The sudden involuntary loss of urine, or difficulty holding onto urine in the bladder is extremely common affecting 60-70% of all women and more so after childbirth and additionally with advancing age. Often the treatment is very simple but because advice from the doctor is not sought often due to embarrassment the correct treatment is not given. There are two types of incontinence:
This is where loss of urine occurs with straining, coughing, laughing or sudden movement. It is usually due to a change in the pelvic anatomy or weakening of the pelvic floor, so when there is a rise in abdominal pressure, the direction of pressure does not act to close the urethra (tube leading from the bladder), but instead is directed on the bladder resulting in involuntary loss of urine.
Raised intra abdominal pressure such as with increased weight, pelvic masses pressing on the bladder (fibroids, ovarian cysts); and chronic cough can worsen these symptoms.
Causes of a weakened pelvic floor can be due to:
Symptoms can include:
Improving acidity with either locally applied oestrogen (pessaries, cream or ring) or increased oestrogen in the blood circulation improve the body’s production of lactic acid and correct the pH. In the short-term re-acidifying naturally with products such as cranberry tablets (not cranberry juice, which is sugary) can be of benefit.
A high carbohydrate or sugary diet can affect hormone production resulting in less efficient ovulation and less production of oestrogen. This therefore effects the pH of the vagina and bladder, resulting in more infections. Cutting out sugar and severely curtailing carbohydrate or eating only low-GI carbohydrate and avoiding snacking can make a massive difference to infection rate.
History and examination will usually give the best idea in the majority of cases but it will usually need backing-up with investigations:
This is an outpatient test where the amount of water tolerated by the bladder is measured and the type of incontinence diagnosed. If a surgical bladder neck elevation is being considered, it is important that this test is done to exclude other causes of incontinence.
If a growth or polyp or stone is suspected, then a scan of the kidneys, urethra and bladder can be helpful.
Antibiotic treatments can be effective for infection and any other obvious cause, and surgery for a stone etc.
Skilled physiotherapy can strengthen the pelvic floor muscles enough to allow the correct direction of muscle onto the bladder neck to close off the urethra again and prevent leakage.
This is beneficial where somebody has got in the habit of keeping their bladder empty, often because of loss of confidence and it can be important to retrain the bladder, to become ‘used to’ having fluid it again. This can be done with taught exercises
These devices are inserted into the vagina and small electric currents directed at the right area of the pelvic floor can produce gradual strengthening of the muscles required to close the urethra at coughing or sneezing.
These are placed by the patient in the vagina and require the patient to squeeze constantly to keep them in place. This results in effective directed full strengthening which can be beneficial.
These are inserted by your GP or Gynaecologist and can result in elevation of the bladder neck with an artificial form of support during coughing and straining. They are more usually a short-term measure whilst surgery is awaited. They can also serve as an effective test of where there is laxity in the bladder neck and to ascertain if surgery is going to help in the long-term.
Weight loss reduces stress incontinence due to less pressure in the pelvic floor region. Other causes of raised intra abdominal pressure, such as fibroids or cysts and correction of the vaginal pH improves bladder instability.
Sometimes stretching the bladder and bladder neck can be helpful at least in the short-term especially where the muscles are overactive. This is usually done by a urologist under cystoscopy control (camera).
There are many different approaches now but they all work on the same principal of elevating the bladder neck and providing support on coughing or sneezing when the patient is vertical. These sling procedures are much less invasive than old-fashioned colposuspension which, was a large operation requiring an abdominal incision and elevation of the vagina to provide stretching and closure of the bladder neck.
Because the pelvic floor tissues gradually lose elasticity with age and loss of oestrogen, this procedure does not usually last much longer than 3-5 years.
Bladder Slings, however are extremely effective, and can in some circumstances be done under local anaesthetic and last a long time.
Loss of oestrogen with age and inadequate hormone production results in weakening of the pelvic floor strength. Replacing this with either topical oestrogen (pessaries, cream or oestrogen ring) will strengthen the pelvic floor and enhance the benefit of exercise and surgery.
Improving circulating oestrogen levels is also of benefit especially where levels are prematurely low.
Medications known as Anticholingerics act on the nerve supplying the bladder and stop the activity of the bladder muscle. These can be associated with side effects such as drowsiness and dry mouth and are not always 100% effective.