Urinary incontinence is the unintentional passing of urine.
Common types of urinary incontinence
1. Stress incontinence
Stress incontinence 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:
- sneezing
- laughing
- heavy lifting
- exercise
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.
2. Urge incontinence
Urge incontinence, or urgency incontinence, is when you feel a sudden and very intense need to pass urine and you are unable to delay going to the toilet. There is 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 (OAB), which is where the bladder muscle is more active than usual.
As well as sometimes causing urge incontinence, OAB can also mean you need to pass urine very frequently and you may need to get up several times during the night to urinate.
3. Mixed incontinence
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.
Investigations
Bladder diary
Your GP may suggest that you keep a diary of your bladder habits for at least three days, so you can give them as much information as possible about your condition. This should include details such as:
- 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
Urodynamic tests
These are a group of tests used to check the function of your bladder and urethra. This may include keeping a bladder diary for a few days (see above) and then attending an appointment at a hospital or clinic for tests such as a urodynamic test. This involves measuring the pressure in your bladder by inserting a catheter into your urethra. Measuring the pressure in your abdomen (tummy) by inserting a catheter into your bottom and asking you to urinate into a special machine that measures the amount and flow of urine.
Treatments
The treatment you receive for urinary incontinence will depend on the type of incontinence you have and the severity of your symptoms.
Conservative treatments, which do not involve medication or surgery, are tried first. These include: lifestyle changes, pelvic floor muscle training ('Kegel exercises') and bladder training. After this, medication or surgery may be considered.
Lifestyle changes
Simple changes to your lifestyle to improve your symptoms. These changes can help improve your condition, regardless of the type of urinary incontinence you have. This includes:
- Reducing your caffeine intake – caffeine is found in tea, coffee and cola and can increase the amount of urine your body produces
- Altering how much fluid you drink a day – drinking too much or too little can make incontinence worse
- Losing weight if you are overweight or obese – use the healthy weight calculator to find out if you are a healthy weight for your height.
- Stop smoking.
Pelvic floor muscle training
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 to outside the body).
Weak or damaged pelvic floor muscles can cause urinary incontinence, so exercising these muscles is often recommended.
Bladder training
If you have 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.
Bladder training 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 six weeks.
If stress incontinence does not significantly improve, surgery for urinary incontinence will often be recommended as the next step.
However, if you are unsuitable for surgery or you want to avoid having an operation, you may benefit from a medication called duloxetine. This can help increase the muscle tone of the urethra, which should help keep it closed.
You will need to take duloxetine by mouth twice a day and will be assessed after two to four weeks to see if the medicine is beneficial or if it is causing any side effects.
Possible side effects of duloxetine can include nausea, dry mouth , fatigue (extreme tiredness) and constipation.
Do not suddenly stop taking duloxetine as this can also cause unpleasant effects. Duloxetine is not suitable for everyone and is not first line treatment for this condition.
If bladder training and life style modification is not an effective treatment for your urge incontinence, Antimuscarinics may prescribed. This may also be prescribed if you have overactive bladder syndrome (OAB), which is the frequent urge to urinate that can occur with or without urinary incontinence.
Possible side effects of antimuscarinics include dry mouth, constipation, blurred vision and fatigue.
In rare cases, antimuscarinic medication can also lead to a type of glaucoma (a build-up of pressure within the eye) called angle-closure glaucoma.
Mirabegron
If antimuscarinics are unsuitable for you, or they have not helped your urge incontinence or have caused unpleasant side effects, you may be offered an alternative medication called mirabegron.
Mirabegron causes the bladder muscle to relax, which helps the bladder fill up with and store urine. It is usually taken by mouth once a day.
Side effects of mirabegron can include urinary tract infections (UTIs), a fast or irregular heartbeat, palpitations (suddenly noticeable heartbeats), a rash and itching.
Tape procedures
Tape procedures can be used for women with stress incontinence. Polypropylene mesh tape is inserted through an incision inside the vagina and threaded behind the urethra (the tube that carries urine out of the body). The middle part of the tape supports the urethra, and the two ends are threaded through two incisions in either the: tops of the inner thigh – this is called a transobturator tape procedure (TOT) or the abdomen (tummy) – this is called a retropubic tape procedure or tension-free vaginal tape procedure (TVT).
By holding the urethra up in the correct position, the piece of tape can help reduce the leaking of urine associated with stress incontinence.
The effectiveness of these tape procedures is similar, with around two in every three women not experiencing any leaking afterwards. Even those who still have some leaking after surgery often find this is less severe than it was before the operation.
However, it is not uncommon for women to need to go to the toilet more frequently and urgently after this procedure, and some find they are unable to completely empty their bladder when they go to the toilet. In some cases, the tape can wear away or move over time and further surgery may be needed at a later stage to adjust it (for example, to make it looser) or to remove it.
Colposuspension
Colposuspension involves making an incision in your lower abdomen, lifting up the neck of your bladder, and stitching it in this lifted position. This can help prevent involuntary leaks in women with stress incontinence.
Autologous Sling procedures
Sling procedures involve making an incision in your lower abdomen and vagina so a sling can be placed around the neck of the bladder to support it and prevent accidental urine leaks. The sling can be made of: tissue taken from another part of your body (an autologous sling) an autologous sling will be will be made using part of the layer of tissue that covers the abdominal muscles (rectus fascia). These slings are generally preferred because more is known about their long-term safety and effectiveness.
The most commonly reported problem associated with the use of slings is difficulty emptying the bladder fully when going to the toilet. A small number of women who have the procedure also find that they develop urge incontinence afterwards.
Urethral bulking agents
An urethral bulking agent is a substance that can be injected into the walls of the urethra in women with stress incontinence. This increases the size of the urethral walls and allows the urethra to stay closed with more force.
A number of different bulking agents are available and there is no evidence that one is more beneficial than another. This is less invasive than other surgical treatments for stress incontinence in women as it does not usually require any incisions. Instead, the substances are normally injected through a cystoscope (thin viewing tube) inserted directly into the urethra.
However, this procedure is generally less effective than the other options available. The effectiveness of the bulking agents will also reduce with time and you may need repeated injections.
Many women experience a slight burning sensation or bleeding when they pass urine for a short period after the bulking agents are injected.
Botulinum toxin A injections
Botulinum toxin A (Botox) can be injected into the sides of your bladder to treat urge incontinence and overactive bladder syndrome (OAB). This medication can sometimes help relieve these problems by relaxing your bladder. This effect can last for several months and the injections can be repeated if they help.
Although the symptoms of incontinence may improve after the injections, you may find it difficult to fully empty your bladder. If this happens, you will need to be taught how to insert a catheter (a thin, flexible tube) into your urethra to drain the urine from your bladder.
Sacral nerve stimulation
The sacral nerves are located at the bottom of your back. They carry signals from your brain to some of the muscles used when you go to the toilet, such as the detrusor muscle that surrounds the bladder. If your urge incontinence is the result of your detrusor muscles contracting too often, sacral nerve stimulation – also known as sacral neuromodulation – may be recommended.
During this operation, a device is inserted near one of your sacral nerves, usually in one of your buttocks. An electrical current is sent from this device into the sacral nerve. This should improve the way signals are sent between your brain and your detrusor muscles, and so reduce your urges to urinate.
Sacral nerve stimulation can be painful and uncomfortable, but some people report a substantial improvement in their symptoms or the end of their incontinence completely.
Posterior tibial nerve stimulation
Your posterior tibial nerve runs down your leg to your ankle. It contains nerve fibres that start from the same place as nerves that run to your bladder and pelvic floor. It is thought that stimulating the tibial nerve will affect these other nerves and help control bladder symptoms, such as the urge to pass urine.
During the procedure, a very thin needle is inserted through the skin of your ankle and a mild electric current is sent through it, causing a tingling feeling and causing your foot to move. You may need 12 sessions of stimulation, each lasting around half an hour, one week apart.
Some studies have shown that this treatment can offer relief from OAB and urge incontinence for some people, although there is not yet enough evidence to recommend tibial nerve stimulation as a routine treatment.
Tibial nerve stimulation is only recommended in a few cases where urge incontinence has not improved with medication and you don't want to have botulinum toxin A injections or sacral nerve stimulation.
Augmentation cystoplasty
In rare cases, a procedure known as augmentation cystoplasty may be recommended to treat urge incontinence. This procedure involves making your bladder bigger by adding a piece of tissue from your intestine (part of the digestive system) into the bladder wall.
After the procedure, you may not be able to pass urine normally and you may need to use a catheter. Due to this, augmentation cystoplasty will only be considered if you are willing to use a catheter.
The difficulties passing urine can also mean that people who have augmentation cystoplasty can experience recurrent urinary tract infections.
Urinary diversion
Urinary diversion is a procedure where the ureters (the tubes that lead from your kidneys to your bladder) are redirected to the outside of your body. The urine is then collected directly without it flowing into your bladder. Urinary diversion should only be carried out if other treatments have been unsuccessful or are not suitable.
Urinary diversion can cause a number of complications, such as a bladder infection, and sometimes further surgery is needed to correct any problems that occur.