Female Urinary Incontinence

Urinary Incontinence

Jane Miller, MD  

Associate Professor of Urology, University of Washington (Seattle, WA)

Elizabeth Miller, MD

Bellevue Urology Associates (Bellevue, WA)

Urinary incontinence (UI) is the involuntary loss of urine.  UI is very common in women.  Approximately 38% of women experience urinary incontinence at some time in their lives.  Although UI can occur at any age, it does become more prevalent as women get older.  UI has been shown to significantly affect patient’s quality of life, sexual function and in some cases their health.  Women with osteoporosis (thinning bones) and urinary urge incontinence (UUI) have been shown to have greater rates of hip fracture due to falling as they hurry to the bathroom.  Patients with UI have higher rates of anxiety and depression.

 There are two major types of urinary incontinence. The first and most common is stress urinary incontinence (SUI)—involuntary urine loss associated with activities such as coughing or sneezing.  It occurs when there is “stress” placed on the supportive structures of the bladder.  The second type of incontinence is urinary urge incontinence (UUI)—involuntary loss of urine associated with an “urge” to go to the bathroom. Some women have a combination of both types, and this is called mixed urinary incontinence (MUI).

Two common misconceptions about UI include that it is a natural part of aging and that surgery is the only treatment option.  Although more common as we age, incontinence is not caused by aging and thus does not mean that we have to accept being wet as we get older.  There are many therapies for UI other than surgery, ranging from dietary changes to pelvic floor muscle exercises (“Kegel’s”) to medications and supportive devices. Ultimately, treatment options depend on the type of UI and your concerns and goals as a patient.

 
Anatomy/Physiology

 
Urine is made by the kidneys as they filter blood and remove waste products as urine. Urine then moves into the bladder through small long tubes called ureters that connect the kidneys to the bladder.  Urine is stored in the bladder until it is full, when the urine is passed out of the body through the urethra. Women who experience SUI will leak urine during activities that increase their intraabdominal pressure, such as coughing, laughing, sneezing, bending, lifting, running and at times simply walking down hill.   This type of urine leakage is a result of either a weakened urinary sphincter—the valve in the urethra that is supposed to stay closed until you are urinating—or because of weakened muscles in the pelvis that no longer hold up the urethra and bladder against the increased intraabdominal pressure.  Although women may have both problems, the weakened supportive pelvic muscles are usually the main cause.

Women who experience UUI will usually leak urine when a strong sudden urge to get to the bathroom occurs. “I just can’t get to the bathroom on time” is a common complaint.   The leakage amount might be quite large, often resulting in embarrassing accidents. Patients with UUI may also leak when they hear or see running water, when they place their key in the door upon returning home, or when they stand up from a chair or get out of bed.  UUI is a result of involuntary bladder contractions or an overactive bladder (OAB). Your bladder has decided it’s time to go, not you. Women with MUI report urine leakage with physical activities and a sense of urge to go to the bathroom.

What causes urethral sphincter weakness or pelvic muscle weakness that leads to SUI? The exact cause of incontinence is unknown. However,vaginal delivery, pregnancy, and genetic factors likely increase risk of developing SUI.  Women who are obese or have chronic constipation or have a chronic cough from asthma or emphysema (smokers) may also be at increased risk. The causes of UUI are not known.  It is thought to be a subtle nerve and muscle problem.  There are patients with strokes or severe neurologic disease who develop OAB as a result, but this is a very small portion of patients with UUI.  Patients with diabetes are also at increased risk for UUI.

 
Diagnosis

In order to be diagnosed, your health care provider must be made aware that you suffer from UI.  Often with limited time, primary health care providers do not ask about UI.  Thus it is often up to the patient.  Patients need to discuss their incontinence symptoms with their provider and if they are unable to address the problem, patients should be referred to a provider that is able.  In general urologists and urogynecologists treat urinary incontinence. The initial visit should include a detailed history and physical examination with a pelvic/vaginal exam.  A urine sample for analysis and possibly culture is usually requested to look for infection, blood or sugar. Often this is all that is required to make an initial diagnosis and make treatment recommendations.  Sometimes, the specialist will request other tests before recommending therapy, such as a bladder diary, a post-void residual measurement (usually done with an office ultrasound machine to measure how much urine remains after voiding) a wet pad collection, and/or a urodynamic study.  Urodynamic studies are done to determine how the bladder, urethra and the urethral sphincter are working, or not working, to determine the possible cause of the incontinence.

 
Treatments

 
Behavioral

 
Behavioral therapies can be useful for both UUI and SUI. (unlike some medical and surgical therapies which are usually directed at one or the other).  Behavioral therapy includes diet modification, timed voiding, and pelvic floor muscle exercises (“Kegel’s”).  Some drinks such as coffee and carbonated beverages can be irritating to the bladder making patients feel the need to go to the bathroom more often and more urgently, so eliminating them can help.  Timed voiding simply means to go to the bathroom before you get an urge to go or before your bladder gets full when you are more likely to lose bladder control.  Pelvic floor muscle exercises help strengthen the weakened support of the bladder thus can help with SUI, but can also be used to tighten the muscles around the urethra to keep it closed when you get an unwanted urge to go and thus may help manage UUI as well.

Medications

Medications are usually used to treat UUI.  There are many available today.  Most of the medications require a 2-4 week trial and may be more successful when done in combination with the pelvic floor exercises and timed voiding.  It may take trying two or three medications to find one that works well for you. If medications don’t work there are other options available for treating UUI.

Devices are usually used to treat SUI.  These include supportive devices that are placed in the vagina called pessaries (also used for pelvic prolapse) as well as urethral inserts that are placed in the urethra to block urine from leaking out.

Bulking Agents

Bulking agents are usually used to treat SUI, most often as a result of a weakened urethal sphinter. There are several agents available (ie Collagen, Deflux, Co-Aptite). These agents are injected into the urethral sphincter by your physician to add bulk or “plump up” the sphincter so it is more difficult for urine to leak through. It is a short procedure often done in the office. The disadvantage of this procedure is that none of the agents are permanent.

Surgery

UUI:  There are surgical treatment options for UUI when medications and behavioral therapy have failed.  These include implantation of a neurostimulator called Interstim, injection of Botox into the bladder wall to relax the bladder muscle and increasing the size of the bladder with a piece of bowel (bladder augmentation).  Implantation of the Interstim device and Botox injections are short, outpatient procedures. Bladder augmentation is a complex surgical procedure done only in unusual circumstances.

SUI:  There have been many procedures developed for SUI.  All of these procedures try to resupport the urethra and at times the bladder.  Today many urologists and urogynecologists prefer midurethral sling surgery to correct SUI.  There are several companies that make these slings with product names such as TVT, SPARC, and MONARCH.  These procedures use a synthetic material formed into a narrow long strip that is placed, through very small incisions, underneath and beside the urethra to help hold it up (a “sling”) under times of increased intraabdominal pressure, such as a cough.   The surgery is done with no more than an overnight stay, many times as an outpatient.  Success rates for curing SUI range from 70-100% of patients. However, no surgery is perfect for everyone and complications can occur.

Conclusion

 
Urinary incontinence is a very common problem.  There are two main types—stress incontinence and urge incontinence.  Patients bothered with urinary incontinence often have to initiate the conversation about this problem with their healthcare providers, but once diagnosed many treatment options—both surgical and nonsurgical are available.