Female Incontinence (UI)

Millions of women experience involuntary loss of urine called urinary incontinence (UI). Some women may lose a few drops of urine while running or coughing. Others may feel a strong, sudden urge to urinate just before losing a large amount of urine. Many women experience both symptoms. UI can be slightly bothersome or totally debilitating. For some women, the risk of public embarrassment keeps them from enjoying many activities with their family and friends. Urine loss can also occur during sexual activity and cause tremendous emotional distress.

Women experience UI twice as often as men. Pregnancy and childbirth, menopause, and the structure of the female urinary tract account for this difference. But both women and men can become incontinent from neurologic injury, birth defects, stroke, multiple sclerosis, and physical problems associated with aging.

Older women experience UI more often than younger women. But incontinence is not inevitable with age. UI is a medical problem. Your doctor or nurse can help you find a solution. No single treatment works for everyone, but many women can find improvement without surgery.

Incontinence occurs because of problems with muscles and nerves that help to hold or release urine. The body stores urine—water and wastes removed by the kidneys—in the bladder, a balloon-like organ. The bladder connects to the urethra, the tube through which urine leaves the body.

During urination, muscles in the wall of the bladder contract, forcing urine out of the bladder and into the urethra. At the same time, sphincter muscles surrounding the urethra relax, letting urine pass out of the body. Incontinence will occur if your bladder muscles suddenly contract or the sphincter muscles are not strong enough to hold back urine. Urine may escape with less pressure than usual if the muscles are damaged, causing a change in the position of the bladder. Obesity, which is associated with increased abdominal pressure, can worsen incontinence. Fortunately, weight loss can reduce its severity.

What are the types of incontinence?

Stress Incontinence

If coughing, laughing, sneezing, or other movements that put pressure on the bladder cause you to leak urine, you may have stress incontinence. Physical changes resulting from pregnancy, childbirth, and menopause often cause stress incontinence. This type of incontinence is common in women and, in many cases, can be treated.

Childbirth and other events can injure the scaffolding that helps support the bladder in women. Pelvic floor muscles, the vagina, and ligaments support your bladder (see figure 2). If these structures weaken, your bladder can move downward, pushing slightly out of the bottom of the pelvis toward the vagina. This prevents muscles that ordinarily force the urethra shut from squeezing as tightly as they should. As a result, urine can leak into the urethra during moments of physical stress. Stress incontinence also occurs if the squeezing muscles weaken.

Stress incontinence can worsen during the week before your menstrual period. At that time, lowered estrogen levels might lead to lower muscular pressure around the urethra, increasing chances of leakage. The incidence of stress incontinence increases following menopause.

Urge Incontinence

If you lose urine for no apparent reason after suddenly feeling the need or urge to urinate, you may have urge incontinence. A common cause of urge incontinence is inappropriate bladder contractions. Abnormal nerve signals might be the cause of these bladder spasms.

Urge incontinence can mean that your bladder empties during sleep, after drinking a small amount of water, or when you touch water or hear it running (as when washing dishes or hearing someone else taking a shower). Certain fluids and medications such as diuretics or emotional states such as anxiety can worsen this condition. Some medical conditions, such as hyperthyroidism and uncontrolled diabetes, can also lead to or worsen urge incontinence.

Involuntary actions of bladder muscles can occur because of damage to the nerves of the bladder, to the nervous system (spinal cord and brain), or to the muscles themselves. Multiple sclerosis, Parkinson’s disease, Alzheimer’s disease, stroke, and injury—including injury that occurs during surgery—all can harm bladder nerves or muscles.

Overactive Bladder

Overactive bladder occurs when abnormal nerves send signals to the bladder at the wrong time, causing its muscles to squeeze without warning. Voiding up to seven times a day is normal for many women, but women with overactive bladder may find that they must urinate even more frequently.

Specifically, the symptoms of overactive bladder include

• urinary frequency—bothersome urination eight or more times a day or two or more times at night
  
• urinary urgency—the sudden, strong need to urinate immediately
  
• urge incontinence—leakage or gushing of urine that follows a sudden, strong urge
  
• nocturia—awaking at night to urinate

Functional Incontinence

People with medical problems that interfere with thinking, moving, or communicating may have trouble reaching a toilet. A person with Alzheimer’s disease, for example, may not think well enough to plan a timely trip to a restroom. A person in a wheelchair may have a hard time getting to a toilet in time. Functional incontinence is the result of these physical and medical conditions. Conditions such as arthritis often develop with age and account for some of the incontinence of elderly women in nursing homes.

Overflow Incontinence

Overflow incontinence happens when the bladder doesn’t empty properly, causing it to spill over. Your doctor can check for this problem. Weak bladder muscles or a blocked urethra can cause this type of incontinence. Nerve damage from diabetes or other diseases can lead to weak bladder muscles; tumors and urinary stones can block the urethra. Overflow incontinence is rare in women.

Other Types of Incontinence

Stress and urge incontinence often occur together in women. Combinations of incontinence—and this combination in particular—are sometimes referred to as mixed incontinence. Most women don’t have pure stress or urge incontinence, and many studies show that mixed incontinence is the most common type of urine loss in women.

Transient incontinence is a temporary version of incontinence. Medications, urinary tract infections, mental impairment, and restricted mobility can all trigger transient incontinence. Severe constipation can cause transient incontinence when the impacted stool pushes against the urinary tract and obstructs outflow. A cold can trigger incontinence, which resolves once the coughing spells cease.

How is incontinence treated?

By looking at your bladder diary, the doctor may see a pattern and suggest making it a point to use the bathroom at regular timed intervals, a habit called timed voiding. As you gain control, you can extend the time between scheduled trips to the bathroom. Behavioral treatment also includes Kegel exercises to strengthen the muscles that help hold in urine.

How do you do Kegel exercises?

The first step is to find the right muscles. One way to find them is to imagine that you are sitting on a marble and want to pick up the marble with your vagina. Imagine sucking or drawing the marble into your vagina.

Try not to squeeze other muscles at the same time. Be careful not to tighten your stomach, legs, or buttocks. Squeezing the wrong muscles can put more pressure on your bladder control muscles. Just squeeze the pelvic muscles. Don’t hold your breath. Do not practice while urinating.

Repeat, but don’t overdo it. At first, find a quiet spot to practice—your bathroom or bedroom—so you can concentrate. Pull in the pelvic muscles and hold for a count of three. Then relax for a count of three. Work up to three sets of 10 repeats. Start doing your pelvic muscle exercises lying down. This is the easiest position to do them in because the muscles do not need to work against gravity. When your muscles get stronger, do your exercises sitting or standing. Working against gravity is like adding more weight.

Be patient. Don’t give up. It takes just 5 minutes a day. You may not feel your bladder control improve for 3 to 6 weeks. Still, most people do notice an improvement after a few weeks.

Some people with nerve damage cannot tell whether they are doing Kegel exercises correctly. If you are not sure, ask your doctor or nurse to examine you while you try to do them. If it turns out that you are not squeezing the right muscles, you may still be able to learn proper Kegel exercises by doing special training with biofeedback, electrical stimulation, or both.

Medicines for Overactive Bladder

If you have an overactive bladder, your doctor may prescribe a medicine to block the nerve signals that cause frequent urination and urgency.

Several medicines from a class of drugs called anticholinergics can help relax bladder muscles and prevent bladder spasms. Their most common side effect is dry mouth, although larger doses may cause blurred vision, constipation, a faster heartbeat, and flushing. Other side effects include drowsiness, confusion, or memory loss. If you have glaucoma, ask your ophthalmologist if these drugs are safe for you.

Some medicines can affect the nerves and muscles of the urinary tract in different ways. Pills to treat swelling (edema) or high blood pressure may increase your urine output and contribute to bladder control problems. Talk with your doctor; you may find that taking an alternative to a medicine you already take may solve the problem without adding another prescription.

Scientists are studying other drugs and injections that have not yet received U.S. Food and Drug Administration (FDA) approval for incontinence to see if they are effective treatments for people who were unsuccessful with behavioral therapy or pills.

Biofeedback

Biofeedback uses measuring devices to help you become aware of your body’s functioning. By using electronic devices or diaries to track when your bladder and urethral muscles contract, you can gain control over these muscles. Biofeedback can supplement pelvic muscle exercises and electrical stimulation to relieve stress and urge incontinence.

Neuromodulation

For urge incontinence not responding to behavioral treatments or drugs, stimulation of nerves to the bladder leaving the spine can be effective in some patients. Neuromodulation is the name of this therapy. The FDA has approved a device called InterStim for this purpose. Your doctor will need to test to determine if this device would be helpful to you. The doctor applies an external stimulator to determine if neuromodulation works in you. If you have a 50 percent reduction in symptoms, a surgeon will implant the device. Although neuromodulation can be effective, it is not for everyone. The therapy is expensive, involving surgery with possible surgical revisions and replacement.
Vaginal Devices for Stress Incontinence

One of the reasons for stress incontinence may be weak pelvic muscles, the muscles that hold the bladder in place and hold urine inside. A pessary is a stiff ring that a doctor or nurse inserts into the vagina, where it presses against the wall of the vagina and the nearby urethra. The pressure helps reposition the urethra, leading to less stress leakage. If you use a pessary, you should watch for possible vaginal and urinary tract infections and see your doctor regularly.

Urethral Slings

Urethral Slings - The Monarc™ Subfascial Hammock treats female stress urinary incontinence by placing a narrow strip of mesh in your body to support the urethra. The Monarc uses what is called a transobturator approach to place the supportive mesh. The transobturator approach avoids the retropubic space, the area of loose connective tissue between the bladder, pubic bone and abdominal wall. With this approach, narrow mesh carriers are passed through an area near the groin at the obturator of the pubic bone. The mesh is then attached and pulled into place under the urethra.

Cystocele Repair

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InterStim® Therapy

InterStim Procedure -InterStim® Therapy for Urinary Control treats urinary retention (inability to completely empty the bladder) and the symptoms of overactive bladder, including urinary urge incontinence (leakage) and significant symptoms of urgency-frequency. It should be used after you have tried other treatments such as medications and behavioral therapy and they have not worked, or you could not tolerate them.

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