Stress: Many women have experienced a small leakage of urine upon sneezing, coughing or laughing. This is usually caused by a weakness in the pelvic floor muscles amd is known as stress incontinence. It is most common during pregnancy and child birth.
Urge: Here, the desire to pass urine comes on too suddenly to reach the facilities. This may result in simultaneous incontinence, or very shortly after. In some cases it may just present with the sensation of urgency but without any actual incontinence - this is sometimes referred to as Overactive Bladder Syndrome. The most common causes of urge incontinence in the UK are infections and a condition known as destrusor (bladder wall muscle) instability.
Mixed: As the name suggests, there are usually features of both stress and urge incontinence present. The causes also tend to also be shared.
Total: In cases of total incontinence, the patient has no warning whatsoever. The sufferer is likely to pass urine almost without realising. This usually indicates severe nerve damage and may be a result from radical surgery, spinal paralysis or conditions such as multiple sclerosis. Total incontinence may also arise when a new channel for urine has formed between the bladder or urethra and the vagina, bypassing the normal anatomical route for urine flow. These channels are referred to as fistulas and usually occur due other diseases affecting the bladder or urethra.
How is incontinence diagnosed?
Urinary incontinence can be diagnosed and managed by your GP, urologist, gynaecologist and in some cases, a neurologist. This section aims to help you make the most of your consultation with your doctor.
Bladder diaries: It is important that you provide your doctor with as much information as possible in order that they may present the most accurate diagnosis. Your doctor will want to know how frequently you pass urine during the day and how often you have to get up during the night. When you do have an accident, how bad is it? They will want to know if you use protective measures against leakages, and if yes, how often are they utilised. In addition, your doctor will probably ask about the impact your symptoms on your daily life, which includes both the physical aspects and its emotional effects. A history of your dietary habits, including the types of beverages your drink, and a list of your current medications, will also be important.
To make the most of your first consultation with your doctor, keep a diary of your symptoms for at least one to two weeks before your appointment. Jotting this down your habits in an incontinence dairy, sometimes referred to as a bladder diary, will be of great help to your doctor.
Examination: Though intrusive, a thorough examination is necessary in order to identify the likely cause of your symptoms. The examination will normally involve a brief neurological examination, a test of your reflexes, abdominal examination, a rectal exam, and an assessment of whether or not you have an enlarged bladder. The doctor will also want to make note of your rectal tone (assessing how pelvic nerves are working) and to rule out constipation. A pelvic exam will asses the pelvic floor muscles and allow the doctor to rule out any prolapses.
Some doctors, as part of their examination, may also carry out a urinary stress test. This involves lying on your back, in much the same position as for a smear. The doctor will then ask you to cough, while they observe urethral meatus (the exit site for urine).
Urinalysis: This test analyses a sample of urine from your first morning occurrence. Special test strips will be used to look for markers of infection. If an infection is suspected, your doctor will usually send the urine off to a microbiology lab to ascertain the type of infection so that the right antibiotic may be prescribed.
Bladder Scan: Patients who mainly have urgency type symptoms, or a mixed picture, may be asked to to have a special ultrasound scan. Patients are first scanned with a full bladder, then asked to empty their bladder and then rescanned. In a normal healthy bladder, there should be no urine left in the bladder after passing urine.
Urodyamnic studies: Urodynamnic studies are usually carried out in specialist clinics. They measure the flow rate of urine in order to rule out any kind of obstruction. This type of test normally involves a tube being passed through the urethra and in to the bladder. Another tube is then inserted into the rectum.
Treatment
Physical therapies
Pelvic floor muscle exercises/ Kegel exercises: Women often feel dismissed when this is the initial management, however there is very good evidence to show them to be effective in the management of stress and mixed incontinence. In fact, pelvic floor muscle exercises are recommended as first line of treatment for stress incontinence. It is usually tailored to the individual patient and organised by specially trained physiotherapists. The evidence for using pelvic floor muscle exercises in urge incontinence is lacking, but most experts feel that it should be included as part of the overall management strategy.
Biofeedback: This works on the principle that by learning what your body is doing and when, you should gain better control over your body. The biofeedback method works by placing an electrode on the skin, over the bladder and pelvic muscles. This transmits images to a screen and both the therapist and the patient may observe and monitor how the muscles work and try to learn how to control them. The evidence for biofeedback, however, is poor.
Inter-vaginal devices: These are cone shaped devices, that come in a set of two or three, with each one being a slightly different weight. The devices are inserted in to the vagina, and the idea is that the patient tries to hold them in the vagina for increasing periods of time. This helps to strengthen the pelvic floor muscles.
Pessaries: Pessaries are ring shaped devices which are inserted by the doctor. They work by providing support to the urethra, preventing it from dropping on coughing, sneezing or laughing. They are primarily used in the treatment of stress incontinence.
Bladder retraining: This is a technique that can be helpful in urge incontinence. Bladder retraining involves passing urine frequently at set times, avoiding the urge to occur. The time between visits to the toilet are gradually increased, with the aim of gradually re-training the bladder to exercise bladder control.
Lifestyle changes: There is some good evidence which suggests that the loss of weight in obese individuals can help improve continence, though in lighter individuals, this is unlikely to make significant differences. With regards to fluid management, again, most doctors will advise patients to watch their intake. The evidence is not convincing, however, and it would be advised to drink enough to produce at least two litres of urine in 24 hours. Caffeine and alcohol are both known to stimulate the kidneys to produce urine, however large studies have not shown any significant difference in those minimising their intake. Here, I believe it's worth reviewing on an individual basis. If it works for you, then keep doing it.
Drug therapy
Author: Dr Shazan Chughtai, MB BS
