Many women find it hard talking about their incontinence, but urinary incontinence is actually very common.

What is urinary incontinence?
Urinary incontinence is the involuntary leakage of urine from the bladder. This is a common problem that can affect both sexes but women are more commonly affected.

Urine is normally prevented from leaking by the urinary sphincter, which is a tight ring of muscle at the neck of the bladder and the support of the muscles of the pelvic floor. Voluntary passing of urine involves relaxing the sphincter and pelvic floor muscles, together with a gentle contraction of the bladder muscle.

For many women the leakage of a small amount of urine on an occasional basis is normal and does not prevent them from getting on with their lives. For other women, urinary incontinence may be serious enough to involve having to change their clothes and to avoid performing certain tasks or exercises. For these women, advice from a health professional is appropriate.

What causes urinary incontinence?
The study of urinary incontinence has revealed two main types of incontinence.

The commonest is called stress incontinence - when the bladder sphincter just gives way under pressure and a small amount of urine escapes on straining, for example when coughing, laughing, sneezing or doing physical exercise.

In severe cases it can happen while walking or when getting up from a sitting position. Stress incontinence is usually the result of weakening of the muscles in the pelvic floor that surround the bladder. This often happens during pregnancy, following childbirth or after the menopause.

The second type of urinary incontinence is called urge incontinence. This happens when the urge to pass urine becomes overwhelming and urine is passed before a toilet can be reached. Urge incontinence is caused by the bladder sending a message to the brain that it is full, often too early and the bladder muscle starts to contract too early (also called bladder instability).

This may be caused by cystitis (urinary infection) or an overactive or unstable bladder, which can sometimes be related to nerve problems including stroke, dementia, multiple sclerosis, or spinal cord injury.

The two types may occur together, but treatment is quite different.

Incontinence can also be associated with narrowings (strictures) of the urethra.

Incontinence can also be caused as a side effect of some kinds of drugs or medicines.

When should I seek medical help?
If you are experiencing more than very occasional episodes of incontinence then you should consult your family doctor.

What will the doctor do?
The doctor will take a medical history and perform a physical examination, which is likely to include a vaginal and rectal examination to assess the pelvic organs. History and examination alone are often insufficient and special tests may also be required to establish what kind of incontinence it is and, therefore, what the treatment options are. A GP may also refer the patient to a physiotherapist, an incontinence advisor or to a hospital specialist (urologist or gynaecologist).

What further investigations may be be necessary?
Bacteriology and microscopy. A simple urine sample analysis by a laboratory for infection will help show if any bacteria are present, and what the best antibiotic would be for them.

Urodynamic studies are special measurements of urine flow and pressure taken with a catheter in the bladder while passing urine. The information gained can distinguish between the two major types of incontinence.

X-rays and ultrasound may be useful in certain patients to check the kidneys and the tubes (ureters) that drain them. It will also show the size and shape of the pelvic organs if any enlargements are detected during the examination.

Cystoscopy, a look inside the bladder using a thin telescope, may be done to check that the inside of the bladder is healthy. It may be performed under a local or general anaesthetic.

How is urinary incontinence treated?
The treatment of urinary incontinence varies according to the type of incontinence, how troubling it is to the woman concerned and also her general level of fitness. The majority of women with urinary incontinence can be effectively managed in general practice with fairly simple treatment, without the need for many of the surgical treatments mentioned below.

Non-surgical treatment for stress incontinence Pelvic floor exercises. The best way to prevent urinary stress incontinence is to perform pelvic floor exercises. To do this, simply tighten the muscles of your pelvic floor as if you are trying to stop the flow of urine. This will make you more aware of these muscles and how to use them. You can also try to put two fingers in your vagina, squeeze and then relax the muscles. When you know which muscles you use to squeeze and relax, you can do the exercises anywhere and anytime.

Slowly count to 10 while you tense the muscle, then count to 10 while you relax again. Repeat this 10 times and do it at least 10 times a day - while watching TV, waiting for the bus and so on. Special weighted cones may be also used to help train the muscles. Doing these exercises regularly throughout life will keep the pelvic muscles in good shape.

Collagen injections around the neck of the bladder are occasionally suitable as an alternative treatment for patients who need but are not suitable for surgery. Incontinence nurses are specially trained in assessing and advising on incontinence, including the provision of aids and supports, and are now part of the nursing service in all areas of the UK.

Surgical treatments for stress incontinence

Anterior vaginal wall repair surgery. If prolapse is the underlying cause of incontinence, then repair of the prolapse, through the vagina, may be sufficient to correct the problem.

Colposuspension. The muscle support of the bladder can also be improved by colposuspension, in which the top of the vagina is pulled forward and stitched. This is generally successful and does not cause any problems with sexual intercourse.

Surgical tape procedure. A similar result to colposuspension can now be achieved by the use of surgical tape, which is positioned so as to support the bladder. This procedure was developed in Sweden and is not readily available yet on the NHS in the UK. There are, however, a number of centres providing private therapy. The operation takes up to 30 minutes to complete and can be performed as a day-case procedure, under a local or a general anaesthetic. The early results show a success rate that is comparable with colposuspension.

Laproscopic (keyhole) surgery is also showing promise as a new technique in treating incontinence.

Non-surgical treatment for urge incontinence

Bladder training aims to teach the bladder not to send signals to the brain too early. A training schedule is devised that gradually increases the length of time a person waits before emptying their bladder, so that reasonable control of a full bladder can be achieved.

Medicines that reduce the excitability of the bladder detrusor muscle, eg oxybutynin, tolterodine. The medicines commonly used to treat urge incontinence can sometimes cause a dry mouth, blurred vision and constipation, though these are not that common in practice providing one commences the patient on a relatively low dose, allowing them to become accustomed to the treatment before increasing the dose as required.

Hormone replacement therapy is useful in helping urge incontinence in women after the menopause. It is not particularly effective in stress incontinence.

Surgical treatment for urge incontinence
Stretching (dilatation) of the urethra under general anaesthetic may be helpful.

What complications might arise from surgery?
Even with the best possible technique, all surgical procedures carry a small but recognised risk of excess bleeding and infection. The individual operations concerned each carry certain risk factors that are best explained by the surgeon performing the operation.

The anaesthetic can cause side effects that can be quite different between individuals, and these should be discussed with the anaesthetist beforehand.

What can a person do to help urinary incontinence?

Eat plenty of fresh fruit, vegetable and cereals to avoid constipation.

Drink at least six to eight glasses of liquid every day.

If you experience urgency that makes you rush to the toilet, drink less tea, coffee and cola that contain caffeine and drink more water.

Take regular exercise - walk as much as possible.

Wear clothes that are easy to manage.

If you have to get up more than once during the night to pass urine (nocturia) then it is advisable not to drink any fluid within three hours of going to bed.

Involve your family in understanding the problems so that embarrassment is not so much of a problem.

Get someone else to do heavy lifting and avoid strenuous exertion in general.

Drinking alcohol is likely to worsen any type of urinary incontinence because it is a diuretic and stimulates the kidneys to produce more urine.

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