Although 30% of women worldwide and 3 to 6 million people (women and men) in the UK struggle with urinary incontinence, it still continues to be a taboo subject.
This might be because there is still little information available for sufferers, leading women and men to believe that they are alone in their suffering or that this is a common and normal problem caused by ageing and that there is nothing that can be done about it. It’s not uncommon for me to hear patients saying that “actually this is not a big problem because it only happens every now and then”. In these cases I always explain that “yes, it’s not a big problem but if left untreated the muscle weakness is just going to get worse”. Since problems tend to get worse with ageing and other aggravating factors, it can then become a big problem.
In other cases, urinary incontinence can lead to major distress, depression, social isolation and decreased quality of life and that is why it is so important to get the word out. There is treatment available and the sooner people have access to it, the better.
In this article, I will explain what urinary incontinence is, what the main causes are and who is more at risk of developing it. I will also help to identify early signs of pelvic floor muscle weakness and talk about possible treatments.
Who is most at risk of developing urinary incontinence?
Urinary incontinence can affect women, men and children. However, it occurs more in women than in men. The women who are most at risk are menopausal women or those of childbearing age. In men urinary incontinence seems to be more prevalent after prostate dysfunction.
What are the main types of urinary incontinence?
According to the International Continence Society there are 4 main types of urinary incontinence.
(1) Stress urinary incontinence – When leakage of urine happens during physical activities or exertion like sneezing or coughing, running or lifting heavy weights.
(2) Urgency urinary incontinence – When leakage occurs accompanied or immediately preceded by a sudden compelling desire to go to the loo that is difficult to delay.
(3) Mixed urinary incontinence – When leakage occurs associated with both urgency and exertion, effort, sneezing or coughing.
(4) Overactive bladder is defined as a sudden urge to empty the bladder that occurs with or without urgency urinary incontinence and usually with increased frequency and nocturia, meaning in these cases the sufferers go to the loo frequently during the day and night. Overactive bladder can be called “wet” if accompanied with leakage of urine or “dry” if is without.
Why can we develop urinary incontinence?
There are some risk factors that can make a person more prone to develop urinary incontinence. Some of the general risk factors identified are: chronic constipation, chronic cough, heavy weight lifting, obesity and ageing. More specifically in women, risk factors have been identified as; women who have developed pelvic organ prolapse, women who have had a hysterectomy, hormonal imbalance, menopause, pregnancy, childbirth – either vaginal delivery or caesarean section, forceps or instrumental deliveries, the number of deliveries, length of the second stage of labour and pelvic floor muscles weakness.
In men the risk factors are associated with prostate dysfunction and pelvic floor muscles weakness. Some treatments for prostate cancer such as prostate surgery and some treatments for an enlarged prostate can contribute to urinary incontinence.
Can urinary incontinence be sign of a more serious health problem?
Although in most of cases urinary incontinence is associated with pelvic floor muscle weakness, in some cases it can also be associated with other serious health conditions. Therefore, a careful diagnosis and screening must always be done by a GP, specialist physiotherapist or specialist medical team.
Can female hormones contribute to urinary incontinence?
The bladder, sphincter and vulvovaginal area have several hormonal receptors specifically for oestrogen. Oestrogen helps to maintain the muscles and keep soft tissues healthy and strong. The decline in the levels of oestrogen during menopause and peri-menopause can lead to vaginal atrophy and urinary incontinence. The same applies to the hormonal changes during the menstrual cycle. Oestrogen levels are lower right before, during, and after a period, making women who have weak pelvic floor muscles more likely to experience leakages during these times of the cycle.
When should someone seek help?
The normal amount of times to go to the loo to empty the bladder a day varies on average between 6 – 8 times and once per night. Pregnant women and women who are still breastfeeding are an exception.
If a person experiences uncontrolled losses of urine with exertion when sneezing, coughing, lifting weights or exercising, and frequent trips to the loo during the day and night, as well as frequent sudden urge to urinate without being able to delay, then it is very important to seek help for guidance and treatment. If these symptoms are left untreated they can become worse over time. Another thing to look for is if pain is present when emptying the bladder.
Are Pelvic floor exercises effective in treating urinary incontinence?
Pelvic floor exercises are proven to be very effective in treating urinary incontinence. A recent Cochrane review provided support for the widespread recommendation that pelvic floor muscle training should be included in first-line conservative management programmes for women with stress, urgency, or mixed urinary incontinence. This is particularly important to know because women are still being offered surgery as a first option without trying conservative treatment first. The NICE guidelines for the management of women and men with urinary incontinence also stated that a trial of supervised pelvic floor muscle training of at least 3 months duration should be offered as first‑line treatment for stress or mixed urinary incontinence. Another recent Cochrane review showed that pelvic floor exercises were successful in preventing urinary incontinence in women having their first baby. All the evidence suggests that everyone (women and men) should be doing pelvic floor exercises to prevent having urinary incontinence later in life.
How can men and women know whether they are doing pelvic floor exercises correctly?
The best way to activate the pelvic floor muscles is to tighten around the front and back passage at the same time as if trying not to pass wind and urine. It’s important to avoid holding your breath or squeezing the muscles of the buttocks and thighs when doing these exercises. An easy way of knowing if the correct muscles are working, is to press gently with one finger on the back passage while activating the pelvic floor muscles. A gentle contraction should then be felt. The other important thing is to be careful and to not over-exercise these muscles. The pelvic floor muscles have the ability to produce two type of contractions: slow or long squeezes – the ones we use to delay urination when needed – and short or fast squeezes – the ones we use when sneezing/coughing or lifting weights to avoid leakages with sudden increases of downward pressure on the pelvic floor. A healthy and functional pelvic floor should be able contract and relax and to do 10 short squeezes and 10 long squeezes, holding the contraction for 10 seconds. However, some people find it really hard to activate or fully relax these muscles or may even feel pain when doing the exercises. In these cases the gold standard is to have a pelvic floor assessment with a specialist physiotherapist. What I want everyone to understand is that it’s not just a matter of doing the pelvic floor exercises. As with other types of muscle training it is all about using the correct technique, because if the exercises are not done correctly, they cause more problems or they will not help at all.
How effective are vaginal cones, pelvic floor exerciser aids and other devices?
A number of studies have demonstrated that vaginal cones and biofeedback exerciser aids are powerful tools in the training of the pelvic floor muscles. For some people, using these devices helps to improve compliance to treatment or training and improves the motivation levels. They also provide an objective measure of the outcomes and help people to know if they are improving. The theory behind the usage of the vaginal cones is that pelvic floor muscles contract involuntarily or reflexively when the cone is perceived to slip out. The weight of the cone is supposed to give a training stimulus that make women/men contract their pelvic floor muscles harder against a resistance. The biofeedback exerciser aids have also been shown to provide a quicker progress in treating urinary incontinence when used in conjunction with pelvic floor active exercises. The NICE guidelines also recommend the use of supervised biofeedback when women/men have difficulties in activating the pelvic floor muscles voluntarily. It is very important to say that none of these devices should be used without seeing a specialist physiotherapist before for a thorough assessment and prescription of a supervised and individualised pelvic floor muscles exercise program.
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