Types of Urinary Incontinence
Urinary incontinence is the unintentional passing of urine. It’s a common problem thought to affect millions of people.
There are several types of urinary incontinence, including:
- stress incontinence – when urine leaks out at times when your bladder is under pressure; for example, when you cough or laugh
- urge incontinence – when urine leaks as you feel a sudden, intense urge to pass urine, or soon afterwards
- overflow incontinence (chronic urinary retention) – when you’re unable to fully empty your bladder, which causes frequent leaking
- total incontinence – when your bladder can’t store any urine at all, which causes you to pass urine constantly or have frequent leaking
It’s also possible to have a mixture of both stress and urge urinary incontinence
What is Stress Urinary Incontinence ?
Stress Urinary Incontinence (or SUI ), is when you leak urine when your bladder is put under extra sudden pressure – for example, when you cough. It is not related to feeling stressed.
Other activities that may cause urine to leak include:
- heavy lifting
The amount of urine passed is usually small, but stress incontinence can sometimes cause you to pass larger amounts, particularly if your bladder is very full.
Causes of Stress Urinary Incontinence
Stress incontinence occurs when the pressure inside your bladder as it fills with urine becomes greater than the strength of your urethra to stay closed. The urethra is the tube urine passes through out of your body.
Any sudden extra pressure on your bladder, such as laughing or sneezing, can then cause urine to leak out of your urethra.
Your urethra may not be able to stay closed if the muscles in your pelvis (pelvic floor muscles) are weak or damaged, or your urethral sphincter – the ring of muscle that keeps the urethra closed – is damaged.
These problems may be caused by:
- damage during childbirth – particularly if the child was born vaginally, rather than by caesarean section
- increased pressure on your tummy – for example, because you are pregnant or obese
- damage to the bladder or nearby area during surgery – such as the removal of the womb (hysterectomy) in women, or removal of the prostate gland in men
- neurological conditions – that affect the brain and spinal cord, such as Parkinson’s disease or multiple sclerosis
- certain connective tissue disorders – such as Ehlers-Danlos syndrome
- certain medications
Urge incontinence, or urgency incontinence, is when you feel a sudden and very intense need to pass urine and you’re unable to delay going to the toilet. There’s often only a few seconds between the need to urinate and the release of urine.
Your need to pass urine may be triggered by a sudden change of position, or even by the sound of running water. You may also pass urine during sex, particularly when you reach orgasm.
This type of incontinence often occurs as part of group of symptoms called overactive bladder syndrome, which is where the bladder muscle is more active than usual.
As well as sometimes causing urge incontinence, overactive bladder syndrome can also mean you need to pass urine very frequently and you may need to get up several times during the night to urinate.
Causes of Urge Incontinence
The reason your detrusor muscles contract too often may not be clear, but possible causes include:
- drinking too much alcohol or caffeine
- poor fluid intake – this can cause strong, concentrated urine to collect in your bladder, which can irritate the bladder and cause symptoms of overactivity
- conditions affecting the lower urinary tract (urethra and bladder)– such as Urinary Tract Infections (UTI’s) or tumours in the bladder
- neurological conditions
- certain medications
Overflow incontinence, also called chronic urinary retention, occurs when the bladder cannot completely empty when you pass urine. This causes the bladder to swell above its usual size.
If you have overflow incontinence, you may pass small trickles of urine very often. It may also feel as though your bladder is never fully empty and you cannot empty it even when you try.
Causes of Overflow Incontinence
Overflow incontinence, also called chronic urinary retention, is often caused by a blockage or obstruction of your bladder. Your bladder may fill up as usual, but as it’s obstructed you won’t be able to empty it completely, even when you try.At the same time, pressure from the urine that’s still in your bladder builds up behind the obstruction, causing frequent leaks.
Your bladder can become obstructed as a result of:
- bladder stones
Overflow incontinence may also be caused by your detrusor muscles not fully contracting, which means your bladder doesn’t completely empty when you go to the toilet. As a result, the bladder becomes stretched.
Your detrusor muscles may not fully contract if:
- there’s damage to your nerves – for example, as a result of surgery to part of your bowel or a spinal cord injury
- you’re taking certain medications
Urinary incontinence that’s severe and continuous is sometimes known as total incontinence.
Total incontinence may cause you to constantly pass large amounts of urine, even at night. Alternatively, you may pass large amounts of urine only occasionally and leak small amounts in between.
Causes of Total Incontinence
Total incontinence occurs when your bladder can’t store any urine at all. It can result in you either passing large amounts of urine constantly, or passing urine occasionally with frequent leaking.
Total incontinence can be caused by:
- a problem with your bladder from birth
- injury to your spinal cord – this can disrupt the nerve signals between your brain and your bladder
- a bladder fistula – a small, tunnel-like hole that can form between the bladder and a nearby area, such as the vagina, in women
Lower Urinary Tract Symptoms (LUTS)
The lower urinary tract comprises the bladder and the tube urine passes through out of the body (urethra). Lower urinary tract symptoms (LUTS) are common in women as they get older.
They can include:
- problems with storing urine, such as an urgent or frequent need to go to the toilet, or feeling like you need to go straight after you’ve just been
- problems with passing urine, such as a slow stream of urine, straining to pass urine, or stopping and starting as you pass urine
- problems after you’ve passed urine, such as feeling that you’ve not completely emptied your bladder or passing a few drops of urine after you think you’ve finished
Experiencing LUTS can make urinary incontinence more likely.
Mixed incontinence is when you have symptoms of both stress and urge incontinence. For example, you may leak urine if you cough or sneeze, and also experience very intense urges to pass urine.
Medications Can Cause Incontinence
Some medicines can disrupt the normal process of storing and passing urine, or increase the amount of urine you produce.
- angiotensin-converting enzyme (ACE) inhibitors
- some antidepressants
- hormone replacement therapy (HRT)
Stopping these medications, if advised to do so by a doctor, may help resolve your incontinence.
In addition to the causes mentioned above, some things can increase your risk of developing urinary incontinence without directly being the cause of the problem. These are known as risk factors.
Some of the main risk factors for urinary incontinence include:
- family history – there may be a genetic link to urinary incontinence, so you may be more at risk if other people in your family have experienced the problem
- increasing age – urinary incontinence becomes more common as you reach middle age, and is particularly common in people over the age of 80
- having lower urinary tract symptoms (LUTS) – a range of symptoms that affect the bladder and urethra
If you experience urinary incontinence, see your GP so they can determine the type of condition you have.
Try not to be embarrassed about speaking to your GP about your incontinence. Urinary incontinence is a common problem and it’s likely your GP has seen many people with the condition. Your GP will ask you questions about your symptoms and medical history, including:
- whether the urinary incontinence occurs when you cough or laugh
- whether you need the toilet frequently during the day or night
- whether you have any difficulty passing urine when you go to the toilet
- whether you’re currently taking any medication
- how much fluid, alcohol or caffeine you drink
Before seeing your GP, it may be useful for you to keep a Bladder Diary for 3-7 days to assist in diagnosing the type of incontinence you have by giving as much information as possible about your condition.
This should include details like:
- how much fluid you drink
- the types of fluid you drink
- how often you need to pass urine
- the amount of urine you pass
- how many episodes of incontinence you experience
- how many times you experience an urgent need to go to the toilet
What Are My Treatment Options ?
Do Nothing-No Treatment
After speaking with your doctor and considering information about SUI, you may choose not to have any treatment, particularly if your symptoms are mild. Absorbent products do not reduce the symptoms of SUI, but you may find that leakage of urine can be sufficiently managed with pads and other absorption aids.
See the Continence Foundation of Australia website www.continence. org.au for more information on incontinence, pelvic floor exercises, referral and products to manage the conditions. You may be eligible for a subsidy for continence products under the Continence Aids Payment Scheme.
Non-Surgical Treatment Options
Non-surgical treatments are recommended as the first line of treatment by the Royal Australian and New Zealand College of Obstetricians and Gynecologists and the Urological Society of Australia and New Zealand (part of the Royal Australasian College of Surgeons).
You may be able to improve symptoms without surgery. The following treatment options are safe, and a combination of these options may give you good results.
Reducing weight, avoiding heavy lifting, avoiding constipation and chronic coughing, stopping smoking and doing lower impact exercises are all non-surgical options that should be considered.
Each of these options can help increase control over your bladder and contribute to overall good health. These changes need consistent effort, over the long term as it takes time for lifestyle changes to work.
Support from a health professional, such as a dietitian or your general practitioner may be helpful, as well as support from family and friends to assist in making these lifestyle changes.
Pelvic Floor Exercises
Your pelvic floor muscles are the muscles you use to control the flow of urine as you urinate. They surround the bladder and urethra, the tube that carries urine from the bladder outside the body.
Weak or damaged pelvic floor muscles can cause urinary incontinence, so exercising these muscles is often recommended.
Ask your GP to refer you to a specialist physiotherapist to start a programme of pelvic floor muscle training.
Your specialist physiotherapist will assess whether you’re able to squeeze (contract) your pelvic floor muscles and by how much.
If you can contract your pelvic floor muscles, you’ll be given an individual exercise programme based on your assessment.
Your programme should include doing a minimum of 8 muscle contractions at least 3 times a day and the recommended exercises for at least 3 months. If the exercises are helping after this time, you can keep on doing them.
Research suggests women who complete pelvic floor muscle training experience fewer leaking episodes and report a better quality of life.
A physiotherapist with a special interest in pelvic floor dysfunction may suggest biofeedback or electrical stimulation. An internal examination and some specialised tests may also need to be performed to assess whether you are doing the exercises correctly and whether they are helping improve your pelvic floor strength.
If you’re unable to contract your pelvic floor muscles, using a device that measures and stimulates the electrical signals in the muscles may be recommended. This is called electrical stimulation.
A small probe will be inserted into the vagina in women or the anus in men. An electrical current runs through the probe, which helps strengthen your pelvic floor muscles while you exercise them.
You may find electrical stimulation difficult or unpleasant to use, but it may be beneficial if you’re unable to complete pelvic floor muscle contractions without it.
Information about pelvic floor exercises, continence nurses and physiotherapists with a special interest in pelvic floor dysfunction is available from the Australian Physiotherapy Association www.physiotherapy.asn.au/APAWCM/Physio_and_You/Pelvic_Floor.aspx or the National Continence Helpline on 1800 33 00 66 or the Continence Foundation of Australia at: www.continence.org.au/pages/pelvic-floor-women.html
Biofeedback is a way to monitor how well you’re doing the pelvic floor exercises by giving you feedback as you do them.
There are several different methods of biofeedback:
a small probe could be inserted into the vagina in women – this senses when the muscles are squeezed and sends the information to a computer screen
electrodes could be attached to the skin of your tummy (abdomen) or around the anus – these sense when the muscles are squeezed and send the information to a computer screen
There isn’t much good evidence to suggest biofeedback offers a significant benefit to people using pelvic floor muscle training for urinary incontinence, but the feedback may help motivate some people to carry out their exercises.
Speak to your specialist if you would like to try biofeedback.
Vaginal cones may be used by women to assist with pelvic floor muscle training. These small weights are inserted into the vagina.
You hold the weights in place using your pelvic floor muscles. When you can, you progress to the next vaginal cone, which weighs more.
If you’ve been diagnosed with urge incontinence, one of the first treatments you may be offered is bladder training.
Bladder training may also be combined with pelvic floor muscle training if you have mixed urinary incontinence.
It involves learning techniques to increase the length of time between feeling the need to urinate and passing urine. The course will usually last for at least 6 weeks.
While incontinence products aren’t a treatment for urinary incontinence, you might find them useful for managing your condition while you’re waiting to be assessed or for treatment to take effect.
Incontinence products include:
- absorbent products, such as incontinence pants or pads
- handheld urinals
- a catheter, a thin tube that is inserted into your bladder to drain urine
- devices that are placed into the vagina or urethra to prevent urine leakage – for example, while you exercise
Speak to your GP about the various medications for stress urinary incontinence or urge incontinence.
Your doctor or a physiotherapist with a special interest in pelvic floor dysfunction can fit you with a removable device called a pessary. This is inserted into your vagina to compress your urethra against your pubic bone and lift the neck of your bladder. Pessaries are made from a variety of materials including vinyl, silicone and latex. You may need to try a few types and sizes of pessaries to find what works for you.
What are Urinary Incontinence Pessaries ?
It is a stiff ring that is inserted into the vagina and worn all day. The pessary holds up the bladder and stops leakage of urine; this device is especially beneficial to those with a dropped bladder or uterus. Urinary incontinence pessaries are very useful for women with stress incontinence.
Fascial Sling Surgery
Autologous fascial sling placement is a procedure to treat stress incontinence (leakage of urine when you exercise, sneeze or strain). Fascia is a sheet of supporting, fibrous tissue that holds body organs in their correct position. The fascia used in this operation can come from the abdominal wall or from the top of the leg. The terms rectus fascia sling (using fascia form the abdominal wall) or
fascia lata sling (using fascia from the outside of the thigh) are sometimes used to describe variations of this procedure.
The bladder and urethra (water pipe) are supported by the pelvic floor muscles and ligaments. If this support is weakened, urine may leak with coughing, sneezing, laughing, lifting or exercise.
Autologous slings are placed around the water pipe (urethra) via the vagina to treat complicated stress incontinence (leakage in women who have undergone previous procedures on the urethra or bladder). The sling is placed under the urethra and cradles it like a hammock. It is then passed through the muscles of the abdominal wall and tightened to provide support.
By using tissue from your body to construct an autologous sling, the risk of infection and the body’s reaction to it is reduced.
The procedure usually requires an overnight stay and takes approximately 1 – 2 hours to perform. It may be performed under general or spinal anaesthetic.
Burch Colposuspension Surgery
Colposuspension (also called Burch colposuspension) is an operation that involves placing sutures (stitches) in the vagina on either side of the urethra (water pipe) and tying these sutures to supportive ligaments to elevate the vagina.
Normally, the urethral sphincter and the muscles and ligaments around the urethra contract to
prevent involuntary leakage of urine. Damage to these structures from childbirth and/or aging can lead to stress incontinence. The sutures in colposuspension elevate the vagina and support the urethra, thus reducing or stopping the leakage.
Colposuspension can be done as open surgery or keyhole (laparoscopic) surgery.
If you have open surgery, your surgeon will make a small cut in your lower abdomen (bikini line) to allow them to reach your bladder. Your surgeon will lift the neck of your bladder by stitching the top of your vagina to the back of your pubic bone. Your surgeon may then put a small camera inside your bladder to check that the stitches are in the right place, and there are no injuries to your bladder.
At around six weeks post op you can gradually build up your level of activity.
After 3 months, you should be able to return completely to your usual level of activity.