Dr Arun

NEWS

June 22, 2016 Menopause, News

Urinary incontinence

Urinary incontinence is leaking of urine that you can’t control. Many women suffer from urinary i­ncontinence. We don’t know for sure exactly how many. That’s because many people do not tell anyone about their symptoms. They may be embarrassed, or they may think nothing can be done. So they suffer in silence.

Urinary incontinence is not just a medical problem. It can affect emotional, psychological and social life. Many people who have urinary incontinence are afraid to do normal daily activities. They don’t want to be too far from a toilet. Urinary incontinence can keep people from enjoying life.

Many people think urinary incontinence is just part of getting older. But it’s not. And it can be managed or treated.

Key statistics

It is thought that urinary incontinence affects up to 37% of Australian adult women. Although it is commonly associated with pregnancy, childbirth and menopause, urinary incontinence affects women of all ages (although the prevalence increases with age) and is not restricted to women who have borne children – in fact, 12% of Australian women who have never had children and are aged under 30 have incontinence.

Studies show that many things increase risk. For example, aging is linked to urinary incontinence. Pregnancy, delivery, and number of children increase the risk in women. Women who have had a baby have higher rates of urinary incontinence. The risk increases with the number of children. This is true for cesarean section (C-section) and vaginal delivery.

Women who develop urinary incontinence while pregnant are more likely to have it afterward. Women after menopause (whose periods have stopped) may develop urinary incontinence. This may be due to the drop in estrogen (the female sex hormone). Taking estrogen, however, has not been shown to help urinary incontinence.

Obesity increases the risk of urinary incontinence. Losing weight can improve bladder function and lessen urinary incontinence symptoms.

What happens normally?

The brain and the bladder control urinary function. The bladder stores urine until you are ready to empty it. The muscles in the lower part of the pelvis hold the bladder in place. Normally, the smooth muscle of the bladder is relaxed. This holds the urine in the bladder. The neck (end) of the bladder is closed. The sphincter muscles are closed around the urethra. The urethra is the tube that carries urine out of the body. When the sphincter muscles keep the urethra closed, urine doesn’t leak.

Once you are ready to urinate, the brain sends a signal to the bladder. Then the bladder muscles contract. This forces the urine out through the urethra, the tube that carries urine from the body. The sphincters open up when the bladder contracts.

What are the types of urinary incontinence?

Urinary incontinence is not a disease. It is a symptom of many conditions. Causes may differ for men and women. But it is not hereditary. And it is not just a normal part of aging. These are the four types of urinary incontinence:

Stress Urinary Incontinence (SUI)

With SUI, weak pelvic muscles let urine escape. It is one of the most common types of urinary incontinence. It is common in older women.

SUI happens when the pelvic floor muscles have stretched. Physical activity puts pressure on the bladder. Then the bladder leaks. Leaking my happen with exercise, walking, bending, lifting, or even sneezing and coughing. It can be a few drops of urine to a tablespoon or more. SUI can be mild, moderate or severe.

Ways to manage SUI include “Kegel” exercises to strengthen the pelvic floor. Lifestyle changes, vaginal and urethral devices, pads, and even surgery are other ways to manage SUI.

Overactive Bladder (OAB)

OAB is another common type of urinary incontinence. It is also called “urgency” incontinence. It affects people’s lives. They may restrict activities. They may fear they will suddenly have to urinate when they aren’t near a bathroom. They may not even be able to get a good night’s sleep. Some people have both SUI and OAB and this is known as mixed incontinence.

With OAB, your brain tells your bladder to empty – even when it isn’t full. Or the bladder muscles are too active. They contract (squeeze) to pass urine before your bladder is full. This causes the urge (need) to urinate.

The main symptom of OAB is the sudden urge to urinate. You can’t control or ignore this “gotta go” feeling. Another symptom is having to urinate many times during the day and night.

OAB is more likely in women after menopause. It is caused by many things. Even diet can affect OAB. There are a number of treatments. They include life style changes, drugs that relax the bladder muscle, or surgery. Some people have both SUI and OAB.

Mixed Incontinence (SUI and OAB)

Some people leak urine with activity (SUI) and often feel the urge to urinate (OAB). This is mixed incontinence. The person has both SUI and OAB.

Overflow Incontinence

With overflow incontinence, the body makes more urine than the bladder can hold or the bladder is full and cannot empty thereby causing it to leak urine. In addition, there may be something blocking the flow or the bladder muscle may not contract (squeeze) as it should.

One symptom is frequent urinating of a small amount. Another symptom is a constant drip, called “dribbling.”

This type of urinary incontinences is rare in women. It is more common in men who have prostate problems or have had prostate surgery.

Diagnosing urinary incontinence

If you experience urinary incontinence, see your specialist so they can determine the type of condition you have.

Urinary incontinence is a common problem and it’s likely your specialist has seen many people with the condition.

Your SPECIALIST will ask you questions about your symptoms and medical history, including:

  • whether the urinary incontinence occurs when you cough or laugh
  • whether you need the toilet frequently during the day or night
  • whether you have any difficulty passing urine when you go to the toilet
  • whether you are currently taking any medications
  • how much fluid, alcohol or caffeine you drink?

Bladder diary

Your SPECIALIST may suggest that you keep a diary of your bladder habits for at least three days, so you can give them as much information as possible about your condition. This should include details such as:

  • how much fluid you drink
  • the types of fluid you drink
  • how often you need to pass urine
  • the amount of urine you pass
  • how many episodes of incontinence you experience?
  • how many times you experience an urgent need to go to the toilet

Tests and examinations

You may also need to have some tests and examinations so that your SPECIALIST can confirm or rule out things that may be causing your incontinence. Some of these are explained below.

Physical examination

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

Your SPECIALIST will carry out a pelvic examination, which usually involves undressing from the waist down. You may be asked to cough to see if any urine leaks out.

Your SPECIALIST may also examine your vagina. In over half of women with stress incontinence, part of the bladder may bulge into the vagina.

Your SPECIALIST may place their finger inside your vagina and ask you to squeeze it with your pelvic floor muscles. These are the muscles that surround your bladder and urethra (the tube through which urine passes out of the body). Damage to your pelvic floor muscles can lead to urinary incontinence.

Dipstick test

If your SPECIALIST thinks your symptoms may be caused by a urinary tract infection (UTI), a sample of your urine may be tested for bacteria. A small, chemically treated stick is dipped into your urine sample. It will change colour if bacteria are present. The dipstick test can also check the blood and protein levels in your urine.

Residual urine test

If your SPECIALIST thinks you may have overflow incontinence, they may suggest a test called residual urine test to see how much urine is left in your bladder after you go for a wee.

This is usually done by carrying out an ultrasound scan of your bladder, although occasionally the amount of urine in your bladder may be measured after it has been drained using a catheter. This is a thin, flexible tube that is inserted into your urethra and passed through to your bladder.

Further tests

Some further tests may be necessary if the cause of your urinary incontinence is not clear. Your SPECIALIST will usually start treating you first and may suggest these tests if treatment is not effective.

Cystoscopy

A cystoscopy involves using a flexible viewing tube, known as an endoscope, to look inside your bladder and urinary system. This test can identify abnormalities that may be causing incontinence.

Urodynamic tests

These are a group of tests used to check the function of your bladder and urethra. This may include keeping a bladder diary for a few days (see above) and then attending an appointment at a hospital or clinic for tests such as:

  • measuring the pressure in your bladder by inserting a catheter into your urethra
  • measuring the pressure in your abdomen (tummy) by inserting a catheter into your bottom
  • asking you to urinate into a special machine that measures the amount and flow of urine

Non-surgical treatments for urinary incontinence

The treatment you receive for urinary incontinence will depend on the type of incontinence you have and the severity of your symptoms. 

Conservative treatments, which do not involve medication or surgery, are tried first. These include:

  • lifestyle changes
  • pelvic floor muscle training (‘Kegel exercises’)
  • bladder training

After this, medication or surgery may be considered.

Medication for Overactive Bladder

Anticholinergics

If bladder training is not an effective treatment for your urge incontinence, your GP may prescribe a type of medication called an antimuscarinic.

Anticholinergics may also be prescribed if you have overactive bladder syndrome (OAB), which is the frequent urge to urinate that can occur with or without urinary incontinence.

A number of different antimuscarinic medications that can be used to treat urge incontinence, but common ones include oxybutynin, and solifenacin.

These are usually taken by mouth daily, although an oxybutynin patch that you place on your skin twice a week is also available.

Your GP will usually start you at a low dose to minimise any possible side effects. The dose can then be increased until the medicine is effective.

Possible side effects of anticholinergics include:

  • dry mouth
  • constipation
  • blurred vision
  • fatigue

You will be assessed after four weeks to see how you are getting on with the medication, and every six to 12 months thereafter if the medication continues to help.

Your GP will discuss any other medical conditions you have to determine which anticholinergics are suitable for you.

Mirabegron

If anticholinergics are unsuitable for you (for example Glaucoma), or they have not helped your urge incontinence or have caused unpleasant side effects, you may be offered an alternative medication called mirabegron.

Mirabegron causes the bladder muscle to relax, which helps the bladder fill up with and store urine. It is usually taken by mouth once a day.

Side effects of mirabegron can include:

  • urinary tract infection(UTI)
  • High blood pressure
  • a rash

Your GP will discuss any other medical conditions you have to determine whether mirabegron is suitable for you.

Surgery and procedures for urinary incontinence

If other treatments for urinary incontinence are unsuccessful or unsuitable, surgery or other procedures may be recommended.

Before making a decision, discuss the risks and benefits with a specialist, as well as any possible alternative treatments.

If you are a woman and plan to have children, this will affect your decision, because the physical strain of pregnancy and childbirth can sometimes cause surgical treatments to fail. Therefore, you may wish to wait until you no longer want to have any more children before having surgery.

Surgery and procedures for stress incontinence

Tape procedures

Tape procedures can be used for women with stress incontinence.

A piece of plastic tape is inserted through an incision inside the vagina and threaded behind the urethra (the tube that carries urine out of the body). The middle part of the tape supports the urethra, and the two ends are threaded through two incisions in either the:

  • tops of the inner thigh – this is called a transobturator tape procedure (TOT)
  • abdomen (tummy) – this is called a retropubic tape procedure or tension-free vaginal tape procedure (TVT)

By holding the urethra up in the correct position, the piece of tape can help reduce the leaking of urine associated with stress incontinence.

The effectiveness of these tape procedures is similar, with around two in every three women not experiencing any leaking afterwards. Even those who still have some leaking after surgery often find this is less severe than it was before the operation.

However, it is not uncommon for women to need to go to the toilet more frequently and urgently after this procedure, and some find they are unable to completely empty their bladder when they go to the toilet.

In some cases, the tape can wear away or move over time and further surgery may be needed at a later stage to adjust it (for example, to make it looser) or to remove it.

Colposuspension

Colposuspension involves making an incision in your lower abdomen, lifting up the neck of your bladder, and stitching it in this lifted position. This can help prevent involuntary leaks in women with stress incontinence.

There are two types of colposuspension:

  • an open colposuspension – where surgery is carried out through a large incision
  • a laparoscopic (‘keyhole’) colposuspension – where surgery is carried out through one or more small incisions using special, small surgical instruments

Both types of colposuspension offer effective, long-term treatment for stress incontinence, although laparoscopic colposuspension needs to be carried out by an experienced laparoscopic surgeon.

Problems that can occur after colposuspension include difficulty emptying the bladder fully when going to the toilet, recurrent urinary tract infections (UTI) and discomfort during sex.

Sling procedures

Sling procedures involve making an incision in your lower abdomen and vagina so a sling can be placed around the neck of the bladder to support it and prevent accidental urine leaks. The sling can be made of:

  • a synthetic material
  • tissue taken from another part of your body (an autologous sling)
  • tissue donated from another person (an allograft sling)
  • tissue taken from an animal (a xenograft sling), such as cow or pig tissue

In many cases, an autologous sling will be used and will be made using part of the layer of tissue that covers the abdominal muscles (rectus fascia). These slings are generally preferred because more is known about their long-term safety and effectiveness.

The most commonly reported problem associated with the use of slings is difficulty emptying the bladder fully when going to the toilet. A small number of women who have the procedure also find that they develop urge incontinence afterwards.

Procedure for urge incontinence

Botulinum toxin A injections

Botox injections can help overactive bladder symptoms in women; not just for wrinkles

Botulinum toxin A, commonly known as Botox injections, best known worldwide for treating wrinkles and other cosmetic purposes. These injections are now approved for use in overactive bladder in Australia.

For these women, Botox injections to the bladder may be offered as a treatment.

What are Botox injections to the bladder?

Botox is a recently approved treatment for OAB that’s delivered via injection. It works by blocking the muscles and nerves that lead to a feeling of urgently needing to urinate. This involves passing a small telescope (cystoscope) into your bladder through your urethra (the tube that carries urine from the bladder to outside the body) and injecting between 10 and 20 injections of Botox® into your bladder wall from the inside. This helps to improve the symptoms of overactive bladder.

What are the benefits of Botox injections?

Botox is highly effective in relieving the frequency and urgency of needing to go to the toilet and reduces urinary incontinence in majority of women undergoing the injection.

For the majority of women, the beneficial effects are usually seen three to four days after the injection. The Botox injection is expected to last for six to twelve months, but this will vary for each woman.

For some women, a single treatment is all that is required: others will need repeated injections.

Any side effects?

 Sometimes urinary retention occurs (inability or difficulty to empty your bladder). In other words, the Botox injection works too well and women cannot pass urine on their own.

However, there is a small risk of you requiring to self catheterise (pass a tube/catheter in to the bladder yourself a few times a day) to empty the bladder.

Blood in your urine –This is usually minor and settles down without any treatment.

Urinary tract infection – Symptoms include increased frequency, pain or burning when passing urine and feeling unwell. This is treatable with antibiotics.

What happens after the treatment?

You can return to work the day after your Botox injection.

You will be seen in the clinic two weeks to one month after the injections.

Dr. A S Arun MD DNB CCST, FRCOG, FRANZCOG

For Treatment enquiries, please contact Dr Arun.

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