By Dr. Nathalie Leroux
Urinary incontinence is defined as the involuntary loss of urine.
Stress incontinence (SUI) is the involuntary loss of urine during increased intra-abdominal pressure or physical exertion. Patients with SUI complain of loss of urine when coughing, sneezing, laughing, exercising, or exerting Valsalva (pushing).
Urge urinary incontinence is the involuntary loss of urine accompanied or immediately preceded by a sensation perceived as a strong urge to urinate. With this condition, patients have difficulty delaying these urgent urges to urinate and must rush to the toilet at the first sensation of urination. Running water, washing hands, exposure to cold, or simply arriving home with the key in the door can trigger sudden urges.
The prevalence of urinary incontinence is estimated to be 25 to 51% of patients in Western societies. SUI accounts for 29-75% of incontinence cases among all patients. Urge urinary incontinence accounts for approximately 33% of cases, with the remainder attributed to mixed urinary incontinence (a mixture of the two conditions). However, the current data is limited, as only one in four women seeks consultation for these symptoms. Many do not report symptoms due to feelings of embarrassment, shame, or lack of access to health services, so they are not counted in these studies.
Urinary incontinence can significantly affect the quality of life, resulting in disrupted social relationships, embarrassment and frustration, and hospitalizations due to skin irritation or urinary tract infection. Up to a third of patients admitted to leaking urine during intercourse. These discharges or the fear of incontinence can contribute to developing sexual dysfunction.
Older women with incontinence are 2.5 times more likely to be admitted to a nursing home. The risk of hip fracture increases with falling, which occurs when a patient rushes to the toilet to avoid incontinence. These risks are by no means trivial. Urinary incontinence is a pathology that deserves to be detected and treated for the general health of the female population.
Several factors can contribute to the development of urinary incontinence. The prevalence and severity of incontinence are more present and increase gradually during adulthood. Incontinence should not be considered a normal phenomenon of aging. Conversely, age-related factors can result in a predisposition to incontinence, such as an overactive bladder or specific bladder dysfunctions. For example, in postmenopausal women, a decline in estrogen can contribute to the development of vaginal atrophy (thinning of the vaginal wall), atrophy of the urethral mucosa (the urethra does not close as well), and loss of compliance (flexibility) of the bladder. As we age, urine is less concentrated during the night, and thus more frequent awakenings are possible.
Pregnancy and childbirth are risk factors contributing to the development of urinary incontinence. Vaginal childbirth can cause direct damage to the pelvic floor muscles and connective tissue attachments in the pelvis. In the ad, trauma to nerve fibres by tissue stretching during childbirth contributes to pelvic floor dysfunction. A cesarean section could be a short-term protective factor compared to vaginal delivery. This protective effect dissipates with subsequent pregnancies or deliveries, decreases with age and disappears entirely in older women.
Body mass index (BMI) is a significant risk factor related to the prevalence of stress urinary incontinence and urge incontinence. They increase proportionally with the rise in BMI. Excess abdominal weight creates excessive intra-abdominal pressure on the pelvic floor compared to women with a healthy weight. Compared to non-obese women, obese women are three times more likely to have urinary incontinence. Promoting weight loss should be a first-line treatment option, and the occurrence of incontinence will decrease significantly with weight loss.
Menopause could affect urinary incontinence, but separating the symptoms associated with the drop in estrogen from those attributed to aging is difficult.
A positive family history, especially for urge urinary incontinence, can be a risk factor for the daughters or sisters of women suffering from this type of pathology.
Obstructive lung disease in women over 60 significantly increases the risk of urinary incontinence. Similarly, smoking is an independent risk factor for urinary incontinence. Both current and former smokers have a two to three times higher risk than non-smokers.
A hysterectomy (surgical removal of the uterus) does not increase the risk of incontinence.
During the first medical encounter, it is essential to highlight the main symptoms that bother the patient. Your doctor will try to obtain information on the situations that cause you to have urinary leakage. The amount of urine lost for stress urinary incontinence is variable, but the loss is usually slight. An overactive bladder occurs when there is an urgent need to urinate, which is sometimes accompanied by incontinence when we cannot locate a toilet in time. The amount of urine passed can be significant with bladder emptying. There are triggers like running water, washing your hands or the key in the door when you arrive home, and knowing that the toilet is not immediately accessible. Some patients will do “mapping” of the bathrooms to know the exact location of the toilets and be able to access them quickly if necessary. An example is remembering all the restroom locations in your mall!
You will be asked about micturition (urinary) frequency, nocturia (getting up at night to urinate) and the circumstances in which incontinence occurs. We will also take stock of your liquid intake, i.e. everything you drink. The more liquids consumed, the more we will have to eliminate and the more it is possible to exacerbate some of our symptoms of urinary incontinence. Many patients already limit their fluid intake on their own to reduce their episodes of incontinence. However, it is crucial to stay well hydrated. The fluid ingested daily should be around 1.5-2 litres of total fluid per 24 hours. Some beverages are very diuretic (causing you to urinate more), such as tea, coffee and alcohol. It is advisable to limit their consumption. To better understand your problem, your doctor may ask you to complete a voiding diary for 24-48 hours.
A physical examination will be essential in looking for signs of skin atrophy or irritation on the external genitalia. The atrophy accompanying the decline in estrogen during menopause can impact urinary loss, which may improve with the treatment of the atrophy. It is also essential to treat any skin conditions that may accompany incontinence. Urine in contact with the skin can significantly cause skin irritation. A summary neurological examination of the perineum should also be included.
Assessing pelvic floor support is critical when evaluating a patient for urinary incontinence. During a gynecological examination, the doctor will ask you to do a Valsalva maneuver (pushing) to determine the presence of pelvic floor prolapses (POP) such as cystocele (the descent of the bladder), rectocele (descent of the rectum) or uterine prolapse (descent of the uterus). On the other hand, it is not because a patient has a bladder descent that she is incontinent. The two conditions can coexist but are different from each other. In stress urinary incontinence, there is hypermobility of the urethra or a lack of support at the level of the anterior vaginal wall. The doctor may ask you to cough during the examination to highlight this hypermobility and the loss of urine. A bimanual exam will complete the assessment of your uterus and ovaries, typical during a gynecological examination, to eliminate pelvic masses.
In general, the investigation is relatively simple, and most often, analysis and culture of your urine will be sufficient. In some more complex cases, a urodynamic assessment could be recommended and will be explained to you by your doctor.
There are multiple treatment options:
Many foods can be acidic and irritate your bladder, causing you to want to go to the bathroom more often. A complete list of these foods exists. However, determining which foods cause the most change in your voiding habits when consumed would be best, as eliminating these irritants can improve symptoms. Caffeine, tea and alcohol are diuretics and will cause you to urinate more and can result in urge incontinence when a bathroom isn’t accessed in time. Also, as mentioned earlier, weight loss can have a significant positive impact on urinary incontinence.
Patients with urinary urgency may have a feeling of wanting to urinate up to 10-15x/day. During an emergency, the detrusor, the bladder’s muscle, contracts independently. It is as if the bladder is emptying itself without the patient’s control.
So the initial goal is to extend the time between toilet visits by an additional 30 minutes at a time. Use Kegel exercises during emergency episodes to suppress the urge to urinate, thus spacing out urination. Using the scheduled voiding method (for example, every 2 hours) ensures that the bladder is empty for a more extended period during the day and allows better control when an emergency occurs. For some patients, emergencies only happen when a specific volume of liquid is reached in the bladder, hence the need to empty it more frequently at the start of treatment.
Local estrogen replacement:
Treatment with local estrogens (in the vagina) improves urethral coaptation and, therefore, closure of the urethra, thus reducing stress incontinence. Hence, the postmenopausal patient with vaginal atrophy will opt for local hormonal treatment to enhance the vaginal and urethral mucosa quality. The situation may differ regarding systemic hormone replacement (by mouth or transdermally). While there is little scientific evidence on the benefits of urogenital tissues, some studies on urinary incontinence have shown that it can worsen when initiating systemic hormone therapy.
Conservative treatment should be the initial treatment offered to all patients. The rationale is to strengthen pelvic floor muscles that support the urethra and surrounding organs such as the bladder, the rectum and the uterus. An effective pelvic floor contraction supports the urethra and prevents leaks on exertion. Also, a more robust pelvic floor in an emergency will help you activate the musculature so you can get to the bathroom quickly and prevent a leak.
Practical pelvic muscle training can improve and sometimes wholly treat patients with mild to moderate urinary incontinence. Kegel exercise is the active and voluntary contraction of the levator ani (pelvic floor) muscles. It may be difficult for a patient to contract these muscles in isolation. Some patients contract the abdominal muscles instead. Others will make the opposite effort, a Valsalva (the effect of pushing). In this case, the symptomatology could worsen following the treatment. It is estimated in some studies that up to 80% of women fail to reproduce adequate contraction of the pelvic floor muscles. Although women can execute this contraction well, muscle recruitment is slow for some, and the force of contraction is weak.
A physiotherapist specializing in perineal rehabilitation can help you train the muscles in this region, which are sometimes difficult to activate. A treatment using a vaginal probe will allow you to see the importance of the contraction you develop during your exercise session and achieve better results. Several physiotherapy sessions may be necessary to obtain satisfactory results. Patients should remember that treating urinary incontinence with physiotherapy can also prevent the development of prolapse or descent of the pelvic organs.
Some lasers may improve symptoms when used in postmenopausal patients with vaginal atrophy.
Another treatment option is vaginal radiofrequency. This treatment leads to tissue regeneration through the direct application of radiofrequency, which increases the local temperature of the treated tissues. Again, this treatment is more aimed at postmenopausal patients who lack estrogen in the urogenital tissues.
Finally, high-intensity focused magnetic resonance technology can be used, and a 65% improvement in symptoms is reported in treated patients. The force of muscular contraction developed during a session is much higher than what we can do individually. It is also possible to sustain this muscle contraction for longer than we can voluntarily do. Appreciable results are possible after six sessions (2 sessions/week).
Pharmaceutical treatment plays a minimal role in the treatment of stress urinary incontinence. Some antidepressants can affect receptors in the urethra.
Several drugs, mainly anticholinergics and B-adrenergic, exist to treat overactive bladder. Some may have side effects. Suppose you are a good candidate for a therapeutic trial. In that case, your doctor will advise you on the drug most appropriate for your situation.
A pessary is a silicone prosthesis inserted into the vagina to correct urinary incontinence and pelvic floor prolapse. There are several types and sizes of pessaries. The one used for incontinence can prevent excursion (mobility of the urethra). The success of the pessary for treating urinary incontinence varies depending on the degree of prolapse and several other factors. Not all women are good candidates for the use of a pessary. This one requires cleaning (removal), which you will be taught. Suppose the patient is not able to take care of her pessaries herself. In that case, this maintenance can be taken care of by CLSC nurses, for example.
Several types of surgeries exist, and their purpose is to treat stress urinary incontinence. Urinary urgency isn’t treated with surgery; these symptoms can sometimes even increase after surgery for stress incontinence. The preoperative evaluation is critical because it is vital to treat any prolapse of the pelvic organs simultaneously with the incontinence to obtain better long-term success in curing these two conditions. Your doctor can discuss all these possibilities and advise you on what best suits your situation.