incontinence

Incontinence

Urinary Incontinence

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The bladder is made of muscle and stores the urine. It expands like a balloon as it fills with urine. The outlet for urine (the urethra) is normally kept closed. This is helped by the muscles beneath the bladder that sweep around the urethra (the pelvic floor muscles). When a certain amount of urine is in the bladder, you become aware that the bladder is getting full. When you go to the toilet to pass urine, the bladder muscle contracts (squeezes), and the urethra and pelvic floor muscles relax.

Complex nerve messages are sent between the brain, the bladder, and the pelvic floor muscles. These make you aware of how full your bladder is and tell the right muscles to contract, or relax, at the right time.

How common is urinary incontinence?

Urinary incontinence is common, especially in women. It can occur at any age, but it is more likely to develop the older you become. It is estimated that about 3 million people in the UK are regularly incontinent. Overall this is about 4% of ALL adults.

However, as many as 1 in 5 women over the age of 40 have some degree of urinary incontinence. The number may be higher as many people don't tell anyone about their problem.

There are different types of urinary incontinence.

* Stress incontinence is the most common form. It occurs when the pressure in the bladder becomes too great for the bladder outlet to withstand. It usually occurs because the pelvic floor muscles which support the bladder outlet are weakened. Urine tends to leak most when you cough, laugh, when you exercise or have sex. In these situations there is a sudden extra pressure ('stress') inside the abdomen and on the bladder. Small amounts of urine may leak, but it may be a lot and causes embarrassment. Stress incontinence is common in women who have had children. It is also more common with increasing age and with obesity.

* Urge incontinence (unstable or overactive bladder) is the second commonest cause. This is when you get an urgent desire to pass urine. Sometimes urine leaks before you have time to get to the toilet. The bladder muscle contracts too early and the normal control is reduced. The cause is not known but it seems that the bladder muscle gives wrong messages to the brain, and the bladder may feel fuller than it actually is.

* Mixed incontinence. Some people have a combination of stress and urge incontinence.

More than 9 in 10 cases of urinary incontinence are due to the above causes. Other causes are less common. They include

*Neuropathic incontinence. This is when the nerves that control the bladder and surrounding structures are affected in some way. For example, some people with multiple sclerosis, spinal cord damage, brain disorders, etc.
*
*Overflow incontinence. This is when there is an obstruction to the outflow of urine. The obstruction prevents the normal emptying of the bladder. A pool of urine constantly remains in the bladder that cannot empty properly. This increases the risk of infection. In men the commonest cause is an enlarged prostate gland.

* Bedwetting (enuresis) usually occurs in children, but some adults are affected.

What can be done about incontinence?

Many people with urinary incontinence do not mention it to anybody - even their doctor. This may be due to embarrassment, or thinking that nothing can be done. Urinary incontinence is often curable. It can usually be improved. Each type of urinary incontinence is treated differently.

* Tell your doctor or practice nurse if you leak urine on a regular basis. They will be able to assess your symptoms. Sometimes a referral to a specialist like Mr Connell is needed to clarify the type of incontinence.

* Treatment depends on the type of incontinence. Separate leaflets discuss stress incontinence, urge incontinence, and their treatment.

* The following are general points that may apply for all types of incontinence.

•Your GP may refer you to a local continence adviser. They can give practical advice on how to manage. They may be able to supply pants, pads, etc. They may also help and advise on treatment.

•Getting to the toilet. Make this as easy as possible. If you have difficulty getting about, consider special adaptations like a handrail or a raised seat in your toilet. Sometimes a commode in the bedroom makes life much easier.

•Caffeine. This is in tea, coffee, coke, and is part of some painkiller tablets. It is a mild diuretic and also stimulates the bladder muscle. So, it will make urine form more often and may make symptoms worse. It may be worth trying without caffeine for a week or so to see if symptoms improve.

•Drinking. Cutting back on the amount of fluid that you drink may be advised in some cases if you drink more than average.

Further help and information

Treatment

What are the treatments for stress incontinence?

Strengthening the pelvic floor muscles is the usual first treatment. About 6 in 10 cases can be cured or much improved with this treatment. Surgery may be advised if the problem continues.

Strengthening the pelvic floor muscles

The pelvic floor muscles are a group of muscles that wrap around the underside of the bladder and rectum (see diagram). Exercises to strengthen these muscles are the usual first treatment. Your doctor may refer you to a continence advisor or physiotherapist to help with this. The sort of exercises advised are as follows.

1. Sit in a chair with your knees slightly apart. Imagine you are trying to stop wind escaping from your anus (back passage). You will have to squeeze the muscle around the anus. You should feel some movement in the muscle. Don't move your buttocks or legs.

2. Now imagine you are passing urine and are trying to stop the stream. You will find yourself using slightly different muscles to the first exercise, and these are the ones to strengthen. Next time you go to the toilet try the 'stop test'. This means halfway through emptying your bladder use these muscles to try and stop the flow of urine. Don't be discouraged if you are only able to reduce it slightly. With time you should be able to stop the flow completely. If you are not sure that you are exercising the right muscles, put a couple of fingers into your vagina. You should feel a gentle squeeze when doing the exercise.

Practising the exercises.

1. Sit, stand or lie with your knees slightly apart. Slowly tighten your pelvic floor muscles as hard as you can. Hold to the count of five, then relax. Repeat at least 5 times. These are called slow pull-ups. Do the same exercises quickly without counting to 5. Repeat at least 5 times. These are fast pull-ups. Do 5 slow pull-ups and 5 fast pull-ups at least 10 times a day.

2. Get into the habit of doing exercises whilst going about everyday life. For example, when answering the phone, washing up, etc.

3. Do the exercise at times when you feel you might leak, for example, when lifting something heavy or when you cough.

4. Do the 'stop test' on your urine once a day. After several weeks the muscles will start to feel stronger. You may find you can hold on longer than 5 seconds and you can do more pull ups without the muscle feeling tired. You should find it easier to stop your urine.

It takes time and practice to become good at these exercises. But, you should start to see benefits after a few weeks. Do persevere and, if possible, continue exercising as a part of everyday life to stop the problem recurring.

Sometimes a continence advisor or physiotherapist will advise extra methods, in addition to exercises, to strengthen the pelvic floor muscles. For example, sometimes a special electrical device is used to stimulate the pelvic floor muscles with the aim of making them stronger.

Surgery

Various surgical operations are used to treat stress incontinence. They aim to 'tighten' or support the muscles and structures below the bladder. Surgery is often successful.

Further help and information

Continence Foundation

307 Hatton Square, 16 Baldwin Gardens, London, EC1N 7RG

Tel (Helpline): 0845 345 0165 Web: www.continence-foundation.org.uk

A national charity dedicated to helping people who have some problem with bladder or bowel control in their adult lives. The Foundation offers information, advice, promotes advances in public and professional education, and campaigns for the improvement of continence services.

Incontact

United House, North Road, London, N7 9DP

Tel: 0870 770 3246 Web: www.incontact.org

For people affected by bowel and bladder continence problems, and their carers.

Comprehensive patient resources are available at www.patient.co.uk

Urge Incontinence

Urge incontinence is a common form of incontinence. Treatment with bladder retraining often works well. Medication may also be advised to 'relax' the bladder. Advice from a continence advisor is also usually helpful.

What is urge incontinence?

* Urgency is a symptom where you get a sudden urgent desire to pass urine. You are not able to put off going to the toilet.

* Urge incontinence is when urine leaks before you get to the toilet when you have 'urgency'.

Urgency and urge incontinence are sometimes called an unstable or overactive bladder, or detrusor instability. (Detrusor is the medical name for the bladder muscle.)

If you have urgency or urge incontinence, you also tend to pass urine more often than normal (this is called 'frequency'). Sometimes this is several times during the night as well as many times during the day. Some women also find they leak urine during sex, especially during orgasm.

How common is urge incontinence?

Urge incontinence is the second commonest cause of incontinence. About 3 in 10 cases of incontinence are due to urge incontinence. It can occur at any age, but commonly first starts in early adult life. Women are more commonly affected than men.

(The most common type of incontinence is stress incontinence which is dealt with in a separate leaflet. Very briefly, stress incontinence occurs when the pressure in the bladder becomes too great for the bladder outlet to withstand. Urine tends to leak most when you cough, laugh, or when you exercise. Some people have both stress incontinence and urge incontinence.)

What causes urge incontinence?

The cause is not fully understood. The bladder muscle seems to contract (squeeze) too early when the bladder fills. The normal bladder control is reduced. The bladder muscle may give wrong messages to the brain, and the bladder may feel fuller than it actually is. Symptoms may get worse at times of stress.

Some general lifestyle measures which may help

* Your GP may refer you to a local continence adviser. They can give practical advice on how to manage. They may be able to supply pants, pads, etc. They may also help and advise on treatment.

* Getting to the toilet. Make this as easy as possible. If you have difficulty getting about, consider special adaptations like a handrail or a raised seat in your toilet. Sometimes a commode in the bedroom makes life much easier.

* Caffeine. This is in tea, coffee, coke, and is part of some painkiller tablets. It is a mild diuretic and also stimulates the bladder muscle. So, it will make urine form more often and may make urgency symptoms worse. It may be worth trying without caffeine for a week or so to see if symptoms improve.

* Drinking. Cutting back the amount of fluid that you drink may be advised if you drink more than average.

What are the treatments for urgency and urge incontinence?

* Bladder retraining is usually advised at first. This can work well in up to half of cases.

* Medication may be advised instead of, or in addition to, bladder retraining.

* Pelvic floor exercises may also be advised if you have some stress incontinence in addition to the urgency symptoms (see separate leaflet on stress incontinence).

Bladder retraining (sometimes called 'bladder drill')

The aim is to slowly stretch the bladder so that it can hold larger volumes of urine. In time, the bladder muscle should become less irritable. This means that more time can elapse between feeling the desire to pass urine, and having to get to a toilet. Leaks of urine are then less likely. A doctor, nurse, or continence advisor will explain how to do bladder retraining. The advice may be something like the following.

Start by making a chart for each day of the week (see example below). Your doctor or nurse may have some pre-printed charts to give you. To begin with it is worth having an old measuring jug by the toilet so you can measure the volume of urine you pass each time you go to the toilet. Make a note of the times you pass urine, and the volume that you pass.

The aim is to 'hold on' for as long as possible before going to the toilet. This will seem difficult at first and sitting on a hard seat may help. With time it will become easier as the bladder becomes used to holding larger amounts of urine. The idea is to try to extend the time between toilet trips. It may take several weeks, but the aim is to pass urine only 5 or 6 times in 24 hours.

Here is an example of the sort of chart that might develop.

Day 1 of bladder retraining

Time:

Urine passed:

8.30am

200ml

10.15am

150ml

12.30pm

100ml

1.30pm etc

50ml etc

You should also note any times that urine leaks. As time goes on the chart should hopefully look more like the following, with larger volumes and longer time intervals.

Day 30 of bladder retraining

Time:

Urine passed:

7.30am

250ml

10.30am

300ml

2.30pm

300ml

5.45pm etc

200ml etc

Bladder retraining can be difficult, but becomes easier with time and perseverance. It works best if combined with encouragement, advice, and support from a continence advisor, nurse, or doctor.

Medication

Medication may be prescribed for urgency and urge incontinence. Various medicines are available and include: oxybutynin, tolterodine, trospium chloride, and propiverine. (These also come in different brand names.) They work by blocking certain nerve impulses to the bladder which 'relaxes' the bladder muscle.

Medication improves symptoms in at least half of cases. The amount of improvement varies from person to person. You may have fewer toilet trips, fewer 'leakages', and less 'urgency'. However, it is uncommon for symptoms to go completely with medication alone.

Symptoms may return after you finish a course of medication. However, if you combine a course of medication with a bladder retraining programme, the long term outlook may be better and symptoms may be less likely to return when you stop the medicine.

Side-effects are quite common with these medicines, but are often minor and tolerable. Read the information sheet which comes with your medicine for a full list of possible side-effects. The most common is a dry mouth, and simply having frequent sips of water may counter this. Other common side-effects include dry eyes, constipation and blurred vision. However, the medicines have differences, and you may find that if one medicine causes troublesome side-effects, a switch to a different one may suit you better.

Further help and information

Continence Foundation

307 Hatton Square, 16 Baldwin Gardens, London, EC1N 7RG

Tel (Helpline): 0845 345 0165 Web: www.continence-foundation.org.uk

Incontact

United House, North Road, London, N7 9DP

Tel: 0870 770 3246 Web: www.incontact.org

For people affected by bowel and bladder continence problems, and their carers.