What is urinary incontinence?

Urinary incontinence (involuntary leaking), unlike premenstrual syndrome or the menopause and HRT, is not a subject that is readily discussed socially. A young woman with this problem runs the risk of shocking her friends or family at the least mention of the subject. Many women with incontinence shy away from discussing it even with their doctor, often for many years, hoping that it will disappear. This is particularly sad, not only because there may be loss of self-esteem and avoidance of socialising, but also because there are invariably treatments that may provide either a complete cure or, at the very least, significant improvement. Often the family doctor may be able to provide initial advice although referral to a specialist physiotherapist may be the best approach.

When specialist advice is required either a urologist, a specialist in urinary problems, or a gynaecologist should be consulted; the two specialities overlap in this area.

What is stress incontinence?

The incontinence occurs in association with physical exertion. This may happen when the pressure within the abdomen is increased during coughing, sneezing or laughing. The 'stress? is physical and not emotional. Jolting movements such as jumping or running may similarly result in embarrassing leaks. In the worst situations, less strenuous movement including walking or moving in bed may be enough. Typically, there is no warning or feeling of need to empty the bladder. Sphincter incompetence means that the muscle that squeezes around the outlet from the bladder is too weak to prevent leakage in 'stress' situations.

What are urgency, urge incontinence and the urge syndrome?


Urgency means that you have a sudden and urgent need to empty your bladder. With urge incontinence there is a knowledge that if a toilet is not readily available, there will be an inevitable leakage. Women with urgency incontinence of urine typically know the location of every public convenience in the localities where they shop.

The urge syndrome is a combination of Frequency, nocturia, urgency and urge incontinence.

What causes stress and urge incontinence?

An anatomical (structural) cause is the most common reason for stress incontinence whereas urge incontinence suggests that the bladder muscle is contracting excessively (detrusor instability) at an inappropriate time. This is also called an unstable bladder. These causes and effects are by no means mutually exclusive: A woman presenting with symptoms of stress incontinence may prove to have detrusor instability and urge incontinence could be related to inadequate support to the bladder outlet.


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What is dribbling incontinence?

A steady uncontrollable loss of urine always requires medical assessment. Sometimes it may be a sign that the bladder is overfull and the leak occurs as the bladder can hold no more. The other cause of dribbling incontinence is that there is a fistula (hole) in the system; this may be termed 'true incontinence'.

How prevalent is urinary incontinence?

Several studies have looked at the incidence of this distressing and common problem. The results show a surprisingly high incidence with at least one woman in twenty aged 15 to 34 years leaking urine at least twice each month and a further 16% having an accident of some degree once a month. For women aged 35 to 64 years, 10% will have two or more accidents monthly and a further 14% will have one accidental loss. In a study in Leicestershire, 41% had some degree of incontinence, 6% reported the problem occurred regularly and 15% required protection during exercise. Studies also show the reluctance of patients to seek medical advice. At least 50% of women with incontinence restricting their lives have not been to their doctor and half the patients seeking medical advice for the first time have had problems for more than four years. Stress incontinence occurs two or three times more often than urge incontinence.

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What is urethral syndrome?

The urethra is the tube leading out from the bladder. Urethral syndrome is an ill defined condition with a variety of symptoms including pain during micturition, urinary Frequency, feeling of pressure behind the pubic bone, and pain during intercourse. The latest suggested cause for this syndrome is infection in the tiny glands that secrete into the urethra. These glands may become infected without there being evidence of infection in the urine when tested. Antibiotics may work particularly when taken for prolonged courses usually small doses over several months. When the problem keeps recurring many urologists will dilate (stretch) the urethra. Chronic urethritis is long-term inflammation of the urethra, the tube that carries urine from the body. Chronic urethritis continues for weeks to months. Chronic urethritis is usually caused either by a bacterial infection or structural problem that results in narrowing of the urethra. The condition is associated with a variety of systemic diseases, emotional disorders, and sexually transmitted diseases such as chlamydia and gonorrhoea.E. coli, a common bacteria responsible for urinary tract infections, may also cause chronic urethritis. The use of personal hygiene products, especially feminine products, can cause chronic chemical urethritis. Symptoms   

  • Urinary Frequency/urgency
  • Urination discomfort, burning, or stinging of the urethra or lower abdomen during urination (see painful urination)
  • Urethral discharge (bloody or pus-like, and often foul-smelling)

Signs and tests of   Urethral Syndrome

  • Urinalysis may show infection or inflammation.
  • Urine culture (clean catch) confirms infection and can show what bacteria is causing the infection.
  • Urethral discharge culture or vaginal culture specimen(s) can rule out sexually transmitted diseases.
  • Cystoscopy and urethroscopy are used to directly examine the urethra. These tests may reveal a urethral stricture (narrowing), a urethral diverticulum (out-pouching), or a mass (such as a urethral tumor).

Treatment of Urethral Sydrome

If there is an infection, you will be given antibiotics. A follow-up urinalysis or culture will be done after you finish all of the medicine. Women who have repeated episodes of intercourse-related urethritis or cystitis may be prescribed a dose of preventive antibiotics. Such therapy is called peri-coital treatment, and involves taking the medicine shortly before or after intercourse. Phenazopyridine (Pyridium) may be prescribed to decrease urinary discomfort. You should stop using any possible chemical irritants. Expectations (prognosis)   In the majority of cases, the cause of the urethritis can be found and treatment will be given. Chronic urethritis, despite the cause, can lead to urethral strictures (narrowing) and may require surgery or another medical procedure to correct the problem.

Complications of Urethral Syndrome.

Prolonged, untreated infection may progress to continued narrowing of the urethra, resulting in difficulty in completely emptying the bladder. Recurrent urinary tract infections may also occur. Less commonly, pyelonephritis (kidney infection) or structural damage to the urinary tract system, including impairment of renal (kidney) function can occur. Prevention   Drinking plenty of water each day can help prevent urethritis. Women who have symptoms that occur within 24 hours of sexual intercourse should always urinate immediately after having intercourse. Taking a small dose of antibiotics after intercourse also decreases episodes of urethritis and cystitis.

How can I record my bladder symptoms Such as Stress Incontience or Urge Incontinence and monitor the result of treatment?


If you have a urinary incontinence problem, it is essential that you seek medical advice early to rule out infection or some other medical reason for your symptom. Bladder training and pelvic floor exercises can provide a cure or valuable improvement for many women. To begin with it is helpful if you can keep a record of how your bladder is functioning before treatment commences. Make a note of the times that you are emptying your bladder and whether the volume is small, average or large. Your particular problem(s) will indicate to you what else needs to be recorded. If, for example, it is incontinence, you need to note every time there is an accident and how much is lost. A daily summary for a week or two on a chart will provide a basis for comparison once treatment begins. Choose a day when you will be at home and measure the volume you void each time you empty your bladder. You will need an ordinary kitchen measuring jug.

What simple measures are available to treat urinary incontinence?

The average fluid intake in a day is four pints; this is e quivalent to about 10 cups. Drinking less puts a strain on the kidneys and drinking more may unnecessarily increase the risks of incontinence. In warmer or hotter climates than the United Kingdom, your fluid intake should be increased.

Excess weight with a large abdominal girth will stretch and damage the pelvic floor. Calorie control and increasing exercise should help. Lifting heavy objects should be avoided. Tight clothes and support girdles should be discarded.

Straining associated with increasing the abdominal muscle activity pushes the abdominal contents firmly down against the pelvic floor muscles. Stretching these muscles decreases their function and the nerve supply to them may also be damaged. A chronic cough is to be avoided. For smokers, the advice is obvious stop! Similarly, constipation requiring straining to empty the bowel should be avoided. Increasing the fibre content of your diet may be all that is necessary. Vegetables, fruit and wholemeal bread may be enough, but cereals particularly with bran in the morning may also be considered.

A retrospective review of the records of 100 women who chose to try a pessary to treat their urinary incontinence was undertaken. Presenting complaints included stress incontinence in 41 women, mixed incontinence in 53 women, urge incontinence in 3 women, and combined prolapse and incontinence in 3 women. All 100 women returned for follow-up visits. Forty women had their pessary size or type adjusted at the first follow-up visit. At a mean follow-up time of 11 months (range, 2-42 months), 59 women continued to experience a complete resolution or decrease in their incontinence and chose to continue use of a pessary. Age, presenting symptoms, degree of pelvic prolapse, and type of pessary did not affect the success of pessary treatment. Urinary incontinence pessaries are effective. More than 50% of women who try a continence pessary will continue to use it to manage their urinary incontinence.0401

For postmenopausal women, hormone replacement therapy HRT (HRT-hormone-replacement-therapy) may provide benefit. Some women already taking HRT find that when they also introduce oestrogen locally into the vagina, there is further improvement in bladder symptoms.

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What are pelvic floor exercises?

Pelvic floor exercises were first developed in the late 1940s. They are designed to strengthen the pelvic floor muscles and reduce stress incontinence. Stronger pelvic floor muscles will help the urethra to stay closed and prevent leakage.

On the next occasion that you go to empty your bladder, prevent the flow starting for a minute or so: you will become aware that you are lifting the pelvic floor.

Next, allow the bladder to become really full and practise tensing the pelvic floor muscles to prevent leaks. When you do empty your bladder, ensure that it really is empty: otherwise there is a risk of infection.

Try stopping your urine flow in mid-stream and you will be aware of that lifting sensation within the lower pelvis caused by the pelvic floor muscles. If the muscles are weak, you may have difficulty initially stopping the flow. It is probably easier to stop the stream at the beginning or end of the flow. As the muscles become stronger it should become possible to stop the flow at any stage. To begin, you will have to learn to become conscious of your ability to contract the pelvic floor muscles. You may find that if you place a finger in the vagina, you will be able to feel the muscles contracting.

Once you have learned to contract the pelvic floor muscles, keep them contracting for five seconds squeezing them as much as possible. Relax the muscles for five seconds and repeat this cycle six times in a minute. You may find the exercises easier whilst sitting or lying down at least to begin with. Keep a record of how many minutes you do the exercises each day. Gradually build up until you can do them for three to five minutes three times daily. The exercises can be undertaken at any time. The important thing is to keep doing these exercises. The daily record should help you to keep going. Some physiotherapists use a perineometer which measures the pressure that you are able to exert. This biofeedback can provide encouragement, as you are able to measure progress.

Electrotherapy is conducted by physiotherapists using electrical stimulation to make the pelvic floor muscles contract. This may be particularly beneficial if you are having difficulty starting the exercises.

As with any exercise, muscles take a while to become stronger so perseverance and patience are essential. If you were planning to swim the channel you would not prepare by trying to swim across from Dover on the first day. You would start with just a few hundred yards and gradually build up over months rather than days. The same is true for pelvic floor exercises. You have to be patient, gradually building up the muscle strength over a few months and then keeping the muscles strong. The aim is to build up gradually to five minutes three times each day. Hopefully you will begin to see progress after a couple of weeks and this should provide any encouragement you may need. It may, however, take two or three months so do not give up too quickly. Once improvement has been achieved, it is important to keep the exercises going although the amount of time spent may be reduced to perhaps two minutes daily.

How successful are pelvic floor exercises?

The originator of pelvic floor exercises, Kegel, found that patients with pure stress incontinence were often much improved within eight weeks. The aim of Kegel exercises is to strengthen muscle tone by strengthening the pubococcygeus muscles of the pelvic floor. Kegel exercises are popularly prescribed exercise for pregnant women to prepare the pelvic floor for the later stages of pregnancy and vaginal childbirth. Kegel's exercises may also increase sexual gratification are said to be help and perhaps prevent vaginal prolapse in women. Kegel exercises may help treat urinary incontinence. If you have severe problems it could take longer so patience and perseverance may be worthwhile. More recent studies suggest success in about 70% of patients with 40% being cured. Failures occur mostly with those patients who do not comply with the treatment regimen.

Almost everything we undertake in life involves risks as well as benefits. There is an element of risk even when going on holiday. There is no medicine or surgical procedure that is without an element of risk. Pelvic floor exercises are absolutely safe. With perseverance, there is likely to be benefit. Pelvic floor exercises commenced after childbirth may reduce problems in later life and there is advantage in seeking advice from a physiotherapist specialising in women's health around this time. The physiotherapist can ensure that you are contracting your pelvic floor correctly by checking with an internal examination. If your are a new mother, pelvic floor exercises can be recommended every time you are feeding or changing your baby. Others may find it useful to have a prompt such as every time they speak on the telephone.

A perineometer is an instrument that measures the strength of voluntary contractions of the pelvic floor muscles. It was Kegel who initiated pelvic floor exercises who developed the perineometer. Ascertaining the air pressure inside the vagina by insertion of a perineometer, while requesting the woman to squeeze as hard as possible, indicates whether or not she would benefit from strengthening the vaginal muscles using the exercises. Modern perineometers measure electrical activity in the pelvic floor muscles and may be more effective in this purpose. Both the perineometer and a digital (internal) examination are effective and concordant in their results in this assessment.

What is bladder training?

Bladder training is designed to retrain your bladder to hold larger volumes of urine. It may be of value if you have Frequency, nocturia, urgency and urge incontinence. If there is any question of infection, this should be checked by your doctor before the training begins. Before commencing the training, you may find it helpful to make a record of how your bladder is behaving.

The objective with bladder training is to teach your bladder that it can hold more than it currently believes. When your bladder has an urge to empty, try holding on for a little longer. It may be for just an extra minute to begin with and this can be built up gradually. The other way to retrain the bladder is to increase the time between visits to the toilet. Again this can be slowly increased in five or ten minute additional intervals. Try keeping your mind busy rather than concentrating on your bladder. If you think about your bladder it will try to convince you that it needs attention. Eventually you should be able to manage four hours unless you have drunk a lot. You can record the number of times you empty the bladder each day on your record card. You can also record the number of times that you had an urge which you were able to overcome. From time to time, find a convenient day when you can measure the volume of urine that you pass and record this. You should be able to reach at least 400 ml.

How effective is bladder training?

A number of studies show success rates in the order of 80% by three months. Usually, within two to three weeks you are likely to have some encouraging benefit. It is important to keep practising bladder training over the years, otherwise your bladder will go back to its old bad habits: it is a matter of mind over bladder.


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Are there any alternative to bladder training for urgency symptoms?


Sometimes bladder symptoms occurring around the time of the menopause or beyond will respond to hormone replacement therapy or local (vaginal) oestrogen pessaries or cream even if there is no obvious sign of vaginal oestrogen deficiency (11). Oestrogen introduced directly into the vagina may be particularly effective. It is an empirical observation that some women who are taking HRT may still present with bladder symptoms that will improve when local oestrogen is added.

A thirty-six year old lady came to hysterectomy for very heavy periods that had not responded to medical treatment. She elected to have both ovaries removed and subsequently had regular oestradiol hormone implants. She was extremely happy with the outcome as she was free to enjoy life without the worry of her heavy periods.

Four years later she was referred to me again as she had developed urge and stress incontinence. There was excellent vaginal support under the bladder and certainly no suggestion of prolapse. Although the vaginal epithelium (lining) appeared healthy, oestradiol vaginal 25 microgram tablets, once each night for ten nights and then weekly were prescribed. At review three months later she was delighted with the result as her bladder was no longer causing any problem. She was advised to reduce the vaginal tablets to every two weeks and adjust the Frequency so that she introduced them according to the response.

There are medications, which may reduce the detrusor (bladder) muscle activity e.g. oxybutynin (Cystrin Pharmacia and Upjohn; Ditropan Lorex), tolterodine tartrate (Detrusitol XL - Pharmacia).


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Medical Treatment for Stress Incontinence

Venlafaxine:

That efficacy of venlafaxine started early and the clinical efficacy associated with the use of the drug continued in the following months. Venlafaxine should be considered a clinically efficient alternative drug in the treatment of stress incontinence of urine.0801

What surgical treatments are available for stress incontinence?

If the incontinence is thought to be related to prolapse, vaginal repair surgery (6) will improve the problem in about 80% of patients. Some surgeons, particularly bladder specialists, may operate through the abdomen rather than the vagina. Stitches are introduced to either side of the urethra and attached to the ligaments or bone at the front of the pelvis (colposuspension). Injections of inert substances can be introduced under the bladder neck. Although with training they are said to be simple to introduce, they are not quite so simple to remove should there be problems. If there is true incontinence associated with a hole in the system (fistula) a urologist (bladder specialist) is likely to be able to close this defect.

Mechanical Aids for Stress Incontinence

For many years a variety of meshes have been introduced under the urethra with varying degrees of success. In the late 90s a simple technique - tension free vaginal tape (TVT) was introduced. A small incision is made under the urethra and the tape is inserted. Some surgeons perform the operation under local anaesthetic. Usually, you can go home the same day.

There are a variety of mechanical aids that put additional pressure on the bladder neck. They are designed to be easy to introduce and remove.

Incontinence Ring

 Stabilizes urethrovesical junction

Increases closure pressure

Management of Vaginal Ring Pessary

1/10 can't be fitted with a pessary.

   Pessaries are not for everyone

Falls out (gaping introitus, degree of prolapse, shape of vagina)

Too uncomfortable (scar tissue, 'bands', cramping, pressure, etc)

Don't like, won't wear, don't return.

Never pressure anyone.

Return for follow-up appointment (1-2 weeks)

Every three months health care provider to remove, clean, inspect and reinsert pessary

Vaginal speculum exams to inspect vaginal tissues for erosion, irritation, infection

May be normal foreign body effect

Culture-antibiotic/antifungal

Estrogen cream/ring; non-estrogen lubricant  

Warm water or betadine douche

More frequent removal and cleaning

Several myths have been refuted:

  • Pessaries are an option for the treatment of urge and mixed incontinence
  • Pessaries are an option for the treatment of vault prolapse
  • Pessaries are an option for young women

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What are urodynamic studies?

If simple treatments are not proving effective and there is doubt as to whether your symptoms are related to detrusor instability or weakness of the pelvic floor, urodynamic studies may indicate the most appropriate mode of treatment. A fine pressure transducer and catheter are introduced through the urethra and into the bladder. The transducer will measure the pressure in the bladder which is also influenced by the pressures within the abdomen. A second balloon and pressure transducer are introduced into the rectum to reflect the abdominal pressure. The associated recording instrument will subtract the rectal pressure from that obtained from the bladder transducer and the result is a true indication of the pressures generated by the bladder.

The bladder is slowly filled and a note made when there is the first feeling of needing to void. If there is detrusor instability, inappropriate increases in bladder pressure will be observed. The pressure transducer is then slowly withdrawn through the urethra and a record of the pressure there is made. This urethral pressure will be low if the bladder symptoms are due to an anatomical weakness. 

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Urinary Incontinence Support Groups:

Members of a support group, provide each other with various types of help and information for a particular shared difficulty.

The support may take the form of providing relevant information,

  • relating personal experiences,
  • listening to others' experiences,
  • providing sympathetic understanding and
  • establishing social networks.

A support group may also provide ancillary support, such as serving as a voice for the public or engaging in advocacy.

Support groups maintain interpersonal contact among their members in a variety of ways.

Support groups also maintain contact through printed information rich newsletters, telephone chains, internet forums, and mailing lists.



Support groups offer companionship and information for people coping with diseases or disabilities. Support groups may not be appropriate for everyone, and some find that a support group actually adds to their stress rather than relieving it.



Evaluation of the quality of Web sites is discussed in (internet information). You may find that several general women's health sites may help you (internet information). The following are more specialised relevant Web sites:-
http://www.continence-foundation.org.uk/ The Continence Foundation, 307 Hatton Square 16 Baldwins Gardens London EC1N 7RJ Tel 0207 404 6875.
www.continence-fdn.ca/ The Canadian Continence Foundation
P.O. Box 417
Peterborough, Ontario
K9J 6Z3
 drygenerations.com/
urologychannel.com/incontinence/
 www.wdxcyber.com/mincont.htm.
 www.continence-foundation.org.uk/phpBB2/viewtopic.
 www.continence-foundation.org.uk
 www. Incontact.org
 www.nafc.org
 www. Allaboutincontinence.co.uk/home/default.
 www. Medhelp.org/HealthTopics/Incontinence.htm



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