Urinary incontinence is the involuntary leakage of urine. In real terms, it is a bladder that ends up controlling your life, and can result in living in continual fear of urine leakage. Whilst not a life-threatening condition, it can have an enormous impact on an individual’s life with a profound loss of quality of life. The effects of incontinence are many, including severe embarrassment, restriction in daily activities and social life as well as limiting the ability to work and travel. People suffering from incontinence bear additional heavy costs due to the use of protection devices such as incontinence pads to help deal with the problem.
The problem of urinary incontinence is extremely common. It is important to remember though that no one need suffer in silence, and that there is much that can be done to treat incontinence. The good news is that almost all people with this very common and debilitating problem can be helped. Our practice specializes in the assessment and management of men and women with urinary incontinence using a multidisciplinary approach that utilises the skills of Urologists, Continence Nurse Specialists as well as specialized Continence Physiotherapists. Many treatment options are available, ranging from physiotherapy and bladder retraining techniques, medication, minimally invasive surgery to more extensive surgery depending on the type and severity of incontinence. Treatments are individualised to each person’s problem and preferences in treatment.
Categorisation of urinary Incontinence (urine loss)
Stress urinary incontinence
|Weakness in the urinary sphincter and/or pelvic floor muscles||Urine loss is triggered by activities that cause a rise in intra-abdominal pressure e.g. coughing, sneezing, jumping, lifting, exercise.|
Urge urinary incontinence
|“Detrusor overactivity” i.e. a bladder muscle that contracts or spasms out of the person’s control, usually at low bladder volumes and with little warning||Loss of urine is preceded by a sudden and severe desire to pass urine with loss of urine typically occurring on the way to the toilet. Typical triggers for urine loss include arriving at the front door (“key in the door”), running water, hand washing, cold weather. Volume of urine loss is variable, ranging from a few drops to flooding (where the entire urine volume is lost)|
Mixed urinary incontinence
|A combination of stress and urge urinary incontinence. It is important to define which symptom is predominant and most bothersome to the patient, and treat this symptom first.||Features of both urge and stress incontinence|
Overflow urinary incontinence
|It occurs when the person is in chronic urinary retention where the bladder is not emptying fully and the leakage is due to an over-distended bladder. Occurs in the setting of bladder outlet obstruction (e.g. due to prostatic enlargement in men or severe prolapse in women), poor bladder muscle function, or nerve damage to the bladder (can occur in both men and women)||Usually associated with a reduced sensation of bladder fullness and a feeling of incomplete bladder emptying. Does not tend to occur unless bladder emptying is very poor with large volumes of urine left behind in the bladder after urination|
|A fistula is an abnormal connection between the urinary tract and other organs, e.g. between the bladder and vagina in women -“vesicovaginal fistula”. Rare in the Western world and tend to occur in women related to previous pelvic surgery.||Continuous insensible (not felt) urine loss from the vagina, usually of large volume|
|Involuntary loss of urine cause by physical (e.g. poor mobility) or mental (e.g. dementia) limitations that result in an inability to toilet normally.||Impaired mobility and/or cognitive function|
Overactive Bladder Syndrome (OAB) - What is it?
OAB is defined as the urgent desire to urinate (with or without urge urinary incontinence) which is usually associated with frequent urination as well as excessive urination at night. About 1/3 of people who suffer from OAB experience urinary incontinence, known as “OAB wet”, with the remaining 2/3 of people having “OAB dry”. It is important to ensure that other conditions causing irritation to the bladder lining are not mistaken for OAB, e.g. urinary tract infections, bladder stones, and bladder tumours.
Assessment of Urinary Incontinence
The assessment of all people with urinary incontinence begins with a full history and physical examination. Valuable information can also be gained from a bladder diary which is completed by giving details of how much and how often urine is passed over a 24-hour period as well as an idea of the frequency of incontinence episodes. Basic investigations such as urine testing and ultrasound assessment of bladder emptying are also performed. The combination of the above tests allows a clinical diagnosis to be made of the type of urinary incontinence and a treatment plan to be formulated in most people.
Urodynamic testing is the “gold standard” test of bladder function. It is used in some patients to better define the type of urinary incontinence and its cause, provide a precise diagnosis to guide treatment, help plan for surgery (if required) and determine bladder function, particularly in the case of people with neurological conditions. This specialized computer-based test involves bladder pressure and urine flow readings and is performed by a Urologist, aiming to reproduce the patient’s bothersome urinary symptoms so that a precise diagnosis of incontinence or bladder abnormality is obtained. Cystoscopy (telescopic examination of the lining of the bladder and urethra) is necessary in some patients to better diagnose the type of incontinence and exclude abnormalities in the inner lining of the bladder
A urodynamic study is a study of how the bladder and urethra work by taking pressure readings of the bladder and urethra using sophisticated computerized equipment. “Fluoroscopic” means that X-rays are taken at the same time to give a picture of bladder and urethral anatomy.
FUDS is the “gold standard” test for assessing bladder and urethral function. It provides invaluable information about bladder function that can help diagnose urinary tract problems and help determine the best treatment for the individual. FUDS helps diagnose and hence plan the treatment of the following problems:
- Female urinary incontinence brought on by activity e.g. coughing, exercise (“stress incontinence”)
- Frequent and urgent urination as well as loss of urine on the way to the toilet (“urge incontinence”)
- Poor urinary stream and sensation of incomplete bladder emptying
- Men with urinary blockage symptoms where it is unclear if this is a problem related to the prostate
- Men with incontinence after prostate surgery such as radical prostatectomy
- Urinary difficulties associated with neurological diseases including problems such as spinal cord injuries, multiple sclerosis, Parkinson’s disease
- Painful bladder conditions
- Prolapse problems in women
The procedure is performed without any fasting or sedation and takes about 40 minutes (but allow 2 hours to include preparation time).
The first part of the test involves passage of urine into a special toilet which measures the flow of urine.
After this, special fine catheters are inserted which fill the bladder with fluid and allow pressure measurements to be recorded. These fine tubes are connected to a computer to provide pressure readings from the bladder as it is filled with fluid by the tube. Patients are asked to describe their sensation of bladder urgency or discomfort during the procedure. During the study patients are asked to cough, strain and pass urine to determine how the urinary tract functions. At the end of the procedure, a flexible cystoscope (small telescope) is inserted into the bladder to inspect the urethra and bladder lining.
Treatment of stress incontinence needs to be individualized and will be determined by many factors including previous treatment, severity of incontinence and the results of the Urodynamic study as well as the individual’s preferences.
- Pelvic floor exercises (Kegel exercises) play an important role in strengthening the supports of the urethra and bladder in all people with incontinence. Intensive pelvic floor physiotherapy for a period of 3-6 months can result in a significant reduction in stress incontinence
- Urethral bulking agents – Minimally invasive surgery performed as a day case where material (such as collagen or a synthetic material) is injected into the urethra using a telescope (cystoscope) to help reduce urinary leakage
- Minimally invasive sling surgery – Mid-urethral slings are thin ribbons of synthetic mesh placed under the urethra which act as a hammock to support the urethra and prevent stress incontinence. These procedures are minimally invasive due to the use of synthetic mesh and usually involve short hospitalization and a quick recovery time
- Fascial sling surgery – Uses natural material such as your own tissue for the sling
- Colposuspension – The bladder neck is elevated and repositioned using abdominal sutures (usually placed by a cut in the lower abdomen)
- Stress urinary incontinence in men most commonly occurs as a result of treatment for prostate cancer. Many treatment options are available, including:
- Pelvic floor exercises
- Urethral bulking agents
- Minimally invasive sling surgery – Synthetic slings have been designed to treat men with stress urinary incontinence, particularly in milder cases
- Artificial urinary sphincter – This mechanical device acts as a valve to control urine loss in severe cases of urinary incontinence and is regarded as the “gold standard” treatment for male stress incontinence.
The initial management of urge urinary incontinence and OAB is non-surgical.
- Pelvic floor exercises
- Bladder retraining
- Anticholinergic medication
If these measures fail to adequately control urge incontinence or OAB symptoms, surgical treatment options available include:
- Botulinum toxin injections into the bladder
- Sacral neuromodulation – it is hoped that the InterStim™ device for this problem will be shortly approved for usage in Australia
- Bladder surgery