Incontinence is the involuntary loss of either urine (urinary incontinence) or faeces (faecal incontinence). A large proportion of adult women have urinary incontinence. There are two main types of urinary incontinence – Stress Incontinence and Urge Incontinence.
This can occur when pressure on the bladder is increased because of coughing, sneezing, laughing, exercise etc. Usually, the muscles at the neck of the bladder form a tight seal to hold the urine in without leaks. If these muscles are weak or damaged, then a sudden increase in pressure may cause some urine to leak out into the urethra, which is the outlet for the bladder. This channel being highly sensitive, the entrance of some urine into it can trigger a contraction of the bladder, causing even more urine to leak out.
Stress incontinence is often caused by damage to the hammock of ligaments that supports the bladder neck. This often occurs after childbirth and is particularly associated with big babies, long labours and deliveries involving instruments (forceps). The symptoms may not be too noticeable at first, but may worsen after the menopause as lack of oestrogen causes the hammock tissue to weaken. Other factors that may contribute to this condition are obesity; chronic diseases which induce persistent coughing, like bronchitis, and smoking-induced coughing.
Some women may have a sag in their ligaments because of a collagen deficiency. Collagen is a protein which is present in great abundance in the body, particularly in connective tissue, and provides elasticity to ligaments and tendons.
The diagnosis of Stress Incontinence is usually based on examination and elimination of more serious underlying causes for incontinence, such as urinary tract infection. Before undergoing any treatment it is important to discuss your symptoms with your GP or health professional.
Treatment of Stress Incontinence involves strengthening the muscles that support the bladder neck to raise the hammock upwards. Pelvic floor exercises are helpful for many women and should be started early in life. It is important that they are done properly, and if there is any doubt or the symptoms are not improving the advice of a physiotherapist is recommended. However, as women grow older, the benefit gained from these may reduce as tissues weaken further with age.
There is now medication available that can lead to a 50% or more improvement in the symptoms of stress incontinence. It works by increasing the tone of the muscle at the neck of the bladder. Like all medication, it may have some side effects, and your doctor can advise you about these.
Many women will find the above measures useful, but for those that don’t, there are various minor surgical procedures that can be performed. If you are being considered for surgery, then your specialist will probably recommend a special test called urodynamics, which involves the use of pressure catheters in the bladder and rectum to measure the changes that happen when your bladder is filling up and when you are straining.
Surgery involves elevating or strengthening the neck of the bladder to make it more difficult for urine to leak out. The commonly used operation is a procedure which suspends the vagina and bladder neck, called a colpo-suspension. It is successful in 80% of women and appears to cause a long-term improvement.
This colpo-suspension technique is now being increasingly replaced by a simpler procedure that involves introducing a tape underneath the bladder neck, which recreates the hammock. These tapes can be inserted under local anaesthetic and be adjusted once in place to the correct position. There are various types of tape available, but the main ones are TVT (tension-free vaginal tape) and TOT (trans-obturator tape). Your specialist will advise you on which is most suitable for you.
The bladder is a balloon with walls made up of muscle fibres, and the muscular part of the bladder is called the detrusor. When urine fills the cavity, the muscle stretches and becomes highly strung. This creates the desire to empty and, when it is appropriate the bladder neck muscles relax, the detrusor contracts and the urine flows out. This movement is usually synchronised, however in some situations the bladder muscles become irritable and will contract at inappropriate times causing a strong urge to pass urine that may cause some urine to leak out.
Bladder infections can cause similar symptoms and it is always important to consult your doctor the correct diagnosis can be made. Bladders often become more sensitive after the menopause and a small dose of oestrogen in the vagina or HRT itself may help.
The main treatments for this condition are bladder retraining and/or medication. Bladder retraining is usually done in conjunction with pelvic floor exercises by a physiotherapist or specialist nurse. There is a variety of medication available that acts by dampening down the irritability of the bladder muscle. Your GP or specialist will advise you which one is the most suitable. If your symptoms do not improve then you may require further test including urodynamics (see above) or a cystoscopy (the passage of a very fine camera into the bladder), which can be done under local anaesthetic. Very rarely more major surgery may be required. The effectiveness of managing and treating urinary incontinence is primarily evaluated not only by the reduction in urine loss or urine leakage undertaken by urodynamic and pad tests, but also by improvement in the quality of life, social functioning and a return to a more normal lifestyle.
This is the involuntary loss of faeces, either liquid or solid. It is an understandably embarrassing condition but is much more common than most people realise. It usually results from damage to the muscles around the anus (sphincters) at the time of childbirth. The situation can usually be markedly improved with simple measures such as pelvic floor exercises and dietary changes, but specialist advice should always be sought to exclude other possible causes. Sometimes the situation may be aggravated by prolapse, which may need to be corrected surgically. Surgical reconstruction of the sphincter muscles may be possible but would need specialist assessment.
Prolapse – Uterine and Vaginal
Prolapse is a gynaecological hernia. When the walls of the vagina become lax, the organs that they should be supporting bulge into the vagina, creating the sensation of a lump hanging down. There are many types of prolapse, which differ according to which organ is affected. The uterus is supported at the top of the vagina, and when the ligaments in this wall loosen, the uterus bulges downward. This condition is called uterine prolapse. Other types of prolapse include prolapse of the bladder into the front wall of the vagina (cystocele), that of the rectum into the back wall (rectocele), and that of the small intestine into the top of the vagina (enterocele). A combination of the last two is known as a recto-enterocele.
Causes of Prolapse
The common causes of prolapse are childbirth, loss of hormones at menopause, being overweight and chronic illnesses which create a lot of pressure inside the abdomen (such as chronic lung disease, which causes considerable congestion and coughing). It is less common in women who have not had babies, and most common in those who have had difficult vaginal deliveries, but there is evidence to indicate that women who have had caesarean sections also develop vaginal wall weakness. This is thought to be due to pregnancy hormones, which allow the tissues to stretch beyond their rebound limits, and also the weight of an ever-growing womb containing the baby. Prolpase can also be exacerbated by the loss of muscle tone associated commonly with ageing.
Those who suffer from uterine prolapse often report a sensation of heaviness or pulling in the pelvis, with a feeling of “sitting on a small ball”. It can also be accompanied by low backache and, in moderate to severe cases, protrusion from the vaginal opening. Uterine prolapse may also cause difficult or painful sexual intercourse.
Lax bladder support leads to a “reservoir effect” where the bladder is not completely emptied when the urine is passed. The remaining urine then irritates the bladder, leading to bladder spasms, which causes urgency and is sometimes severe enough to produce an involuntary leakage. The lowering of the neck of the bladder with prolapse can result in stress incontinence, which involves the leakage of urine into the urethra as a response to any sudden pressure, often followed by a contraction of the bladder causing even more leakage. A lax and irritable bladder may also leak during intercourse, due to the pressure exerted upon it.
Those who suffer from rectal prolapse complain of a sensation of bulging in the vagina when they strain to open their bowels. There is in effect an “S-bend” effect in the vagina, where faeces move into the reservoir created by the prolapse. Despite the urgency to open the bowels, very little bowel motion is likely to occur, as the reflexes tend to be lost due to this pouch effect. Constipation and irritable bowel syndrome may result from this. When the small intestine is also prolapsed, patients complain of a tangible bulge and a dragging or “balloon like” sensation in the upper vaginal wall. This may also make intercourse painful.
Prolapse is usually diagnosed by a pelvic examination.
It is usual practice to send patients to physiotherapy sessions to help with their symptoms. Logic suggests that when the elasticity of the vaginal walls has been exceeded, the physiotherapy exercises would not allow the tightening to occur to any significant effect. However, some women do report improvement in bowel and urinary symptoms to some extent because of these exercises. When the prolapse is troublesome, soft ring pessaries are available. The effect of these is to hold the walls of the vagina away from the centre and hence tighten the “hammock” of tissues that hold the organs. These rings are changed regularly, and are often used along with topical estrogen creams. When the prolapse involves the womb or the top of the vagina, or when there is no womb from a previous hysterectomy, another device called a shelf pessary is inserted, which effectively “dams up” the prolapse. Again, use of hormone creams help keep these devices in place on a long-term basis.
When these pessaries are not effective or uncomfortable and unacceptable, surgery is the next step. Vaginal repairs can be performed where the prolapse is reduced and supporting sutures inserted. Various other materials have been used to provide longer lasting repairs in the form of nylon mesh, etc. but it is now more commonly practiced to use animal tissue grafts to support the repairs, with good results. Pig material is now widely used successfully, with very few side effects. Patients should discuss possible treatment options with their doctor.