Other problems associated with urinary incontinence
When a doctor sees a patient with incontinence for the first time, he or she will ask about other aspects of the patient’s health as well, because some other conditions have a link with incontinence.
Periods and fibroids
You will be asked about your periods, because if these are heavy and painful it is possible that you may have fibroids. Fibroids are benign tumours growing in the wall of the womb. They are very common and usually do not cause problems.
If, however, they do cause distortion of the pelvic organs, they can interfere with the bladder or your periods. In particular they can increase abdominal pressure and add to the displacement of the bladder neck associated with incontinence. If you are likely to need surgery for incontinence, this may be a good time to assess whether the fibroids also need treatment.
Prolapse
Prolapse is the movement of the vaginal wall from its normal position along with the bladder, bowel or womb. It is caused by damage to the ligaments in the pelvis. These ligaments act as guy ropes supporting the womb and the strength-giving layers overlying the bowel and bladder. The main causes of prolapse are childbearing and any condition leading to chronic straining (constipation, smoker’s cough or being overweight).
There are several different types of prolapse and these are graded according to severity. A cystocele is a prolapse of the front wall of the vagina with the bladder following behind. Uterine prolapse refers to the uterus (womb) coming down through the vagina. A rectocele is a prolapse of the back wall of the vagina with the bowel coming down behind.
Prolapse may occur on its own or together with other symptoms such as incontinence or difficulty passing a bowel motion. Common complaints include the feeling of ‘something coming down’ and discomfort or pain during sex.
Treatment of prolapse depends on several factors, including your wishes and how much the prolapse interferes with your life. The best results are usually obtained by surgery which aims to fix the organs back into their proper positions, but this is not always the most appropriate treatment. You may not have completed your family (and another childbirth could cause the prolapse to recur), may be unfit to have surgery, or may just not want it.
Sometimes silicone rings called pessaries can be placed in the vagina. If these cure symptoms they can be used on their own, just needing to be changed every six months. A major drawback is that the pessary sits in the vagina and therefore sexual intercourse can be difficult.
Diabetes
Diabetes may affect the bladder in many ways, from causing frequency as a result of excessive drinking, to damaging the nerve supply to the bladder. In the latter case diabetes can cause urodynamic detrusor overactivity or difficulties emptying the bladder or both, depending on the exact effect of the diabetes on the nerves.
It is therefore important that, if you have symptoms of diabetes (thirst, frequency and weight loss), or if you have a strong family history of diabetes, you are checked for this.
Irritable bowel syndrome
It is not uncommon to find that women who have bladder symptoms, particularly of an unstable bladder, also have bowel symptoms. Irritable bowel syndrome can cause a variety of effects from abdominal bloating and constipation to diarrhoea. The symptoms may vary from time to time and be related to other factors, such as stress or your periods.
The first choice of treatment for irritable bowel syndrome is to increase dietary fibre to encourage normal bowel action. Medications such as peppermint preparations and anti-spasmodics can be used to try to regulate bowel spasms. Laxatives may be used if constipation is a problem.
Drug treatment for an unstable bladder may worsen constipation and this must be borne in mind if it is likely to be a problem.
Back problems
Lower back problems can cause pinching of the nerves supplying the bladder as they exit the spinal canal.
This in turn can alter the functioning of these nerves, and may lead to difficulties in emptying the bladder. Hence a back problem may present as a urinary problem. Treatment of the bad back by properly supervised physiotherapy can reduce the pressure caused by entrapment of the nerves and lead to an improvement in symptoms.
Fistulae
A fistula is an abnormal track between two cavities – for example, the bladder and vagina – and can lead to incontinence. This can allow urine to leak directly into the vagina rather than being stored in the bladder.
Fistulae occur for several reasons. In developed countries the most common cause of fistulae is as a result of cancer or radiotherapy for cancer, because cancer and the radiotherapy weaken the muscles. They may also occur after an operation where the surfaces have become damaged, particularly after a hysterectomy.
In other parts of the world the most common cause is abnormally long (obstructed) labour when giving birth. This leads to a pressure sore that erodes, usually between the bladder and the vagina. Fistulae may also be congenital, that is, you may be born with them.
Fistulae are uncommon problems that require specialist care. They will sometimes heal without an operation, but this may take some weeks, during which time a catheter would be needed to keep the bladder empty. Operations for fistulae require great skill, and postoperative care, to help prevent a recurrence.
Congenital defects
Congenital defects are conditions where a child is born with an alteration in the normal anatomy, such as an ectopic ureter. This is a condition where the ureter (the tube connecting the bladder with the kidney) does not connect with the bladder. Instead it is connected direct to the vagina, which again causes leaking as the bladder is bypassed.
These are normally diagnosed in early life and treated appropriately.
KEY POINTS
- Other health problems can be linked to incontinence
- Surgery should aim to treat all problems at once
- Treatment needs to be tailored to individual needs
