Causes and Treatment Options

It is generally thought that between 10-12% of women regularly experience urinary incontinence with the incidence being far higher in some groups. The most common form of urinary incontinence amongst women is stress urinary incontinence. This is followed by urge incontinence, and many women experience both forms of incontinence with a mixture of symptoms.

Diagnostic Assessment

When a woman presents with reported symptoms of urinary incontinence it is most important to rule out other pathology before making a diagnosis of stress urinary incontinence (SUI), urge incontinence (UUI), or mixed incontinence. This should involve a medical history including any head, neck or back injury, relevant conditions e.g. diabetes, sports activity, parity, family history and both urinary symptom analysis and physical examination.

Symptom analysis includes reported episodes and nature of incontinence. Urinary analysis to test for bladder or urinary tract infection and to exclude haematuria should always be undertaken. If feasible, direct her to fill out a urinary diary to document both time and amount of voiding, and the volume and nature of her fluid intake.

Physical examination should rule out constipation, prolapse, masses or tumours, fistulae and damage from pregnancy, childbirth or previous surgery or injury. Neurological symptoms and mental state should be assessed in case of head trauma, multiple sclerosis, Parkinson’s disease, Alzheimer’s, etc.

Finally, an assessment of quality of life, mobility and toilet access may be applied to determine need for treatment.

Stress Urinary Incontinence

Stress urinary incontinence describes the complaint of involuntary leakage of urine on effort or exertion, or on sneezing or coughing. This may be a small amount, but it can sometimes be significant.

Treatment alternatives

Lifestyle

Review lifestyle for food and fluid intake, weight reduction and smoking. Overweight people have a greater tendency to stress incontinence because of increased abdominal pressure. Smokers cough more, which can result in an increased incidence of leakage.

• Do not drink too much or too little. Reducing fluid intake to decrease urine may produce further irritation of the bladder and promote infection.
• Avoid caffeine and fizzy drinks, which may irritate the bladder, as may alcohol.
• Review current medication for interaction or iatrogenic effects.

Pelvic Floor Muscle Exercise

The generally accepted first treatment for stress incontinence is pelvic floor muscle exercise, to improve bladder support and closure pressure of the urethra. Referral to a physiotherapist is the most effective way of ensuring that the exercises are being done correctly and so give the best chance for success. Physical examination will help determine the status of the pelvic floor muscles and so allow the physiotherapist to advise on a personalized exercise regime.

Biofeedback and electrical stimulation aid in the execution of pelvic floor muscle exercise for both men and women and ideally should be recommended by a physiotherapist or continence professional.

Medical devices

Absorbent incontinence products designed specifically for urinary incontinence are the most popular products amongst patients, to protect against urine leakage. There are both disposable and reusable products and although all products are not alike, many are developed to a high technological standard and provide the user with flexibility and ease of use. Patients may use several different types of pads or pants depending on their daily needs. There are pads and pants developed for specific purposes, which can be slim and unobtrusive for day use or substantial enough to contain heavy leakage.Continence advisers can give the best guidance on what to use and local continence organisations can help with consumer issues.

Other products for urine collection and inhibiting urine flow may also be used to contain leakage in certain circumstances. Catheters may be used as a temporary measure, after surgery, or as a long term solution. Catheters may be intermittent or indwelling and are connected either to a drainage bag held on the person or to a valve which allows the catheter to be emptied in a vessel on a regular basis. Indwelling suprapubertal catheters may be surgically introduced through the abdomen rather than via the urethra. Patients or carers may be trained to change and clean these.

Pharmacological and surgical interventions (under certain conditions)

Pharmacological intervention

New agents are available which aid in stress incontinence. These are called dual noradrenaline/serotonin reuptake inhibitors and are available in selected European markets. Studies have suggested that the best results are achieved if these are used in association with pelvic floor muscle exercises.

Surgical intervention

A urologist or urogynaecologist can advise on all the available surgical procedures for stress urinary incontinence. There are both open procedures and day procedures as well as the use of bulking agents. For most patients, surgery for stress incontinence should be considered as tertiary care after conservative and pharmacological interventions have not produced the desired result.

Urge Incontinence

Urge incontinence or overactive bladder refers to the overactivity of the detrusor muscle of the bladder that creates an increased urgency, with little or no warning, and often accompanied by leakage of urine. In severe cases, the volume of leakage can be large. Urinary frequency (more than eight times per day) and nocturia (one or more per night) may also occur.

Treatment alternatives

Lifestyle

Make getting to the toilet as easy as possible. This may involve special adaptations to the patients living area. A raised toilet seat, handrails, commodes in the bedroom, all may aid in helping the patient, as may easily opened clothes if manual dexterity is a problem.

Bladder Retraining

Bladder retraining is a behavioural technique designed to increase the capacity of the bladder and decrease the frequency of urination. Over time, the bladder becomes less irritable and able to cope with larger volumes of urine. A urinary diary is the first step in assessing urge incontinence and setting up a course of bladder retraining.

Pelvic Foor Muscle Exercise

Pelvic floor muscle exercise is most successful with stress incontinence and mixed incontinence, but may be of value to those with urge incontinence, to strengthen the musculature and minimalise or eliminate leakage. Biofeedback and electrical stimulation aid in the execution of pelvic floor muscle exercise and ideally should be recommended by a physiotherapist or continence professional.

Medical devices

Some women experience sudden involuntary urine loss and choose to wear an absorbent incontinence product when they are in at-risk situations. There are several styles and shapes of pads and pants which suit varying amounts of leakage. There are both disposable and reusable products available and an experienced continence advisor who can direct the patient to the most appropriate form of protection which is designed to absorb urine rather than a sanitary towel which is designed to absorb blood.

Other products for urine collection and inhibiting urine flow may also be used to contain leakage under certain circumstances. Catheters may be used as a temporary measure, after surgery, or as a long term solution. Catheters may be intermittent or indwelling and are connected either to a drainage bag held on the person or to a valve which allows the catheter to be emptied in a vessel on a regular basis. Indwelling suprapubertal catheters may be surgically introduced through the abdomen rather than via the urethra. Patients or carers may be trained to change and clean these.

Pharmacological and surgical interventions (under certain conditions)

Anitmuscarinics and anticholinergics may be prescribed for detrusor muscle overactivity. Surgical intervention for urge incontinence without stress incontinence symptoms is rare.

Mixed Incontinence

With mixed incontinence, the symptoms of stress urinary incontinence co-exist with those of urge incontinence. According to the most recent guidelines for the International Committee on Incontinence, it is recommended to treat the predominant symptom first.

Other Forms of Incontinence

There are other forms of incontinence which may not fall into the above categories.

• Giggle incontinence: A form of incontinence generally experienced in youth, but may continue into adulthood. Urination triggered by laughter, result of instable detrusor muscles and may be hereditary.
• Functional incontinence: The inability to reach the toilet to urinate either due to disability (physical or mental) or infirmity.

The stigma associated with urinary incontinence often keeps men from seeking medical assistance and it is much more common than is often thought, though less prevalent than in women. Men of all ages can be affected.

The incidence of urinary incontinence among men at the age of 50 compared to women of the same age is lower. As age increases, male incidence increases. It is not, however, simply a function of ageing, it is directly related to other illnesses such as enlarged prostate, prostate cancer, and neurological conditions such as multiple sclerosis, Parkinson’s disease, and Alzheimer’s. To a lesser extent, the incidence of diabetes and overweight as well as other risk factors increase the incidence of urinary incontinence in men.

The treatments below are suggested for those patients with non-complicated incontinence, that is without recurring incontinence, or incontinence associated with pain, haematuria, recurrent infection, voiding problems, prostate irradiation, or radical pelvic surgery. For patients presenting with these symptoms, immediate referral to a urologist is recommended.

Diagnostic Assessment

Male incontinence can be broken down into symptom groups which may aid in assessment. Men with post-micturition dribble may be helped by pelvic floor muscle exercise and urethral milking. Stress urinary incontinence (SUI) in men is seen mostly after prostatic surgery and urge incontinence (UUI) often involves prostatic enlargement or benign prostatic hypertrophy (BPH), obstruction or other surgical procedures such as bowel resection. The term mixed incontinence applies when both symptoms are present.

A thorough history should be taken to determine the nature of the incontinence, noting any previous surgical procedures, and other relevant illnesses or medications.

Physical examination should include abdomen/bladder for stone, diverticulum or tumours, rectal for faecal impaction, sacral neurological and central nervous system to include mental status and other neurological factors. Urinalysis should be performed to rule out infection and haematuria. Treat any infections and reassess.

Quality of life should be assessed to determine impact of incontinence on the individual and at the same time, assess mobility and toilet access.

Stress Urinary Incontinence (Post-Prostatectomy)

Stress urinary incontinence in men is generally experienced after prostate surgery, though it is not unknown in other circumstances, and presents with the involuntary loss of urine with activity such as coughing, running, jumping, etc. Each man will differ. Some will experience only a small amount of sporadic urine loss, possibly short term, while others may experience constant, long term leakage. Many will recover continence completely given proper treatment.

Treatment alternatives

Lifestyle

Review lifestyle for food and fluid intake, weight reduction and smoking. Overweight people have greater abdominal pressure. Smokers cough more, which can result in an increased incidence of leakage.

• Do not drink too much or too little. Reducing fluid intake to decrease urine may produce further irritation of the bladder and promote infection.
• Avoid caffeine and fizzy drinks, which may irritate the bladder, as may alcohol.
• Review current medication for interaction or iatrogenic effects.

Pelvic Floor Muscle Exercise

Pelvic floor muscle exercise is the most effective treatment for post-prostatectomy urinary incontinence. Combined with bladder retraining and voiding diaries, many will achieve full continence, provided there has been no damage to the urethral sphincter during surgery. Biofeedback and electrical stimulation aid in the execution of pelvic floor muscle exercises and ideally should be recommended by a physiotherapist or continence professional. Research has been done to examine the role of biofeedback and electrical stimulation in post prostatectomy urinary incontinence and has been shown in many cases to be beneficial.

Bladder Retraining

Bladder retraining may also be useful after prostatic surgery, if the man is experiencing urgency and urge incontinence. Increasing amounts of urine are held in the bladder for controlled amounts of time to increase the capacity of the bladder. The goal is to break the cycle of frequency, urgency, and urge incontinence. A continence advisor or specialist physiotherapist can help with this training.

Medical Devices

Absorbent incontinence products for men are made in the form of pouches, drip collectors and pads. Most disposable products use technology to turn urine into a gel like substance so it is retained in the pad and reduces the chance of leakage. A recent study has examined the effectiveness of various absorbent incontinence products for men.

Catheters may be used as a temporary measure, after surgery, or as a long term solution in certain circumstances. Catheters may be intermittent or indwelling and are connected either to a drainage bag held on the person or to a valve which allows the catheter to be emptied in a vessel on a regular basis.

Male condom or sheath collection devices should be fitted by a specialist device professional and fit loosely over the penis either emptied by a bag or a valve.

Pharmacological and Surgical Interventions (under certain conditions)

If basic management has failed and incontinence markedly disrupts quality of life, further interventions should be considered and referral to a urologist is advised. This includes procedures such as male slings and bulking agents, or artificial sphincter.

URGE INCONTINENCE

Urge incontinence is defined as an involuntary loss of urine with a strong desire to void. As with stress urinary incontinence, urge incontinence should be initially treated with non-invasive means. The greatest risk factor for urge incontinence is organ enlargement (eg BPH) and prior surgery.

Treatment alternatives

Lifestyle

• Do not drink too much or too little. Reducing fluid intake to decrease urine may produce further irritation of the bladder and promote infection.
  
• Avoid caffeine and fizzy drinks that act as a bladder stimulant, as may alcohol.
  
• Reduce weight, which causes extra abdominal pressure, and stop smoking which causes increased coughing and resultant leakage.
• Incontinence protection may be used during diagnosis and treatment, if the treatments are not entirely effective, and to increase confidence during stressful periods.

Pelvic Floor Muscle Exercise

There is some evidence, that in some cases, strengthening the pelvic floor may aid in minimising the incidence of leakage in men with urge incontinence. Biofeedback and electrical stimulation aid in the execution of pelvic floor muscle exercise and ideally should be recommended by a physiotherapist or continence professional.

Bladder Retraining

Bladder retraining is a highly effective tool in treating urge incontinence. The capacity of the bladder is slowly increased in small, incremental, controlled steps. Patient compliance and self-motivation are important as well as adhering to the slow pace of training to ensure maximum success.

Medical Devices

Men who experience a sudden urge to urinate may wear absorbent incontinence products designed for men/male anatomy. These products are either disposable or reusable and come in a number of shapes and styles which include drip collectors, pouches and sock like pads. Each product varies as to absorbency and comfort. It is best to consult a continence advisor to assess daily needs and determine the most appropriate mix of products for the individual patient.

Other products for urine collection and inhibiting urine flow may also be used to contain leakage in certain cases. Catheters and devices to aid men with pelvic floor muscle exercise or to inhibit stress urinary incontinence may be suited to some patients for whom other methods of treatment are not indicated. Catheters may be used as a temporary measure, after surgery, or as a long term solution. Catheters may be intermittent or indwelling and are connected either to a drainage bag held on the person or to a valve which allows the catheter to be emptied in a vessel on a regular basis. Indwelling suprapubertal catheters may be surgically introduced through the abdomen rather than via the urethra. Patients or carers may be trained to change and clean these. Male condom or sheath collection devices should be fitted by a specialist device professional and fit loosely over the penis either emptied by a bag or a valve.

Other Interventions (under certain conditions)

If the above treatments are not effective after approximately 3-4 months, reassess and consider further intervention and referral. The options available from a specialist physiotherapist include further physical techniques such as electro-stimulation and biofeedback.

Pharmacological intervention is also available in the form of antimuscarinic or anticholinergic drugs. Neuromodulation, autoaugmentation, bladder augmentation and urinary diversion may also be used.

Mixed Incontinence

The term mixed incontinence is used when symptoms of both urge and stress urinary incontinence are present. It is advised by the International Continence Committee of the WHO that the symptoms of the predominant condition be treated first. However, the first-line treatments for both urge and stress urinary incontinence are the non-invasive measures of lifestyle intervention, bladder retraining and pelvic floor muscle exercise. If there is a failure or limited success with these techniques, drugs may be administered for the most prominent symptoms remaining. Failing that, referral for further investigation should follow.

Post-Micturition Dribble

Post-micturition dribble is treated with a combination of pelvic floor muscle exercise to strengthen the sphincter and urethral milking after voiding.

Other Forms of Incontinence

There are other forms of incontinence which may not fall into the above categories.

• Overflow incontinence: As the name implies, there is a constant flow of urine, as if the bladder is ‘overflowing’. This is often caused by a mechanical obstruction such as faecal impaction, prostate enlargement, nerve damage, or urethra abnormatlities.
• Functional incontinence: The inability to reach the toilet to urinate either due to disability (physical or mental) or infirmity.

Faecal incontinence is the loss of bowel control, resulting in involuntary passage of faeces. The ability to hold stool and maintain continence requires normal function of the rectum, anus and the nervous system. 

This can be characterized by the occasional leakage of stool with the passage of gas or the complete loss of bowel control

Common causes

• Constipation – causes a weakening of anus and intestines
• Impacted stool in rectum
• Severe diarrhoea
• Anal sphincter muscle damage
• Nerve or other muscle damage
• Gynaecological, prostate or rectal surgery
• Chronic laxative abuse

Typical treatment

Lifestyle intervention

It can help to change the diet: eliminate alcohol and caffeine, and add more fibre to increase bulk of stool.

Bowel retraining

Bowel retraining can help promote a better muscle tone.

Interventions

• Absorbent incontinence products
• Medication such as Loperamide (Imodium) to control diarrhoea and potentially eliminate incontinence
• Surgical treatment to rectify clearly identified cause

Here is some advice from physiotherapists on exercises for the pelvic floor muscles. It is designed to be shared with patients - so please feel free to copy and paste the text into your own patient materials.

WOMEN

Training the muscles of the pelvic floor can be an effective way to minimise or prevent leakage of urine. They can be activated voluntarily, training costs nothing and has no side effects, so you may wish to try this before starting other treatment methods. Improvement may not be immediate but don’t give up. After 2-4 months training you should notice a difference.

The pelvic floor muscles are a group of muscles inside the pelvis that form its floor – hence the name. They surround the urethra (bladder passage), vagina and ano-rectum (back passage) and should, along with the sphincter muscles, maintain control over these openings, preventing leakage of urine or faeces. The muscles should also support the urethra, bladder, womb and rectum and withstand all increases in abdominal pressure that occur during physical exercise. If the pelvic floor muscles are weak leaking can occur, e.g. with coughs, sneezes, physical activity.

How to find them

Finding the right muscles is important, and it can be difficult to do this for yourself. Studies have shown that some 30% of women who try to tighten their pelvic floor muscles do so incorrectly. Common mistakes include tensing the buttocks and thighs instead of the pelvic floor muscles, breath holding, or pushing down instead of squeezing and lifting in and up.

The following test should prove helpful. Try interrupting the flow when you urinate. Feel which muscles you are using to do this. These are the muscles you need to work on. Note that this is only a test to identify the correct musculature and should not be repeated on a regular basis. It might also help if you tighten your anus as if holding in wind (gas).

Correct contraction of the pelvic floor muscles feels like a squeeze and a small lift under the pelvis up into the body, around the vagina and anus. There should be no accompanying movement of other parts of the body, e.g. the buttocks or inner thighs, and don’t hold your breath.

If you have a problem identifying the right muscles, you may want to check for yourself. Looking at the area in a mirror, as you squeeze you should see some tightening and movement in (not down towards the mirror). Or, you can wash your hands then insert one or two fingers into your vagina and feel for a squeeze against them as you tighten the muscles. Alternatively, your doctor may be able to check for you, or refer you to a specialist clinician (e.g. physiotherapist) for assessment.

Strengthening the muscles

When you have learned to use the muscles correctly, exercise them regularly, ideally several times a day. It will only take a few minutes and can be done in many different positions, e.g. sitting, standing, lying down. Nobody can see what you are doing. At first, you may only be able to squeeze and hold for a second or two. As you improve, build this up to a maximum of 10 seconds. Always rest between squeezes for at least as many seconds as you have held for, e.g. 5 second hold, 5 second rest. At the start, your muscles may feel tired after just a few squeezes. As you improve, increase this gradually to 10 repetitions. You can also practise some fast, hard contractions. Just squeeze the same muscles as hard as you can, then let go straight away. Repeat up to 10 times.

Use the muscles when you need them

As well as exercising, use the muscles when you need them, e.g. squeeze and hold before you cough, sneeze, laugh, lift, bend – anything which puts pressure on your pelvic floor and might make you leak.

In order to get the best possible results, you should continue to train as described above for around 6 months. After 2-4 months of regular exercise you should already be able to notice a difference. When the desired effect has been achieved, you will be able to reduce the frequency, but remember to carry on using the muscles, day to day when you need them, as described above. Research shows that many women who have trained intensively maintain their improvement months or even years later.

It is never too late to start pelvic floor exercises. Women in their 70s and older can improve or eliminate their symptoms. When you incorporate the exercises into your daily routines they will become as natural as brushing your teeth. If your symptoms do not improve consult your doctor. He/she will be able to advise you on what else can be done, e.g. referral to a specialist physiotherapist or nurse, or to a gynaecologist or urologist.

MEN

The best way to find the pelvic floor muscles for men is to squeeze the muscles around your back passage as if holding back wind (gas). The pelvic floor muscles will automatically contract with this action. You should feel a definite squeeze and lift action of the penis – it may raise a bit when the muscle is contracted. Once the PFM are located, exercise them on a regular basis to strengthen and tone.

First squeeze and hold the muscles for a count of 5. Release, rest for a few seconds and repeat this about ten times or until tired. Increase the count and increase the number of repetitions as the muscles strengthen. The second exercise is to contract the muscles quickly in rapid succession. Squeeze, release then repeat ten times. Breathe well throughout the exercises and don't hold your breath. Make sure these muscles are fully relaxed.

There should be significant improvement after daily exercise of 30-40 repetitions in about a three to four month period.