Stress incontinence
The most common type of incontinence is stress incontinence, which accounts for around 40 to 50 per cent of women with the condition. Leakage occurs with exertion such as coughing, sneezing or playing sports.
The most severe sufferers will leak with the slightest pressure on the bladder. Other women have a problem only during periods of extra exertion such as when playing sport. Fear of leaking will often stop women doing everyday activities such as aerobics or playing with grandchildren, and can be very restrictive.
A common way of women ‘managing’ the condition is to empty their bladders regularly so that there is never enough urine there to cause a serious problem. They are then able to avoid embarrassing wet patches by the use of pads so that a small leakage does not disrupt their lifestyle.
Women may find themselves having to visit every toilet between the shops and home, however, or working in an office where frequent trips to the toilet become embarrassing. Others seek help because they are no longer able to cope with the frequent changing of underwear or the prohibitive cost of buying pads.
What causes it?
Stress incontinence commonly occurs as a result of a combination of weakening of the urethral sphincter or bladder neck, which seals the bladder between voidings, and a change in the position of the bladder neck. There may thus be a wide variety of causes: hormonal changes during pregnancy and the menopause, physical damage from childbirth or straining, as with a chronic cough or constipation. Many women have a mixture of stress incontinence and urge incontinence.
As we saw earlier, the urine inside the bladder exerts a pressure on the bladder neck, which squeezes shut to resist this pressure and retain the urine inside the bladder. To stay dry, the sphincters in the bladder neck must remain tightly closed when the pressure on the bladder from the outside increases from coughing, sneezing or laughing.
Normally, the position of the bladder neck is such that any rise in pressure from coughing affects both bladder and urethra equally. If the bladder neck moves down from its normal position, the urethra is no longer squeezed or compressed by the rise in pressure. This results in the sphincter mechanism being put under more strain and urine escapes.
ge girls are prone to an embarrassing but self-limiting condition called giggle incontinence, where they leak on laughing, but not at any other time. This condition is not properly understood, but it does not usually cause major problems and women can be reassured that it will resolve spontaneously without medical intervention.
Treatment
There are a wide range of treatments for stress incontinence, from physiotherapy to drug treatment to surgery. To decide which is best, doctors will look at when the problem occurs, what is causing it, and your needs and desires. For example, you may wish to reduce the leakage so that it can be managed with little disruption to your life, but may not want to embark on surgery, even though it could leave you completely dry.
Non-surgical treatments
Physiotherapy
Physiotherapy should be available to all women. The type of physiotherapy commonly employed for incontinence is called pelvic floor exercise or training. This incorporates a series of exercises contracting the pelvic floor muscles, using repetition and endurance exercises designed to re-educate and strengthen the muscles in the pelvic floor, and leading to increased support of the bladder and urethra.
It is safe and effective with no side effects. It does, however, rely heavily on your motivation, and also needs proper teaching and follow-up. It is ideal for women awaiting, or unwilling to undergo, an operation or those medically unfit for surgery. Results of physiotherapy are not immediate and frequent regular exercises must be continued for at least three to six months to allow improvement, but maximum benefit is achieved only by correct long-term usage.
Pelvic floor exercises should be taught by properly trained physiotherapists and continence advisers. You can be referred by your GP or you can see a physiotherapist privately without necessarily having seen a doctor. Normally you make several visits to the instructor to check that the contractions are being performed correctly and to help you to maintain motivation.
The assessment usually involves an internal examination where your ability to squeeze is manually graded by the instructor, who will look at the strength of the contraction, the length of maximum contraction and the number of repetitions performed. Alternatively, a device called a perineometer may be used. This consists of a vaginal probe attached to a pressure gauge, from which the strength of the contraction can be read off. Some women are unable to contract their pelvic floor muscles to command or are unaware of what the sensation of a contraction is, and these women require extra help with learning the skill.
Success rates vary but with good tuition and motivation up to 70 per cent of the women may improve to their satisfaction, although only 25 per cent are completely cured.
Cones
Weighted vaginal cones can also be used to strengthen the pelvic floor muscles, and may be particularly helpful in learning to identify the muscles of the pelvic floor. The cone is held in the vagina; when this can be done for two successive periods of 15 minutes, an identically sized but heavier cone is substituted. There are from three to five different weights in a set of cones.
Cones are usually easier to learn how to use than traditional pelvic floor exercises, and require less follow-up supervision. However, pelvic floor exercises still form an essential part of treatment. Although cones can be purchased through medical supply companies, it is usually better to buy them through a continence adviser or physiotherapist. This is because not all women are suitable for cones and proper assessment is required first. If you have a large prolapse, for example, the cone can sit behind it without ever strengthening the pelvic floor muscles and in this case the cones are not beneficial.
Biofeedback
Biofeedback may also help women to become more aware of their pelvic floor muscles. The use of a perineometer, as described above, is an example of biofeedback: seeing the reading on the pressure gauge change will help the woman to recognise what a contraction of the pelvic floor feels like, and will help her to learn to control the muscles.
Electrical stimulation
These techniques provide ‘passive’ muscle stimulation to increase muscle tone, and allow women to become aware of the pelvic floor. They can be used under supervision or at home after the technique has been learned. The stimulation makes the pelvic floor muscles contract and, by feeling this happen, the woman will become more aware of where these muscles are and what they do.
There are currently three forms of electrical treatment:
- Interferential
- Faradism
- Maximal electrical stimulation (MES).
The difference between the types of stimulation allows slightly different applications of the treatment, the choice of which should be left to the instructor.
Interferential is normally used only in hospital and works by applying current through four electrodes, producing a current that crosses the bladder. It can also be used for urgency or mixed incontinence.
Faradism and MES use one or two electrodes and have the advantage that they can be used at home after initial supervision.
Drug therapy
In the past drug therapy has been thought to be unhelpful where the stress incontinence is caused by weakness of the bladder neck. However, where there is evidence of oestrogen deficiency, treatment with oestrogen may be an important factor in increasing the success of other forms of treatment such as pelvic floor exercises. It works by improving the strength of tissues in the bladder neck, vagina and pelvis, which weaken as a result of low oestrogen levels. However, it is not in itself a cure for incontinence.
Very occasionally a medication called phenylpropanolamine (which is contained in some common cold remedies) is used. It artificially helps the muscle in the bladder neck contract to maintain a tight seal. Similar to oestrogen, it is used together with other therapies to make up a whole programme of treatment for the individual. The use of this medication is, however, restricted because pelvic floor exercises achieve better results and have no side effects.
There is now an option of a drug for stress incontinence. Duloxetine chloride is a drug similar in nature to Prozac (fluoxetine – an antidepressant of the type called a selective serotonin reuptake inhibitor). It activates the muscle by increased nerve stimulation from the lower part of the spine.
Its main side effects are nausea, which affects one in five women, and insomnia. These side effects are usually mild and transient. It helps up to 50 per cent of women and on average reduces leakage episodes by 50 per cent.
The great advantages of duloxetine are that it offers a completely new option. It may help in women who want to avoid surgery and also those in whom surgery is undesirable. It may yet prove to be helpful as a kick start to pelvic floor exercises, offering a short-term ‘boost’ while the exercises start to work.
Duloxetine does have the side effects of nausea and sleep disturbance but this is dramatically reduced by starting on a low-dose 20 milligrams (mg) twice a day and increasing if necessary to 40 mg to get the best effect on bladder symptoms if required. Approximately 10% of patients will become completely dry on duloxetine.
Surgical treatment
To date over 250 different operations have been described for treating incontinence. A number of factors are taken into account when deciding which is the best choice for a particular woman, including whether it is a first operation or repeat surgery, the facilities locally and the wishes of the patient. All surgery carries risks and, the larger the operation, the greater the risk of complications.
There may thus be a trade-off where a smaller procedure may be preferred because it is easier and quicker, even though the success rate may be lower. Smaller procedures also have quicker recovery times.
Incontinence operations divide broadly into five different classes of operation. Some operations require the surgeon to open up the abdominal cavity; in others the operation can be done through the vagina.
Abdominal procedures have higher success rates than the other types of operation, but also tend to take longer to recover from. They are considered bigger operations because they require an incision on the abdominal wall along the bikini line.
Sling procedures
These operations pass a sling under the urethra and attach it to the abdominal wall. There is a wide variety of materials used for the sling, from autografts (strips of material removed from another part of the body such as the rectus sheath) to artificial materials such as Teflon or Goretex tape. This is also an abdominal procedure.
Over the last 15 years there have been a number of sling procedures developed, the most well known of which is tension-free vaginal tape (TVT). This and the 15 similar operations offer the advantage of being commonly performed with the patient awake.
Over the last few years the second generation of synthetic sling procedures has emerged known as the ‘transobturator tapes’. The tapes differ from the ‘TVT’-style procedure by the direction in which the tape runs. The transobturator tapes (TOTs) merge from the inner aspect of the thigh as opposed to the retropubic (behind the pubic bone) (TVT)-style procedures, which emerge above the pubic bone. Transobturator tapes appear to be as effective with similar results to the TVT-style procedures, but have a lower risk of injury to the bladder. However, they are associated with an increased risk of pain in the thigh.
Most recently third-generation synthetic sling operations have been developed. These are so-called ‘minimally invasive slings’. Their place has yet to be fully evaluated. If they prove to be effective, these will probably be available as an ‘office procedure’, which would mean that they could be done under a local anaesthetic without having to go to the operating theatre.
These type of procedures are thought to be potentially even safer and easier than the TVT type, but their role and effectiveness are currently being evaluated.
The results from the TVT suggest that this is as successful as conventional surgery, although long-term results are not currently available. There are also several other companies offering tape procedures that mimic the TVT coming on to the market.
Colposuspension
Colposuspension literally means ‘supporting the vagina’. This is achieved by carefully dissecting the bladder neck free of its attachments and passing stitches through the supporting structures at the side. These stitches are then tied to the ligament or to the bone itself on the inside of the pelvis.
The operation takes place through an abdominal incision along the bikini line, and hence takes longer to recover from than the procedures above.
Bladder neck injections
The simplest type of procedure is the bladder neck injection. This involves injecting one of a number of bulking agents around the bladder neck. Some surgeons undertake this as a day-case procedure under local or regional anaesthetic, but more commonly it is performed under general anaesthetic. There are currently four or five different injectables being marketed.
This type of operation is aimed at increasing the resistance at the bladder neck by bringing the edges of the neck together so that urine cannot easily leak out. This type of operation has a relatively low absolute cure rate, although more often than not it does lead to some improvement. It is relatively easy to repeat if necessary and does not usually cause significant scarring.
Very occasionally, after the operation women have problems emptying their bladders, but this is usually transient and most women tolerate the injection well with little discomfort.
Vaginal repair
The aim of a vaginal repair is to reposition the bladder and urethra by pushing them up from below. This type of operation can be performed to repair a prolapse (where part of the vagina or the uterus has moved down into the pelvis) or to raise the bladder neck to restore continence – restoring the bladder to its proper position.
Vaginal repair is a simple procedure to perform and patients recover rapidly. It is often initially successful and is currently the second most common type of operation performed. However, recent studies have cast doubts on its long-term success rate.
After surgery
One of the most common side effects of this sort of surgery is transient obstruction, where the woman has problems emptying her bladder. In the short term this may happen to as many as 20 per cent of women. For most, however, it is no more than a minor set-back and, given a longer period of time, bladder function returns to normal.
Simple retraining in how to empty your bladder properly may be needed, such as sitting with your legs further apart and tilting the pelvis by leaning forwards.
However, some women require a longer period of catheterisation to rest the bladder (usually around 10 to 14 days). Occasionally women need to be taught how to catheterise themselves if the voiding difficulties persist. This can usually be achieved easily and should be no more troublesome than having to change a tampon.
Most women agree that the inconvenience of having to catheterise is far less than the stigma and loss of self-esteem of the incontinence. Sometimes it is possible to predict who is at risk of voiding difficulties before surgery. In these cases self-catheterisation may be taught before surgery.
The other complication of these operations is the development of irritative symptoms such as frequency and urgency. This occurs in around 10 per cent of women. Nobody understands the reason for this and it is not usually predictable. It is likely that, if you had frequency and urgency before the operation, you will have it afterwards, or it may get worse.
Using devices to contain leakage
Another approach to the management of stress incontinence focuses not on curing the problem but on containing it by physically limiting leakage. Over recent years, there have been several attempts to market devices that have not been commercially successful. They are not currently available in the UK. These devices may come back on to the market in the future. Many are disposable and may eventually be available over the counter.
The advantages of these devices is that they are simple to use and allow the woman total control; they need to be used only when required. Sometimes women find that using an ordinary tampon may compress the urethra enough to allow continence.
The use of a tampon may be applicable when doing aerobics or during times of physical exertion. It is important to remember that the manufacturers do not recommend the use of tampons at times other than periods, and that they need to be removed after use to reduce risks of infection.
KEY POINTS
- Stress incontinence accounts for 40 to 50 per cent of women with incontinence problems
- It can be caused by anything that weakens the bladder neck support -usually as a result of childbirth - causing its position to drop
- Pelvic floor exercises can help up to 75 per cent of women
- There is a range of surgical operations to treat the condition
- Duloxetine offers a drug treatment alternative to physical therapy and
