Urinary incontinence

For as many as 1 in 3 women bladder control is a struggle. Thousands of South African women lose bladder control over time resulting in the unintentional passing of urine. This can be a few drops of urine when coughing or sneezing or the passing of a full bladder or passing some urine as soon as the urge to urinate arises. Urinary incontinence can start as early as the teens or the twenties in females and progressively worsens after pregnancy, childbirth and menopause.

For many women incontinence is something they have come to accept as “normal”. This means that it is very important to help women understand that incontinence is not normal and when they discuss it with you to help them get the medical care and assistance they need.

What is incontinence?

Incontinence is the involuntary loss of urine control.  While there are many different types of incontinence the two main types  include:

Stress Incontinence:

• Passing of urine during coughing, laughing, sneezing, jogging or running.
• This type of incontinence normally gets worse after childbirth and with age.
• The pelvic floor muscles which support the bladder and vagina weaken resulting in a lack of control over keeping the urine in the bladder. When pressures rise (as it does when someone for example sneezes) urine leaks out of the bladder – normally a few drops at a time.

Urge Incontinence

• Passing of urine in large volumes as soon as the urge to pass urine arises (i.e. the person cannot “hold urine in” to get to the toilet).
• This type of incontinence normally arises due to contraction of the bladder walls such as when the bladder is irritated. Urge incontinence is often caused by damage to the nerves supplying the bladder wall, infection of the bladder, emotional anxiety or other causes of bladder irritation.

What symptoms will clients complain of?

Your clients will complain of different symptoms depending on the type of incontinence they experience.

• Passing a few drops of urine when coughing, sneezing, laughing, running, jumping etc
• Precipitous loss of bladder control when the urge to pass urine arises

Depending on the cause of incontinence your clients may also complain about other symptoms associated with incontinence such as:

• A sensation of burning when passing urine
• Loss of sensation to their buttocks
• Inability to sense the urge to pass urine

Managing incontinence

Ensure clients speak to their doctor about managing their incontinence. A urologist or gynaecologist usually deals with these issues. Your client may need to consult a physician, neurologist or neurosurgeon depending on the cause of their incontinence.

The doctor will review your client’s history and the likely causes for the incontinence. There are many tests for incontinence including stress tests (irritation of the bladder), urine analysis (assessment of urine chemical characteristics), urodynamic studies (test of bladder filling and emptying) and cytoscopy (a scope of the bladder).

Your client’s doctor will need to look for:

• Chronic conditions such as diabetes mellitus and hyperthyroidism which are uncontrolled and can also worsen incontinence.
• Medications for high blood pressure such as diuretics (e.g. Lasix®, HCTZ®), alpha-adrenergic antagonists (e.g. Cardugen®) and angiotensin-converting enzyme (ACE) inhibitors (e.g. Accupril®) can all be associated with incontinence.

Treatment

Handling incontinence is highly dependent on the cause of the condition. In some women, incontinence is part of an underlying disease such as multiple sclerosis, stroke or spinal cord injury while in others it is an isolated issue only in the bladder.

Non-medical treatments:

There are many ways most women go about trying to control their incontinence. The majority cope with pads, panty liners and frequent toilet visits to try and control their symptoms.

You can advise your clients to try the following for urge/stress incontinence:

• Lifestyle changes: Quitting smoking and losing any extra weight can help regain bladder control for some women.
• Pelvic floor exercises: Also known as ‘Kegel” exercises – strengthening of the pelvic floor muscles can help to develop bladder control. Kegel exercises need to be done regularly and consistently to get the best results.
• Vaginal weights: These small cone-shaped weights are inserted into the vagina and strengthen the muscles in the vaginal wall helping to correct urge incontinence.
• Biofeedback: A small pressure-sensitive probe is inserted into the vagina and helps teach patients which muscles to stimulate/control to regain bladder continence. Clients normally require 10 to 12 sessions to develop bladder control.

Medications:

Certain medications can help clients maintain bladder control including:

• · Anticholinergics: These can help prevent bladder spasm/contractions. Medications include oxybutynin (e.g. Lendritro®, Lyrinel®), trospium chloride (e.g. Uricon®),  tolterodine (e.g. Detrusitol®) and darifenacin (e.g. Enablex®).
  • Hormone replacement therapy (HRT): If menopausal, HRT including oestrogen patches, cream or pills can help with stress incontinence.

Surgical treatments:

For some clients medications and non-medical treatments may not be adequate or suitable to control their symptoms. In these women surgery may be of assistance. There are many types of surgery to treat incontinence, but broadly they include:

• Suspension operations: An operation in which the bladder neck is surgically re-supported.
• Sling operations: An operation where the bladder valve is tightened using artificial materials or strips of mesh.
• Artificial urinary sphincters: An operation in which a synthetic valve is inserted to replace the bladder valve.

• Botox® injections: Injections of botulinum toxin type A into the bladder muscle can help to relax the bladder for up to several months, treating symptoms of bladder over activity.

Getting back in control

Urinary incontinence is an unpleasant reality for many women. The majority wait until symptoms are extremely severe before seeking help. It is important to refer women to their doctor for thorough investigation and work-up regarding their condition. There are many lifestyle changes and pelvic strengthening techniques which would allow women to regain their bladder control. Where these are not sufficient there are medications and surgical procedures to ensure women don’t have to live with this condition.

Dr Karen Koch