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Urinary incontinence in women


Expert reviewer Professor Raj Persad, Consultant Urological Surgeon
Next review due October 2019

Urinary incontinence is any involuntary leaking of urine. It becomes increasingly common with age. Around one in three women over 40 have stress incontinence. But around one in ten women aged between 20 and 24 are also affected.

Urinary incontinence is a serious issue that can be very upsetting but it can often be treated. Embarrassment and worry about having an accident may prevent women from going out or joining in with social or physical activities. It may even lead to depression.

Embarrassment may also prevent you discussing symptoms with your doctor. But you shouldn’t ignore urinary incontinence. If it’s left untreated, it can increase the chance of infections, kidney injury and (particularly in older people) falls.

Image of an older woman gardening

Types

There are two main types of incontinence that affect women.

  • Stress incontinence is when urine leaks after sneezing, coughing or other exertion.
  • Urgency incontinence is a sudden need to pass urine without warning and is difficult to delay.

You may have ‘mixed incontinence’ which means you have both stress incontinence and urgency incontinence.

Urgency incontinence is most often caused by an overactive bladder. This kind of incontinence is usually the most distressing in terms of its impact on quality of life. If you have an overactive bladder, you won’t necessarily have incontinence as well – you may just get the sudden urges but not leak. If you have an overactive bladder, you usually have to pass urine often, including having to get up during the night.

Symptoms

The main symptom is leaking urine. But this can vary quite a bit, from leaking a few drops to complete loss of control.

Urgency incontinence means you have a sudden need to pass urine and leak before you are able to reach the toilet. This is sometimes simply referred to as ‘overactive bladder’.

Stress incontinence is leaking urine when you cough, sneeze, laugh or otherwise increase the pressure in your abdomen (tummy), for example when exercising.

Causes

The cause depends on the type of incontinence.

Having a baby can weaken and stretch your muscles, leading to stress incontinence later in life. Incontinence is more likely with increasing numbers of vaginal deliveries.

About one in five women having surgery for a prolapsed (dropped) womb will have stress incontinence afterwards. Ask your surgeon about having surgery to treat or prevent incontinence at the same time. You will then be less likely to develop stress incontinence. Urgency may be caused by:

  • having a urinary tract infection or other medical condition
  • too much caffeine (this is found in tea, coffee and some soft drinks)

Some risk factors are associated with both types of incontinence:

  • a history of constipation and straining to pass bowel movements
  • being overweight
  • taking diuretics regularly (water tablets)

Diagnosis

If you’re having problems with any type of urinary incontinence, you need to see your GP. It will help if you keep a ‘bladder diary’ for between three and seven days beforehand and take it with you. You should record:

  • when you drink
  • what you drink and approximately how much
  • when you pass urine (including getting up in the night)
  • when you have urges to urinate
  • any incontinence or leaking

Your GP will ask about symptoms and examine you. They want to find out which type of incontinence you have and rule out any underlying causes. These could be other medical conditions or medicines you may be taking, particularly if the incontinence has worsened since you started any new medication.

Your doctor may need to examine your back passage (rectum) and vagina as well as feel your abdomen. They will be looking for other conditions that may be causing your incontinence, such as the womb slipping down from its normal position (a prolapse). They will also check the muscle tone and health of the tissues in the area, which can thin and shrink after menopause.

Tests

In many cases, incontinence in women can be diagnosed through medical history alone. However, you may have to give a urine sample for testing in the surgery. If there are any signs of infection, your GP will send a sample to the lab and may give you antibiotics.

You may have to go for an ultrasound, to check that you are emptying your bladder properly. Some women may need urodynamic tests, which measure your urine flow and how much your bladder can hold. Your doctor will explain these tests fully before doing them.

Treatment

From experience and research in treating many women with urinary incontinence, doctors now know that it is best to try the least invasive treatments first. This is most likely to be successful for many women and least likely to cause harm. That means most treatment and management is likely to come about through nurses in community incontinence services. Your GP should only refer you to a specialist if:

  • you have tried all non-surgical treatments for incontinence and they haven’t helped
  • your womb or bladder has slipped down from where it should be (prolapsed)
  • your doctor can feel a lump or other sign of abnormality when they examine you
  • you cannot pass urine at all
  • you have lasting bladder pain
  • you have blood in your urine
  • you’ve already had surgery for urinary incontinence, cancer surgery or radiotherapy to your lower abdomen

The treatment you need will depend on whether you have stress incontinence or urgency incontinence with an overactive bladder. Some women have mixed incontinence, which includes both. Your doctor will treat whichever are the most troublesome symptoms.

Self-help

There are some things you can do to help and your doctor is likely to suggest these first if they apply to you.

  • If you are overweight, losing weight definitely helps to improve symptoms of both stress and urgency incontinence.
  • If you exercise regularly, you are less likely to have urinary incontinence in middle or older age.
  • If you drink a lot of fluids, cutting down can help with overactive bladder but may not help with incontinence.
  • Cutting down on caffeine may help with symptoms of urgency and frequency.

There are devices you can wear inside your vagina or urethra (the tube that carries the urine from your bladder and out of your body). The device presses the urethra shut and helps to prevent leaks. You can only use these occasionally, but they may help when you are exercising. They can cause soreness, slight bleeding and infection but some women find them helpful. You can also try wearing a tampon, which may work just as well. To find out more, speak to your incontinence service.

While you are waiting for treatment, you may need to wear disposable pads and pants. Some women prefer these to having treatment, but it’s still important to see your GP, to discuss how they can help. Pads and pants are available commercially or you may be able to get them on prescription if your incontinence is severe (though this may depend on where you live). To avoid skin irritation, you need to change wet pads frequently.

If you are looking after someone with memory loss or confusion who is incontinent, taking them to the toilet regularly, for example every two hours, may help.

Managing stress incontinence

Your pelvic floor muscles are located between your legs. They are shaped like a sling and support your pelvic organs (uterus, vagina, bowel and bladder), giving you control when you urinate. Weak pelvic floor muscles are a major cause of stress incontinence in women who’ve had children. Your incontinence service will assess how well you can contract these muscles. If they are working, you will need to tense and relax them repeatedly, three times a day. If you can’t contract them, your incontinence nurse may suggest an electrical device to help stimulate the muscles.

Pelvic floor muscle training can really help, but only if you perform the exercises properly and regularly. After three months, your incontinence nurse will check if they’re helping. If they are, you’ll need to carry on doing them daily.

Medicines for stress incontinence

If you have gone through the menopause and have shrinkage and thinning of the vaginal tissues (atrophy), your doctor may give you vaginal oestrogen cream. This can help with incontinence symptoms but won’t cure it.

A medicine called duloxetine can help to reduce leaking in stress incontinence in the short term, but is not a cure. It has side-effects, particularly sickness, and won’t suit everyone.

Surgery for stress incontinence

If the less invasive treatments don’t help you, your GP will refer you to a specialist to discuss surgery. The main types of surgery include the following.

  • Tape procedures. In this procedure a piece of mesh tape is placed under your urethra to support it, and the ends pulled through two small cuts either in your lower abdomen (tummy) or groin.
  • Colposuspension. In this procedure your surgeon will lift the neck of your bladder by stitching the top of your vagina to the back of your pubic bone. Most people will have open surgery for this procedure.
  • Sling procedure. This procedure is similar to the tape procedure. But rather than using an artificial mesh, your surgeon will use a piece of your own tissue as the sling to support your urethra.
  • Injections of bulking agents into the wall of the urethra. This narrows your urethra, helping you to hold urine in your bladder. The effects of this procedure may wear off over time and you may need to have further injections.
  • Having an artificial urinary sphincter inserted. The device has a cuff that wraps around your urethra and stops you from passing urine. You can then release the cuff by pressing a small pump, which is inserted under the skin of your labia.

Each procedure comes with its own risks and benefits. It’s important to discuss these and any complications you might experience with your doctor before you agree to go ahead with the procedure.

Procedures using mesh are associated with more severe complications, which has raised the issue of whether they should be done or not. Until certain conditions to ensure safety are met, the NHS has put a ban on surgeons carrying out these procedures.

If you’ve had the procedure and haven’t experienced any complication, try not to worry – it’s likely that everything is fine. For some people, the benefits of having the procedure will actually outweigh the risk. However, if you have the procedure, it’s really important to discuss and be fully aware of the risks involved so you can make an informed decision on whether you want to go ahead with the procedure or not. Speak to your surgeon for more advice.

Managing urgency and overactive bladder

Your GP will suggest six weeks of bladder training. This means you learn to gradually increase the time between wanting to pass urine and emptying your bladder. If you keep it up, it may help with urgency and mean you have to pass urine less often. Doing bladder training alongside giving up caffeine may be enough to solve the problem of an overactive bladder.

Your GP may prescribe a medicine called desmopressin. This can help to cut down urgency and frequency, but may not help with leaking.

Medicines for urgency and overactive bladder (OAB)

Most of the medicines used for urgency and OAB are ‘anti-muscarinics’. These can cure incontinence in some people. Most can cause dry mouth and constipation, but these can be signs that the medicine is working, which takes about four weeks. The medicines have different side-effects, so if one doesn’t suit you, you can try another. There is a particular risk of side-effects for older people, who may be encouraged to try other measures in the first instance.

If anti-muscarinic medicines are not right for you, your doctor may suggest mirabegron, which works just as well as anti-muscarinic medicines. This helps to relax the bladder so that it can fill with urine. It does still have side-effects and as it’s a new medicine, the long-term effects are not fully known.

Your GP will recommend medicines that work in line with any other conditions you have, or other medications you may be using. They will check your progress after around four weeks. If you continue on medicine treatment, you will have a review annually.

Other treatments for urgency and overactive bladder

If medicine treatment doesn’t help, your doctor will refer you to a specialist, who may suggest:

  • botulinum toxin injections into the bladder
  • electrical nerve stimulation
  • surgery

Botulinum injections can be very successful in treating urgency incontinence, but the effects may not last long and you will need to have the treatment repeated. One serious side-effect is being unable to pass urine at all, so you need to be able to put a tube into your bladder (self-catheterise) if this happens.

There are two types of electrical nerve stimulation (ENS). Sacral ENS involves putting an implant in your back, which can help your bladder to work properly. You’ll need to have tests to see if it is likely to help you. You can only have this treatment if you’ve tried medicines and botulinum toxin and you can’t self-catheterise.

Tibial ENS involves stimulating a nerve near your ankle to help control your bladder. You have 12-weekly sessions and may need more, as the effects may wear off. This treatment isn’t used routinely as there is less evidence that it helps. You may be able to try it if other treatments haven’t worked or aren’t suitable. If no other treatments have helped, your specialist may suggest surgery. They may suggest making your bladder bigger (augmentation) or diverting urine away from the bladder into a bag (urinary diversion). These are major operations. You will need tests beforehand and your surgeon will fully explain the procedure and all the possible complications to you.

Prevention

You may be able to lower your risk of urinary incontinence by:

  • maintaining a healthy weight
  • starting to practise pelvic floor exercises during or soon after your first pregnancy


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Related information

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  • Produced by Liz Woolf, Freelance Health Editor, October 2016
    Expert reviewer Professor Raj Persad, Consultant Urological Surgeon
    Next review due October 2019



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