Urinary incontinence

Urinary incontinence (involuntary leakage of urine) is a common problem affecting approximately 1 in 3 people over the age of 60 years. It is seen more frequently in women, but can affect men as well among whom it is often caused by prostatic surgery. Incontinence is not life threatening, but can significantly impair patients’quality of life by affecting their physical, psychological and social wellbeing.

Urinary incontinence is either caused by an overactive bladder, a weak pelvic floor/urinary sphincter or a combination of both. Patients with an overactive bladder are said to have urgency incontinence and report symptoms such as going to the toilet too often, having to rush to the toilet and getting up at night to urinate. Those with a weak pelvic floor/urinary sphincter are said to have stress urinary incontinence and report leakage on exertion such as coughing, sneezing, bending, lifting and exercising. Patients with both types of symptoms are said to have mixed urinary incontinence.

The diagnosis is established by a careful history, bladder diary (documenting fluid intake and urine output), physical examination and specialised investigations such as flow rates, post-void bladder scan and urodynamics.

For patients with urgency incontinence, the initial management includes the following:

  • Life style changes including optimisation of weight and fluid intake and avoidance of irritant fluids such as caffeinated and carbonated drinks.
  • Bladder retraining trying to increase the intervals between voids.
  • Pelvic floor exercises – Strengthening the pelvic floor has been shown to suppress the urge to urinate. This can be learnt under the formal guidance of a dedicated physiotherapist.
  • Anti-cholinergic medication – These are pills that calm down the bladder and are effective in about 60% of patients.

If these measures fail, more invasive options are available and include the following:

  • PTNS – An outpatient treatment, similar to acupuncture and involves electrical stimulation of a nerve at the ankle. It is safe and effective for patients with mild to moderate symptoms.
  • Intravesical injection of Botox – Involves a minor day case procedure where botox is injected at several places in the bladder wall. It is performed via a telescope inserted into the urethra (water pipe). It has an 80% success rate. The only serious side effect seen in about 10% of patients is a temporary impairment of bladder emptying requiring use of a catheter. The treatment needs to be repeated once every 6-9 months.
  • Sacral Neuromodulation – A small electronic device that can be considered as a bladder pacemaker, is implanted into the lower back in two stages. Once successfully implanted, it works in about two thirds of patients for about 8 years.
  • Bladder augmentation – Major surgery involving enlarging the bladder with a patch of the patient’s own bowel. Almost always results in impaired bladder emptying that can require intermittent self-catheterisation.
  • Urinary diversion – This is used as a last resort for patients who either are not willing to use a catheter or have failed other forms of treatment.

For patients with stress urinary incontinence, the initial management includes the following:

  • Weight optimisation
  • Pelvic floor exercises
  • Regulation of fluid intake
  • Attention to aggravating factors e.g. cough, constipation etc.

If these measures fail, the subsequent options are surgical and involve the following:

  • Mid urethral tape – Also called a tension free trans-vaginal tape (TVT) or trans-obturator tape (TOT). This is a minimally invasive operation, performed as a day case under a general anaesthetic. Results are very good with an improvement in continence in 80-85% of cases. Long term complications include a ~5% risk of problems with bladder emptying requiring the use of a catheter, a small risk of chronic pain in the groins and bladder overactivity.
  • Colposuspension – An open (through a horizontal lower abdominal incision) or laparoscopic (key hole) operation to hitch the bladder neck up and anchor it to the back of the pubic bone. A bigger operation than mid urethral tapes with similar results.
  • Pubo-vaginal slings – Not unlike the mid urethral tapes, but it uses tissue harvested from the patient’s own body. It involves major surgery through an abdominal incision like that of colposuspension as well as vaginal incision as in mid urethral tapes. Is generally reserved for cases who have failed the first two less invasive options.

The Royal Free Private Patients Unit has a highly effective team of comprehensively trained consultants, specialist nurses and physiotherapists offering the highest quality care. We have significant experience not just in diagnosing the cause of incontinence, but also the most effective and least invasive methods of successfully treating it.