Urinary Incontinence

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Urinary incontinence is defined as the involuntary loss of urine from the bladder. It is thought that almost 20% of Australian adult women suffer from urinary incontinence (1). It affects women of all ages (although the prevalence increases with age) and is not restricted to women who have borne children.

Urinary incontinence can have a significant impact on women’s lives. They may avoid participating in their favourite sport or even leaving the house due to the risk of urine leakage. Urinary incontinence can also result in a negative body image and/or reduced self esteem.

Despite its prevalence, approximately 60% of people suffering from urinary incontinence do not seek professional help for their condition (2). It appears that a combination of embarrassment and the belief that urinary incontinence is a natural consequence of ageing and childbirth deters women from seeking the appropriate treatment.

Although common, urinary incontinenceis not normal and should be addressed in the same way as other health problems, by consulting a health professional. Women should not resort to simply relying on incontinence pads and pants to manage the condition. Treatment for urinary incontinence can be very effective and is often relatively simple.

This factsheet provides information on the different types of urinary incontinence and outlines treatment processes with the aim of encouraging women to seek the help they require.

The urinary system

An awareness of how the urinary system normally works is helpful to understand the different types of urinary incontinence. Urine is a waste product produced by the kidneys when they filter the blood. The kidneys constantly produce urine which trickles down through two tubes (ureters) into the bladder. The bladder functions as a storage capacity for the urine and is able to hold between 350-500 mls, although this tends to decrease with age. Urine leaves the body through the urethra, a tube which leads from the bladder to the outside of the body.

The female urinary system

Urine stays in the bladder because the muscles encircling the urethra (urethral sphincter muscles) act as a valve, keeping the urethra shut. The urethral sphincter muscles work in conjunction with the pelvic floor muscles which are stretched like a sling from the pubic bone to the base of the spine. If the pelvic floor muscles are weakened the urethral sphincter muscles may not be able to close as tightly, allowing urine to leak.

When the bladder fills, nerve endings in the bladder wall send messages to the spinal cord and then to the brain, creating a sensation to urinate. The brain then sends messages to both the urethral sphincter muscles and the pelvic floor muscles, telling them to relax. The urethral sphincter muscles and the pelvic floor muscles in turn send messages to the bladder muscle (detrusor) which contracts and pumps the urine out through the urethra.

When all the urine has been emptied from the bladder the urethral sphincter muscles and the pelvic floor muscles contract, closing the urethra, and the bladder muscle relaxes. Adults with normal bladder function, who drink 2 litres of fluid daily, will generally pass urine 4-7 times a day (every 3-4 hours). On average, a person will pass between 250-500 mls of urine each time.

Diagnosis

It is important that women suffering from urinary incontinence seek medical help and do not accept it as a normal development. Women with an incontinence problem should firstly visit their general practitioner. A thorough consultation will assist in achieving an accurate diagnosis and identifying appropriate treatment options.

The general practitioner will firstly take a complete history, including a description of symptoms (frequency, amount of urine lost, when urine loss occurs). They may also ask questions regarding pregnancies and deliveries, surgical history, bowel function, previous urinary tract infections and the use of any medications.

An abdominal and pelvic examination will be conducted to check for any problems in the bladder or pelvic organs (tumours, prolapse). They may also assess the strength of the pelvic floor muscles and determine if urine leakage occurs with increased abdominal pressure. Women will often be asked to complete a bladder diary which involves recording details such as: fluid intake; frequency of urination; degree of urgency when urinating; when leakage occurred; and the amount of leakage.

A general practitioner may refer a woman to a continence nurse adviser, a continence physiotherapist, a urologist (a doctor specialised in treating problems of the urinary system) or a urogynaecologist (a gynaecologist who specialises in the female urinary system). In some areas, there are also continence clinics providing expertise in the investigation and management of incontinence.

There are a range of other tests that may be conducted as part of a urinary incontinence diagnosis. These include:

Midstream urine sample - to check for disease, infection or other abnormalities.

Renal ultrasound - an ultrasound examination of the urinary system is useful in determining the state of the ureters and if there is a residual urine problem. It may also show other problems like bladder tumours or fibroids, which can cause obstructions to the urinary tract.

X-rays - if there has been a history of urinary tract infections, x-rays may be used to exclude any problems with the kidneys. X-rays can also be useful in detecting kidney or bladder stones.

Cystoscopy - a small magnifying instrument (cystoscope) is passed up the urethra to view the inside of the bladder. The cystoscope can be used to detect any inflammation, stones or growths in the bladder or an obstruction in the urethra.

Urodynamic assessment - conducted in order to gain a more accurate picture of the functioning of the bladder and urethra. The assessment measures the rate and pressure of the urine flow and the capacity of the bladder. Urodynamic assessment is particularly appropriate for women who have a combination of stress and urge incontinence.

Urodynamic assessment should always be performed before any surgical intervention is planned to ensure the bladder condition is suitable for surgery.

The diagnosis will determine what type of urinary incontinence a woman has – stress, urge, combination stress and urge, overflow or functional.

Stress incontinence

The most common form of urinary incontinence is stress incontinence and it occurs during activities which increase abdominal pressure (eg., while coughing, sneezing, laughing, lifting heavy objects or during physical activity). Increased abdominal pressure increases pressure in the bladder which in turn forces the urethra to open, resulting in the loss of urine.

Causes
Stress incontinence most often results from weakened pelvic floor muscles which support the bladder and the urethral sphincter muscles. Pregnancy and childbirth are the most common causes of weakened pelvic floor muscles. During pregnancy, hormonal changes and the extra weight and pressure of the baby contribute to weakening. The pelvic floor muscles may also be weakened during childbirth, particularly in a prolonged second stage of labour, if the baby is bigger than 4kg in weight or there is an instrumental delivery. It is estimated that up to 46% of women experience some degree of incontinence during pregnancy, with up to 30% having an incontinence problem following delivery (3,4).

Pelvic floor muscles weakness can also be caused by the straining often associated with constipation or coughing. Therefore, smokingis associated with stress incontinence as smokers often suffer from chronic coughing. Excess weight is a contributing factor as the pelvic floor muscles are forced to carry a heavier load. It has also been found that some women have a genetic predisposition to pelvic floor weakness.

At menopause the reduction in oestrogen levels can contribute to a loss of tone in the urethra, therefore, affecting its closing pressure. Reduced oestrogen levels also cause the pelvic floor muscles to become less elastic and, therefore, may aggravate existing muscle weakness.

Treatment
Pelvic floor exercises
These exercises are designed to strengthen the pelvic floor muscles through actively tightening and lifting them at intervals. Strong, well activated pelvic floor muscles help support the bladder, uterus and bowel. The exercises are designed to work three different parts of the pelvic floor muscles: the muscles that control urine flow; the muscles that control the anal sphincter (muscles around the anus) and the muscles that surround the urethra and vagina. The pelvic floor muscles also interact with the deep abdominal muscles.

The exercises can be performed sitting, standing or lying down. A woman can do pelvic floor exercises while waiting in a queue or sitting at the office desk, without anyone noticing. The number of exercises required depends on the woman’s existing pelvic floor muscle strength but, generally, she will be required to do the exercises 5-6 times a day. It may take 2-3 months to notice a significant improvement. As with any exercise program, women should start gradually, building up the number of contractions and perform the exercises regularly. More important than having strong pelvic floor muscles, however, is the ability to activate them in time against increases in abdominal pressure (eg., when sneezing, coughing or lifting).

As some women have difficulty performing the exercises correctly, seeking assistance from a physiotherapist to learn the correct techniques is recommended. If not done properly (if women bear down, for instance) the exercises may exacerbate symptoms.

Vaginal cones can assist women who are having trouble identifying their pelvic floor muscles. The cones come in different weights and are placed inside the vagina, while a woman is in a standing position. A woman will contract her pelvic floor muscles to hold the cone in place and prevent it from slipping. Women will generally start with a light cone and then progress to a heavier cone as their pelvic floor muscles become stronger.

Similarly, biofeedbackuses a sensor to measure pelvic floor muscle contractions in order to provide immediate ‘feedback’ to a woman on whether she is performing the exercises correctly. The sensor is either an internal sensor placed in the vagina or a skin patch placed externally.

If a woman’s pelvic floor muscles are very weak or the nerve supply to the muscles is damaged electrical stimulation may be an option. It consists of temporarily placing electrodes in the vagina and/or rectum. Small pulses of electricity generate muscles contractions and can help women identify how to do the contractions themselves.

Electromagnetic stimulation of the pelvic floor muscles is a relatively new therapy. Women sit, fully clothed, in a specially designed chair which produces pulsed magnetic fields. These fields cause the pelvic floor muscles to contract and relax. The medical community’s views on this treatment option are currently divided. Further studies are required to establish the optimum length/amount of stimulation, the long term effectiveness and how the therapy compares to other pelvic floor therapies (5).

Achieving sensible weight loss through a combination of dietary changes and regular exercise can lead to an improvement in urinary incontinence symptoms as there is a reduction in the pressure placed on the pelvic floor.

Pessaries may be an option for women who have incontinence as a result of genital prolapse, but for whom surgery or other treatments are unsuitable (eg., elderly women). Pessaries are placed in the vagina, where they help re-position the bladder and urethra, limiting the leakage of urine. Pessaries must be fitted by a medical professional. Pessaries do not deal with the underlying cause of the incontinence and they can cause irritation and increase the risk of urinary infections.

There is no evidence that oral hormone replacement therapy (HRT) is effective at treating stress incontinence. Results from a large trial found that oral HRT actually increased a woman’s risk of urinary incontinence (6). While topical oestrogen (vaginal cream) is often prescribed to women there is little evidence that it is beneficial in treating stress incontinence itself (7).

Urethral injections involve injecting a substance such as collagen, fat or a synthetic material into the tissues around the urethra. The substance ‘bulks up’ the area and, therefore, tightens the seal of the urethra. Urethral injections may need to be topped up and can be costly. They do, however, provide an alternative for those women who are unable or do not wish to have surgical treatment. New injectable substances are currently being trialled (8).

There are a number of surgical procedures for the treatment of stress incontinence. While there are a two main approaches (colposuspension and sling procedure) there are several variations within these. Generally, surgery to correct stress urinary incontinence repositions the bladder and urethra to their normal positions and/or provides the bladder with support.

Surgery should only be considered after trialling conservative treatments and following a urodynamic assessment to ensure the diagnosis is correct and the leakage condition is favourable to surgical correction. Success rates and risks vary for different procedures and so women should discuss this with their doctor prior to surgery. Women should be aware that surgery may not result in a complete resolution of incontinence symptoms.

In a colposuspension procedure the front wall of the vagina (where the urethra is located) is lifted and stitched to strong ligaments near the pubic bone. This results in the bladder neck being elevated to its proper position. The most popular variation of the colposuspension procedure is Burch colposuspension. Burch colposuspension is performed both abdominally and laparoscopically (key hole surgery).

A sling procedure involves placing either a piece of fascia (strong tissue that covers the body’s muscles) or a synthetic material under the urethra like a hammock to support it. Some of these procedures require a general anaesthetic, while others can be done under a regional anaesthetic. The procedure generally requires small incisions in the abdomen and/or vagina.

Urge incontinence

Urge incontinence consists of a sudden and urgent desire to urinate and the inability to hold the urine until a toilet is reached. Urge incontinence is usually caused by the bladder muscle contracting involuntarily. Urge incontinence is sometimes also referred to as overactive bladder or detrusor instability. Women with urge incontinence may have to go to the toilet very frequently.

Causes
Urge incontinence can be associated with poor bladder habits. As children we are often instructed by parents and teachers to go to the toilet when told to rather than when there is a need (eg., “Go to the toilet before we leave”). Women often continue to do this in adulthood, going to the toilet ‘just in case’. Going to the toilet when it is not really required can irritate the bladder muscle, causing it to spasm before the bladder is full. This results in the bladder becoming less able to hold a normal quantity of urine. Also, as we age our bladders are able to hold less urine.

Nerve damage, neurological conditions (multiple sclerosis, Parkinson’s disease), stones in the urinary tract, tumours, prolapse anduterine fibroids can also cause urge incontinence, as can some medications and previous incontinence surgery. Interstitial cystitis, a severe and chronic pain syndrome affecting the bladder, can also result in urge incontinence. Certain food and beverages can cause irritation to the bladder, exacerbating urge incontinence. Caffeine, alcohol, artificial sweeteners, carbonated beverages, citrus juices and citrus fruit, highly spiced foods and tomatoes and tomato based products are most likely to cause irritation (9). Similarly, a low fluid intake causes the urine to become very concentrated which can irritate the bladder.

Treatment
A woman’s control of her bladder can be improved through training it to hold more urine. Bladder re-training includes timed deferment (resisting the urge to urinate for a specific period of time) and timed voiding (urinating to a schedule and gradually increasing the length of time between toilet visits). A bladder diary is often used to assist women to keep a track of their progress. It may take up to three months of bladder re-training before there is a significant improvement.

Before commencing a bladder re-training program women should first learn several urge control techniques to help them reach the toilet dry. These include pelvic floor contraction; distraction (thinking or doing other things to take the focus away from the urge to urinate); applying pressure to the clitoris or perineum (by using hand pressure, a rolled towel, corner of a table); toe curling; squeezing the buttocks; drawing in the lower abdomen; and breathing exercises. Women may also wish to use incontinence pads and pants during the bladder re-training phase to build confidence in their ability to defer going to the toilet.

Pelvic floor exercises, electrical stimulation and electromagnetic stimulation are also used in the treatment of urge incontinence (see stress incontinence treatment section). Women can also try limiting the intake of caffeine and other bladder irritants.

A variety of medications are used in the treatment of urge incontinence. The most widely used are anticholinergics, which work by inhibiting bladder contractions, which delays the urge to urinate. Side effects can include dry mouth, constipation, blurred vision and palpitations. Newer anticholinergics tend to have fewer side effects.

Botulinum toxin (or botox) has been the subject of several trials in the treatment of urge incontinence. Botox is injected into the bladder muscle where it prevents involuntary contractions. While results from trials are promising, further research is required (10).

Combination stress and urge incontinence

Women often have a combination of both stress and urge incontinence. The contributing factors can be the same or they may be completely unrelated. Therefore, treatment options need to address both forms of incontinence.

Overflow incontinence

Overflow incontinence occurs when the bladder cannot empty completely. This results in an over distended bladder and eventually the urethral sphincter muscles will open causing urine to leak. Women with overflow incontinence may only have a weak dribbling stream of urine or feel that they need to empty their bladder but cannot. The residual urine in the bladder can cause recurrent bladder infections.

Causes
Overflow incontinence may be due to an obstruction or blockage to the bladder opening (stones, tumour, uterine fibroid, prolapse or a full bowel due to constipation). Damage to the nerve supply to the bladder, medical conditions like multiple sclerosis or diabetes, drugs and recent gynaecological surgery can also result in people may not being able to sense their bladder is full.

Treatment
If the cause of the overflow incontinence cannot be corrected (ie., removal of stone, fibroid), intermittent self catheterisation is the best management option. Intermittent self catheterisation involves inserting a catheter (small tube) through the urethra to drain the bladder several times a day. It is useful in eradicating infections due to residual urine and can also stop leakage problems. It can be used on both a temporary and permanent basis.

Functional incontinence

Functional incontinence results from the inability or unwillingness to reach a toilet on time. It is more common in the elderly or disabled.

Causes
Restricted mobility due to arthritis or other disabilities can make it difficult for a woman to access a toilet in time. The inconvenient/unsuitable positioning of the toilet can also be a contributing factor (eg., toilet located downstairs, not suitable for wheelchair access). In addition, a woman may have decreased awareness and/or a personal reluctance to go to the toilet (eg., Alzheimer’s disease).

Treatment
Relatively simple strategies such as replacing button and zippers on pants with velcro or press studs and improving lighting or installing hand rails may assist some people in reaching the toilet in time. Intermittent self catheterisation may be an option for those people whose physical disabilities make it difficult for them to reach a toilet. For those who have decreased awareness or a personal reluctance, the use of incontinence products may be the best management strategy.

Prevention

There are a number of steps that can help to reduce the chance of incontinence occurring. They include:

• Drink between 1.5-2 litres of fluid every day, the majority of which should be water. An adequate fluid intake helps keep the urine diluted (less irritation to the bladder) and maintains the bladder’s ability to hold urine. Women, however, should also avoid a fluid intake that is too high as this can result in a worsening of urinary frequency and leakage.
• Maintain good bladder habits by only going to the toilet when the bladder is full. Avoid going ‘just in case’. It is important that parents and teachers educate children about good bladder habits. For instance, they should avoid instructing children to go to the toilet for convenience sake.
• Adopt a good toileting position (see diagrams below). Using this position when urinating will help properly empty the bladder and bowel without straining. Women should avoid ‘hovering’ over the toilet seat, a common behaviour when using public toilets.
• Perform pelvic floor exercises regularly, especially during pregnancy, following childbirth and into menopause. In conjunction, strengthen deep abdominal muscles.
• Treat the cause of any chronic coughing or sneezing (ie., manage asthma, hay fever).
• Hold a firm abdomen while walking and standing as this maintains pelvic floor support.
• Maintain a healthy weight and avoid smoking.

Good toileting position

• Forward leaning position.
• Feet may be supported on a low stool (15cm in height) or with heels raised and the weight resting on the balls of the feet.
• Back remains straight while keeping the normal curves.
• Forearms or hands rest on the knees.
• Hips are flexed slightly more than 90 °.

References

1 Chiarelli P et al. Etsimating the prevalence of urinary and faecal incontinence in Australia:systematic review Aust J Ageing 2005; 24:1:19-27
2 Current Therapeutics. Disease focus: Female incontinence Curr Ther 1999; 40:1/2:16
3 Wesnes SL et al. Urinary incontinence during pregnancy Obstet Gynecol 2007; 109:4:922-8
4 Glazener CM et al. New postnatal urinary incontinence: obstetric and other risk factors in primiparae BJOG 2006; 113:2:208-17
5 Quek P. A critical review on magnetic stimulation:what is the role in the management of pelvic floor disorders? Curr Opin Urol 2005; 15:4:231-235
6 Hendrix S et al. Effects of estrogen with and without progestin on urinary incontinence JAMA 2005; 293:8:935-948
7 Palmer MH & Newman DK. Urinary incontinence and estrogen: Is hormone replacement therapy an effective treatment? Am J Nurs 2007; 107:3:35-37
8 Rackley R. Injectable bulking agents for incontinence EMedicine http://www.emedicine.com/med/topic30249.htm [website] date accessed: 23 May 2007
9 Tyler A. Bladder control: There’s no need to suffer in silence Female Patient S16 1999; 27-31
10 Schurch B. Botulinum toxin for the management of bladder dysfucntion Drugs; 66:10:1301-1318

Further help and information from Women's Health Queensland Wide

Health Information Line:
Our free statewide line is staffed by women's health nurses and midwives. They provide women with up to date information, support and referral to health practitioners and services. Women can contact the Health Information Line by phone or email via the 'Ask a Health Question' page on the website. All phone calls and emails are confidential.
(07) 3839 9988 or 1800 017 676 (toll free outside Brisbane)

Library:
Our free lending library offers a select range of books on major women's health topics. Topic-based booklists are availableon our website, or can be posted out; books can be requested by phone or email and are posted to borrowers.
Contact on administration : (07) 3839 9962

Website:
All our factsheets and booklets are available on our website. The website also features articles on women's health from our newsletter, student factsheets, upcoming events, library services and 'Ask a Health Question' page. A list of reputable links is also available where women can search for further information on health topics.
www.womhealth.org.au

Further reading

See our

• Genital prolapse factsheet
• Incontinence library booklist

Other sources of information

Continence Foundation of Australia
1800 33 00 66 (National Continence Helpline)
www.contfound.org.au
The helpline is a free national service for people of all ages with incontinence, their carers, families and health professionals. The Foundation's website provides information on incontinence, resources for health professionals and information on financial assistance for continence aids and appliances.

National Public Toilet Map
www.toiletmap.gov.au
The National Toilet Map identifies the location of more than 14 000 public and private toilet facilities across Australia. The Map was designed specifically to assist persons experiencing incontinence with travel and daily living arrangements.

This factsheet was originally published By Women's Health Queensland Wide (Women's Health) in June 2000. It was revised by Kirsten Braun and the Editorial Committee at Women's Health in September 2004 and August 2007.

Last Modified: September 1, 2007