Urinary incontinence

HAVING involuntary loss of urine might not always be an accident, but may be a condition called urinary incontinence.

Urologist Dr Gareth Reid said urinary incontinence is defined as the involuntary loss of urine that represents a hygienic or social problem to the individual, but it should not be thought of as a disease because there is no single specific cause. Dr Reid said urinary incontinence is largely underreported and underdiagnosed because of the social stigma it carries.

“Up to 50 per cent of women will not seek medical attention for this disorder due to the associated social stigma. According to the International Continence Society, urinary incontinence affects up to 200 million people worldwide,” he said.

Of note, the urologist explained that women are affected twice as commonly as men, and there appears to be evidence that the incidence of urinary incontinence is higher in the Caucasian population when compared to the black population. He further explained that the risk of incontinence also increases with age and pointed out that there are many different types of incontinence, the most common types being stress incontinence, urge incontinence, mixed incontinence, overflow, and functional incontinence.

“Stress incontinence occurs when there is leakage of urine associated with increased pressure within the abdomen. Put simply, there is loss of urine when an individual laughs, coughs, climbs stairs, sneezes or does any heavy physical activity,” Dr Reid said.

He added that in stress incontinence, what occurs is that there is either weakening of the pelvic floor muscles or the sphincter that helps to close off the urethra.

“So as the pressure in the abdomen increases, this causes the pressure in the bladder to increase, and this pressure exceeds the closing pressure in the urethra and the urine therefore will escape from the bladder,” he said.

The urologist explained that there are many causes of stress urinary incontinence in women. The common causes include:

1. Having had many children through vaginal deliveries or a history of a difficult vaginal delivery. Dr Reid said in such cases, pregnancy and childbirth strain and weaken the muscles of the pelvic floor causing a condition called urethral hypermobility. He said in urethral hypermobility, the urethra does not close properly, which is one of the main causes of stress incontinence.

2. A prolapsed uterus, which, according to Dr Reid, causes the uterus to protrude into the vagina.

3. Oestrogen deficiencies that occur after menopause can cause the lining of the urethra to thin out so that the urethra may not close properly. He said this explains why the risk of stress incontinence increases with age.

4. Injury from surgery or radiation can cause stress incontinence. “Injuries from previous surgeries can damage or weaken the bladder neck muscles,” he said. Of note, he added that in men stress incontinence can occur after treatment to the prostate, whether it be surgery or radiation.

Other types of incontinence include:

1. Urge incontinence, which Dr Reid said is the involuntary loss of urine associated with a sudden compelling desire to pass urine, which is difficult to delay. Causes of this form of incontinence include urinary tract infections, inflammation of the urethra (urethritis), the ageing process, emotional disorders such as anxiety and depression, medications such as sleeping pills, central nervous system disorders such as Parkinson’s disease, multiple sclerosis, or a history of a stroke and radiation to the pelvis. Dr Reid said urgency and urge incontinence in men can occur due to an enlarged prostate.

2. Mixed incontinence, which is a combination of symptoms of both urge incontinence and stress incontinence.

3. Functional incontinence, which the urologist says occurs in individuals who have mental or physical disabilities that keep them from urinating normally, although the urinary system itself is structurally intact.

Regardless of the type of incontinence, Dr Reid said the associated complications are significant.

“Patients may feel humiliated, isolated, and helpless about their condition. Incontinence can interfere with social and work activities. Also, depression is very common in women with incontinence, and for men it has emotional effects on them,” he said.

He added that studies of patients with prostate cancer suggest that incontinence can be a much more distressing side effect for men than erectile dysfunction (also a side effect of prostate cancer treatment).

Treatment options depend on the type of incontinence diagnosed.

“In patients with stress incontinence, treatment involves attempts to strengthen the pelvic floor muscles. This occurs in the form of pelvic floor muscle strengthening exercises, previously described as Kegel exercises. This involves the patient learning how to contract the muscles in the pelvic floor by attempting to contract the muscles in the pelvis during urination to slow or stop the flow of urine. Once these muscles have been identified, then the patient should practise these contractions five to 15 times in a row, holding the contraction for about five seconds. This should be repeated about three times daily. This has been shown to improve continence rates significantly,” he said.

“Alternatively vaginal cones, which are a set of weights ranging from 20-65 grams, can be placed within the vagina. The patient places the lightest weight within the vagina and is then asked to stand and contract the pelvic floor muscles to keep the cone inside. This acts similarly to the Kegel exercises and requires repetition. Medication for stress incontinence include the use of some antidepressants (duloxetine), but this is only useful in very mild stress incontinence.”

There are also many surgical techniques that can essentially restore the bladder, neck and urethra to their normal position to prevent incontinence.