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Understanding female urinary incontinence

Main Line Health October 15, 2009 Menopause and You By Marc Toglia, MD

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 percent 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 completely.

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.

Urgency urinary incontinence – “the overactive bladder”

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.

Overflow incontinence

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 non-relaxing 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 tract infections.

Seeking help

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

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 urinate.

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 be avoided.

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.

Medication

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 constipation.

Surgery

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 percent. 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 Menopause and You, 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 health care provider with your specific concerns and questions.

To speak with our nurse counselor, call 1.888.876.8764 or email whs@mlhs.org.

Membership on the medical staff of Main Line Health hospitals does not constitute an employment or agency relationship.