Female urinary incontinence

Urinary incontinence is the inability to control the flow of urine. It occurs with aging and is a common side effect following surgery on the bladder as well radiation therapy.

Physiology of bladder function

Normal bladder filling depends on unique elastic properties of the bladder wall that allow it to increase in volume at a pressure lower than that of the bladder neck and urethra (otherwise incontinence would occur). Despite provocative maneuvers such as coughing and straining, voluntary bladder contractions do not occur and patient remains dry. Bladder emptying is dependent on the relaxation of the urethral sphincter a few milliseconds before the onset of the detrusor (bladder muscle) contraction. With normal, sustained detrusor contraction, the bladder empties completely.

The Types of Urinary Incontinence

Stress urinary incontinence:

Leakage of urine during physical movement (coughing, sneezing, exercising).

Urge urinary incontinence:

Leakage of urine at unexpected times, including during sleep. This can be associated with feeling of urgency and frequency resulting in untimely urination.

Overflow urinary incontinence:

Unexpected leakage of urine because of a full bladder.

Mixed urinary incontinence:

Usually the occurrence of stress and urge incontinence together.

Women experience incontinence 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 (such as birth defects, strokes, Parkinson and multiple sclerosis) and physical problems associated with aging. It is important that your doctor screen you for urinary tract infection as it is commonly the causative factor in your urinary incontinence.

The level of incontinence differs for each person and depends upon the treatments that they have had, however for some people the phenomena may be short lived while for a few it may be permanent. Special test such as uroflow and urodynamics studies can provide further information on your bladder function and bladder outflow.

There has however been a lot of progress in dealing with continence issues and there are a wide variety of aids and equipment for collecting urine, preventing infection and protecting the skin and surrounding area. There are also a number of exercises that can be done to strengthen the urinary sphincter muscle that controls the opening and closing of the bladder.

Non-surgical and conservative measures:

Pelvic floor exercises are an important and relatively easy way to improve your bladder control. When done correctly they can build up and strengthen the muscles that help you hold urine. The pelvic floor is made up of muscles stretched like a hammock from the pubic bone in the front through to the bottom of the backbone. These firm supportive muscles help to hold the bladder, womb and bowel in place and also function to close the bladder outlet and the back passage. Pelvic floor exercises strengthen the muscles that support the pelvic contents and prevent the escape of wind, faeces or urine. Stronger muscles can also enhance sexual satisfaction for both partners.

Bladder retraining and timed voiding can be utilised to overcome urgency and stretch out the intervals between trips to toilet. Electrical stimulation is the application of an electrical current to stimulate the pelvic muscles or their nerve supply and can directly improve pelvic muscle strength and so to assist in bladder control. This is achieved by inserting a vaginal device into the vagina. This device generates electrical stimuli. Electrical stimulation may also be used to inhibit the overactive bladder.

Medications such as anti-cholinergic can decrease the urinary urgency and urge incontinent episodes. However common side effects include dry mouth and eyes, and constipation.

Surgical options:

These days, most of the surgery for stress urinary incontinence is minimally invasive and can often be performed either as a day stay or overnight procedure. Depending on the severity of your urinary incontinence, the following surgery may be the appropriate treatment option.

  1. Mid-Urethral Slings (trans-vaginal or trans-obturator)
  2. Bulking agents
  3. Fascial Slings (pubovaginal)
  4. Artificial urianry sphincter

In women with urge and urge incontinence, the surgical options include

  1. Intravesical botox injection (into bladder)
  2. Sacral neuromodulation ("bladder pacemaker")