One of the most common complaints we see in clinical practice is urinary incontinence, or the involuntary leaking of urine.
Many women are reluctant to discuss this complaint with their providers as they are embarrassed, are unaware that treatments exist, and/or fear surgery. I commonly hear from my patients that they thought that leaking urine is “what happens as women age” and “normal after childbirth”. While the prevalence of leaking urine does increase with age, we don’t consider this a normal symptom, and treatment does exist!
How common is urinary leakage?
It is estimated that between 26-61 percent of women seek care for urinary incontinence. Weekly leaking of urine has been reported in 10 percent of women in an ethnically-diverse US urban population and 16 percent of non-pregnant women > 20 years in a nationally representative sample. Furthermore, a study conducted to assess the prevalence of urinary stress incontinence in a group of elite female athletes, found that 45.5 percent of all participants reported leakage of urine associated with sneezing and coughing.
What are the types of urinary incontinence?
The main types of urinary incontinence are stress, urge, and overflow incontinence. Many women have symptoms of more than one type of incontinence. In practice we most frequently see stress, urge and mixed incontinence, which we will discuss below.
Stress incontinence, now commonly referred to as “activity induced” incontinence, is the involuntary loss of urine with increases in abdominal pressure (eg jumping, coughing, and sneezing) in the absence of a bladder contraction. This is the most common form of incontinence in younger women. Stress incontinence is usually associated with urethral hypermobility, where the pelvic floor musculature and vaginal connective tissue can no longer support the urethra and bladder neck. As a result, the bladder neck and urethra can no longer close completely against the anterior vaginal wall. The loss of support of the pelvic musculature and connective tissue is usually caused by chronic pressure (high impact activity, obesity, or chronic cough), genetic influences, or trauma due to childbirth.
Urge incontinence is the involuntary loss of urine following a strong urge to void. It is believed that this type of incontinence results from detrusor muscle (the muscle that lines the bladder) overactivity, which leads to uninhibited detrusor muscle contractions during bladder filling. The term “overactive bladder” describes a syndrome of urinary urgency with or without incontinence.
Mixed incontinence occurs when women have symptoms of both stress and urgency incontinence.
How will my symptoms be evaluated?
The initial evaluation of urinary incontinence involves classifying the type of incontinence. In addition to assessing symptoms in the office patients are usually asked to complete an incontinence questionnaire and bladder diary from home. The bladder diary gives us information regarding the amount of leakage and the timing between voids. A physical exam is performed to evaluate for vaginal atrophy, pelvic masses, and prolapse of the pelvic organs. Laboratory testing usually involves ruling out infection and abnormal cells that may be indicative of bladder cancer. Further testing may include urodynamic studies, which assess function of the urinary tract.
What are my treatment options?
After we have properly identified the type of incontinence present our initial approach usually involves lifestyle modification. Obesity is a known risk factor for urinary incontinence, and weight loss in obese women appears to improve symptoms significantly. We also suggest avoidance of beverages and food that may irritate the bladder. Smoking cessation is also encouraged.
Exercises to strengthen the pelvic floor, commonly referred to as Kegels, have shown to be helpful for women who suffer from stress incontinence. Initial instruction is usually performed in our office. Women who are unable to isolate their pelvic floor musculature or have poor tone may benefit from supplemental therapy to include pelvic floor physical therapy, vaginal weighted cones, and biofeedback.
Bladder training is an effective treatment option for women with urge incontinence. Bladder training involves timed voiding where women are instructed to void by the clock at regular intervals. Urgency between voiding is controlled with distraction or relaxation techniques. The time between voiding is gradually increased until a patient can wait three to four hours between voids without urinary incontinence or frequent urgency.
When the above mentioned treatment options fail vaginal pessaries, pharmacologic options and surgery are usually the next line of treatment. Pessaries are plastic devices that the patient can insert into their vagina and work by improving urethral function. Patients are “fit” for a pessary and taught how to insert and remove these devices in our office. Pharmacologic therapy is usually reserved for urge incontinence and include use of medications that increase bladder capacity and decrease bladder urgency by blocking a specific neurotransmitter during bladder filling (thus decreasing detrusor muscle instability). Surgical options offer high cure rates for stress incontinence. A mid-urethral sling can be inserted through a small vaginal incision and placed at either the bladder neck or the urethra for the purpose of support.
A randomized controlled trial performed in 2013 compared subjective improvement rates between initial therapy with midurethral-sling procedures versus pelvic floor physical therapy. The study showed that the patients who underwent sling procedures had higher rates of subjective improvement and objective cure at one year.
What is the bottom line?
You do not need to suffer. Please feel comfortable speaking with your healthcare provider if you are leaking urine. There are many treatment options, many of which are non-invasive, to help stop urinary leakage. We are here to help and are highly trained in treating this common, yet rarely discussed, concern.