The inability to contain urine (urinary incontinence) is very common: about half of all women have, at least occasionally, urinary incontinence and about 20% of women of working age experience regular, disturbing incontinence.
There are three types of urinary incontinence. All patients who book an appointment because of incontinence problems are asked to fill in forms which describe the patient’s symptoms and the degree of inconvenience or frank disability due to incontinence. This provides some guidance for the direction of further examinations and treatments.
Stress urinary incontinence is usually due to weakening of the structural support of the urethra. Some urine leaks on straining, sneezing or coughing. Some of the predisposing factors may be childbirth, injuries at childbirth, overweight, age-related impairment of muscle strength, problems with the blood circulation and the connective tissue of the pelvis, and estrogen deficiency.
Urge incontinence is a condition where urine leaks in connection with a compelling and urgent need to urinate and is due to impairment or loss of functional bladder control. The bladder reacts even to the slightest stimulus, e.g., sensation of bladder filling, hearing purling water. It contracts and this leads to numerous restroom visits and, in time, to leakage of urine. Dryness of the mucous membranes, urinary tract infections, habits, diseases of the bladder wall or injuries may predispose to urge incontinence. The cause may also remain unknown. By retirement age up to four fifths of all cases of incontinence are urge incontinence.
Mixed urinary incontinence is when the patient has symptoms of both types of incontinence.
Treatment of urinary incontinence
Stress incontinence may be treated conservatively or surgically. The important elements of conservative treatment are self-training or training guided by a physiotherapist of the pelvic muscles, weight reduction and estrogen treatment. If conservative measures are insufficient for treating stress incontinence and the symptoms impair the patient’s quality of life, surgery is a treatment option. Surgery aims at reinstituting the anatomical support of the urethra, which is necessary so that the urethra can close during strain. The currently most common operation in Finland is placement of a supportive band at the midportion of the urethra (tension-free vaginal tape [TVT), transobturator tape [TOT] or tension-free vaginal transobturator tape [TVT-O]).
Urge incontinence is treated conservatively by relaxation training of the pelvic muscles, modified drinking habits, rationalization of urination frequency, treatment of the mucous membranes, bladder training and medication. The goal of treatment is to inhibit the reflex that causes involuntary and frequent urination. For this, estrogens may be used, as well as drugs that reduce bladder contractibility, e.g., mirabegron, oxybutynin, tolterodine, trospium chloride, solifenacin, darifenacin and fesoteradin. Since these drugs have a fast onset of action, they may also be used on-demand, e.g., when symptoms are socially disturbing, as during theater visits.
Treatment of mixed incontinence follows the principles for whichever of the two components (stress or urge) is more significant. The primary choice in both cases is conservative treatment, but surgery may be an option if conservative treatment does not provide sufficient relief.