Urinary incontinence

What is urinary incontinence?

Urinary incontinence is the involuntary loss of control of urine which is socially and hygienically unacceptable. It is a very common condition and recent data has shown that up to 30% of Malaysian women had experienced incontinence.


What are the causes?

A normal bladder can accommodate a significant volume of urine with no appreciable rise in pressure. Urine is prevented from leaving the bladder by the constant contraction of the sphincter (figure 1) which works like a tap. During urination, the bladder muscle contracts, raising the pressure inside the bladder and at the same time, the sphincter opens up to allow urine to leave the bladder. Incontinence can result from abnormal bladder contractions or a weak sphincter mechanism. The most common cause is stress incontinence which occurs mainly in women. This usually occurs as a result of weakened pelvic floor muscles after childbirth. The other common cause is uncontrolled bladder contractions called detrusor instability or unstable bladder. The bladder muscle escapes volitional control and spontaneous contractions cause the urge to pass water when the bladder is not yet full. When this contraction produces a pressure which is too great to control urine leaks out and causes incontinence. In men prostate enlargements are the most common reason for incontinence. Spinal cord injuries and strokes are the other causes that occur within our community.

Figure 1

What are the symptoms?
In patients with stress incontinence, the urinary leak occurs due to physical stress. Depending on the degree of pelvic floor weakness leakage may occur in response to coughing or sneezing, jumping or jogging or lifting heavy objects. In severe cases the leak can occur with almost any daily activity. Patients with unstable bladders often have the urge to pass water despite the fact that their bladders are not yet full and thus they have to run to the toilet very often. If for some reason they are delayed in reaching the toilet a urinary leak may occur. Elderly men with prostate enlargements experience incontinence which is similar to the patients with unstable bladders. They also tend to have a slow urinary stream.

What tests are available?

A urine test is most commonly done but rarely provides very much information. The key test that will evaluate all urinary incontinence accurately as well as tailor the treatment to the particular disorder and patient is the urodynamics test (figure 2). This is done by inserting two very tiny tubes into the bladder as well as a balloon catheter into the rectum and measuring bladder and rectal pressures during artificial filling of the bladder with saline. The patient will be asked to void during this test to measure voiding pressures as well. Ultrasound of the kidneys may be done in selected patients to exclude kidney damage.

Figure 2

What treatment is available?
There are many varied types of treatments available and up to 80% of incontinence is curable. The cornerstone of good treatment is an accurate diagnosis from urodynamics. Patients with stress incontinence from a weakened pelvic floor can improve significantly by doing simple pelvic floor exercises or use devices like vaginal clones or biofeedback equipment. Electrical stimulation of the pelvic floor may be helpful for patients with mild degree of stress incontinence. For more severe stress incontinence surgery is the main recourse. Surgery ranges from minimally invasive procedures such as injections of substances into the urethra to increase resistance (figure 3) to open reconstrutive surgery. As for the unstable bladder, medications are the mainstay of treatment along with a self-administered plan of bladder training. Even patients with spinal cord injuries and paralysis can achieve continence by simple manoeuvres like clean intermittent self catheterisation. In this procedure the patient inserts a clean catheter into his/her urethra to empty the bladder and maintain continence. A variety of surgical procedures that are highly successful are also available including the use of an artificial urinary sphincter (figure 4). The bottom line is that continence can be achieved in most situations if proper urological consultation is sought and urodynamics done.

Figure 3

Figure 4