Urinary Incontinence : Symptoms, Causes and Treatment

Approximately a million women suffer from a condition medically termed as urinary incontinence. This refers to the involuntary leakage of urine, which becomes a social and hygienic problem for adult women.

In the U.S., it is estimated that at least 10 million women suffer from distressing urinary incontinence. The Asian Society of Female Urology puts the incidence of urinary incontinence in India at 12 per cent.

If incontinence is so prevalent then why isn't anybody talking about it? Studies tell us 58 per cent of women perceived urine loss as a normal consequence of aging and that less than 40 per cent will actually talk to their physician about it. Incontinence is an even more hidden topic than menopause.

Millions suffer in silence and embarrassment. Urinary incontinence often takes over the patient's life limiting social activity and even work. It threatens self-confidence and self-esteem, inhibits sexual activity and exercise, and can even affect the way people dress.



Not normal


Urinary incontinence is not a normal part of aging. The aging process merely predisposes a woman to urine loss. Weak muscles, childbirth, poor nutrition and fluid intake, gynaecological surgery, urinary tract infections, spinal cord injuries and emotions all play a role in the aetiology of incontinence.

Although incontinence occurs in men, its prevalence is less than one third that of women and in most cases has a defined aetiology.

Determining the cause of the women's incontinence is the key to its management. Impaired mobility, chronic constipation and prescription drugs, which can cause bladder dysfunction, should be addressed in the incontinent elderly.

Causes


The two most common causes of incontinence involve bladder instability (Urge Incontinence) and anatomic lack of urethral support (stress incontinence). Overflow urine loss and lack of tone in the urethra (bladder tube) can happen as age advances.

Stress incontinence is the leakage of urine with activities that increase pressure inside the abdomen like coughing, sneezing and laughing. Women can also lose urine while engaging in sports, bending, getting up from a seated position and lifting weights.

Urge incontinence is leakage of urine accompanied by a sense of urgency. Women typically complain of losing urine before they can make it to the bathroom. The sound of running water and activities like washing dishes can also precipitate sudden bladder spasms resulting in urine loss.

Investigation


Investigating a woman with urinary incontinence would involve a careful history and thorough physical examination. Physicians as well as patients should understand that urinary incontinence is not life threatening. However, it severely affects quality of life (QOL).

Incontinence can affect different women in different ways. A housewife may not be as bothered by her incontinence as a working woman. Hence questionnaires to determine the impact of incontinence on quality of life should be given to patients and answered before treatment commences.

A three-day diary that gives details of the frequency of urination, quantity, urgency, stress or related events and the quantity of fluid intake is mandatory.

Simple tests like urine dip, culture, blood sugar and thyroid function tests can be done. A bladder scan can be done to check the post-void residual.

Higher investigations would include a cystourethroscopy to look inside the bladder and urethra. Probably the most favoured investigation would be Multichannel urodynamics.

This test uses small catheters to measure abdominal, urethral and bladder pressures. Moreover the presence or absence of bladder spasms, which cause urgency, can be determined.

Urethral relaxation with lack of urethral tone resulting in stress incontinence can be diagnosed.

Treatment for urinary incontinence can either be surgical or conservative.

Treatment


Behavioural modification including regulation of fluid intake and avoiding caffeinated drinks, spicy food, citrus fruits and chocolates help in reducing bladder spasms. Timed voiding reminds the patient to void at frequent intervals and helps in training the bladder. Appliances like pessaries and bladder neck support prosthesis may offer a temporary solution.

Pelvic floor muscle training (PFMT) forms the mainstay of conservative treatment. Strong pelvic muscles prevent bladder spasms and also strengthen the support to the urethra. Biofeedback is computer-assisted visual feedback, which help women to isolate and strengthen pelvic floor muscles.

Functional electrical stimulation (FES) makes use of a low-grade electric current that stimulates the pelvic floor muscles and strengthens them.

Medications to relax the bladder muscle and to strengthen the urethral tone are available in the market. However, side effect profile of these medicines may limit their prolonged use.

In postmenopausal women, local estrogen cream helps alleviate symptoms of urgency and frequency.

Surgery


Surgical treatment involves either anchoring the bladder supports to a higher point as in Burch Colposuspension or supporting the urethra by means of a small polypropylene tape kept under it. The tape, which is in the form of a sling, acts as a backstop and prevents leakage of urine during rises in intra-abdominal pressure.

This sling surgery is done as a day care procedure and has a success rate of 85-95 per cent over a nine-year period. Injectables like collagen and silicon polymers can be used to bulk up the urethra and provide tone.

Incontinence is a fairly common problem though women may be reluctant to discuss it. As our population ages we can expect a larger proportion to suffer from it.

As this problem "comes out of the closet" it is the responsibility of physicians to inform patients of the choices available for treatment. Currently all women with incontinence can be helped if not cured. Finally, one should never think of incontinence as something they have to put up with or as part of growing old.


Source: The Hindu