Incontinence, urinary

Urinary incontinence is the unintentional passing of urine. It is a very common problem that is thought to affect about three million people in the UK.

Anyone can experience urinary incontinence, although it is more common in people who are older. The condition affects far more women than men, and it is thought to occur in one in five women who are over 40 years of age.

How the bladder works

The bladder is a stretchy muscular bag that collects and stores urine. It is located in the middle of the pelvis at the lowest point in the abdomen, immediately behind the pubic bone.

The bladder is constantly receiving urine from the kidneys, which filter it down to the bladder through tubes called ureters. The urine is held in the bladder by the pelvic floor muscles, which keep the urinary opening (urethra) closed.

Once the bladder is full, a signal is sent to the brain which triggers the need to pass urine. At a suitable time, the brain tells the pelvic floor muscles to relax and the bladder contracts to push the urine out.

However, this process can be interrupted in several different ways, resulting in urinary incontinence.

Types of urinary incontinence

There are various types of urinary incontinence, but the two main types are known as stress incontinence and urge incontinence.

• Stress incontinence - occurs when the pelvic floor muscles are too weak to prevent urination.
• Urge incontinence - is thought to occur as a result of incorrect signals being sent between the brain and the bladder.

These two types of urinary incontinence are thought to be responsible for up to 90% of all cases of the condition. It is also possible to have a mixture of both stress and urge urinary incontinence.

What can be done

Urinary incontinence can be an uncomfortable and upsetting problem. Many people may think that it is an inevitable part of aging, but there are several forms of treatment, including exercises, medicines and electrical therapy, that can help ease the symptoms.

The main symptom of urinary incontinence is a loss of bladder control that causes you to pass urine when you do not mean to. However, when and how this happens varies depending on the type of urinary incontinence that you have.

Stress incontinence

Stress incontinence is the most common type of urinary incontinence, particularly among women who have had children, or been through the menopause.

Stress incontinence is not related to feeling stressed, but occurs when your bladder is put under an extra amount of sudden pressure.

If you have stress incontinence, you may find that urine leaks out during physical activities such as:

• coughing,
• sneezing,
• laughing,
• heavy lifting, or
• exercise.

The amount of urine that is passed is usually small, but stress incontinence can also cause you to pass larger amounts, particularly if your bladder is very full.

Urge incontinence

Urge incontinence is where you have an unstable, or overactive bladder, and it is the second most common type of urinary incontinence.

If you have urge incontinence, you may feel a sudden, very intense need to pass urine, before quickly releasing large amounts of urine. There is often only a few seconds between the need to urinate and the release of urine.

Your need to pass urine may be triggered by a sudden change of position, or even by the sound of running water. You may also find that you pass urine during sex, particularly when you reach orgasm.

If you have urge incontinence, you may need to pass urine very frequently. You may need to get up several times during the night.

Overflow incontinence

Overflow incontinence is a type of urinary incontinence that is common in men who have an enlarged prostate gland, which can obstruct the bladder.

If you have overflow incontinence, you may find that you pass small trickles of urine very often. It may also feel as though your bladder is never fully empty, and you cannot empty it even when you try.

Total incontinence

Urinary incontinence that is severe and continuous is sometimes known as total incontinence. It usually occurs as a result of a congenital (present from birth) bladder disorder, after surgery, or following an injury.

Total incontinence may cause you to constantly pass large amounts of urine, even at night. Alternatively, you may pass large amounts of urine every so often and leak small amounts in between.

Urinary incontinence occurs when the normal process of passing urine is interrupted. This can happen for a number of different reasons, which, in most cases, are related to the different types of urinary incontinence.

How urine is normally passed

Your bladder collects urine from your kidneys and stores it until it is full, stretching like a balloon as it fills up. Normally, your pelvic floor muscles, which surround your urinary opening (urethra), hold it closed and prevent any urine from being passed until you decide to do so

When your bladder is full, a nerve signal is sent from your bladder to your brain, which lets you know that you need to pass urine. When you get to a toilet, another nerve signal is sent from your brain to your pelvic floor muscles, which relax at the same time as your bladder contracts. This allows urine to be pushed out of your bladder through your urethra.

The various causes of urinary incontinence are described below.

Causes of stress incontinence

Stress incontinence occurs when your pelvic floor muscles have been weakened, and can no longer keep your urethra fully closed. Any sudden extra pressure on your bladder, such as laughing, or sneezing, can cause urine to leak out of your urethra.

Your pelvic floor muscles can be weakened by a number of different factors which are outlined below.

• Pregnancy and childbirth - this can sometimes overstretch, and strain, your muscles.
• Menopause - a lack of the hormone, oestrogen, can weaken your muscles.
• A hysterectomy (removal of the womb) - this type of surgery can sometimes damage your muscles.
• Age - as you get older, your muscles naturally become weaker.
• Obesity - being obese can put excess stress on your muscles.

Causes of urge incontinence

Urge incontinence occurs when your bladder contracts too early, often before it is full, and before you have a chance to get to a toilet. It is not known exactly why this happens, but it may be due to mixed up signals between your brain and your bladder.

In most cases, it is not possible to find a cause for urge incontinence and, if this is the case, the problem may be diagnosed as 'overactive bladder syndrome'. However, some specific causes of urge incontinence have been identified, such as those described below.

• Urine infections - such as cystitis (inflammation of the bladder lining).
• Conditions that affect the nervous system - such as Parkinson's disease, multiple sclerosis, and stroke.
• An enlarged prostate gland in men - this can irritate your urethra (urinary opening) and lower bladder.

Causes of overflow incontinence

Overflow incontinence is often caused by a blockage, or obstruction, to your bladder. Your bladder may fill up as usual, but as it is obstructed, you will not be able to empty it completely even when you try to.

At the same time, pressure from the urine that is still in your bladder builds up behind the obstruction, causing frequent leaks.

Your bladder can become obstructed by a number of things as outlined below.

• An enlarged prostate gland in men - this is the most common cause of overflow incontinence.
• Urinary stones - small, hard, stone-like lumps that can form in your bladder.
• Constipation - a build up of stools (faeces) can obstruct your bladder.
• Surgery for urinary incontinence - if the operation overcorrects the problem.

Causes of total incontinence

Total incontinence occurs when your bladder cannot store any urine at all. It can result in you either passing large amounts of urine constantly, or passing urine periodically, with frequent leaking.

Total incontinence can be caused by a number of things as outlined below.

• A bladder defect - which you were born with.
• Injury to your spinal cord - this can disrupt the nerve signals between your brain and your bladder.
• A bladder fistula - a small, tunnel-like structure, which can develop between your bladder, and a nearby area, such as the vagina.

Other causes of urinary incontinence

In some cases, mild urinary incontinence may only be experienced occasionally. If this is the case, your urinary incontinence may be due to one of the following contributory factors.

Certain medicines

Some medicines can disrupt the normal process of storing and passing urine. These include diuretics, which are often taken to treat high blood pressure, and increase the amount of urine that you produce, and muscle relaxants, which you may take if your muscles are very tense.

You may also experience slight urinary incontinence as a result of taking sedatives, or sleeping tablets.

Certain drinks

Some drinks, such as those containing alcohol, or caffeine, act as diuretics. This means that they cause your bladder to fill up quicker than usual. Drinking alcohol can also make you less aware of when you need to pass urine.

It is also possible for some drinks to irritate your bladder, and cause a sudden need to pass urine urgently. These drinks include citrus fruit juices, such as orange juice, and drinks that contain artificial sweeteners.

Urinary tract infections (UTIs)

If bacteria are able to enter your urinary tract through your urethra, you may develop an infection in your bladder which increases your urge to pass urine.

You may also experience a painful burning sensation when you pass urine, or your urine may smell stronger than usual.

Smoking

If you smoke, frequent coughing can result in urinary incontinence, and make any existing incontinence worse.

Coughing places excess strain on the ring of muscle (sphincter) at the base of your bladder and, over time, constant coughing that is caused by smoking, can severely weaken it.

If you are experiencing urinary incontinence, you should see your GP. Do not be embarrassed about talking to your GP about your incontinence; they are there to help you.

In order to provide treatment for your condition, your GP will need to decide which type of urinary incontinence you have and, to establish this, they will ask you several questions about your symptoms and medical history.

Your GP may also suggest that you keep a diary of your bladder habits, for at least three days, so that you can give them as much information as possible. You should include details such as how much fluid you drink, how often you need to pass urine, and the amount of urine that you pass.

You may also need to have some tests so that your GP can confirm, or rule out, certain external factors that may be causing your incontinence. Some of these tests are outlined below.

Physical examination

Your GP may examine you to assess the physical health of your urinary system.

If you are female, your GP may examine your vagina to check the strength of your pelvic floor muscles. If you are male, your GP may examine your rectum (back passage) to check whether or not your prostate gland is enlarged.

'Dipstick' test

If your GP thinks that your incontinence may be caused by an infection, a sample of your urine may be tested for bacteria. A small, chemically treated stick will be dipped into your urine sample and it will change colour if there are bacteria present. The dipstick test can also check the blood and protein levels in your urine.

Bladder ultrasound scan

If you are unable to fully empty your bladder, you may have a bladder ultrasound scan. An ultrasound scan uses high frequency sound waves to create an image of the inside of your body, and can show how much urine is left in your bladder after you go to the toilet.

During a bladder ultrasound, a thin, flexible tube (an endoscope) is inserted into your urethra and gently fed through to your bladder. You will be awake when this happens, but you may be given a sedative and a painkiller to help relax you.

Residual urine test

A residual urine test may be used if a bladder ultrasound scan fails to show the amount of urine that is left in your bladder after you go to the toilet.

As with a bladder ultrasound scan, a residual urine test involves a thin, flexible, hollow tube (a catheter) being fed through your urethra to your bladder. Any urine that is left in your bladder will be drained out through the catheter, so that the amount can be measured.

The treatment you receive for urinary incontinence will depend on the type of incontinence you have, and the severity of your symptoms. If your incontinence is caused by an underlying condition, such as an enlarged prostate gland (in men), you will receive treatment for this first.

Lifestyle changes

Your GP may suggest that you make some simple changes to your lifestyle in order to reduce your incontinence. These changes can help improve your condition regardless of the type of urinary incontinence that you have.

For example, your GP may recommend:

• reducing your caffeine intake,
• changing the amount you drink - reducing it if it is too much, or increasing it if it is too little, and
• losing weight - if you are overweight, or obese.

Stress incontinence

Initial treatment for stress incontinence involves making simple lifestyle changes, such as those described above, and doing exercises in order to strengthen your pelvic floor muscles.

Pelvic floor exercises

Your GP may refer you to a physiotherapist who will assess whether you are able to contract your pelvic floor muscles, and by how much. If you are unable to contract them, using a device that measures and stimulates the electrical signals in the muscles, may be recommended. If you can contract your pelvic floor muscles, you should:

• do a minimum of eight muscle contractions, at least three times a day, and
• continue to do the exercises for a minimum of three months to begin with, and continue to do them after this time, if they help.

Surgery

If lifestyle changes and pelvic floor exercises prove to be unsuccessful in treating your stress incontinence, surgery may be recommended. Before making your decision, you should discuss the risks and benefits of surgery with your health care professional, plus any possible alternative treatments. If you plan to have children, this will be an important factor that will affect your decision.

A surgeon who has had specialist training in incontinence surgery should carry out surgery for stress incontinence. There are a number of different surgical procedures that can be used to treat stress incontinence. These are outlined below.

Sling procedures

Sling procedures involve inserting something into the neck of the bladder to help support the urethra. For example, a strip of tape, made out of polypropylene (a synthetic material) may be inserted into your bladder, underneath your urethra, in order to support it, and stop urine from leaking out. Alternatively, tissue from another part of your body may be used to support your urethra.

Sling procedures can be carried out using either local, or general, anesthetic. Following the procedure, the recovery time is usually quite short. You may be able to return home after 1-3 days, and resume normal activities soon afterwards.

Colposuspension

Colposuspension is another surgical procedure that is sometimes used to treat stress incontinence. In this operation, your bladder neck is lifted.

The surgeon makes a cut in your lower abdomen, and puts stitches through the walls of the bladder neck. You will need to be in hospital for about a week. A laparoscopic colposuspension is the same procedure, using keyhole surgery.

Bladder neck injections

Bladder neck injections are where collagen, or another synthetic material, is injected into the wall of the urethra, in order to strengthen it, and stop urine from leaking out. The procedure can usually be performed under either local or general anaesthetic.

Compared with other forms of treatment, there is less chance that injections will cure your incontinence, and you may need to have further treatment because the effect of the injections can wear off over time.

Artificial sphincter (valve)

To control the flow of urine from your bladder into your urethra, an artificial sphincter (valve) can be inserted. However, this procedure is usually only recommended if other treatment methods have failed because the side effects can be serious.

If initial surgery to treat stress incontinence has proven unsuccessful, before having another operation, urodynamic tests, which measure the flow of urine, should be carried out to determine why your bladder and urethra are not working properly.

Medication

Medication is not normally used to treat stress incontinence, although a medicine called duloxetine, is a possible alternative to surgery.

Urge incontinence

As with stress incontinence, if you have urge incontinence (or overactive bladder syndrome), initial treatment should involve making the lifestyle changes described above.

Bladder training

If you have been diagnosed with urge incontinence, your GP may refer you to a specialist for 'bladder training'. This involves learning techniques that will help you to increase the length of time between feeling the need to urinate and actually passing urine. The course should usually last for a minimum of six weeks.

If you have a memory disability, you may be given specific training to help prevent leakages. This may involve a carer reminding you to go to the toilet at set times.

Medication

If bladder training is not an effective treatment for your urge incontinence, and you still need to pass urine frequently, your GP may prescribe an antimuscarinic. Antimuscarinics are a group of medicines that can have side effects. Your GP should discuss this with you.

Oxybutynin is the first antimuscarinic that should be prescribed for you. However, if you do not get on with oxybutynin, your GP may prescribe an alternative, such as darifenacin, solifenacin, tolterodine, or trospium. Your GP should monitor your progress carefully to check that the new medicine does not cause you problems.

Surgery

If lifestyle changes and medication prove unsuccessful in treating your urge incontinence, your GP may suggest surgery. Before making a decision, your GP should discuss any risks and benefits, and any possible alternatives, with you. If you plan to have children, this will be an important factor that will affect your decision.

A surgeon who has had specialist training in incontinence surgery should carry out surgery for urge incontinence. There are a number of different surgical procedures that can be used to treat urge incontinence. These are outlined below.

Sacral nerve stimulation

If your urge incontinence is the result of an overactive bladder muscle, a procedure known as sacral nerve stimulation may be recommended. During the operation, an implant is inserted into your bladder to help you to gain more control over it.

Augmentation cystoplasty

In a procedure known as augmentation cystoplasty, your bladder is made larger by adding a piece of tissue from your intestine into the bladder wall. After the procedure you may not be able to pass urine normally, and you may need to use a catheter (a thin tube that is passed through your bladder and into your urethra).

Urinary diversion

Urinary diversion is a procedure where the tubes that lead from your kidneys to your bladder (ureters) are redirected to the outside of your body. The urine is collected directly without it first flowing into your bladder. Urinary diversion should only be carried out if other treatments have proved unsuccessful, or are not suitable.

Prior to having a surgical procedure to treat urge incontinence, you should have urodynamic (urine flow) tests to determine why your bladder and urethra are not working properly.

After having any of the above surgical procedures, you should receive check-ups on a regular basis for the rest of your life.

Botulinum toxin A

Another possible treatment for urge incontinence involves injecting the sides of your bladder with botulinum toxin A. As with augmentation cystoplasty, after the injections, you may not be able to pass urine normally, so you will need to insert a catheter in order to drain the urine from your bladder. Also, botulinum toxin A is not currently licensed for use in the UK, so you should be made aware of any associated risks before deciding to have the treatment.

Mixed incontinence

If your urinary incontinence is a combination of both stress incontinence and urge incontinence, your initial treatment will depend on which of your symptoms are the most problematic.

Other treatments

In addition to the treatments outlined above, there are a number of things that you might find useful in helping you to manage your urinary incontinence. These are listed below.

• Absorbent products - such as incontinence pants, or pads.
• Hand-held urinals - urine collection bottles.
• Catheters - a thin tube that is inserted into your bladder to drain urine.
• Devices that are placed into your vagina, or urethra, to help prevent urine leakage. These may be particularly useful during exercise.

If you have to urinate frequently during the night (nocturia), a medicine called desmopressin may be recommended. However, in the UK, desmopressin has not been licensed for treating nocturia, so your GP should make you aware of any associated risks and benefits before you decide to use it.

Complementary therapies

The NHS does not recommended using complementary therapies to treat incontinence.

There are a number of complications that can occur as a result of urinary incontinence. These are outlined below.

Skin problems

If you have urinary incontinence, you may develop sores, a rash, or a skin infection due to your skin being wet all the time.

Urinary tract infections (UTIs)

If you have urinary incontinence, your risk of getting urinary tract infections is increased.

Prolapse

Prolapse is a complication of urinary incontinence that can occur in women. It happens when part of the vagina, bladder and, in some cases, urethra, drop down into the entrance of the vagina. Weak pelvic floor muscles often contribute to the problem. Prolapse usually needs to be repaired using surgery.

Day-to-day activities

Urinary incontinence can prevent you from taking in part in normal, day-to-day activities. For example, you may not feel comfortable socialising, taking part in sports, or group activities, or travelling long distances.

Working life

Urinary incontinence can have a negative impact on your work life. The feeling of needing to constantly urinate may affect your ability to concentrate, and you may

need to get up from your desk to visit the toilet frequently. You may also feel very tired if your urinary incontinence continually disrupts your sleep.

Personal life

Urinary incontinence can also often have a negative impact on your personal life. Those close to you may find it difficult to understand your condition, and you may

find it embarrassing, as well as frustrating. You may avoid having sex due to the risk of urine leakage. Anxiety and depression are common conditions for those

with urinary incontinence.

It is not always possible to prevent urinary incontinence. However, there are a number of things that you can do to decrease the risk of developing the condition.

Weight

Maintaining a healthy weight for your height and build by eating a healthy, balanced diet, and taking plenty of regular exercise, may help you to avoid getting urinary incontinence.

Diet

Eating a healthy, balanced diet that including at least five portions of a variety of fruit and vegetables, plus plenty of fibre, will help you prevent getting constipated. Constipation is a risk factor for urinary incontinence. If you have urinary incontinence, you should avoid eating foods that make your condition worse.

Drinking

Depending on your particular bladder problem, your GP will be able to advise you about the amount of water that you should drink. If you have urinary incontinence, you should also cut down on alcohol and drinks that contain caffeine, such as tea, coffee, and cola. These are diuretics which cause your kidneys to produce more urine, and they can also irritate your bladder.

The recommended daily amount of alcohol is 3-4 units, for men, and 2-3 units, for women. One unit of alcohol is equal to half a pint of normal strength beer, one small glass of wine, or a single, pub measure of spirit.

If you have to urinate frequently during the night (nocturia) try not to drink any fluids for three hours before you go to bed.

Exercise

Keeping active is a very important part of leading a healthy lifestyle, and it can help to prevent a number of serious health conditions, including urinary incontinence. Make sure that you do a minimum of 30 minutes of exercise, at least five times a week.

Being pregnant and giving birth can weaken the muscle that controls the flow of urine from your bladder (urinary sphincter). Therefore, if you are pregnant, strengthening your pelvic floor muscles can help to prevent urinary incontinence.

Men can also benefit from strengthening their pelvic floor muscles by doing pelvic floor exercises.

Smoking

If you smoke, your risk of developing urge incontinence is increased. Therefore, you should try to give up. Your GP will be able to provide you with advice about quitting smoking. Alternatively, you can call the NHS smoking helpline number on 0800 169 0 169 for information and advice.

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