Finding out what’s wrong
The National Institute for Health and Clinical Excellence (NICE) issued guidance on the management of urinary incontinence in women in October 2006. These guidelines support the philosophy that every woman should be treated based on her symptoms initially and the treatment should be based on what the predominant symptom is (stress incontinence or urgency incontinence). Initial treatment should be conservative in terms of bladder re-training or pelvic floor re-education. Details of the guidelines are available on the NICE website: www.nice.org.uk.
Where to go for help
If you suffer from incontinence, even only slightly, and it is affecting the way that you live, you should ask for help. Your GP is the first port of call. He or she may be able to identify a cause such as a urinary infection and give you treatment. More often, you will be referred for specialist assessment at your local hospital or through the local District Continence Advisory Service.
This service is responsible for treating most patients in the community. This is done through the running of community-based clinics and liaison with both GPs and hospital services. The continence advisers are a group of health-care workers who work specifically in treating incontinence. They are trained nurses who have developed specialist skills in assessing and treating the condition. They are usually responsible for teaching and following up pelvic floor exercises, bladder drill and self-catheterisation.
Local continence advisers are also responsible for supplying aids and appliances. This is done through liaison with the health authority supplying, and the district nurses distributing, the appropriate pads, pants or appliances.
Investigating the problem
As we have seen, incontinence can have several different causes and, before treatment can begin, the doctor will need to find out exactly what is causing your particular problem.
One of the first things that will be checked for is a urinary tract infection, because this is easily treatable and can cause false results in later urodynamics tests.
The main aim of investigation is to find out if you have stress incontinence caused by weakness of the bladder neck, or urge incontinence caused by an unstable bladder. It may not be easy to tell from your symptoms alone, because these can be variable and one individual may have a mixture of both types of problem. If this is the case, treatment may be started and then the tests repeated to see what progress is being made.
The tests will also pick up other rare forms of incontinence. Women with recurrent infections or other bladder symptoms may also need investigating before proper treatment can be started.
Simple tests
A simple way to check the bladder function is to fill in a five-day chart that measures how much you drink and how much urine is passed, along with the frequency of urination. This is called a frequency volume diary and shows quickly and accurately how the bladder normally functions.
The diary may in itself pick up the cause of the problem – for example, someone developing diabetes will show increased drinking and increased frequency of voiding. Inadequate fluid intake can also show up: this leads to highly concentrated urine, which irritates the bladder, producing symptoms of frequency and urgency. It can also predispose you to urinary tract infections, because passing only small quantities of urine diminishes the body’s natural defences against bacteria entering the bladder.
Leakage can be measured with a pad test. A weighed sanitary towel is worn for about an hour with a full bladder. During this time you do a series of basic exercises such as sitting down and standing up, walking up and down stairs, or washing the hands. The pad is then reweighed to calculate the weight and hence the volume of urine lost.
Urodynamics
The standard tests performed to assess bladder function are referred to as urodynamics. They measure the relationship between pressure and volume in the bladder and whether or not this is normal.
When urodynamic tests are performed, you have to attend the clinic with a full bladder, and pass urine into a special toilet that measures the urinary flow rate. You are then examined and a small pressure (detector) transducer is placed in the bladder and one in the back passage. Although this is often embarrassing it should not be painful.
The bladder is then filled through a catheter so that it is full again within five minutes. During this time the pressures from the two transducers are recorded. When the bladder is full again, simple tasks such as coughing or jumping are performed to see what happens to the pressures and whether there is leakage. Lastly the bladder is emptied into the special toilet with the pressure lines still in place for a ‘pressure–flow plot’, which allows analysis of bladder pressure during urination.
Although nobody likes the thought of these tests, they can usually be performed relatively easily and with dignity. The doctors and nurses who perform them are all skilled in the techniques and try to make the tests as tolerable as they can.
In some hospitals, cystometry (measurement of the pressure and volume of the bladder when full and during emptying) may be used with X-ray imaging to look at the relationship of the bladder neck to the leakage during coughing. This test is of particular value in women who have had previous surgery or complicated problems, and is known as video urodynamics.
The information provided by urodynamics is limited, because it provides only a snapshot of the bladder’s function over a relatively short period of time (approximately 20 minutes while the test is performed). Ambulatory urodynamics allow the conditions that provoke problems to be mimicked under test conditions. It normally takes four hours and allows the bladder to fill with urine naturally, rather than a fast fill (called a ‘retrograde fill’) through a catheter. It is currently available only in a few hospitals in the UK.
Imaging techniques
There are two procedures that are commonly used to find out whether other parts of the urinary tract have been affected. These tests look for damage caused by infections or from the passage of urine the wrong way up the ureter from the bladder to the kidney, and they also check for kidney stones.
The first is called an intravenous urogram or, more commonly now, a CT urogram. This involves injecting dye into a vein in the arm, which is then excreted through the kidneys. A series of X-rays (radiographs) are taken at timed intervals. The dye outlines the kidneys, ureters and bladder, allowing the anatomy of the whole area to be observed.
The second technique is an ultrasound scan, which is used to look at the bladder and the kidneys.
Cystoscopy
A cystoscopy is performed to look at the inside of the bladder. A cystoscope is a narrow ‘telescope’ that is passed into the bladder through the urethra.
There are two types: a flexible cystoscope under local anaesthetic or a rigid cystoscope under general anaesthetic. The advantage of the rigid cystoscope is that it allows samples of the lining of the bladder to be taken for analysis.
Quality of life
Increasingly doctors with an interest in bladder problems are asking patients to complete quality-of-life questionnaires. These questionnaires allow the doctor to assess the impact of symptoms on the patient’s day-to-day life and help highlight the important issues for patients. A variety of different questionnaires is used. Commonly questionnaires fall into two groups:
- The first is generic questionnaires, which allow researchers to compare the impact of different diseases on the quality of life of patients. These tend to be less sensitive questionnaires to change within a disease and for this reason the disease-specific questionnaires were invented to allow measurements of change in quality of life in response to treatments for a particular disease. The most commonly administered questionnaires include the King’s Health Questionnaire, the Bristol Female Lower Urinary Tract Questionnaire and more recently the ICI (International Consultation on Incontinence) Questionnaires.
- The second category is the electronic questionnaires that are now being developed such as the e PAQ. This questionnaire can be completed on line at ePAConline.co.uk.
Psychology of incontinence
There is increasing recognition by doctors and researchers that the impact of urinary incontinence is quite significant and the trigger factors or motivating factors for women seeking help may be different. Commonly, for example, women are worried about the future and not becoming ‘a smelly old lady’ or ‘the lady on the bus’ or they may be worried about the impact that their symptoms have on their femininity and personal relationships.
Some researchers are now beginning to look at this and the impact of psychology on the physical symptoms that patients suffer.
KEY POINTS
- Investigation is necessary to distinguish urodynamic stress incontinence, urodynamic detrusor overactivity and other causes of incontinence
- A frequency volume chart (urinary diary) is a simple way of showing how the bladder normally functions
- Urodynamics are standard tests carried out to assess bladder function
- Cystometry studies the pressure-volume relationship in the bladder
