What are the Types and Symptoms of Urinary Incontinence?

1) Stress Urinary Incontinence (SUI)

You may experience involuntary urinary leakage during physical exertion, such as coughing, sneezing, laughing, jumping, running, or exercising. This form of urinary leakage is defined as stress urinary incontinence or SUI. Those with more severe SUI may also leak with less strenuous actions such as brisk walking. The increased intra-abdominal pressure momentarily overwhelms the ability of your urethral (the tube that connects the bladder to the outside of the body) sphincter muscles to stay closed, resulting in urine leakage that can range from a few drops to more significant amounts soaking through pads, underpants or even clothes.

SUI may occur when your pelvic floor muscles, which support your pelvic organs in terms of anatomy and function, are weakened or traumatised. Pregnancy, childbirth (especially vaginal births), nerve damage, chronic cough etc., are major risk factors that weaken one’s pelvic floor. Due to differences in pelvic anatomy and certain risk factors unique to women, SUI is more commonly encountered in ladies than men.

2) Urge Urinary Incontinence (UUI)

You experience involuntary urinary leakage preceded by an urgent, uncontrollable need to urinate, which is difficult to defer. Most commonly, women describe experiencing a strong urge and not being able to make it to the toilet in time before urinary leakage occurs. This phenomenon is known as urge urinary incontinence, or UUI for short.

This is different and often confused with another condition of having an overactive bladder (OAB), where one feels the urge to pass urine frequently and goes to the toilet often. Although some women with OAB also experience UUI, not every woman with OAB has UUI, i.e. the latter typically can control urinary leakage until after they reach the toilet.

In normal circumstances, when a healthy bladder is full, the brain signals the bladder muscles to contract whilst simultaneously getting the urethral sphincter and pelvic floor muscles to relax, resulting in the passage of urine. In cases of OAB, the bladder muscles are overly active and start contracting even before the bladder is full, resulting in you perceiving a strong, urgent need to visit the toilet. The cause of OAB can be temporary, e.g. in cases of urinary tract infection (UTIs), or can be caused by damage to the neurological system, e.g. older age, long-standing diabetes, stroke, multiple sclerosis, dementia etc. It can also be exacerbated by weak pelvic floor tone, certain medications (e.g. blood pressure or heart drugs that reduce fluid accumulation within the body), or excessive caffeine/ sugar/ salt/ preservatives/ alcohol intake.

Women with severe cases of OAB and/or UUI can face significant hindrances to their daily work, social life, sleep and exercise as they find themselves planning their lives and routines around proximity to the bathroom. Over time, this could eventually take a toll on interpersonal relationships with friends, family and loved ones, leaving one with low self-esteem, poor body image, stress over potential “accidents”, or even depression.

3) Mixed Incontinence (SUI and UUI)

You experience involuntary urinary leakage that is preceded by an urgent, uncontrollable need to urinate and physical exertion. In most cases, there will be one form of incontinence that bothers you more (i.e. SUI more than UUI, or vice versa).

4) Overflow Incontinence

You frequently urinate in small amounts with no bladder sensation and no perception of your bladder being full. The bladder is often incompletely emptied due to certain medical conditions, and the nerves supplying the bladder get irreversibly damaged over time. This type of incontinence is more common in men than women as they are at higher risk of having a bladder outlet obstruction due to prostate issues.

What are the Causes of Urinary Incontinence?

There are many potential causes of urinary incontinence, including:

1) Aging and Menopause

Your muscles will typically weaken as you grow older, and the damage sustained to muscles, ligaments and nerve supply in your younger years usually becomes more pronounced as you age and undergo hormonal changes as you transit into menopause.

2) Pregnancy

Pregnancy and childbirth can damage your pelvic floor muscles supporting your bladder, causing urinary incontinence. Studies have shown that assisted vaginal deliveries, particularly forceps delivery, result in greater pelvic floor damage.

3) Surgery

Certain types of surgery, such as a hysterectomy or prostate surgery, can result in nerve tissue injury and pelvic floor dysfunction, leading to urinary incontinence.

4) Bladder or Prostate Cancer

Growths that result in bladder outlet obstruction, i.e. not allowing the bladder to empty completely, can result in overflow incontinence. Certain cancer treatments like pelvic radiation can also affect your ability to control your bladder.

5) Neurological Conditions

Conditions such as dementia and Alzheimer’s disease can affect either your cognition or mobility and hinder you from perceiving a full bladder and/or having the ability to reach the bathroom or unbutton your pants in time to urinate.

6) Infections

Urinary tract infections (UTIs) of the bladder or kidneys or bladder and kidney stones can irritate your bladder/urinary tract and result in urinary frequency, urgency or even urinary incontinence. In such cases, urinary incontinence is typically short-term and can resolve after treatment of the infection/stones.

7) Medications

Some medications cause side effects which may lead to incontinence, such as muscle relaxants and sedatives.

What are the Treatment Options for Urinary Incontinence?

Many patients avoid seeking help because they think urinary incontinence is a minor problem or that they can do nothing about it. Such avoidance can lead to deterioration until it hinders your daily activities. In the initial stages, incontinence may be infrequent, but it can progress from leaking several times weekly to daily. It could also be a symptom of a more severe condition.

Hence, if you suspect that you may be suffering from urinary incontinence, you must seek help early from a healthcare professional. Some causes of urinary incontinence are temporary and easily treatable, while others may be more serious and persistent.

Methods like incontinence pads for urinary leakage are temporising measures and do not allow for proper identification, diagnosis and treatment of the root cause. Instead, you should go to a urogynaecologist for an accurate diagnosis and management strategy.

Here are some treatment options for stress urinary incontinence – do note that treatment options need to be individualised by your urogynaecologist according to your unique clinical circumstances.

1) Pelvic Floor Exercises

Otherwise known as Kegel exercises, these serve to strengthen the bulk and tone of your pelvic floor and alleviate the symptoms of SUI. It is important to perform pelvic floor exercises daily and consistently, and these can be taught in the clinic setting and reinforced with help from a trained women’s health physiotherapist.

2) Lifestyle Modifications

It is important to maintain a healthy body mass index (BMI) as being overweight puts chronic strain on the pelvic floor muscles and puts one at increased risk of developing SUI. Hence healthy eating and regular physical activities are important in keeping weight under control. If you are suffering from other medical conditions that predispose you to physical exertion, which worsens your SUI, e.g. chronic cough, asthma, or other lung diseases – you should work closely with your doctor to improve control of these.

3) Mid-Urethral Slings

Your doctor will place a small synthetic tape or mesh around the mid-segment of your urethra. The most commonly performed ones in Singapore are tension-free vaginal tape (TVT) or transobturator tape (TOT).

This surgery is typically done under general anaesthesia, and involves a small cut hidden inside the vagina, as well as 2 sub-centimeter cuts either in the lower abdomen (for TVT) or in the inner thighs (for TOT). A cystoscopy (bladder scope) is usually performed in conjunction with mid-urethral sling placement to ensure the absence of bladder injuries.

After the surgery, a urinary catheter is placed to help drain and rest the bladder overnight, and this is removed the following day with checks to ensure proper emptying of the bladder before you are discharged.

This procedure is highly effective in the treatment of SUI, with success rates of up to 95%. The risks of this surgery include 1-5% chance of bleeding, injury to surrounding structures, including the bladder/urethra/vagina, difficulty with emptying the bladder fully, urinary urgency, frequency, infection, pain or mesh extrusion.

Occasionally, the synthetic tape can be substituted with a biological/autologous fascial sling, i.e. fashioning the sling from your own tissue; this is not commonly performed in Singapore.

If you have coexisting pelvic organ prolapse, the surgery for pelvic reconstruction and mid-urethral sling can be performed together.

4) Burch colposuspension

This was the surgery that was most commonly performed before the advent of mid-urethral slings, and the main aim was to lift (and hence provide additional support) the bladder neck to strong ligaments on the back of pubic bones via sutures. It is performed abdominally, either open (laparotomy) or laparoscopically (keyhole), and has a success rate of 85% at 1 year. This surgery is now much less performed as mid-urethral sling procedures are typically faster, much more straightforward and involve quicker recovery.

5) Bulking Agents

This surgery involves doing a cystoscopy (bladder scope) and using it to guide the injection of bulking agents into the wall of the urethra. This helps to reduce the degree of urinary leakage on physical exertion by constricting the diameter of the urethra. Although the least invasive surgical option, it is known to lack long-term efficacy and typically requires repeated procedures to maintain results.

Due to different pathophysiology, the treatment options for urge urinary incontinence (UUI) are different from SUI (surgery, unfortunately, is not effective in treating UUI) and mainly comprise of:

• Lifestyle Modifications
  Moderating the intake of things that can irritate the bladder e.g. caffeinated beverages, alcohol, foodstuffs that are high in sugar, salt and preservatives, as well as quitting smoking, can help reduce the sensation of urinary urgency and frequency. Drinking fluids and going to the toilet regularly (i.e. every 2-3 hours) helps to build a regular bladder routine – keeping a bladder diary can be very useful in having an overview of one’s drinking and voiding habits throughout the day and night, on both weekdays (workIng) and weekends (non-working) days as well. If you have known medical conditions such as diabetes mellitus, heart/kidney disease etc which require you to be on medications that may result in more frequent urination, work with your doctor to optimize control of these conditions and possibly explore a change of medications that can keep your condition under control yet reduce the incidence of you needing to visit the toilet too frequently. It is also important to maintain a healthy body weight.
• Bladder Training
  This should be done in conjunction with pelvic floor exercises and keeping a bladder diary, to understand your bladder capacity and adjust the interval that you should be trying to hold your bladder for. A normal bladder capacity typically ranges between 300-400ml; if you find that your bladder diary shows that you frequently visit the toilet to void low volumes e.g. 100ml or so, then bladder training will be useful in helping you regain control over your bladder, rather than the other way round. The aim of bladder training is to control the feelings of urgency, increase the time interval between toilet visits, and increase the volume of urine that your bladder can comfortably hold. For example, if you find yourself going to the toilet every hour but voiding only 100ml each time, set a target to hold for an additional 15 minutes when the feeling of urgency hits. This should be done by sitting down on a firm surface, crossing your legs and tightening your pelvic floor muscles. Stay still and distract yourself e.g. by scrolling through your phone and reading a quick newspaper article until the peak of the urgency sensation passes. Then slowly make your way to the toilet and record the volume of urine you pass. Over weeks and months of bladder training, most women should find that they slowly regain control of their bladder and are less likely to plan their daily activities around the toilet.Bladder training is a process that needs time and patience, as many times the bladder would have already learnt many “bad habits” over a long period of time which now need to be unlearned – it is also important to understand that there will be good and bad days so you should not get discouraged easily.
• Medications
  There are several medications available to reduce the sensitivity of an overactive bladder by relaxing your bladder muscles and diminishing bladder spasms; in doing so, they increase the interval between toilet visits and decrease the feelings or urgency and episodes of urge urinary incontinence. They are usually taken orally and may take some time before effects on your bladder are noticeable. Some side effects include dry mouth, constipation, drowsiness etc and your urogynaecologist will be able to work closely with you to ensure the most suitable medication at the lowest possible effective dose for your situation.