Urinary Incontinence Information

Urinary incontinence is passing urine when you don't mean to because of partial or total loss of control of the bladder. It is estimated that 3-6 million people in the UK have some degree of incontinence. Urinary incontinence becomes more common as people get older but it does not only affect older people. It is twice as common in women than men and affects many women who have had children.

When you need to pass urine your bladder tells your brain it is full. Even when the bladder is full, the majority of people can control the need to urinate until they get to a toilet. Then your brain tells your pelvic floor muscles to relax and your sphincter (the opening at the neck of your bladder) to open. Your bladder muscle tightens (contracts) and pushes the urine out.

If you have incontinence, either the muscles or the nerve supply are not working properly to control your bladder. The two main types of urinary incontinence are stress incontinence (a small amount of urine leaks out during physical activity) and urge incontinence (the bladder empties completely).

Symptoms

Stress incontinence

Stress incontinence is the most common type of incontinence. This is when a small amount of urine leaks out during physical activity, including coughing, sneezing, laughing, heavy lifting or sex (usually at penetration). This is because your pelvic floor muscles are weak and can't tighten (contract) properly. Usually only a little bit of urine leaks out but it can be very embarrassing. This type of incontinence is common in women after having children or after the menopause.

Urge incontinence

Urge incontinence is the second most common type of incontinence. It is also known as having an unstable or overactive bladder. With this type of incontinence, the bladder contracts involuntarily, leading to a loss of bladder control and the release of large amounts of urine. This happens because there is a problem with the messages between the brain and the bladder. The bladder may feel fuller than it is and tells the brain it is full too early. The bladder muscle squeezes too early and empties completely - often before you have a chance to get to a toilet.

Urge incontinence may happen during any activity, even when you're sat still. It is often triggered by a sudden change of position, is worse in times of stress and can happen during sex, particularly when you orgasm. People with urge incontinence often go to the toilet a lot during the night.

Overflow incontinence

This kind of incontinence is also known as incomplete bladder emptying. It is most common in older men who often have a slightly enlarged prostate gland, which is just underneath the bladder. The urine outflow tube passes through the middle of the prostate, and any enlargement of the gland presses on the urine tube. This makes it difficult for the bladder to empty and fill up completely, and a pool of urine constantly remains in the bladder. The area behind the obstruction is tense and highly pressurised and the bladder regularly releases a small involuntary dribble of urine. This condition is very rare in women.

Reflex bladder

Some people have no control over their bladder at all. This is called reflex bladder. Some people have it all their lives and some develop it after injury or illness.

Mixed incontinence

Some people suffer from stress and urge incontinence at the same time.

Nocturia

People who need to go to the toilet more than normal during the night are said to have a condition called nocturia.

Causes

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

A small amount of urine drips constantly from your kidneys to your bladder through tubes called ureters. The amount of urine made depends on a number of things including how much you drink, eat and sweat.

The bladder relaxes and stretches like a balloon as it fills with urine. The bladder normally fills up without you noticing to about 280ml of urine. A full bladder contains about 350ml of urine. When it is full, you start to experience pain and an urgent need to empty the bladder.

The outlet for urine (the urethra) is normally kept closed even when it is under pressure from a full bladder. The ring of muscle at the opening at the neck of the bladder is called the sphincter. The muscles beneath the bladder that surround the urethra are called the pelvic floor muscles. Your pelvic floor muscles help to hold your bladder and urethra in place. When the muscles get weak, it is hard to stop urine from leaking out.

When you go to the toilet to pass urine, the bladder muscle contracts (squeezes), and the urethra and pelvic floor muscles relax. Complex nerve messages are sent between the brain, the bladder, and the pelvic floor muscles. These make you aware of how full your bladder is and tell the right muscles to contract, or relax, at the right time.

Some of the possible causes of urinary incontinence are outlined below.

Physical disabilities or mobility issues that prevent you getting to the toilet in time.
Side effects of drugs you are taking, particularly drugs that cause you to produce or retain more urine or blood pressure drugs that relax the sphincter.
Constipation (a full rectum can affect bladder function by direct pressure).
Untreated diabetes.
Having surgery in the pelvic area including hysterectomy.
Having a tumour or lump in the pelvic area.

Some of the possible causes of stress incontinence are outlined below.

Pregnancy.
Being overweight - this puts stress on the muscles.
Injuring or straining the area when giving birth to a child or children.
The weakening of the muscles as you get older, especially after the menopause.
Damage to muscles around the sphincter following prostate surgery (men only).
In women after the menopause, the lack of oestrogen can lead to a weakening of the muscles associated with the bladder and the urethral sphincter.

Some of the possible causes of urge incontinence are outlined below.

Infections of the bladder or urinary tract, including cystitis.
Sphincter disorders or neurological disorders that affect the nerves including stroke, Parkinson's disease, brain tumours, Multiple sclerosis, spinal cord injury.
Forms of dementia such as Alzheimer's disease.
Blockages caused by bladder stones or very occasionally tumours.
An irritable or unstable bladder where the bladder muscle tightens from time to time, pushing out a little urine into the top of the urethra where the sphincter helps to keep the tube closed. The pressure of urine at this point causes a strong desire to relax the sphincter and pass urine.

Overflow incontinence occurs when the bladder fills but because of an obstruction such as an enlarged prostate gland, it cannot be empted normally. Once full, the bladder overflows and leaks small amounts of urine on an almost continuous basis.

Diagnosis

Don't be embarrassed about going to see your GP about your incontinence. It may be useful to keep a diary of your bladder habits because they will ask you questions such as:

How often do you need to go to the toilet?
Do you need to go to the toilet during the night?
Is it painful to pass urine?
How much urine do you pass?
Do you drink a lot of tea, coffee, or alcohol?
Are you stressed?
Do you leak urine when you laugh, cough or when you are exercising?
Do you leak urine during sex, particularly when you orgasm?

You may need to have some examinations and you may be referred to a hospital specialist (urologist or gynaecologist).

Tests may include:

Urinalysis often used to decide what antibiotics would work.
Urodynamic tests - tests of bladder function and bladder pressure. Measurements of urine flow and pressure are taken by having a catheter placed in your bladder while you are passing urine. This helps to distinguish between the two main types of incontinence.
A pad test can help the doctor find out how much urine you lose in an hour, on average. When you have a full bladder, you will be given a pad to place in your pants and asked to perform daily activities such as stretching.
Men may have their urinary flow rate checked and a rectal examination (to look for prostate cancer).
You may need X-rays or an ultrasound to check the kidneys and ureters.
A cystoscopy - may reveal stones, polyps (small abnormal tissue growths) or tumours.

These tests will help your GP to rule out other causes of your symptoms such as an infection, diabetes, bladder cancer, a tumour, or prostate cancer (in men).

Treatment

Stress incontinence

Pelvic floor exercises (also known Kegel exercises) are the best way to help strengthen the pelvic floor muscles. Your GP may refer you to a continence advisor or physiotherapist for advice. You can get vaginal cones (small, plastic, cone-shaped weights) that you hold inside your vagina to help you do pelvic floor muscle exercises. They are available from some pharmacies.

Some people may be referred for treatment with electric stimulators. These are used on your pelvic floor muscles to help increase their strength.

Some women find that addition oestrogen improves the strength and elasticity of their muscles, so HRT may be a consideration.

In some cases, but only if other treatment has not worked, your GP may refer you for surgery. The surgical procedures used to treat stress incontinence include:

Colposuspension - is an operation to lift your bladder neck. The surgeon makes a cut in your lower abdomen and puts stitches through the walls of the bladder neck. You will be in hospital for about a week. A laparoscopic colposuspension is the same procedure using keyhole surgery.
bladder neck injections - injections of collagen or another synthetic material are put into the wall of the urethra to strengthen it. It can be performed under local or general anaesthetic. Results will probably only last a few years and the procedure may need to be repeated.
Vaginal repair - is surgery to lift the bladder neck. This procedure is usually only used on women who have had a prolapse (part of your vagina and bladder drop).
bladder neck suspensions - raises the bladder neck, using stitches through the urethra and attached above the muscle in the abdominal wall.
Sling procedures - a sling is inserted to support the neck of the bladder and the urethra. If you have this procedure, you will be in hospital for about 5-6 days. More recently, this technique has been performed using tension-free vaginal tape (TVT). This involves placing a U-shaped piece of synthetic tape underneath the urethra and stitching it to the abdominal wall. It can be done with local or general anaesthetic. Recovery time is fairly quick. You can go home after 1-3 days and you can get back to your usual activities quite quickly.

After surgery you will probably have to have a catheter in for a week or so. This is a thin tube that drains away your urine. Some women have problems emptying their bladders after surgery but usually this is only temporary. You may be advised to see a physiotherapist for a while. You should avoid any unnecessary exertion for at least three months.

Urge incontinence

The best way to improve urge incontinence may be to retrain the bladder. This is also known as 'bladder drill'. Over time, you can gradually stretch the bladder so that it can hold more urine. This means that you will have more time to get to the toilet after you feel the urge and you are less likely to leak urine. Your doctor, nurse, or continence advisor (a nurse specially trained to help people with incontinence) will explain how to do bladder retraining.

There are drugs available to relax the bladder by blocking certain nerve impulses. These drugs are called anticholinergics and include oxybutynin, tolterodine, trospium chloride, and propiverine. They may have side effects such as a dry mouth, blurred vision and constipation so you should speak to your doctor about which one will suit you best.

If you have a bladder infection it may respond to treatment with antibiotics.

Often, a combination of drugs and bladder retraining is the best treatment. Surgery, or treatment with electric nerve stimulators, is occasionally used in the treatment of urge incontinence.

In the case of male overflow incontinence from prostate gland enlargement, the treatment is to relieve the outflow obstruction by an operation to remove part of the prostate.

Special incontinence clothing, pads and urine collecting devices are available. Some people use a device that literally stops urine leaking out: a penile sheath for men or a barrier device that acts like a tampon for women. Call NHS Direct on 0845 4647 for details of your nearest continence service who can advise if you are eligible for free supplies.

You should make sure that getting to the toilet in a hurry is easy and perhaps consider having a commode in your bedroom.

Complications

Skin may be damaged by constant contact with urine. Skin bacteria can break down the urea in urine to form ammonia. Sometimes incontinence is complicated by thrush infection of the genital area. This is more likely in people with diabetes.

Prolapse is a complication that can occur in women. It happens when part of your vagina; bladder and maybe your urethra drop down into the entrance of your vagina. Weak pelvic floor muscles can contribute to this. Prolapse usually needs to be repaired with surgery.

Prevention

Men and women can do pelvic floor exercises to strengthen the pelvic floor muscles. If you have strong pelvic floor muscles you may be less likely to experience incontinence as you get older.

Pregnant women can start pelvic floor exercises during pregnancy and continue after they have given birth. Some women find that taking additional oestrogen (female hormone), given in HRT keeps the muscles strong and flexible after the menopause.

Men can do pelvic floor exercises to avoid leaking after urinating. There is also a technique in which you squeeze the urethra after urinating to get any excess urine out. Your GP, nurse or incontinence advisor will be able to advise you. Also avoid any heavy lifting as this weakens the pelvic muscles.

People who smoke are more likely to experience urge incontinence. So, if you smoke, try to give up. Avoid alcohol and drinks with caffeine in such as tea, coffee and cola. These are diuretics which means they make your kidneys produce more urine. Do not cut down on the amount of water you drink. This will only make your urine more concentrated and may make urinating more painful. You could try not drinking any fluids three hours before going to bed.

Glossary

Abdomen: The abdomen is the part of the body between the chest and the hips.
Anaesthetic: Anaesthetic is a drug used to either numb a part of the body (local), or to put a patient to sleep (general) during surgery.
Antibiotic: Antibiotics are medicines that can be used to treat infections caused by micro-organisms, usually bacteria or fungi. For example amoxicillin, streptomycin and erythromycin.
Bacteria: Bacteria are tiny, single-celled organisms that live in the body. Some can cause illness and disease and some others are good for you.
Bladder: The bladder is a small organ near the pelvis that holds urine until it is ready to be passed from the body.
Blood: Blood supplies oxygen to the body and removes carbon dioxide. It is pumped around the body by the heart.
Brain: The brain controls thought, memory and emotion. It sends messages to the body controlling movement, speech and senses.
Catheter: A catheter is a thin, hollow tube usually made of rubber that is placed into the bladder to inject or remove fluid.
Constipation: Constipation is when you pass stools less often than usual, or when you are having difficulty going to the toilet because your stools are hard and small.
Cystoscopy: A cystoscopy is a procedure to view the inside of the bladder using a thin instrument with a light and a tiny telescope (cystoscope), which is inserted into the urethra.
Disease: A disease is an illness or condition that interferes with normal body functions.
Drip: A drip is used to pass fluid or blood into your bloodstream, through a plastic tube and needle that goes into one of your arteries or veins.
Incontinence: Incontinence is when you pass urine (urinal incontinence), or stools or gas (faecal incontinence), because you cannot control your bladder or bowels.
Kidney: Kidneys are a pair of bean-shaped organs located at the back of the abdomen, which remove waste and extra fluid from the blood and pass them out of the body as urine.
Pain: Pain is an unpleasant physical or emotional feeling that your body produces as a warning sign that it has been damaged.
Sneezing: Sneezing is an involuntary expulsion of air and bacteria from the nose and mouth.
Spinal cord: The spinal cord is a column of nervous tissue located in the spinal column. It sends messages between the brain and the rest of the body.
Tissue: Body tissue is made up of groups of cells that perform a specific job, such as protecting the body against infection, producing movement or storing fat.
Ultrasound: Ultrasound scans are a way of producing pictures of inside the body using sound waves.
Ultrasound scan: Ultrasound scans are a way of producing pictures of inside the body using sound waves.
Urethra: The urethra is a tube that carries urine from the bladder to the outside of the body.
Urinalysis: Urinalysis / UA is when a urine sample is tested, commonly to check for any signs of infection, or protein or sugar levels.
X-ray: An X-ray is a painless way of producing pictures of inside the body using radiation.