Urinary incontinence is involuntary loss of urine, ranging from a few drops to complete emptying of the bladder. It is a common problem in women. The type of incontinence and how much the complaints affect daily life are the main factors that determine the choice of treatment.
Types of urinary incontinence
- Stress urinary incontinence: leakage of urine when coughing, sneezing, laughing, lifting or exercising. It is linked to weakening of the pelvic floor muscles and of the tissues that support the urethra (the tube that carries urine out of the body).
- Urgency urinary incontinence: leakage of urine together with a sudden, strong need to pass urine that is hard to postpone. Frequent urination and waking at night to urinate may also occur. This group of symptoms is called overactive bladder; leakage is not always present in overactive bladder.
- Mixed urinary incontinence: stress and urgency symptoms occur together. Treatment is planned according to the predominant symptom.
Possible causes
Pregnancy, vaginal birth, menopause and aging can weaken the pelvic floor muscles and the tissues that support the urethra. Excess weight, long-term constipation, a persistent cough and frequent heavy lifting increase the load on these structures. A urinary tract infection, diuretic medicines, caffeine and alcohol can also trigger or worsen leakage. Conditions that affect the nervous system, such as diabetes, stroke and multiple sclerosis, can disrupt bladder control. An abnormal connection between the urinary tract and the vagina (fistula), which can develop after surgery, radiation treatment or childbirth, can also cause continuous leakage of urine. Bulging of the bladder into the front wall of the vagina can accompany urinary complaints; this is covered on the Cystocele (Bladder Prolapse) page.
Assessment
When leakage happens, how often and how much, fluid intake, current medicines, previous births and past surgery are discussed. A bladder diary kept for at least three days, covering both a usual working day and a day off, is used in the assessment. The examination checks for pelvic organ prolapse, for leakage when coughing and for whether the pelvic floor muscles contract correctly. A urine test is carried out. If there is difficulty passing urine or recurrent urinary tract infection, the amount of urine left in the bladder after urinating is measured with ultrasound.
Urodynamic testing measures the pressures in the bladder as it fills and empties, using thin catheters, and is not needed for every woman. It is not usually performed before a first operation when the history and examination clearly show stress incontinence. It is performed before surgery if the type of incontinence is unclear, urgency symptoms predominate, there is difficulty passing urine, there is anterior or apical (uterine or vaginal vault) prolapse, or there has been previous surgery for incontinence.
Non-surgical options
- Lifestyle changes: losing weight if the body mass index is over 30, reducing caffeine, adjusting fluid intake if it is very high or very low, preventing constipation and stopping smoking are recommended.
- Pelvic floor muscle exercises (Kegel exercises): for stress and mixed incontinence, a regular exercise program supervised by a specialist and continued for at least three months is recommended as first-line treatment. If it helps, the exercises are continued.
- Bladder training: a program lasting at least six weeks that is based on lengthening the intervals between urinating in a planned way. It is recommended as first-line treatment for urgency and mixed incontinence.
- Vaginal estrogen: for women with vaginal dryness and thinning related to menopause, estrogen applied in the vagina may be recommended for overactive bladder symptoms.
- Support devices: devices placed in the vagina may be used occasionally in situations where leakage is expected, such as exercise.
Medicines and further treatments for overactive bladder
If bladder training is not sufficient, medicines that reduce involuntary contractions of the bladder muscle may be used; it may take at least four weeks to see a clear benefit. With one group of these medicines (anticholinergics), dry mouth and constipation are common. Because their long-term effects on cognitive function are not known for certain, the choice is made carefully, particularly in older people and in those taking other medicines; medicines that relax the bladder muscle in a different way can also be used. If medicines do not help enough, bladder wall injection of botulinum toxin or methods based on stimulating the nerves that control the bladder (sacral or tibial nerve stimulation) may be discussed after assessment with urodynamic testing. After botulinum toxin injection, the risk of urinary tract infection increases, and in some people the bladder does not empty fully, so urine may need to be drained with a catheter for a time. The effect of the injection is not permanent, and it may need to be repeated. Tibial nerve stimulation is given as regular sessions over several months. Sacral nerve stimulation begins with a test stimulation; it may not help enough in every person, further surgery may be needed because of problems with the device, and long-term follow-up is required.
Surgical options for stress incontinence
When non-surgical treatments have not helped enough and surgery is being considered, the following options are discussed:
- Colposuspension (Burch procedure): the vaginal tissue on either side of the bladder neck is lifted with permanent stitches to structures behind the pubic bone. It is performed as open or laparoscopic (keyhole) surgery.
- Autologous fascial sling: a strip of connective tissue taken from the abdominal wall or the thigh is placed under the urethra.
- Mid-urethral sling: a narrow strip made of synthetic mesh is placed under the middle part of the urethra through a small incision in the vagina. The strip is passed either behind the pubic bone (retropubic route) or through the groin area (transobturator route). It is a permanent implant, and complete removal may not be possible if needed.
- Bulking injection: a permanent bulking material is injected around the urethra. It is considered when other operations are unsuitable or not acceptable. Limited evidence suggests that it is less effective than the other operations and that its effect wears off over time; repeat injections may be needed.
The method is chosen by considering together the severity of the incontinence, previous surgery, any accompanying prolapse, general health and the person’s preference. If a future pregnancy is planned, postponing surgery is usually advised because pregnancy may affect the result of the operation.
Regulation of synthetic mesh
Synthetic mesh inserted through the vagina has been re-evaluated for safety in many countries. In England in 2018, operations using vaginally inserted mesh for incontinence and prolapse were paused until set safety conditions were met; these operations were allowed only when no other suitable option was available and under close oversight. The 2019 guideline of NICE, the body that issues national clinical guidance in England, lists the retropubic mid-urethral sling among the options, but requires that it be explained beforehand that the sling is permanent and may not be completely removable. The same guideline recommends the transobturator route only in specific situations in which the retropubic route should be avoided. The mesh products whose sale the US Food and Drug Administration (FDA) ordered to be stopped in 2019 were intended for transvaginal prolapse repair; that order does not cover slings for incontinence. The use of mesh in prolapse surgery is covered on the Cystocele (Bladder Prolapse) page.
After surgery
After mid-urethral sling surgery, people often go home the same day or after a short hospital stay. Straining, strenuous exercise, heavy lifting and intercourse are avoided for a time; this period is determined at the follow-up examination. A follow-up visit within six months of surgery for stress incontinence is recommended, including a vaginal examination if a mesh sling was used.
Possible risks
Surgery for incontinence may involve bleeding, infection, urinary tract infection and problems related to anesthesia. Difficulty passing urine may develop after surgery; a catheter may then be needed for a time, and rarely the stitches or the sling may need to be loosened or removed. Urgency symptoms may appear for the first time or worsen, and incontinence may persist. The bladder or urethra may be injured while the sling is placed. With mid-urethral slings, the mesh may become exposed in the vagina, and long-lasting pain in the groin or vagina and pain during intercourse may develop; these may require further treatment or surgery. Evidence on the long-term adverse effects of these operations, including those that use mesh, is limited.