URINARY INCONTINENCE

This is the accidental loss of urine against one’s control. It affects up to 15% of women and 5% of men in their mid-40s and increases with age. There are various causes. For example, Overactive Bladder (urge incontinence), weak muscles / pelvic floor (e.g. stress incontinence after childbirth), a mixture of the two conditions, neurological causes, i.e. neuropathic bladder due to Parkinson’s disease, stroke, multiple sclerosis, spinal injury or spina bifida), surgery (e.g. radical prostatectomy) or ‘overflow’ due to prostate enlargement resulting in a very full bladder. Depending on the cause, there are simple and effective treatments available. These include pelvic floor exercises taught by a specialist physiotherapist, lifestyle adjustment (drinks, caffeine), medication, minimally-invasive surgery (e.g. injection, tension-free vaginal tape, trans-obturator tape).

Overactive Bladder Syndrome (OAB)

Incidence and Demographics:
An overactive bladder can affect men and women at any age.
OAB is a prevalent and challenging urological problem affecting 25-30% of the adult population aged over fifty.

ADDITIONAL INFORMATION

How does the bladder work?

The bladder is formed from the detrusor muscle. Normally this muscle is relaxed. In a normal functioning bladder, as the bladder fills up, the detrusor muscle gradually stretches. Most people will feel the need to urinate when the bladder is about half full. But they can usually hold on for some time after that.

When the need to pass urine is felt, the detrusor muscle contract and the bladder sphincter relax and urine comes out through the urethra in a coordinated controlled fashion.

Normally a bladder needs to be emptied 4-8 times a day, depending on fluid intake and what you drink.

If you get sudden urges to go to the toilet, you could be suffering from an overactive bladder. This is sometimes called irritable or detrusor overactivity. This means that your bladder wants to squeeze out urine even if it is not full and you are not ready to pass urine.

The sudden urge to go to the toilet is called urgency. If you do not get there in time and have an accident, it is called urge incontinence.
You may also have to go to the toilet many times during the day (frequency) or more than twice at night (nocturia). Some people find that at night they do not wake up in time and will wet the bed (nocturnal enuresis).

What causes these symptoms?

  • The fluids we drink can cause problems- caffeine, fizzy and sweetened drinks or alcohol may irritate the bladder and cause urgency and frequency. On the other hand, not drinking enough fluids makes the urine very concentrated and this can also irritate the bladder.
  • A common cause of urgency and frequency is infection. A urine test to check for infection can be arranged by your doctor or nurse.
  • Urgency can also be caused by bladder stones and bladder tumours; your doctor will investigate this.
  • Conditions such as diabetes, men with prostate problems and women who have operations for stress incontinence can develop an overactive bladder.
  • Specific nerves and the muscles surrounding your bladder regulate bladder function. These symptoms may be caused by any disruption to the regulation, and this includes:
    • Pregnancy and childbirth
    • Pelvic surgery
    • Prostate surgery
    • Natural aging process
    • Chronic disease
    • Medication
    • Trauma
    • Obesity

To make a diagnosis, your doctor or nurse specialist may take your medical history, test your bladder function and ask you to complete a voiding diary.

Investigations

  • Urinalysis – a sample of urine is tested to see if any infection, blood or other abnormality can be detected.
  • Residual urine – this is to find out how much urine is left in your bladder after urinating. Your nurse will check your residual urine by using an ultrasound machine to take a scan your bladder.
  • Internal investigations – The doctor will gently place a finger into the vagina (for women) or back passage (for men) and ask you to squeeze your muscles. This can show how strong the pelvic muscles are. For men an examination of the back passage may also be used to detect if the prostate gland is enlarged.
  • Urodynamics – This is a more advanced test to help find the cause of bladder problems (women should not need this test before non-surgical treatments. It involves putting a thin catheter (a small soft plastic tube) into the bladder through the urethra, and another into the rectum through the anus. This can be a bit uncomfortable but the catheter is removed as soon as the test is over. This test is usually carried out in a Urology outpatients department, and can take up to one hour.

For some people a cure is possible whilst for others their symptoms can be managed with appropriate treatment and lifestyle measures so their daily activities aren’t impeded.

Treatment

Once you know what is causing your bladder problem, you will be able to discuss possible treatments with your doctor or nurse specialist.

Healthy drinking habits/Behavioural modification
It is important to drink at least 1.5 to 2 litres of fluid daily. Drink plain water, fruit juice, some fruit and herbal treas. Drinks containing caffeine; for example, coffee, strong teas and chocolate, or fizzy drinks and some fruit teas containing hibiscus can make your problem worse. Alcoholic drinks can also irritate the bladder.

Bladder retraining
Many people with urgency will get into the habit of going to the toilet often; trying to make sure they are never “caught short”. This can worsen the problem because the bladder gets used to holding less and less urine, causing it to shrink. It becomes even more sensitive and overactive.

Bladder retraining takes time, and a cure does not happen overnight, but it can be very successful. Keep a record of how often you pass urine and how much and what you drink. Keep a record of at least three days for your doctor to review. When you get the urge to urinate, hold on for a bit, just a minute or two to start with. Try to hold on a little bit longer each time you feel the urge to go. Bladder retraining slowly stretches the bladder muscles.

Pelvic floor muscle exercises
Surgery to the bladder and/ or the prostate can cause the bladder neck sphincter muscle can become weakened and make you more reliant on your pelvic floor muscle. Pelvic floor muscle exercises can be very beneficial when you are doing bladder retraining. A pelvic muscle squeeze will help you hold on longer when you have urgency and have to rush to the toilet.

The exercises can help you reduce the number of times you have to rush to the toilet. Every time you work your pelvic muscles it encourages your bladder to relax, making it easier to hold more urine.

How to find the pelvic floor muscle?
The following techniques may help you to locate your pelvic floor muscle:

  • Imagine lifting your scrotum off the chair whilst in sitting.
  • Imagine trying to stop urinating.

When exercising the pelvic floor muscles you should not tighten your buttocks, stomach or inner thighs.

When to perform them?
Pelvic floor exercises can be performed whilst in sitting, standing or lying position.

Exercises
Follow these instructions:

  • Slowly tighten your pelvic floor muscle and hold for 5 seconds, then relax for 5 seconds. Repeat this exercise up to 10 times.
  • Breathe as you would normally, without holding your breath.
  • Ensure all other muscles are fully relaxed especially your buttocks, stomach and shoulders.
  • Tighten and relax the pelvic muscle as quickly as you can again 10 times.

You should aim to do a set of slow and fast pelvic floor exercises at regular intervals at least 10 times a day.

Medication

There are many medications available which can help you to control your bladder and reduce wetting, these are called anticholinergic or antimuscarinic drugs (solifenacin, fesotrodine, propiverine etc). These medicines are available as tablets, as a liquid or as a patch. In some cases drugs may be the best long-term way to control your symptoms.

These drugs can be very effective although, like all drugs, they sometimes have side effects, like dry mouth or nausea. It can take several weeks before you notice a difference in your symptoms.

Electrical stimulation of the pelvic floor

Neuromodulation

Surgery:
Your Urologist can tell you which operations may be suitable for you.

  • Botulinum toxin
  • Sacral nerve stimulation
  • Bladder Augmentation

Living with an overactive bladder

Some people cannot be completely cured of a bladder problem and others may need extra help. Special products and devices are available to help manage symptoms and allow you to get on with your daily activities.

Specially designed pad and pants absorb leaks, and can be used during the day and at night.