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| Urinary incontinence in women |
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Written by Dr John Pillinger, GP
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What is urinary incontinence?
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| Many women find it hard talking about their incontinence, but
urinary incontinence is actually very common. |
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Urinary incontinence is the involuntary leakage of urine from
the bladder. This is a common problem that can affect both sexes but women are
more commonly affected.
Urine is normally prevented from leaking by the urinary
sphincter, which is a tight ring of muscle at the neck of the bladder and the
support of the muscles of the pelvic floor. Voluntary passing of urine involves
relaxing the sphincter and pelvic floor muscles, together with a gentle
contraction of the bladder muscle.
For many women the leakage of a small amount of urine on an
occasional basis is normal and does not prevent them from getting on with their
lives.
For other women, urinary incontinence may be serious enough to
involve having to change their clothes and to avoid performing certain tasks or
exercises. For these women, advice from a health professional is
appropriate.
What causes urinary incontinence?
The study of urinary incontinence has revealed two main types of
incontinence.
The commonest is called
stress urinary incontinence (SUI) -
when the bladder sphincter just gives way under pressure and a small amount of
urine escapes on straining, for example when coughing, laughing, sneezing or
doing physical exercise.
In severe cases it can happen while walking or when getting up
from a sitting position. Stress incontinence is usually the result of weakening
of the muscles in the pelvic floor that surround the bladder. This often
happens during pregnancy, following
childbirth or after the
menopause.
The second type of urinary incontinence is called urge
incontinence. This happens when the urge to pass urine becomes overwhelming and
urine is passed before a toilet can be reached.
Urge incontinence is caused by the bladder sending a message to
the brain that it is full, often too early and the bladder muscle starts to
contract too early (also called bladder instability).
This may be caused by
cystitis (urinary infection) or an overactive or
unstable bladder, which can sometimes be related to nerve problems including
stroke,
dementia,
multiple
sclerosis, or spinal cord injury.
The two types may occur together, but treatment is quite
different.
Incontinence can also be associated with narrowings (strictures)
of the urethra.
Incontinence can also be caused as a side effect of some kinds
of drugs or medicines.
When should I seek medical help?
If you are experiencing more than very occasional episodes of
incontinence then you should consult your family doctor.
What will the doctor do?
The doctor will take a medical history and perform a physical
examination, which is likely to include a vaginal and rectal examination to
assess the pelvic organs.
History and examination alone are often insufficient and special
tests may also be required to establish what kind of incontinence it is and,
therefore, what the treatment options are.
A GP may also refer the patient to a physiotherapist, an
incontinence advisor or to a hospital specialist (urologist or
gynaecologist).
What further investigations may be be necessary?
Bacteriology and
microscopy. A simple
urine
sample analysis by a laboratory for infection will help show if any
bacteria are present, and what the best antibiotic would be for
them.
Urodynamic studies
are special measurements of urine flow and pressure taken with a catheter in
the bladder while passing urine. The information gained can distinguish between
the two major types of incontinence.
X-rays and
ultrasound may be useful in certain patients to check
the kidneys and the tubes (ureters) that drain them. It will also show the size
and shape of the pelvic organs if any enlargements are detected during the
examination.
Cystoscopy, a look inside the bladder using a thin
telescope, may be done to check that the inside of the bladder is healthy. It
may be performed under a local or
general
anaesthetic.
How is urinary incontinence treated?
The
treatment of urinary incontinence
varies according to the type of incontinence, how troubling it is to the woman
concerned and also her general level of fitness.
The majority of women with urinary incontinence can be
effectively managed in general practice with fairly simple treatment, without
the need for many of the
surgical treatments mentioned
below.
Non-surgical treatment for stress incontinence
The best way to prevent urinary stress incontinence is to
perform
pelvic floor muscle exercises. To do
this, simply tighten the muscles of your pelvic floor as if you are trying to
stop the flow of urine. This will make you more aware of these muscles and how
to use them. You can also try to put two fingers in your vagina, squeeze and
then relax the muscles. When you know which muscles you use to squeeze and
relax, you can do the exercises anywhere and anytime.
Slowly count to 10 while you tense the muscle, then count to
10 while you relax again. Repeat this 10 times and do it at least 10 times a
day - while watching TV, waiting for the bus and so on. Special weighted
vaginal cones may be also used to help
train the muscles. Doing these exercises regularly throughout life will keep
the pelvic muscles in good shape.
Collagen injections around the neck of the bladder are
occasionally suitable as an alternative treatment for patients who need but are
not suitable for surgery. Incontinence nurses are specially trained in
assessing and advising on incontinence, including the provision of aids and
supports, and are now part of the nursing service in all areas of the
UK.
Surgical treatments for stress incontinence
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Anterior vaginal wall repair surgery. If
prolapse is the underlying cause of incontinence, then repair of the prolapse,
through the vagina, may be sufficient to correct the problem.
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Colposuspension. The muscle support of the
bladder can also be improved by colposuspension, in which the top of the vagina
is pulled forward and stitched. This is generally successful and does not cause
any problems with sexual intercourse.
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Surgical tape procedure. A similar result
to colposuspension can now be achieved by the use of surgical tape, which is
positioned so as to support the bladder. This procedure was developed in Sweden
and is not readily available yet on the NHS in the UK. There are, however, a
number of centres providing private therapy. The operation takes up to 30
minutes to complete and can be performed as a day-case procedure, under a local
or a general anaesthetic. The early results show a success rate that is
comparable with colposuspension.
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Laproscopic (keyhole) surgery is also showing promise
as a new technique in treating incontinence.
Non-surgical treatment for urge incontinence
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Bladder training aims to teach the bladder
not to send signals to the brain too early. A training schedule is devised that
gradually increases the length of time a person waits before emptying their
bladder, so that reasonable control of a full bladder can be
achieved.
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Medicines that reduce the excitability of
the bladder detrusor muscle (anticholinergics), such as
oxybutynin (eg Lyrinel XL)
or tolterodine (eg Detrusitol XL). The
medicines commonly used to treat urge incontinence can sometimes cause a dry
mouth, blurred vision and
constipation, though
these are not that common in practice providing one commences the patient on a
relatively low dose, allowing them to become accustomed to the treatment before
increasing the dose as required.
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Hormone replacement therapy is useful
in helping urge incontinence in women after the menopause. It is not
particularly effective in stress incontinence.
Surgical treatment for urge incontinence
Stretching (dilatation) of the urethra under general
anaesthetic may be helpful.
What complications might arise from surgery?
Even with the best possible technique, all surgical procedures
carry a small but recognised risk of excess bleeding and infection. The
individual operations concerned each carry certain risk factors that are best
explained by the surgeon performing the operation.
The anaesthetic can cause side effects that can be quite
different between individuals, and these should be discussed with the
anaesthetist beforehand.
What can a person do to help urinary incontinence?
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Eat plenty of fresh fruit, vegetable and cereals to avoid
constipation.
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Drink at least six to eight glasses of liquid every
day.
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If you experience urgency that makes you rush to the toilet,
drink less tea, coffee and cola that contain caffeine and drink more
water.
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Take regular exercise - walk as much as possible.
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Wear clothes that are easy to manage.
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If you have to get up more than once during the night to pass
urine (nocturia) then it is advisable not to drink any fluid
within three hours of going to bed.
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Involve your family in understanding the problems so that
embarrassment is not so much of a problem.
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Get someone else to do heavy lifting and avoid strenuous
exertion in general.
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Drinking alcohol is likely to worsen any type of urinary
incontinence because it is a diuretic and stimulates the kidneys to produce
more urine.
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Last updated 06.07.2005
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