Urinary Incontinence

What is Urinary Incontinence?

Urinary incontinence is generally defined as a complaint of any involuntary leakage of urine.

What are the types of urinary incontinence?

The most common types are:

• Stress urinary incontinence – the involuntary loss of urine during physical exertion (exercise or lifting of objects) or during coughing or sneezing
• Urge urinary incontinence – the involuntary loss of urine associated with the feeling of a sudden desire to void
• Continuous urinary incontinence – complaint of a continuous involuntary loss of urine

What are the causes and risk factors of urinary incontinence?

Factors associated with urinary incontinence include: pregnancy, mode of delivery, aging, previous continence or prolapse surgery, body mass index (BMI), prior hysterectomy, and physical work requiring heavy lifting.

Other potentially reversible causes of urinary incontinence are best remembered by the word DIAPPERS which means Dementia/delirium, Infection, Atrophic vaginitis, Psychological, Pharmacologic, Endocrine, Restricted mobility, and Stool Impaction.

What happens when you have urinary incontinence?

Stress urinary incontinence – The female pelvic organs (urethra, bladder, vagina, uterus, rectum) are supported by the pelvic floor muscles and ligaments. Pregnancy, childbirth, menopause and obesity are just some of the conditions that may affect these supporting structures. Stress incontinence happens when these muscles and ligaments around the bladder and urethra weaken, preventing them from closing the urethra as tightly as they should during increases in abdominal pressure like coughing or laughing.

Urge urinary incontinence – The bladder basically has two main functions - to store and empty urine. During filling, the bladder muscles have to continually adjust and relax to accommodate urine (average capacity is 400-600ml) while the urethral muscles remain contracted in order to prevent leakage. During voiding, the bladder muscles contract and the urethral muscles relax in a synchronized manner in order to effectively empty the bladder. This relaxation and contraction movements are coordinated and regulated for a normal voiding cycle. Urge incontinence happens when there is inappropriate or untimely bladder contractions which affects the coordination of the bladder and urethra, leading to an involuntary loss of urine. These involuntary bladder spasms may be caused by infection, damages to the bladder wall or to the nerves of the bladder, or disorders of the nervous system. Certain medical conditions (diabetes) and medications (diuretics) can cause or worsen urge incontinence. 

Continuous urinary incontinence - A continuous involuntary loss of urine is usually caused by some anatomical or structural problem in the urinary tract. An abnormal opening connecting the bladder and the vagina (vesicovaginal fistula) causes continuous loss of urine into the vaginal vault. These fistulas may happen after surgery (hysterectomy or cesarean section), prolonged labor during childbirth, or radiation treatment for pelvic cancers.

How is urinary incontinence diagnosed?

A detailed medical history is first obtained to identify potential risk factors. Physical examination (pelvic exam) will be done to detect any structural conditions that cause leakage. Other tests include:

1. Urinalysis – to assess for any infection of the urinary tract
2. Pad test – a pad is worn while several activities are performed, and leakage is confirmed if the pad stains with urine
3. Ultrasound– can show any changes that happen to the bladder and urethra when one coughs or strains, and may show other possible causes of incontinence
4. Urodynamic tests – measures the bladder capacity and pressure, and differentiates between stress and urge incontinence
5. Cystoscopy – an instrument used to look inside the urethra and bladder to confirm any structural problem (fistula or diverticulum)

You may also be asked to keep a voiding or bladder diary to assess your baseline urinary habits. This is a record of the amount of fluid you drink, the number of voids you make, and the amount of leakage that happens in a day.

What are the available treatment options?

Treatment depends on the type of incontinence that you have.

Conservative treatment is initially advised. This includes:

1. Lifestyle change – Certain food and drinks may cause you to urinate more often. Avoiding caffeinated drinks like coffee, tea and cola may help control frequency. If you have nocturia, avoiding too much fluid a few hours before you sleep may also help. Weight loss may be beneficial in relieving extra pressure placed on the bladder. Smoking has also been considered a bladder irritant so cutting down on smoking may alleviate some symptoms.
2. Bladder training – The first step is by completing a bladder diary. This helps you study your pattern of voiding and leaking, as well as assess how much fluid intake you have and if it affects your urine frequency. With this information, you can time when you have to go the bathroom, as well as adjust your intake in order to avoid frequent voiding or accidental leakage.
3. Pelvic floor muscle exercises – this is called the Kegel exercise, and the most essential part of the exercise is making sure that the right muscles are being used. Your doctor may help to make sure you are squeezing the right muscles. Strengthening these muscles and knowing the right time to squeeze them help in controlling the leaks that occur due to urgency. Some symptoms of stress incontinence may also improve after 3 to 6 months of regular exercises.
4. Pessary – this is a device that is placed in the vagina. This may be worn to help control leakage during activities that cause incontinence. This usually benefits women who have stress incontinence associated with prolapse, those with mild stress incontinence, and those who want temporary relief while waiting for definitive surgery.

Surgery may be indicated in some women who do not respond to conservative therapy. The type of surgery will depend on patient-related factors (e.g., diabetes mellitus, cancer), urethral function, and co-existing problems (e.g., prolapse, diverticulum, cancer). Surgical options include:

1. Retropubic colposuspension – a transabdominal procedure wherein the periurethral tissues near the bladder neck are sutured to a ligament of the pubis. This aims to return the bladder neck to an intra-abdominal location preventing stress incontinence.
2. Periurethral/Bulking injections – a bulking agent (commonly made of collagen and water based gels) is injected around the urethra narrowing the lumen and effectively improving urethral coaptation.
3. Minimally invasive sling procedures – a suburethral sling (made of native tissue or synthetic mesh) is placed at the level of the midurethra in a tension-free manner.

What are the possible complications of urinary incontinence?

Urinary incontinence basically affects your quality of life. Women who suffer from it may experience emotional distress due to the inappropriate leakages, and at times, especially in chronic cases, depression.

At The Medical City, what are the related services available?

At The Medical City, we have a complete roster of competent urogynecologists who can assess and treat patients with urinary incontinence. A comprehensive urodynamic evaluation is offered for patients with Urinary Incontinence at the Pelvic Floor Center with the following services:

1. simple office cystometrogram
2. uroflowmetry
3. multi-channel cystometry
4. urethral function test (urethral pressure profilometry)
5. electromyography (EMG)
6. pelvic floor ultrasound
7. bladder scan
8. cystourethroscopy

References:

• Walters, Mark D and Mickey M. Karram. Urogynecology and Reconstructive Pelvic Surgery Fourth Edition. Philadelphia: Saunders, 2015.
• International Urogynecological Association (IUGA) website.
• Department of Obstetrics and Gynecology – Section of Urogynecology
• Center for Patient Partnership