Female Incontinence Overview

What is urinary incontinence?

Urinary incontinence is the involuntary loss of urine through the urethra, or "leaking urine". Incontinence is very common in women at all ages, but the risk of incontinence increases as women age. Approximately 10% of women between the ages of 15-24 complain of occasional incontinence, and the risk of incontinence increases to 25% or greater in women over 70 years old. Risk factors for incontinence include multiple childbirths, menopause, stroke, and multiple vaginal or pelvic surgeries. Many women accept incontinence as a necessary part of aging, but there are a variety of treatments available that can stop incontinence or decrease it dramatically and greatly improve a women's quality of life.

What causes urinary incontinence in women?

There are several types of urinary incontinence in women, and some women may have a combination of two types of incontinence.

Urge Incontinence

One type of incontinence is called "urge incontinence", or "overactive bladder". In this type of incontinence women may feel the urge to urinate but cannot get to the bathroom in time before urine starts to come out. This type of incontinence is caused by the bladder squeezing, or contracting, before a person is on the toilet and ready to urinate. The natural reaction when a women feels that she may not make it to the toilet is to squeeze the pelvic muscles to hold back the urine, but the bladder will usually "win out" and overpower the pelvic muscles and urine will come out. Sometimes the amount of urine that leaks out will be small, but for some patients the entire bladder may empty, causing a lot of incontinence and distress. It is not uncommon for women to have this type of incontinence just as they get near a bathroom, for example when they arrive home and are getting their keys out to enter the house, but some women will have overactive bladder throughout the day or night. Sometimes an overactive bladder contraction can be triggered by coughing, laughing, or sneezing; the leakage may start several seconds after the event that triggers the incontinence.

Stress incontinence

Another common type of urinary incontinence is called stress incontinence. Stress incontinence occurs when a women leaks urine if she coughs, laughs, sneezes, exercises, has intercourse, lifts heavy objects, or performs any activity in which abdominal pressure pushes on the bladder. In normal women the urethral sphincter muscles are able to hold back the urine despite the increased abdominal pressure pushing on the bladder. However, in some women the support of the urethra weakens, so that increased abdominal pressure causes the bladder and urethra to "drop" or bulge into the vagina. This stretches the normal urethral sphincter muscles out of position and urine can be forced into the urethra. The urethral sphincter muscles have normal strength, but they may not be able to hold back the urine when they are stretched out of position and a small squirt of urine may leak out. Some women with stress incontinence will also have weak support of the bladder, uterus and may feel the bladder or uterus bulging to the vaginal opening. In some women with stress incontinence the bladder does not "drop", but the urethral sphincter muscles are so weak that urine leaks out with even a small cough, laugh, or sneeze. This condition is called "type 3 stress incontinence" or "sphincter weakness incontinence", and is usually quite severe. Approximately 1/3 of women with stress incontinence will also have urge incontinence, which may be caused by urine leaking into the urethra and causing a sensation of the need to urinate.

Other types of incontinence

Overflow incontinence occurs in women who are not able to empty the bladder because of weak bladder contractions. The bladder may fill to the point where it cannot hold anymore urine and some may leak out. This type of incontinence is rare. Continuous leakage of urine may indicate a fistula, or hole, between the bladder and vagina. This can occur rarely after hysterectomy or vaginal surgery but is also quite rare. Some patients with a normally functioning urinary system may have incontinence that is caused by poor mobility or dementia. If a patient is unable to get to the toilet because they have poor mobility they will eventually urinate into a pad or diaper. If a patient is demented and does not understand the need to go to the toilet then they may be incontinent despite having a normal urinary system.

Treatment options for urinary incontinence in women

There are a number of treatment options for urinary incontinence in women, and the best treatment depends on the cause of incontinence, an individual woman's health, and also a woman's feeling about the treatment options.

Treatment of "urge incontinence or "overactive bladder "

There are several different treatments for urge incontinence. Your urologist will first rule out other causes of incontinence such as back problems, urinary infection, endometriosis or other causes. If a woman has urge incontinence and stress incontinence, both types of incontinence may go away if the stress incontinence is treated (see below). Some women, particularly post-menopausal women, will get significant from the use of estrogen vaginal cream. Other women may benefit from pelvic floor biofeedback therapy, which trains the brain and pelvic floor muscles to work together. Most women with urge incontinence will get improvement from medications which cause the bladder to relax and give more warning about the need to urinate before the bladder will start to contract. These medications can be taken as a daily pill or capsule or can be given as a skin patch that is changed twice a week. These medications have minor side effects, most commonly dry mouth or constipation.

Some men or women have severe urge incontinence that does not respond to medication. Fortunately, there are treatments available that can provide significant improvement for many patients. The most well established of these treatments is sacral nerve root stimulation, or Interstim®. Interstim® involves placement of a small electrode next to the nerves that leave the tailbone and go to the bladder. The electrode is connected to a small "pacemaker" which stimulates the nerves with a very gentle electrical impulse. This stimulation can cause the bladder to behave in a much more normal manner, and some patients can see dramatic improvement in their symptoms. Another promising treatment is injection of Botox® into the bladder wall through a telescope inserted into the bladder. This treatment can provide 6-12 months of improvement in urinary symptoms for 70-80% of patients, but it must be repeated because it does not provide a permanent cure. The urologists at MBUA have the most experience in the Monterey Bay area with these new treatments.

Treatment of stress incontinence

Non-Surgical Treatment:

Because stress incontinence is caused by weakness in the support of the bladder it is not usually treatable with medication. However, many women with stress incontinence will also have urge incontinence, and medication may be recommended as a trial to see if it helps decrease the incontinence. In addition, some women will get improvement of their stress incontinence after using vaginal estrogen cream for several months. Pelvic muscle exercises, or Kegel exercises, can help to strengthen bladder support and decrease incontinence in some women, but women must continue the exercises if they hope to have long-term improvement. Some women have trouble strengthening the pelvic muscles properly. Pelvic floor biofeedback therapy can be helpful in many women to help the brain and pelvic muscles to learn to work together. This safe, non-invasive treatment consist of weekly one-hour sessions with a medical assistant in our office and is covered by most insurance plans. There are no medications available at this time that can treat stress incontinence.

Surgical Treatment:

The most effective treatment for stress incontinence is surgery to strengthen support of the bladder and prevent the bladder and urethra from dropping during a cough or sneeze or other activity. We call this type of surgery "minimally-invasive urethral sling" surgery. Sling surgery for treatment of stress incontinence has a 90% or higher chance of curing this type of incontinence, and 80% of women are still cured of incontinence 8-10 years after surgery. This type of surgery is usually done through the vagina without the need for major abdominal surgery, and in many cases the surgery lasts less than 30 minutes and women can go home the same day. This type of bladder surgery can also be performed at the same time as a vaginal hysterectomy or surgery to correct more severe bladder bulging. If a women is undergoing abdominal surgery for some other reason (such as abdominal hysterectomy) surgery to prevent stress incontinence can be performed at the same time. A less effective type of surgery for stress incontinence is called intra-urethral injection surgery. In this type of surgery a telescope is passed into the urethra and an substance, usually collagen derived from cows, is injected under the lining of the urethra to "puff" it up and help it to "stick together" and prevent leakage. This type of surgery does not correct the underlying cause of the incontinence and usually requires several outpatient injections under anesthesia in order to be effective. In the short term approximately half of women see improvement, but by two years after injection less than 25% of women still feel that the treatment was effective. At MBUA we feel that urethral injection treatments are less effective than the "sling surgery" and recommend it only for certain women who have failed surgery or have other special circumstances.