine and trospium chloride also work in a similar way to oxybutynin, but have to be taken several times a day. Flavoxate has less severe side effects than oxybutynin, but is less effective.
In the past, propantheline was often used, but this has more side effects than other drugs.
Imipramine and amitriptyline help urge incontinence by a different action from their antidepressant effect, and are particularly useful for women whose main problem is incontinence during orgasm or having to pass urine at night.
Desmopressin is sometimes used for people whose main problem is constantly having to get up and pass urine at night.

Special devices. A number of special devices to help keep the urethra (pee hole) closed are available.

Devices such as Miniguard, FemAssist and Capsure are tiny caps that are placed over the urethra. They stay in place by suction or the use of an adhesive. They can irritate, but can be helpful for some women with mild incontinence.
Appliances such as the Urethral Plug, Reliance Insert and Femsoft are inserted into the urethra to plug it. They are tricky to use, and you have to be shown how by a continence adviser or doctor. They are suitable only for short periods, such as during exercise. The main problems are discomfort and infection, or the device may move up inside and be impossible to remove without specialist medical help.

Hormone replacement therapy (HRT). In the past, doctors thought that HRT might help stress incontinence and overactive bladder. This has now been disproved by a study in the USA of more than 25 000 women. In fact, women taking HRT were more likely to develop stress incontinence or overactive bladder. If they already had a leakage problem, HRT made it worse (Journal of the American Medical Association 2004;172:1919–24).

Botulinum toxin (Botox). Tiny injections of botox into the wall of the bladder are being investigated as another method of calming the bladder muscle in urge incontinence. The effects are said to last for about 8 months and then have to be repeated. At present, there is little scientific evidence about whether these injections are truly effective (Cochrane Database 2007: CD005493).

Special hospital tests. If the cause of your incontinence is not obvious to your doctor, you may be referred to hospital for urodynamic tests to obtain an accurate diagnosis. These may cause some discomfort a small tube (1 mm in diameter) is inserted into the bladder to measure pressures, and sometimes a small tube is also inserted into the back passage.

A surgical operation is a last resort, and you would need to have urodynamic tests first, to be absolutely sure what type of incontinence you have. This is because surgery is usually only for stress incontinence it cannot really help overactive bladder. If the pelvic floor muscles have become weak, the bladder neck and top of the urethra will not be in their correct position, and so will not function effectively (with the help of the pelvic floor muscles) to stop leakage of urine. Surgery aims to lift the neck of the bladder and the urethra, and secure them in their anatomically correct position. There are many different operations for stress incontinence, but the commonest are as follows.

The tension-free vaginal tape (TVP) sling operation is now very popular. It is possible to do it under a local anaesthetic or spinal block (that is, without a general anaesthetic). Working through the vagina and two small incisions in the abdomen, the surgeon places special polypropylene (prolene) tape beneath the urethra, and adjusts the tension on the tape until it is just right. One study showed that it cures almost 70% of people (British Medical Journal 2002;235:67–70).
Other sling operations involve passing a piece of tissue or artificial material (such as silastic or nylon) under the urethra and bladder neck, to support them like a hammock, and attaching it to the wall of the abdomen and the pelvic bones on each side. The cure rate is about 66%, but later problems (such as an urgent need to pass urine, or damage to the urethra from the tightness of the support) can occur (New England Journal of Medicine 2007;356:2143–55).
In the Burch colposuspension operation, the surgeon attaches the top of the vagina to ligaments that lie close to the pubic bones, thereby supporting the bladder neck. This is a more major operation than the tension-free tape operation. The cure rate is approximately 50%, but problems (such as an urgent need to pass urine) can occur later (New England Journal of Medicine 2007;356:2143–55).

Bulking injections (for stress incontinence) use collagen, fat or particles of silicone rubber to bulk up the tissues around the urethra and bladder neck. The collagen given in these injections comes from the hides of freshly slaughtered cattle. These cattle are bred and live in closed herds in the USA, and never receive any animal protein in their diet. It is therefore very unlikely that collagen injections could transmit mad cow disease (BSE). Some people are allergic to collagen, so everyone is given an allergy test 4 weeks beforehand.

A newer option is a gel made from non-animal stabilized hyaluronic acid (NASHA) and dextran, both of which are natural substances.

The material is injected by inserting a needle alongside the urethra, or into the urethra and through its wall. A local anaesthetic is given to prevent pain. Most women need two or three injections, given at weekly intervals. They have to be given by an expert, and you will need urodynamic tests first to measure how your bladder is working.

About 60–70% of women find their symptoms are cured or improved by the treatment. However, the effect may not last. After 3 years only 50% remain cured, and after 5 years only 26%. For this reason, bulking injections are not often used in Europe, but they may be suitable for people who are not fit enough for a surgical operation.

Electrostimulation. An electrode in the vagina, attached to a battery, makes the pelvic floor muscles contract. The electrical current is tiny, so there is no need to worry. The apparatus is used for 30 minutes a day. This normally has to be arranged through a hospital clinic, because it is suitable only for women with severe incontinence who cannot be treated by other methods.

The future. A number of possible new treatments are being investigated. Scientists in Australia have tested a new treatment for stress incontinence. They took cells from women's muscles and injected them into the ring of muscle at the bladder neck. They also injected other cells (fibroblasts) into the wall of the bladder. The treatment appears to be very effective, but more studies are needed (Lancet 2007;369:2179–86).

Written by: Dr Margaret Stearn
Edited by: Dr Margaret Stearn
Last updated: Wednesday, February 10th 2010

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Posted by sarah on 21/01/2009 at 12:18:00 pm

I have had incontinence for a while I am so ashamed humiliated and feel very low your self esteem goes

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