Women's Health Specialists of St. Louis
Obstetrics and Gynecology

Articles - Incontinence

Few patients will dare to mention that they involuntarily leak urine. Yet recent studies reveal that this affects more than 50% of the population of women between the ages of 20-80 years. It is estimated that $26 billion is spent a year in the management of incontinence. So what causes incontinence? The most common type of urine loss is referred to as stress urinary incontinence. It is the loss of urine that occurs with an increase in abdominal pressure such as when laughing, jumping, sneezing, coughing, and lifting. This is caused by a loss of the support of the bladder and urethra. There is a direct relationship between vaginal childbirth and stress urinary incontinence. The larger the child and or the more children born vaginally, the greater the risk of incontinence. This occurs because of the stretching and injury that occurs to the vagina during delivery. Symptoms of incontinence may be mild or absent until menopause when a decrease in the hormone levels causes further weakening of the estrogen sensitive tissues. Kegel exercises or the flexing of the muscles which are used to stop the flow of urine rarely work for two reasons. First, like any other exercise, they need to be performed routinely. At least five sets of 20 should be done daily. Secondly, by the time that women become symptomatic, the tissues are so weak (atrophic) that they are no longer in an anatomically correct location. For example, the stretching and tearing of the vaginal supports may allow for the bladder to fall down onto the vagina. This is referred to as a cystocele. The rectum can also bulge into the vagina and this is called a rectocele. Sometimes the very supports of the uterus are stretched to such an extent as to allow the uterus to sag down into the vagina or even protrude from the vaginal opening. This is referred to as uterine prolapse. All of these defects are uncommon in women who have not had a vaginal delivery. They may be more severe in women who have had large (8 pounds or more) children, who smoke, who are over weight, and whom routinely perform heavy lifting.

Other types of urinary incontinence exist such as urge incontinence. Urge is also referred to as detrusor instability or "over active bladder." It is not necessarily related to anatomic changes but rather is the result of inappropriate contraction of the muscle (detrusor muscle) of the bladder. This type of incontinence may respond to medications that relax the muscle of the bladder. Other types of incontinence include mixed incontinence which is a combination of stress and urge incontinence, and overflow incontinence. Over flow is caused by an under active detrusor muscle and results in constant dribbling as the full bladder continues to fill and overflow. This type of incontinence is secondary to bladder injury from chronic illnesses like diabetes, radiation therapy, or radical pelvic surgery. Finally, functional incontinence is secondary to impairment of physical or cognitive function. For example, a woman with a recent concussion and hip injury may not be able to get to the restroom prior to urinating because of both confusion and lack of speed.

So how do you get evaluated for incontinence? The type of incontinence can often be determined by your physician with history and physical exam. In some cases further bladder testing or urodynamics may be indicated to determine the type of incontinence that is present. Treatment of stress urinary incontinence must be surgical in order to repair the anatomical defects. Detrusor or urge incontinence may be treated with medications which are now available in pill or patch form.