Urinary incontinence is any involuntary or unwanted loss of urine. It is considered a medical condition if it happens regularly. The risk of developing incontinence increases with age, but younger people may also develop it. Women are more likely to suffer from this condition than men. Incontinence is common and causes distress and embarrassment. Many people go without treatment because they feel uncomfortable discussing incontinence with their doctor. If incontinence is frequent or affects your quality of life, it is important to seek medical advice. In most cases, incontinence can be treated or cured with various treatment options. These include pelvic floor exercises, drug treatment, or surgery. You can discuss which treatment is best for you.
Understanding urine and the bladder
The kidneys make urine continuously. A trickle of urine is constantly passing to the bladder down the ureters (the tubes from the kidneys to the bladder). You make different amounts of urine depending on how much you drink, eat, and sweat. The bladder is made of muscle and stores the urine. It expands like a balloon as it fills with urine. The outlet for urine(the urethra) is normally kept closed. This is helped by the muscles below the bladder that surround and support the urethra (the pelvic floor muscles).When a certain volume of urine is in the bladder, you become aware that the bladder is getting full. When you go to the toilet to pass urine, the bladder muscle squeezes (contracts) and the urethra and pelvic floor muscles relax to allow the urine to flow out. Complex nerve messages are sent between the brain, the bladder, and the pelvic floor muscles. These tell you how full your bladder is and tell the correct muscles to contract or relax at the right time.
How common is urinary incontinence?
Urinary incontinence is common, especially in women. It can occur at any age, but it is more likely to develop the older you become. Overall this is about 4 in 100 adults. However, as many as 1 in 5 women over the age of 40 have some degree of urinary incontinence. The number of people affected may be even higher as many people don’t tell anyone about their problem. One reason why some people do not tell their doctor about incontinence is due to embarrassment. Some people also wrongly think that incontinence is a normal part of ageing or that nothing can be done about it. This is wrong as it can be treated in many cases. Some of the most common causes of urinary incontinence are:
• Hormone deficiencies
• Weak pelvic floor muscles
• Neurological lower urinary tract dysfunction
• Urinary tract infections
Common risk factors include:
• Pelvic surgery
Types of urinary incontinence
There are different types of urinary incontinence, depending on how and when you lose urine. This is related to which part of the lower urinary tract is affected.
• Stress incontinence is the most common type. It occurs when the pressure in the bladder becomes too great for the bladder outlet to withstand. It usually occurs because the pelvic floor muscles which support the bladder outlet are weakened. Urine tends to leak most when you cough, laugh, or when you exercise (such as when you jump or run). In these situations there is a sudden extra pressure (‘stress’) inside the abdomen and on the bladder. Small amounts of urine may leak, but sometimes it may be quite a lot and cause embarrassment. The common reason for the pelvic floor muscles to become weakened is childbirth. Stress incontinence is common in women who have had several children. It is also more common with increasing age and with obesity.
• Urge incontinence (unstable or overactive bladder) is the second commonest cause. This is when you get an urgent desire to pass urine. Sometimes urine leaks before you have time to get to the toilet. The bladder muscle contracts too early and the normal control is reduced. The cause is not known but it seems that the bladder muscle gives wrong messages to the brain, and the bladder may feel fuller than it actually is.
• Mixed incontinence. Some people have a combination of stress and urge incontinence. More than 9 in 10 cases of urinary incontinence are due to the above causes. Other causes are less common. They include:
• Neuropathic incontinence. This is when the nerves that control the bladder and surrounding structures are affected in some way. For example, some people with multiple sclerosis, spinal cord damage, brain disorders, develop this type of incontinence.
• Overflow incontinence. This is when there is an obstruction to the outflow of urine. The obstruction prevents the normal emptying of the bladder. A pool of urine constantly remains in the bladder that cannot empty properly. However, pressure builds up behind the obstruction. The normal bladder emptying mechanism becomes faulty and urine may leak past the blockage from time to time.
• Bedwetting (enuresis) occurs in many children, but some adults are affected.
It is important to know which type of incontinence you have. He or she will be able to assess your symptoms, examine you and may do some simple tests to try to clarify the cause.
Sometimes a referral to a specialist is needed to clarify the type of incontinence. The sort of tests that may be done by your doctor or specialist to clarify the cause include the following:
This is a simple dipstick test to check for infection, sugar (glucose), blood or protein in urine. A urinary tract infection (UTI) can cause incontinence, particularly in older people. Diabetes causes sugar in the urine and may cause increased thirst and an increased desire to urinate. Diabetes also puts you at more risk of UTIs. Diseases of the kidney may cause blood or protein in the urine. Visible blood in the urine can be a sign of serious bladder problems or a UTI.
Treatment depends on the type of incontinence. For example: pelvic floor exercises may cure or improve stress incontinence; bladder training may help urge incontinence; medications are sometimes used to help stop urge and stress incontinence. Other types of incontinence are less common and treatments vary, depending on the cause. Lifestyle changes may also significantly help some types of incontinence. These can include:
Changing how much you drink. If you drink large volumes, it follows that you will pass more urine. If you suffer with incontinence, you should not restrict your fluid intake too much, as you risk having a lack of body fluid (dehydration). Restricting fluids can also irritate the bladder and so make urge incontinence worse. However, if you drink excessively, moderation may improve your symptoms.
Drinking 6-8 glasses of water per day is recommended. However, there is no scientific evidence we should drink that much. In practical terms, it is best to drink when we need to, to quench our thirst. Remember that about one fifth of the water we take every day is hidden in food and that other drinks contain water.
Changing what you drink. Drinks containing caffeine (for example, tea, coffee, hot chocolate, and cola) make urge incontinence worse. This is because caffeine is a natural diuretic. Diuretics are chemicals that make you need to pass urine. If you drink a lot of caffeine-containing fluids then consider switching to decaffeinated alternatives.
Changing when you drink. You should try to maintain a normal life as much as possible with regard to drinking and visiting the toilet. However, drinking late at night may mean your sleep is disturbed by the desire to get up and go to the toilet.
Weight loss. It has been shown that losing a modest amount of weight can improve urinary incontinence in overweight and obese women. Even just 5-10% weight loss can help symptoms. If you are overweight and incontinent then you should first try to lose weight in conjunction with any other treatments.
Toilet habit. This is also dealt with in bladder training but in general it is best to visit the toilet only when you need to, rather than “just in case”. Depending on how much (and what) you are drinking and your level of activity (how much you are sweating), it is normal to pass urine every 3-4 hours on average.
Avoiding constipation. Try to maintain a healthy balanced diet that contains plenty of fruit, vegetables and soluble fibre. Severe long-term (chronic) constipation can stop the bladder emptying properly and cause overflow urinary incontinence (as well as stool (faecal) incontinence). Dehydration can also cause constipation.
Sometimes physiotherapists can help with pelvic floor exercises. In some situations, you and your doctor may decide to wait and see how things go before trying treatment. This is because some mild cases get better on their own over time and without treatment. Sometimes a specialist (usually a urologist or aurogynaecologist if you are a woman) needs to be involved in more difficult cases. Surgery can be done to treat incontinence, especially stress incontinence. If your incontinence persists and is not helped by treatment, it can be managed, by using of pants, pads, and other products. These days there are many different aids, gadgets and appliances that can greatly help when living with incontinence.
Dr Dadhich Suman is Gynaecologist at Apollo Hospital Muscat