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Urinary incontinence is the unintentional leaking of urine. This can affect 20% to 30% of women but may be much more common in the older age group.
Pre-disposing factors
Stress incontinence is much more common in women who have been pregnant. Obviously, the bigger the baby and the more deliveries; the stronger the chance of development of stress incontinence. Instrumental delivery such as forceps may be another aggravating factor.
These two conditions pre-dispose to a weakening of the supporting tissues and may lead to incontinence.
- Increased intra-abdominal pressure.
Chronic coughing, constipation and being overweight may all increase the chances of stress incontinence.
Diabetes, pelvic masses and multiple sclerosis may put a patient at increased risk.
Types of incontinence and respective treatment
There are four different types of Incontinence: Stress incontinence, Urgency Incontinence (Detrusor Instability), Mixed pictures of both urgency incontinence and stress incontinence, and Overflow Incontinence.
We will discuss these four types and explain respective treatment.
Before any treatment, an investigation is always done. Two investigations are undergone:
Midstream urine is always done to exclude an underlying infection.
This test will always be performed to differentiate between genuine stress incontinence (due to weakness) and urgency incontinence (due to an 'overactive bladder' or detrusor instability).
Stress incontinence
Is the leakage of urine which occurs during actions such as coughing, sneezing, jogging, jumping or playing sport. This is usually as a result of muscle weakness and is generally a result of pregnancy and method of delivery.
- Treatment of Stress Incontinence
- - Conservative treatment of genuine stress incontinence
- Pelvic floor muscle exercises (Kegels).
In a young woman, these may be of great help and it is often very useful to have a physiotherapist to help a patient find the 'correct muscles' to contract. The exercises need to be performed regularly.
These are mechanical devices that are inserted into the vagina to help support the bladder neck. Are particularly useful if one is older and wants to avoid surgery.
- - Surgical treatment
Surgery would be performed if there is a failure of physiotherapy or pelvic floor exercises and symptoms persist.
- Mid-urethral sling procedures.
These tapes or mesh slings have become very popular over the last few years. A synthetic tape is inserted under the urethra (bladder neck) and prevents urine from leaking when there is an increase in abdominal pressure. There are relatively few complications and the procedure is done as a Day Only operation. The success rate seems to be as good if not better than open operations, which require prolonged hospitalization and recovery.
- Open bladder neck repair (colposuspension).
These procedures are the 'gold standard' of stress incontinence surgery. They have been done for a number of years and certainly have an 85% success rate. However, the patient needs to be hospitalized for 4 or 5 days and there is a few weeks recovery. The operation seems to have been superseded by the sling procedures.
The colposuspension can also be done laparoscopically and has a similar success rate.
Urgency Incontinence (Detrusor Instability)
This type of incontinence is usually associated with an inability to hold urine. It usually follows a strong desire to pass urine and this is followed by leakage. This may be aggravated by caffeine or an infection. The urgency may also cause frequent visits to the toilet at night.
- Treatment of Detrusor Instability (overactive bladder)
This is a technique where one has to 'learn' to increase the length of time between each voiding of the urine. As soon as one gets the urge to void, one has to keep going for a little longer. Progressively one will increase the voiding time and reduce the urgency.
There are new medical treatments which are 'antispasmodic drugs'; these will improve the urgency and also decrease going to the toilet at night. They do have minor side effects but the newer forms of medication seem to have much fewer side effects.
These pessaries have been shown to help some cases of urgency and urgency incontinence.
Other forms of Incontinence
Mixed pictures of both urgency incontinence and stress incontinence may occur.
Overflow Incontinence
Due to inability to void, is uncommon.
Complications
There are obviously general risks to surgery as there would be with any other procedure. The specific risks include:
- Overactive bladder following surgery.
This may cause urgency and urgency incontinence. This is usually not permanent.
- Difficulty in passing urine and possible long term retention of urine.
This may be common complications of surgery but usually improves with time. Just fewer than 5% of women may have long term difficulties.
Is an easily treatable side effect.
May be reported after some forms of sling or mesh procedures and could last for some time.
May occur at the time of surgery. However, this is uncommon. There are a few more uncommon and rarer complications. |