Urinary incontinence in women: the extent of the problem, diagnosis

mature caouple on the beach hugging each other

Dr. René Rottenberg

Specialist in gynecology and obstetrics, Grand-Rue, Coppet

April 14, 2022

Urinary incontinence is the loss of bladder control. The extent of the problem varies. It can manifest itself as occasionally leaking urine when you sneeze or cough, to completely being unable to control it at all. It mostly happens after the age of 50, but it’s known to happen earlier as well. In order to get a diagnosis, it is important to visit your doctor or gynecologist. It’s diagnosed with a complete physical examination. Treatments can also vary depending on the age, type, tolerance for specific medications, and more. There are also surgical methods if need be. Some of the risk factors include age, being overweight, smoking, family history, etc.

Want to learn more? Keep reading the article by Dr. René Rottenberg!

The involuntary loss of urine is considered by many to be an inescapable phenomenon, a kind of fatality, to which one must resign oneself. Moreover, the loss of control over one’s natural needs forces these people to remain silent, and they fear the contempt of those around them. As a result, medical care is not sought, for fear of disclosing a pathology of this type. The problem is significant since it probably affects half of all women over the age of 50, and it is estimated that approximately 500,000 women in Switzerland suffer from some form of urinary incontinence.

There are essentially 3 forms of incontinence:

  • Stress incontinence
  • Emergency incontinence
  • Mixed incontinence, which is a mixture of the first two forms.

Stress incontinence:

This is the loss of urine when coughing, laughing, sneezing, carrying heavy loads, walking fast, or doing various gymnastic exercises. It is a weakening of the sphincter and muscle structures of the pelvic floor so that during such an effort the intro-abdominal pressure exceeds that of the urethra (the tube leading from the bladder to the outside), thus causing leakage.

This form of incontinence is most often found in young women up to the age of 50-55 years and is caused by various situations that can lead to this weakening:

  • Pregnancy, with the delivery of heavy children, traumatic deliveries, physically demanding professions where standing is most frequent, such as fieldwork, waitressing, nursing and caretaking. Some situations present risks such as obesity or smoking, the former due to the excessive weight that is more difficult to contain in the urogenital hiatus, the latter due to repeated episodes of bronchitis that increase the abdominal pressure each time with often significant coughing fits.

Some of these situations, which cause stress incontinence, are accompanied by an anatomical defect commonly known as “organ descent”, where the bladder unwinds and pushes the wall of the vagina outwards, or the uterus, poorly retained by its ligament system, tends to prolapse, or finally, the rectum pushes the posterior wall of the vagina outwards as well These 3 situations of weakening often result in the impression of weight (or ball) in the vagina that is embarrassing for the patient.

Urge incontinence:

This is a loss of urine that occurs when the bladder muscle, which is outside of voluntary control, contracts inadequately outside of a “normal” time of need to urinate; normality in this area corresponds to a bladder filled with between approximately 300 and 600 ccs of liquid. Furthermore, in the normal state, the initiation of micturition is under voluntary control, in the sense that once the filling capacity is reached, we allow, by different mechanisms, the opening of the urethral canal and the initiation of a contraction of the bladder muscle, thus the micturition. In the abnormal state, this or these contractions occur outside of any voluntary command. The muscle works by itself. Various situations can initiate these abnormal contractions, such as the impression of having a full bladder when it is not, indirect phenomena, such as hearing or seeing water flowing, a simple cough, a urinary infection, or various illnesses, one of the signs of which may be urinary incontinence of this type, such as Parkinson’s disease, diabetes, multiple sclerosis.

Mixed urinary incontinence:

Urinary leakage is due to one or the other of the two phenomena (stress or urgency) with usually one of the two predominating over the other. In the elderly, mixed urinary incontinence occurs in 60 to 70% of cases. This concept involves another neurological defect, namely that the bladder is too full and the signal is not transmitted to the brain, and the initiation of micturition does not occur. The bladder, not being able to go beyond a certain capacity, empties itself in small quantities to simply eliminate the overflow.

How to diagnose

The essential elements of the diagnosis are based on the history and physical examination. About 80-85% of incontinence can be diagnosed by these two means. The remaining 15-20% will require specialized examinations called urodynamics, which consist of the measurement of simultaneous intravesical and intraurethral pressure, giving us valuable information about the efficiency of the urethral sphincter. In addition, during regular filling of the bladder, the activity of the bladder can be measured in an attempt to highlight the contractions described above. This is an outpatient examination during which a very thin urinary catheter is placed in the bladder through which the filling can take place and measurements can be made. The examination takes between 30 and 60 minutes. It is not painful. Beforehand, the patient will have been checked for a urinary infection. Other examinations may be necessary, such as X-rays of the bladder and urethra to establish the degree of weakening of the anatomical structures supporting the perineum (cystography, ultrasound). Occasionally, electro-myographic examinations may also be requested to determine the integrity of the muscles in the region. A compliment to this examination may be requested in the form of a neurological examination to look for specific pathologies as described above. As part of the physical examination, the examiner will perform what is called a muscle test of the levator ani muscle, which consists of depressing the vulva towards the This is done by inserting two fingers into the vagina and asking the patient to resist. In this way, both the initial state before treatment and the progress made if this examination is repeated after treatment can be assessed. In the elderly (over 80 years of age) the examinations and diagnosis will, of course, be adapted to the conditions, i.e. social environment, general condition, the possibility of self-care, or dependency. In the case of an elderly person in an institution, the detection of bladder muscle contractions is more straightforward, in the patient’s bed, by observing changes in the level of perfusion connected to a urinary catheter.

It is very likely, as, in most areas of public health, that preventive measures for urinary incontinence will be by far the most effective in reducing the extent of the problem. It is likely that the female perineum and all the structures that form it, if not strengthened early on, will be insufficient to ensure continence and the anatomical support of the intra-pelvic organs, which are its functions, in the long term. It could be said that specific pelvic floor gymnastics could already be systematically integrated into the school curriculum! (this is not done systematically). It is also clear that childbirth should be as non-traumatic as possible, and accidents The impact of these preventive measures cannot be prejudged at this time, given the lack of hindsight. The impact of these preventive measures cannot be prejudged now, given the absence of hindsight; it can nevertheless be speculated that it would not be zero.

The current treatments, when the pathology of incontinence is proven, are of 2 types, namely:

– Conservative treatments

– Surgical treatments

CONSERVATIVE TREATMENTS:

These are essentially aimed at patients with a moderate degree of incontinence, i.e. characterized by involuntary leakage of urine, when coughing, sneezing, carrying loads, during certain gymnastic exercises. Often it is simply a question of a weakening and relaxation of the muscles of the perineum and the muscles surrounding the urinary sphincter. These muscles can be strengthened by specific exercises, which can be done at home or with the help of a physiotherapist or a midwife specializing in this area. The exercises consist mainly of resistance, squeezing against a form placed at The patient is given a monitor inside the vagina, connected to a screen, where the muscular force exerted by the perineum is recorded by peaks of varying height. This allows the patient to control her effort and to see her progress. This technique is called “retro-control” or biofeedback. Conversely, from the machine and its screen, we can send an electrical stimulation, felt as a vibration, to the rings situated on the intra-vaginal probe and practise an electrostimulation which will allow the patient to become aware of her perineum on the one hand, and on the other hand to obtain progressively stronger contractions of the muscles. This electrostimulation is painless. It can also be applied in different ways, with different electrical frequencies depending on the aim. The frequencies will be higher if we are looking to strengthen the muscles and lower if we are looking to stabilise a bladder that contracts on its own.

This means that this treatment can also be applied to emergency incontinence. Sometimes bladder stabilising drugs are added to these electro-stimulation treatments when the aim is to treat emergency incontinence. The results of these conservative treatments are encouraging, since about half of the patients, if they are well selected, will respond favourably. Another selection criterion is the absence of significant bladder descent.

If organ descent is associated with incontinence, and surgery is to be avoided, prostheses, called pessaries, can be tried. These are rings, cubes or cups, inserted into the vagina, which push the prolapsed organ(s) back into the vagina, thus cancelling the “ball” effect in the vagina. These pessaries are not perceived by the patient, they act as a vaginal tampon. The patient manages her pessary herself, removing it every one to three evenings and reintroducing it herself the following morning. She will avoid vaginal irritation or ulceration by coating her pessary with oestrogen cream. Estrogens not only protect the vaginal mucosa but also help to reduce the problem of urgency. They have a purely local effect and are not dangerous.

Surgical treatments:

There are now 150 known surgical procedures for the correction of urinary incontinence. This of course reflects the fact that there is still no one intervention that is better than all the others and that research is still ongoing. The success of these interventions, when well-chosen and well-performed, i.e. in expert hands, is around 85% – 92%. These interventions can be either vaginally or abdominally. The current trend is to simplify the procedures and the principle generally advocated today is that of providing support to the urethra when it is insufficient, rather than “raising the organs”.

This is how a thin support band is installed between the skin of the vagina and the urethra, creating a sort of solid hammock on which the urethra will rest in case of abdominal effort such as coughing or sneezing. This solid support will guarantee continence.

Techniques may vary and the passage of the sling through the “obturator holes” of the pelvis, while still supporting the urethra, is a similar approach, but one that seeks to minimize certain complications. This technique is now widely used by many surgeons.

Special case of the elderly:

In institutions, it is clear that many pathologies can be found in the same person over 80 years old. Urinary incontinence is very frequent at this age, most often mixed, and relatively difficult to treat.

The treatments are essentially behavioral and consist of micturition calendars and schedules, correction of bad drinking habits (sufficient quantity of beverages, about 1.5 L/day, regular micturition every 2-3 hours, even without need, avoidance of diuretic drinks such as tea, coffee, coca-cola), attempts to take charge of the micturition function by the patient him/herself, and this requires patience, empathy, and compassion on the part of the nursing staff. For the moment, all too often, these staffs are insufficient in number to take this problem seriously and certainly, a special effort must be made for this category of patients.

The time is past when you have to hide if you have this type of problem. You have to talk to your doctor, the means to help are there, available, and much less traumatic than in the past.

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