Urinary incontinence in women

Urinary incontinence (UI) – involuntary loss of urine – is a problem that affects millions of women. Some may leak a little urine while coughing or jogging, others may feel a sudden strong urge to urinate before losing a large amount of urine, and a few women experience both.

Whether it’s just a minor discomfort or a completely debilitating problem that impacts your lifestyle, the good news is that UI is a treatable medical condition that in many cases can be cured.

Studies have found that doctors often don't detect UI or treat it properly, so even though it might be awkward, it’s up to you to speak up and get professional help from your GP or urogynaecologist (doctor who specialises in female urinary and associated pelvic problems).

In Australia, the National Continence Helpline’s trained continence nurse advisors will listen to your concerns, supply information and refer you to the most suitable health professional with experience in UI where you can get further advice and support. Contact the Helpline on freecall 1800 33 00 66.

There are many causes of urinary incontinence, including pregnancy and childbirth, menopause and obesity. But physical age-related problems and neurological injury or diseases such as multiple sclerosis, stroke and Parkinson’s disease can also cause incontinence. While women are twice as likely as men to experience UI, and it affects older women more than younger women, incontinence isn't an unavoidable part of getting older.

Incontinence occurs due to problems with muscles and nerves that help to hold or release urine. During urination, bladder muscles tighten to move the urine stored there into the urethra. The sphincter muscles around the urethra relax simultaneously so that urine can leave the body. When these muscles relax without warning or the sphincter muscles aren't strong enough to retain urine, incontinence will occur. Damage to these muscles may also result in leakage as there's less pressure than usual.

Types of female UI
Sometimes, women experience temporary (transient) incontinence, which can be triggered by several things including urinary tract infection, certain medicines, severe constipation and even a cold.

When you experience UI for longer periods, these are the most common types you need to know about:

Stress incontinence
Stress incontinence usually occurs during physical activities such as coughing, laughing, sneezing and shouting, or any other exertion (e.g. jogging, bending, pushing/pulling) that increases pressure inside the abdomen and pushes down on the bladder, causing urine to leak out involuntarily. Stress incontinence is common in women and is often caused by weakened pelvic floor muscles or other physical changes resulting from pregnancy, childbirth and menopause.

If nerves that control the bladder are damaged, or structures supporting your bladder, i.e. the vagina, pelvic floor muscles and ligaments weaken, the bladder can shift slightly downward. This prevents the muscles that usually force the urethra shut from squeezing completely tight and causes urine to leak into the urethra during physical stress.

Some women with UI may find that it gets worse during menopause or during the week before their menstrual period when lower oestrogen levels might cause reduced muscular pressure around the urethra.

Urge incontinence
This entails leaking urine for no apparent reason after suddenly feeling an urge to urinate. Inappropriate bladder contractions due to abnormal nerve signals often cause urge incontinence. Damage to nerves and muscles of the bladder, the nervous system (brain and spinal cord) and conditions such as stroke, uncontrolled diabetes, Alzheimer’s disease, multiple sclerosis, and Parkinson’s disease can cause or worsen urge incontinence.

In some women with urge incontinence, leakage can also occur while washing dishes or hearing running water, while certain fluids and medications such as diuretics can make the condition worse.

When women experience a combination of stress and urge incontinence, it's known as mixed incontinence. According to studies, it's the most common type of urine loss in women.

Overactive bladder
For many women, emptying their bladder up to seven times a day is normal, but when abnormal nerves send signals to the bladder at the wrong time, it could mean you have an overactive bladder and need to urinate even more often.

Overactive bladder symptoms may include needing to urinate eight or more times a day and a few times at night (frequency), a sudden strong urge to urinate immediately (urgency), nocturia (awakening at night to urinate), and gushing or leaking urine that follows a sudden strong urge.

Functional incontinence
If you have a physical condition or illness such as arthritis or Alzheimer’s disease that affects your movement or cognitive functions, you may be incontinent because you're unable to reach a toilet in time.

Overflow incontinence
Women rarely experience this type of incontinence, which happens when the bladder spills over because it doesn't empty properly.

Causes include a blocked urethra, urinary stones, weak bladder muscles or nerve damage from diabetes and other illnesses.

Talking to your doctor about UI
We understand that you may feel embarrassed about discussing UI with your doctor or gynaecologist, but remember that millions of women have the same problem and many have been treated successfully. You’ll need to take the first step and schedule an appointment. Try to select a doctor with experience in treating incontinence.

During the visit, your doctor will do a physical examination, take your medical history and look for signs of other conditions such as prolapse (where the vagina or bladder begins to protrude from its normal position) that may be causing the problem. It’s likely the doctor will do tests to measure how well your bladder functions and how much it can hold. Other tests may include blood tests, a urine analysis and a bladder stress test during which loss of urine is measured while coughing or bearing down.

Useful tip: Keep a bladder diary for a week or so before your visit to the doctor and take it along with you. Make a note of how often you empty your bladder, how and when you leak urine and what you were doing at the time (e.g. sneezing, coughing, laughing, picking something up or sleeping) as well as the amount of leakage (e.g. just a few drops or a large amount).

Treatment options
There are many ways to treat UI and you may have to try several before finding the most suitable one for you. That is why it’s important to know about the different treatment options and to make sure you discuss them with your doctor. It’s best to focus on the most troublesome aspects of the condition.

Remember that treatment will largely depend on the type of UI, the severity and the one most appropriate for your lifestyle. Most doctors agree that treatment for UI should start with the least invasive (lifestyle changes, behavioural therapies, medications). Only then should you consider more invasive methods such as surgery.

Lifestyle treatment options for UI include:

Pelvic floor exercise programmes (Kegel exercises) strengthen the muscles you use to stop urinating and can help to reduce or cure stress leakage. It’s very important to learn how to do these exercises correctly, as clenching hundreds of times a day or trying to stop the urine flow simply won’t work. Ask your doctor or the National Continence Helpline to refer you to a continence or pelvic floor physiotherapist who specialises in exercises to strengthen the pelvic floor muscles.

Medicines work in different ways to help prevent incontinence, so ask your doctor if they will be a good treatment option for you. Medicines can help by slowing the production of urine, relaxing the bladder muscles, preventing bladder spasms or blocking abnormal nerve signals that cause the bladder to contract at the wrong time. Remember that all medicines have side effects. Take the medication exactly as prescribed and tell your doctor if you're taking any other over-the-counter medicines that may interact with bladder control drugs.

Bladder training (also called timed voiding) entails limiting fluid intake at certain times of the day and planning regular trips to the toilet before you get the urge to urinate.

Biofeedback uses electrical stimulation via sensors that a therapist attaches to an electrical patch over your bladder and urethral muscles to make you aware of signals and how your body works. By monitoring when your bladder and urethral muscles contract, you can gain control over these muscles.

Adapting lifestyle habits. These include quitting smoking, losing weight, avoiding alcohol, cutting down on beverages containing caffeine and avoiding lifting heavy objects. Get advice from a trained medical professional.

Medical devices and techniques
The most common medical device to treat stress incontinence is a vaginal pessary. A doctor or nurse inserts this stiff ring into the vagina, which pushes up against the urethra and vaginal walls. It works to reduce stress leakage by helping to reposition the urethra.

It’s important to see your doctor regularly if you use a pessary, as it may increase the likelihood of vaginal and urinary tract infections.

Surgery is usually only performed if other treatments for stress UI haven't been effective or if you have severe incontinence. Ask a medical specialist whether surgery will help your specific UI and what type of surgery would be best for you.

Lastly, remember that incontinence is treatable at all ages, and that all types of UI are treatable. You need not suffer in silence.

1. National Kidney and Urologic Diseases Information Clearinghouse Patient booklet: What I need to know about bladder control for women www.kidney.niddk.nih.gov
2. www.continence.org.au
3. www.uptodate.com/contents/treatment-and-prevention-of-urinary-incontinence-in-women?source=search_result&search=urinary+incontinence&selectedTitle=2~150
4. http://effectivehealthcare.ahrq.gov/ehc/decisionaids/urinary-incontinence/