Incontinence can be divided broadly into the following types but 90% of patients suffer from stress and/or urge incontinence:
- Stress incontinence – leakage during periods of abdominal pressure (coughing, sneezing, lifting, straining).
- Urge incontinence – leakage which follows an irresistible urge to pass urine.
- Mixed incontinence – combined stress & urge incontinence.
- Overflow incontinence – inability to empty the bladder with resulting overflow of urine.
- Functional incontinence – inabilty to use the toilet in time due to poor mobility or brain disorders.
- Continuous incontinence – constant leakage of urine due to an inherited abnormality or sphincter (valve) injury (often caused by surgery).
- Post-micturition dribble – leakage from the urethra a few minutes after passing urine (not to be confused with terminal dribbling when it is difficult to shut off the stream immediately after passing urine – usually a sign of prostatic obstruction).
- Giggle incontinence – tends only to occur in young girls and normally resolves as the child grows.
What are the facts about incontinence of urine?
- 60-80% of patients have never sought medical advice for their condition and 35% view it simply as part of the ageing process.
- Incontinence is caused by bladder abnormalities and/or sphincter (valve) weakness.
- Stress incontinence is due to sphincter weakness for which the commonest causes are multiple childbirth or prolonged labour.
- Urge incontinence is caused by bladder abnormalities for which the commonest cause is an overactive bladder (OAB).
- Conservative treatment can be successful in improving most forms of incontinence.
- Surgery is effective in incontinence, if conservative measures do not work, but there is a late failure rate for all types of surgery.
What should I expect when I visit my GP?
A full history
Your GP will take a structured, urological history to ascertain what type of incontinence you have and how this affects your day-to-day activities. You may be asked to complete a questionnaire in advance of your appointment to help your GP obtain a more accurate picture. Your past medical and obstetric history are important in any discussion, as are your daily fluid intake, the drugs you are taking, your bowel function, your smoking habits and any other urinary symptoms you may be experiencing.
A physical examination
A full physical examination will be performed, including measuring your blood pressure and assessment of your body mass index (BMI). Particular attention will be paid to the abdomen (to feel for an enlarged bladder) and to vaginal or rectal examination. It is helpful to have a full bladder when you are examined because it may mean that you can reproduce the leakage for your GP. A full neurological examination with assessment of your reflexes should also be performed.
a. General blood tests.
The actual tests performed will be left to your GP’s discretion. It is usual to measure kidney function and to check the blood cells for anaemia or other problems.
b. Urine tests
A routine dipstick test will be performed. A urine sample will normally be sent to the laboratory to exclude infection.
c. Bladder Ultrasound
Your GP may wish to arrange an ultrasound scan. This is to check your kidneys, to assess your bladder emptying and to find out whether your symptoms are caused by a problem within or close to the bladder. Thereafter, additional tests will only be performed after your GP refers you to a uro-gynaecology clinic.
What treatment is available for this problem?
If you have an enlarged bladder, a mass arising from the pelvis (or urinary tract), blood in your urine or a large, troublesome vaginal prolapse, your GP will arrange your referral to a urologist or uro-gynaecologist. In most patients, however, your initial management will take place under the supervision of your GP.
1. General measures
Simple measures such as reducing caffeine intake, reducing what you drink, losing weight and carrying out pelvic floor exercises may be helpful. You should avoid taking drugs which cause you to make more urine (e.g. diuretics). You should stop smoking. For some patients, using simple pads to catch the leakage may be sufficient. If surgery is not appropriate for any reason, inserting a catheter into the bladder (pictured) or using intermittent self-catheterisation may resolve the incontinence.
2. Stress incontinence
- Weight loss – may reduce the incontinence to manageable levels without any further treatment.
- Physiotherapy – combined with electrical stimulation or the use of vaginal cones can improve many patients with stress incontinence.
- Oestrogen supplements – may help women with incontinence due to post-menopausal tissue atrophy.
- Drugs – there are now some drugs available which can help women with stress incontinence.
- Periurethral injections – using collagen or artificial materials.
- Bladder neck suspension – realigning the bladder neck and urethra
- Sling procedures – using natural or synthetic materials to lift up the bladder neck.
- Artificial urinary sphincter – implanting a controllable valve mechanism around the urethra or bladder neck.
- Diversion of urine into a conduit will, of course, cure incontinence but should be regarded as a last resort when all other measures have failed.
3. Urge incontinence Non-surgical treatment
- Drugs – designed to inhibit uncontrolled bladder contractions
- Behavioural modification/biofeedback
- Treat the underlying cause – e.g. prostate obstruction, bladder tumour, bladder stone or urethral stricture.
- Stretching of the bladder- by overfilling with fluid at the time of telescopic inspection under general anaesthetic.
- Botox injections- by injecting into the bladder wall using a telescope under local or general anaesthetic.
- Sacral neuromodulation – implantation of a stimulator & electrodes into the nerves which supply the bladder.
- Augmentation cystoplasty – enlargement of the bladder using a segment of bowel.
- Diversion of urine into a conduit should be regarded as a last resort when all other measures have failed.
4. Overflow incontinence
If the underlying cause of the overflow incontinence can be clearly identified, it should be treated. Men with chronic retention of urine may benefit from TURP. If surgery is not appropriate, a simple urethral catheter can be inserted into the bladder or self-catheterisation started. Permanent urethral catheterisation in women with overflow incontinence can cause significant problems with bladder neck erosion and catheters falling out. Intermittent self-catheterisation is normally better for women.
5. Continuous incontinence
If there is a fistula causing continuous incontinence, this can be repaired surgically. An urethral catheter or intermittent self-catheterisation may be preferred if surgery is not appropriate.
6. Post-micturition dribble
The vast majority of men with post-micturition dribble have no underlying problem apart from a failure of the normal “milk-back” mechanism after passing urine. Simple massaging of the urethra towards the tip of the penis can reduce troublesome dribbling. Thijs helps to expel the last remaining drops of urine. If an underlying cause is identified on ultrasound scanning (e.g. urethral stricture or diverticulum), telescopic surgery may be advised, although this does not always eliminate the dribbling completely.