Bladder incontinence


Bladder or urinary incontinence is common. Different types of incontinence, what is normal, the causes and symptoms of incontinence, and how incontinence is diagnosed, are discussed.

What is incontinence?

Woman needing the toiletIncontinence is the accidental or involuntary leakage of urine, faeces or wind. It is a common condition; one in three women who have had a baby, and up to 10% of women who haven't had a baby, have bladder incontinence. There are always ways that incontinence can be improved. Mild symptoms unfortunately tend to worsen over time, so seek help as soon as possible. Know that it's never too late, and you are never too old to improve.

What is normal bladder function?

According to the Continence Foundation of Australia, a normal bladder:

  • empties 4-8 times each day (every 3-4 hours)
  • can hold up to 400-600ml of urine (the sensation of needing to empty occurs at 200-300ml)
  • may wake you when it is full, but gives you enough time to find a toilet
  • does not leak urine.

Bladder incontinence – types and symptoms

Women can have both urinary and bowel incontinence. Below are different types of bladder incontinence.

Types of incontinence Signs and symptoms
Urge incontinence (urinary)

The bladder muscle contracts with little warning and you may feel:

  • a need to pass urine often
  • an urgent desire to pass urine
  • a need to pass urine frequently overnight
  • as if you have an overactive bladder.
Stress incontinence (urinary) Urine leaks when you exert yourself, such as when you sneeze, cough, laugh or jump, due to mobility in the bladder neck because of a weak pelvic floor.
Mixed incontinence You experience both urge and stress symptoms.
Overflow incontinence Occurs when the bladder fails to empty properly, becomes over-full and then tends to leak – it may be caused by poor contraction in the bladder muscle or by certain neurological or medical conditions, such as diabetes.

Causes of incontinence

The pelvic floor muscles – the 'sling' of muscles that supports the bladder, bowel and uterus – can stretch and weaken, leading to continence issues.

diagram of female pelvic floor

The following may also contribute to incontinence:

  • pregnancy and childbirth
  • being overweight
  • chronic constipation that causes you to strain
  • chronic coughing
  • chronic back pain
  • frequent lifting of heavy objects, including children and weights at the gym
  • reduction in the hormone oestrogen after menopause
  • some medications
  • diabetes
  • pelvic or abdominal surgery
  • caffeinated drinks.

Diagnosis

Many women are embarrassed to talk to their doctor about bladder incontinence, or are unsure what incontinence is. If you are worried about leakage, try to tell your doctor what's happening, no matter how trivial you think it is.

The causes of bladder incontinence can be diagnosed by a number of different methods:

Diagnostic approach What to expect
Medical history

Your doctor may ask you questions about:

  • how often you leak urine
  • how much urine leaks
  • when the leakage of urine occurs
  • whether there is any burning sensation when you urinate
  • whether the bladder feels empty after urinating
  • how often you urinate during the day
  • how often you urinate during the night
  • your daily fluid intake
  • how many pregnancies you have had
  • your experience and length of labour and delivery (vaginal, forceps, vacuum delivery, episiotomy or caesarean section) and any complications during or after delivery
  • the birthweight of your baby
  • respiratory conditions that cause you to cough often
  • how often you lift heavy weights
  • any surgery that might have contributed to the symptoms
  • medications you are taking.
Physical examination

The physical examination will assess:

  • the function of your pelvic floor muscles
  • whether there is any vaginal prolapse.
Bladder diary Asks you to write down when you go to the toilet, and measure how much urine you pass each time.
Urodynamics A test of bladder function, which fills the bladder and determines what causes it to leak and how well it empties.
Bladder ultrasound An ultrasound is used to measure how much the bladder holds, and to detect any leftover or residual urine in the bladder after passing urine.
Midstream urine test You may need to provide a urine specimen to check for, and exclude, bladder infection.

Prevention & management

You can help to prevent and manage bladder incontinence with a number of simple dietary and lifestyle actions.

Water

Drink 6-8 cups or glasses of fluid per day. This does not have to be only water, and includes all of your drinks. Reducing your fluid intake does not reduce incontinence. Concentrated urine due to lack of fluids can lead to urinary burning and make you more likely to develop a urinary tract infection.

Once you have had your 6-8 cups or glasses of fluid, reducing your fluids after your evening meal will help you to stop getting up overnight.
Caffeine and alcohol Eliminate caffeinated drinks (remember chai, green tea and energy drinks may be caffeinated). Fizzy drinks and drinks with added colouring and sweeteners, as well as alcohol, can worsen symptoms and cause increasing frequency.
Fibre

To avoid constipation, which can worsen bladder leakage, try to eat plenty of fibre. Each day, eat:

  • 2 serves of fruit
  • 5 serves of vegetables
  • 5 serves of cereals/breads.
Physical activity

Aim for 30 minutes of moderate physical activity most days of the week. This maintains general muscle function and mobility.

Avoid fitness activities that cause bladder leakage – they won't make it better.

See Pelvic Floor First for a fitness program that is safe for your pelvic floor.
Pelvic floor exercises

Do pelvic floor exercises regularly so that you can use the muscles to help prevent leakage.

You may need to see a pelvic floor physiotherapist if your technique is incorrect, and to teach you bladder retraining techniques.
Lifting Avoid heavy lifting, as this can weaken your pelvic floor; take particular care lifting children, and weights at the gym. Learn to 'brace' your pelvic floor muscles prior to any lifting.
Coughing
  • If you smoke, the chronic coughing associated with smoking can weaken your pelvic floor – for help to quit, call the Quitline on 13 7848 or visit the Quit website
  • Visit your doctor if you have ongoing respiratory problems that cause you to cough.
Menopause hormone therapy (MHT)
  • In some women, incontinence becomes worse after menopause due to a reduction in the hormone oestrogen
  • Sometimes the use of oestrogen therapies, particularly vaginally, may help – speak to your doctor for more information.
Toilet habits
  • Empty your bladder only when you have the urge to do so
  • Avoid the habit of going to the toilet 'just in case'
  • Sit down properly with your feet firmly supported to fully relax your pelvic floor and sphincter muscles, and lean forward with your elbows on your knees
  • Don't strain to empty your bladder
  • Don't stop the flow of urine midstream as an exercise, as this can send incorrect messages to your bladder and stop it from emptying completely
  • Take your time; don't rush.
Bladder training You can be guided through bladder training by a continence nurse or pelvic floor physiotherapist at a public hospital, continence clinic or private clinic.
Medication Your doctor might prescribe medication to treat your bladder incontinence once it has been fully assessed.
Surgery Some types of bladder incontinence can be managed with surgery. If appropriate, your doctor will refer you to a specialist gynaecologist or urologist.
Continence products Continence pads and accessories can help you feel more comfortable and secure, and help maintain your quality of life while you are seeking treatment. Continence panty liners are just as small as other liners, but are specifically designed to absorb urine, so do a better job. You can discuss these products with your doctor, continence nurse, pelvic floor physiotherapist or pharmacist.

Treatments

For urgency & urge incontinence

Medications that can calm down an overactive bladder:

  • Oxybutynin (Ditropan™)
  • Darifenacin (Enablex™)
  • Solifenacin (Vesicare™)
  • Mirabegron (Betmiga™) – may also increase bladder capacity
  • Topical/vaginal oestrogen cream, pessary or tablet
  • Botox injections into the bladder wall under general anaesthetic by a specialist, if all other treatments have failed.

For stress incontinence

  • Pelvic floor rehabilitation with exercises to strengthen the pelvic floor, preferably under supervision of a pelvic floor physiotherapist; to find one in your area, visit the Continence Foundation of Australia website.
  • Vaginal pessary: a device that is placed high in the vagina to hold up the bladder neck and any prolapse that is present. It may be shaped like a ring, but can be a number of other shapes, including a mushroom-like pessary. The size and shape will be determined by your doctor. The pessary requires cleaning every 3-6 months and can be done by either yourself or your doctor. If the size and position is right, then you will be unable to feel it.
  • A sub-urethral sling, of which there are many types, is the recommended surgical procedure for stress incontinence. A common method used is the retro-pubic mid-urethral sling (tension-free vaginal tape), which is inserted through the vagina, up behind the pubic bone and out through the abdominal wall, avoiding the bladder. Cure rates are high in more than 90% of women.

Interstitial cystitis/painful bladder syndrome

Persistent bladder pain affects quality of life considerably. Why it occurs is not exactly known, and there may be more than one cause. The diagnosis is made when no other causes of bladder pain can be found. It often coexists with other chronic pain syndromes such as fibromyalgia and irritable bowel syndrome.

This condition is not to be confused with overactive bladder syndrome, which presents with urinary urgency, but typically not with bladder pain.

Symptoms and diagnosis

The possible symptoms include:

  • bladder discomfort, especially with the bladder filling, and eased with emptying
  • urinary urgency
  • frequent emptying of bladder during the day
  • lower abdominal pain
  • pain with emptying (voiding) bladder
  • nocturia (frequent waking overnight to empty the bladder)
  • dyspareunia (painful sex)
  • pelvic tenderness felt on examination.

A urine test will most likely show no evidence of bladder infection. Cystoscopy (an examination of the inside of the bladder) is usually performed to exclude other causes of bladder pain.

If you have these symptoms and have been investigated with no other causes found, such as a urinary tract infection, ask your doctor for referral to a gynaecologist, urogynaecologist or urologist for further management.

Treatment and management

The aim of treatment is to provide symptom relief. There is a wide range of therapies used. Education and psychological support are necessary because of the impact of the symptoms on mood and wellbeing.

There are a number of ways you can help to manage the symptoms:

  • apply heat or cold to the perineum or lower abdomen
  • avoid some foods or drinks, such as caffeine and alcohol
  • drink adequate fluids throughout the day: neither too much nor too little  (6-8 cups or glasses of fluid per day is recommended)
  • identify and avoid activities or exercises that make symptoms worse.

A pelvic floor physiotherapist can help with bladder retraining, which can reduce urgency and also relax the pelvic floor, which is often overactive.

Many medications have been used, taken both orally or administered into the bladder. The latest therapy that seems to benefit some women is the injection of Botox into the bladder wall under anaesthesia.

References

  1. www.nice.org.uk/guidance/cg171

  2. www.pelvicfloorfirst.org.au (for safe exercise routines on your pelvic floor)

  3. www.continence.org.au

Last updated 26 September 2018 — Last reviewed 04 August 2018

This web page is designed to be informative and educational. It is not intended to provide specific medical advice or replace advice from your health practitioner. The information above is based on current medical knowledge, evidence and practice as at August 2018.

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