This is the most common cause of urinary incontinence in women and is often caused by a weakness of the ligaments or muscles under the bladder. There are 2 main treatment options:
Pelvic floor physiotherapy
Pelvic floor exercises / physiotherapy can improve the bladder control of approximately 60% of women with stress incontinence – it is therefore usually a good idea to try this before considering surgery as an operation may not be necessary. The exercises can work very quickly for some women who regain “The Knack” of squeezing their muscles at the correct time. Sometimes it can take several weeks to fully regain the strength in the muscles around the bladder.
Physiotherapy also involves advice regarding your own anatomy (and what has gone wrong), lifestyle changes, bladder retraining and fluid modification. Pelvic floor stimulators or vaginal cones (see image opposite) can also be used.
Pelvic floor exercises can be taught by Jackie Walker (Urogynaecology nurse specialist Jackie Walker). In addition we work closely with the physiotherapy teams at Spire Hospital Harpenden, Spire Hosiptal Bushey and the Redbourn Physiotherapy clinic.
Surgery
For those women with stress incontinence who don't improve with pelvic floor exercises surgery is usually the next step. Day case sling operations such as a TVT procedure are the most popular and successful.
Mr Hextall performs 150-200 Tension-free Vaginal Tape (TVT) procedures each year. Through tiny incisions in the pubic hair and vagina a small sling/tape is inserted under the bladder to give extra strength and support.
Most women go home the same day with a short recovery period of about 5 days before driving is allowed. Sometimes it can take slightly longer before patients are ready to return to work. For further details of the expected recovery after a TVT procedure click here.
The TVT operation does not work for everyone with stress incontinence but the success rates are very good. Analysis of over 500 women having a TVT under Mr Hextall's care show:
- 93% Cured of stress incontinence
- 4% Improved
- 3% No change (procedure not effective)
As we perform so many of these operations we have developed very safe techniques with a very low risk of complications such as bleeding or infection. Some women do notice that their flow can be a little slower but it is unusual to develop severe problems with difficulty emptying. The effect on the symptom of urgency, which can also bother some women with stress incontinence, is less predictable but does improve in the majority of patients.
There are a number of causes of urge incontinence and sometimes it is necessary to perform some tests to see what is happening.
Many women have urgency because they have an Overactive bladder. This condition has a number of other names including detrusor overactivity, detrusor instability, irritable bladder and unstable bladder.
An overactive bladder squeezes when you don't want it too. It is often a worse problem than stress incontinence because urgency may come on suddenly and a large volume of urine can leak – causing urge incontinence. Often women have other troublesome symptoms such as urinary frequency and they make have to get up several times each night - disturbing their sleep.
What causes an Overactive bladder?
No one is sure why an overactive bladder develops. Some patients remember having problems controlling their urine as a child – perhaps they were a late bed wetter, frequently had to leave the class to pass urine while at school or had accidents in the playground while laughing with friends. Other women develop symptoms of urgency as they get older and may find they have to rush to pass urine if they listen to running water, wash their hands or put the key in the door. There are lots of theories why an overactive bladder may develop. It may be that the bladder muscle becomes irritable, the nerves to the bladder are oversensitive or the area in the brain which controls the bladder is malfunctioning.
What treatments are available?
1. Fluid modification. Sometimes patients drink a lot of tea, coffee or caffeinated drinks which may irritate the bladder and make the symptoms of frequency or urgency worse. It is often useful to complete a bladder diary so that we can accurately record how much fluid is taken in during the day, the number of times a patient goes to the toilet and the amount passed each time. Using this information, some women are asked to drink a little more (if they are not drinking enough then the urine can become very concentrated and this may irritate the bladder) or, alternatively, reduce their fluid intake because if they are drinking too much, this may make them go to the toilet even more often.
2. Bladder retraining. Many patients have got into the habit of doing to the toilet "just in case" because they are worried about developing urgency and leaking. Over time this means that the bladder will hold less and less so making the symptoms of an overactive bladder worse. Bladder retraining is used to try and gradually increase the time between visits to the toilet so that eventually the bladder holds more urine and patients gain greater control.
3. Physiotherapy. Many patients find that pelvic floor exercises, often under the supervision of a physiotherapist, can improve bladder control. As well as strengthening muscles, the physiotherapist will teach some distraction techniques, (e.g.) thinking of work or holiday while you have a strong desire to go to the toilet can make this sensation disappear over 30 seconds or so, and then you can calmly walk to the lavatory.
4. Medication. Many tablets are available to try and calm the bladder and stop it squeezing when it shouldn't. A patch can also now be used. Approximately 60-70% of patients will gain some improvement with the medication. Unfortunately, it has to be used long term and some patients can develop side effects such as dry mouth or constipation.
5. Bladder Botox injections. Botulinum toxin is not yet licensed for use within the bladder. However, in recent years physicians in both America and Europe have reported its successful use in the treatment of bladder overactivity, which is one of the commonest causes troublesome symptoms of urgency, frequency and urinary incontinence. Click here for Bladder Botox information sheet.
6. Surgery. Women with Mixed Incontinence (an overactive bladder and a weakness causing stress incontinence) may benefit from surgery but usually only when the bladder has been calmed down by medication.