Urinary Incontinence

UI is the involuntary loss of urine which is objectively demonstrable and causes a social or hygienic problem. It is estimated that anywhere between 25-70% of women suffer from this problem. However the prevalence of urinary incontinence in the community has been severely underestimated. This is because 40% women feel embarrassed to talk about this problem to their doctors and >60% women perceived urine loss as a normal consequence of ageing. Less than half the individuals living in the community with UI seek treatment.

The medical consequences of UI include rash, pressure sores, skin and urinary tract infections and falls. Psychosocial consequences include restriction of social and sexual activity and depressive symptoms. There are three major types of urinary incontinence.

Stress Urinary Incontinence

SUI is the involuntary loss of urine with any activity that increases intra-abdominal pressure like coughing, sneezing and laughing. Lifting weights can also contribute to this. The majority of women affected by SUI find it a problem. SUI can have a major impact on all aspects of well being. Since SUI is mainly prevalent in young and middle aged women who have an active professional or social life, this might have a greater impact. These women may experience limitations in terms of physical (playing sports, lifting heavy weights) occupational and social activities because of fear of leakage of urine and related consequences(e.g.smell of urine, wetness, visibility of pads etc). SUI can also affect a woman’s sex life, social activities and interpersonal relationships.

What Causes SUI?

The two most common causes that have been sited so far have been increased mobility or descent of the urethra or defect in the sphincter mechanism of the urethra. Recently diminished activity of the nerve (pudendal nerve) that supplies the sphincter has also been shown to cause SUI.

Example:

  • I lose/urine when I cough, laugh or sneeze.
  • I lose urine when I cheer loudly at a cricket match.
  • I lose urine when I skip or play tennis.

Surgical Treatment Incontinence

Burch Colposuspension

This has been the gold standard for treatment of SUI. The procedure can be done by the open or laparoscopic technique. This entails suspending the bladder to a higher position thereby providing support to the urethra.

Slings

TVT (Tension free Vaginal Tape)

The procedure described in 1995 caused a landmark change in the management of SUI. This involves support of the urethra by means of a polypropylene mesh placed at the mid-urethra. The tape acts like a backstop and prevents leakage of urine during increase in intra- abdominal pressure. The procedure can be done on an outpatient basis and success rates over a 7 year period have been in the range of 85-95%.

TOT (The Transobturator Tape)

This is the latest procedure on the block. The needle used in the TOT does not travel a great deal inside the abdomen and hence complications noted with the TVT procedure are minimized. The tape lies like a hammock beneath the midurethra. This procedure is also done on an outpatient basis.

Injectables

These are substances that are used to bulk up the urethra in patients with incontinence. They are also done as day care procedures. However the success rate of this procedures is low . A variety of substances from collagen, Teflon, carbon beads, fat and blood can be injected.

Overactive Bladder (Urge Incontinence)

In order to understand the Overactive bladder (OAB) we first have to learn certain terminologies.

Frequency

If a person voids more than 7 times during the day he or she is said to have frequency.

Urgency

Urgency is the sudden compelling desire to void accompanied by a fear of leakage.

Nocturia

If a person voids more than once during the night he or she is said to have nocturia.

Urge Incontinence

If a person is not able to hold the urine till he or she reaches the bathroom, it is termed as Urge Incontinence. When a person has frequency, urgency, nocturia with or without urge incontinence he or she is said to have an Overactive bladder.

What causes OAB?

The reason why OAB develops is not very clear. 90% of OAB is supposed to be due to Idiopathic(reason not known) causes .OAB it is said, arises mainly because there is a bladder brain discordant activity with the bladder reacting on its own without impulses from the brain. However pelvic organ prolapse and sling surgeries for stress urinary incontinence where the sling is placed tightly can be the reason for OAB developing.

Example:

  • I feel the sudden urge to go to the toilet and wet my pants.
  • By bladder wakes me up 3 to 4 times at night
  • I put the key in the door and before I can open, I wet myself
  • I have bladder spasms when I wash dishes.
  • I wake up in the morning and my bed is wet

Mixed Incontinence

Top Mixed incontinence is a combination of stress and urge incontinence. Though SUI is the most common type of incontinence, typically people walking into a referral centre have mixed incontinence. These women typically lose urine while coughing, sneezing laughing and also leak with a sense of urgency. Women with mixed incontinence have to be carefully managed as both types of incontinence have a devastating impact on quality of life.

Did You Know?
Overactive baldder (OAB) symptoms are more bothersome than SUI due to the unpredictable manner in which they occur. OAB affects quality of life more severely than diabetes.