Thursday 15 December 2016

Urinary Incontinence: Suffering in Silence

By Dr Su Hamid, Obstetrician and Gynaecologist

Urinary incontinence is defined as involuntary loss of urine. According to the American Medical Association, this lack of bladder control affects 10 to 20 percent of people older than 65.

It may not be life threatening, but it has a significant impact on the quality of life for this particular age group of women. 

Many of these women do not seek help due to the embarrassment felt.

There are multiple reasons for incontinence, and if managed adequately, most of the women affected by it will benefit by gaining back their confidence to rejoin society.

Below are the types of incontinence, symptoms and background, tests and diagnosis, and prevention, treatment, and management. Mixed incontinence is the combination of any of the different types of incontinence below.

Stress Incontinence


There is loss of urine when coughing or sneezing, but does not happen when sleeping.


The pressure within the abdominal cavity (intra-abdominal pressure) that causes the rise in the bladder pressure is not transmitted to the part of the urethra closest to the bladder (proximal urethra); urethra is where the urine flows from the bladder and leaves the body. 

This is caused by the loss of pelvic structure due to lack of support attributed to pelvic relaxation. Pelvic relaxation is the weakening of the supportive muscles and ligaments of the pelvic floor.

Tests and Diagnosis

Pelvic examination: This may reveal that the wall between the bladder and vagina has weakened, allowing the bladder to droop into the vagina (cystocele).

Neurologic examination: The assessment of the sensory neuron and motor responses, such as the reflexes, are normal.

Q-tip test: The test is positive; when a lubricated cotton-tip applicator is placed in the urethra and intra-abdominal pressure increases, the Q-tip will rotate more than 30 degrees.

Urine test and culture: The test results are normal.

Cystometric studies: The studies measure how much fluid the bladder can hold, how full it is before the need to urinate is felt and the pressure of the urinary flow. The results are normal with no involuntary bladder spasm (detrusor contractions) where the bladder muscle squeezes abruptly without warning, thereby causing an urgent need to pass urine.

Prevention, Treatment and Management
  • Stop smoking, cut down on alcohol and caffeine.
  • Use an internal vaginal device (intravaginal device) such as a pessary or cone to elevate and support the bladder neck and urethra; success rate is up to 70%.
  • Go on estrogen replacement therapy if vaginal atrophy (atrophic vaginitis) is determined where the vaginal walls are thinning, drying and inflammation is present due to lack of estrogen.
  • Opt for surgery to elevate the urethral sphincter, so that it is restored to the intra-abdominal location.
    • Burch procedure; success rate is up to 90%.
    • Suburethral sling procedure such as the Tension-free Vagina Tape (TVT); it does not elevate the urethra, but forms a resistant platform against the intra-abdominal pressure.
    • Periurethral bulking injections such ovine collagen such as Contigen or calcium hydroxyapatite.

Urge (Hypertonic) Incontinence


The loss of urine occurs in large amounts often without warning, at day and night. The most common symptom is urgency.


The involuntary rises in the bladder pressure from involuntary bladder spasm (detrusor contractions), attributed to unknown cause (idiopathic), which cannot be voluntarily suppressed.

Tests and Diagnosis

Pelvic examination: The result is normal. 

Neurologic examination: The assessment is normal.

Urine test and culture: The test results are normal.

Cystometric studies: The results show a normal residual volume, but involuntary bladder spasm (detrusor contractions) is present even with small volume of urine in bladder.

Prevention, Treatment and Management
  • Modify behaviour as the first line of treatment; organize the fluid intake habit by reducing fluid intake and avoiding liquids during evenings, and gradually increasing the interval between voiding. This is can be done by doing time voiding or bladder training that involves training the body to have a more normal pattern of voiding by using urge suppression techniques to calm the urge and wait to go pass urine until the next scheduled voiding interval.
  • Opt for medications that inhibit involuntary bladder spasm (detrusor contractions) such as Oxybutynin, Vesicare, Enablex and Betmiga.
  • Opt for functional electrical stimulation where mild electric current is delivered to the nerves in the lower back or the pelvic muscles that are needed in passing urine.

Irritative (Sensory) Incontinence


The loss of urine occurs with urgency, frequency and with pain or discomfort (dysuria), at day or night.


The bladder spasm (detrusor contractions) is stimulated by irritation from conditions such as infection, stone, tumour, or a foreign body.

Tests and Diagnosis

Pelvic examination: There is tenderness in the region above the pubic or the front bone of the pelvis (suprapubic); but otherwise, the result of the examination is normal.

Urine test and culture: The test results will show abnormalities such as bacteria and elevated white blood cells count, which suggest an infection; or the abnormal presence of red blood cells which suggests a stone, foreign body, or tumour. The urine culture is positive if there is infection.

Prevention, Treatment and Management
  • Treat infections with antibiotics.
  • Undergo cystoscopy where the doctor look inside the bladder and urethra using a cystoscope, which is a thin, lighted tube that is inserted into the urethra and bladder to diagnose and remove, stones, foreign bodies, and tumours.

Overflow (Hypotonic) Incontinence


The loss of urine occurs intermittently in small amounts and may be accompanied by the feeling of pelvic fullness, at day and night.


The rises in bladder pressure occur gradually from an over distended, hypotonic bladder. When the bladder pressure exceeds the urethral pressure, involuntary urine loss occurs, but only until the bladder pressure equals the urethral pressure. 

The bladder never empties and this may be caused by denervated bladder (e.g. diabetic neuropathy, multiple sclerosis) or systemic medications (e.g. ganglionic blockers, anticholinergics).

Tests and Diagnosis

Pelvic examination: The result may show normal anatomy.

Neurologic examination: The assessment will show a decrease in the perineum’s main nerve’s (pudendal nerve) sensation.

Urine test and culture: The test results are usually normal, but may show an infection.

Cystometric studies: The results show a markedly increased residual volume, but involuntary bladder spasm (detrusor contractions) does not occur.

Prevention, Treatment and Management
  • Intermittent self-catheterization where a catheter or tube is used to drain the urine from the bladder may be necessary. 
  • Discontinue the offending systemic medications.

Urinary Fistula


The loss of urine occurs continually in small amounts, at day and night. There is usually a history of either radical pelvic surgery or pelvic radiation therapy. 

Urinary fistula can be an abnormal passage or opening that has formed between urinary tract organs (urethra, ureter tubes, bladder, kidney) that process and excrete urine or between urinary tract organ and another close by organ such as the colon or vagina.


The normal urethral-bladder mechanism is intact, but is bypassed by urine leaking out through a fistula from the urinary tract.

Prevention, Treatment and Management
  • Repair the fistula surgically. 
If urinary incontinence affects your daily activities, do not hesitate to see your doctor. Your doctor can advise on prevention and the suitable treatment and management for your condition.


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IMPORTANT: The information on this blog is for informational purposes only and not intended to be a substitute for professional medical advice, diagnosis or treatment in any manner. Always seek the advice of your doctor or other qualified health provider with any questions you may have concerning your health or anything related to it. 

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