There are many types of urinary incontinence.

• Urge incontinence is caused mainly by the presence of elements that irritate the bladder, such as the presence of urinary tract infection (UTI), bladder stones or even bladder tumours.
• Overactive bladder syndrome (OAB) is a diagnosis of exclusion where there are no identifiable causes irritating the bladder, yet there is a severe urge to empty the bladder.
• Stress urinary incontinence (SUI) is usually related to a weak pelvic outlet from previous trauma, multiple pregnancies, or undue repeated high abdominal pressure such as recurrent persistent cough, obesity or constipation.
• Overflow incontinence occurs when the bladder is very full but unable to empty, and is related to weak bladder contraction in diabetics or patients affected by stroke.

Women who have had vaginal deliveries or are post-menopausal are at higher risk. You are also at risk if you are obese. The intake of irritants such as coffee or tea may worsen the problem.

The diagnosis is often obtained from a well-taken history and complete physical assessment. The latter gives the doctor an idea of your pelvic floor muscle tone and helps to exclude other diagnoses with similar symptoms.

Tests to exclude urinary tract infection, stones and bladder tumours may be needed. In some people, urodynamic studies, a complex assessment of changes in bladder activity during filling and emptying, may be needed to confirm the diagnosis.

Treatment strategies differ depending on the cause of the incontinence.

For stress urinary incontinence (SUI), treatment methods may be surgical or non-surgical.

Non-surgical options for SUI may include:

1. Bladder retraining and pelvic floor exercises. This option includes Kegel exercises to strengthen the pelvic floor muscles that help hold in urine. If done correctly and diligently, this can improve the quality of life of at least 40-50 per cent of women with SUI. The best results occur in the pre-menopausal age group, but older women can also benefit from this.
2. Vaginal devices for SUI, such as a ring pessary that presses against the wall of the vagina and the nearby urethra. The pressure helps reposition the urethra, leading to less stress leakage.

Surgical options for SUI may include:

1. Collagen injections. Bulking agents, such as collagen, are injected near the urinary sphincter. As the body may, over time, slowly eliminate certain bulking agents, repeat injections may be needed.
2. Surgery for SUI. These are broadly classified into two categories:
   • Retropubic suspension such as Burch colposuspension, where surgical threads called sutures are used to support the bladder neck.
   • Sling procedures, where slings of natural tissue or man-made mesh are used to support the bladder neck and urethra. The most common type used today is tension-free vaginal tape (TVT).

For urge incontinence and overactive bladder, treatment options include:

1. Removal of the irritant. This includes reducing the amount of coffee and tea intake.
2. Medication. The first line of treatment , drugs called anticholinergics block the nerve signals causing frequent urination and urgency and bladder spasms, but the main dose-limiting problem is the side effect of mouth and throat dryness. If you have glaucoma, ask your doctor if these drugs are safe for you.
3. Injections for an overactive bladder. Those people who are unable to tolerate anti-cholinergics may be offered an injection of botulinum toxin A into the bladder wall. Botulinum toxin relaxes the bladder muscles, reducing its overactivity.
4. Neuromodulation. The stimulation of nerves to the bladder leaving the spine (neuromodulation) can be effective in some people for whom urge incontinence does not respond to behavioural treatments or drugs. However, the therapy is expensive, involving surgery with possible surgical revisions and replacement.

Pelvic floor exercises taught and practised early, before menopause, will help women reduce the risk of severe SUI in older age. Reducing the intake of coffee and tea may reduce the symptoms of urge incontinence.

Ref: T12