Understanding Female Urinary Incontinence | PDF
R. Toglia, MD
System Chief, Division of Urogynecology and Reconstructive Pelvic
Main Line Hospitals
Urinary incontinence can become a troublesome and sometimes
embarrassing condition. Dr. Marc Toglia shares important information on
new treatments available to reduce these symptoms. — Beverly
Vaughn, MD, Medical Coordinator, Menopause and You Program
Urinary incontinence can be described as the unintentional loss of
urine. It is a condition that occurs commonly in adult women, especially
following pregnancy and delivery. It is estimated to affect between 15%
and 50% of the adult female population in the United States. Although
the prevalence of incontinence increases with age, it should not be
considered a normal part of the aging process. When urinary incontinence
occurs often enough to be a personal, emotional, or physical problem, it
is time to seek help. Many women are too embarrassed by their symptoms
to seek out help. Fortunately, the majority of women can be successfully
treated, and effective treatment options do not always involve surgery.
Symptoms and Types of Incontinence
There are several different types and causes for urinary incontinence,
and effective treatment options are different for the different types of
incontinence. A brief description of the lower urinary system will help
you to understand the different types of urinary incontinence more
The lower urinary tract consists of a reservoir (the bladder) and a
valve (the urethra). The bladder is responsible for the collection and
storage of urine. In its resting state, the bladder stays relaxed, and
allows urine to accumulate and to be stored without drawing much
attention to itself. The urethra, or muscular valve, regulates the flow
of urine, and prevents unintentional leakage, both at rest and during
periods of exertion (exercise, coughing, laughing, etc.). Urinary
incontinence can occur if the urethra becomes weakened (which commonly
occurs after pregnancy and delivery) or if the bladder becomes
"excitable" and contracts without "permission."
Stress Urinary Incontinence (“The Leaky Valve”)
Stress incontinence is the most common type of urinary incontinence
affecting women. The urethra is a muscular valve that is normally closed
at rest and relaxes to allow the bladder to empty. During periods of
physical exertion, the urethral valve closes tighter to prevent
involuntary loss of urine. The muscles of the urethra can weaken as the
result of pregnancy and delivery, heavy lifting or straining, and during
the process of menopause, which can weaken the supportive vaginal
tissues. Women with stress incontinence report leakage of small amounts
of urine with such activities as coughing, sneezing, laughing, exercise
or jumping. If the urethral weakness becomes significant enough, women
will report leakage with minimal activities, such as walking or position
change, or will leak larger amounts of urine with activity.
Women with urgency incontinence experience loss of urine in association
with a sudden and compelling sensation to empty their bladders (urinary
urgency). Typically, leakage occurs before they can make it into the
bathroom in time. The loss of urine is often sudden, uncontrollable, and
can be substantial enough in amount that the woman will wet through her
clothes. Some women will experience urgency without leakage that is
significant enough to disrupt their daily activities. Urgency and
leakage may be precipitated by drinking fluids, the sound of running
water or when changing positions. Many women with urgency incontinence
feel the need to go to the bathroom very often (urinary frequency) or
may be awakened several times at night in order to empty their bladder.
Some women may experience bed wetting or leakage of urine during sex.
Women with overflow incontinence experience two seemingly opposite
problems. On the one hand, the bladder does not empty sufficiently
(either due to a weak bladder muscle or a nonrelaxing urethra), yet on
the other hand will experience leakage when the bladder becomes so full
that urine is forced to leak out. Women with overflow incontinence
typically experience a diminished sensation to void and have a slow or
delayed urinary stream. They also commonly experience frequent urinary
One of the most helpful things you can do to start to understand and
treat your condition is to keep a diary of your urinary habits,
including how often and when you urinate, and how frequently you
experience leakage of urine or experience urgency. It is also helpful to
record whether the episode of leakage was associated with activity, or a
sudden, strong urge to void. Recording the type and amount of fluid
intake is also important. Keep this diary for three or four days, and
bring it to your next appointment to review with your doctor.
Urinary incontinence can be treated by many different types of
physicians, including family doctors, gynecologists and urologists.
However, physicians who have developed special skills and significant
experience in the evaluation and treatment of incontinence are becoming
increasingly more common. Urogynecology is a specialized branch of
gynecology that focuses on the treatment of urinary incontinence and
pelvic floor disorders in women. Similarly, some urologists have also
developed specialized interests and have received additional training in
this field and may refer to themselves as female urologists. In general,
these two types of specialists have the training and expertise to manage
all types of incontinence and related problems, and can offer their
patients a wide array of treatment options.
Treating Urinary Incontinence
Therapies for urinary incontinence vary based on whether a woman is
experiencing stress incontinence, urgency incontinence, or perhaps a bit
of both. Therapies for urinary incontinence include pelvic floor muscle
therapy, medical therapy with drugs, behavioral modification with
bladder retraining, and surgery. Surgery is most effective in treating
stress urinary incontinence, although pelvic floor muscle therapy can
sometimes be helpful in mild cases. Urgency incontinence is typically
treated with a combination of medication, bladder retraining, and
behavioral modification. Patients with a combination of urgency
incontinence and stress incontinence are somewhat more challenging to
treat, and will often require a combination of treatments.
Behavioral modification can be very effective in managing overactive
bladder symptoms, including urinary urgency, frequency, and urgency
incontinence. The goal of behavioral modification is to retrain the
bladder and to help you regain control over how often you need to
Another important aspect of treatment is fluid and dietary management.
Remember—what goes in, must come out! Therefore, drinking large amounts
of fluids or drinking frequently may cause you to void more frequently.
Most women should drink eight 8-ounce glasses of fluid per day (64
ounces total). If you are having problems with urinary frequency, try to
drink smaller amounts of fluids spread out evenly throughout the day.
Water or milk are the beverages of choice.
Drinks that contain a lot of acid (e.g. carbonated beverages, coffee and
tea) can irritate the bladder and increase urgency and frequency.
Vitamin C (ascorbic acid) is another common bladder irritant and should
Pelvic Muscle Exercises
Kegel exercises, or pelvic muscle lift exercises, can help a woman to
identify and activate a group of specialized muscles that surround the
vagina, bladder and rectum. Activating these muscles can help to
diminish the urgency to urinate and sometimes lessen leakage of urine
that is associated with exertion (stress incontinence). It usually takes
weeks or months to strengthen these muscles before you see improvement.
To find the proper muscles, try to pull in on your pelvic floor, so that
your anus and vagina move inward towards your abdomen. Imagine that you
have a tampon inside the vagina that is falling out, and that you must
tighten your muscles in order to hold it in.
Do not be discouraged if you do not feel a strong lift at first.
Additionally, it is important that you do not use the muscles of your
abdomen, buttocks, or legs to assist this exercise, and do not hold your
breath. A detailed instruction sheet on kegels can be downloaded from www.urogyn-philly.com/non-surgical_therapies.php.
Medications are commonly used to treat the symptoms of urinary
frequency, urgency, and urgency-related incontinence. These medications
are highly effective at decreasing these symptoms, although they may not
eliminate them completely. Common medications include Detrol LA,
VESIcare, Ditropan XL, and Enablex. It will often take several weeks to
see an improvement in symptoms, and sometimes the dose of the medication
will need to be adjusted. Common side effects include dry mouth and
Minimally invasive mid-urethral sling surgery is currently the “go to”
procedure to treat stress urinary incontinence. The TVT sling was
introduced in the United States in 2008 and has revolutionized the
treatment of stress incontinence. The procedure is typically performed
as an outpatient procedure with sedation and local anesthetic
through a few half- inch incisions. With an experienced surgeon, most
women can empty their bladder the same day as surgery and go back to
work in one to two days. Long-term success rates are better than 85%. A
small synthetic tape is placed beneath the urethra to help stabilize and
compress this structure. However, if the sling is placed too tight,
voiding can be difficult.
As with most specialized, minimally invasive techniques, it is important
to find a surgeon with extensive experience with the technique, and who
is familiar with how to deal with the potential complications.
This article is part of the Menopause and You library,
a Web-based program sponsored by Women’s Health Source.
It is intended as an information resource providing guidelines for
women. As always, check with your own healthcare practitioner with your
specific concerns and questions.
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