Factors that increase the risk of female urinary incontinence

In a study carried out in Spain – EPICC study – which was released at the 2007 National Congress of Urology, the following data were given:

• Women under 45 years of age: they had 6.4% urinary incontinence.
• Women between 45 and 54 years of age: the percentage was 10.5%.
• Women between 55 and 64 years of age: 15.5% suffered from some type of urine incontinence.

What types of incontinence are there?

Basically we find:

• Stress Incontinence: is the one in which there is a weakness of the ligaments of the pelvic floor and the urethra; as a consequence, the bladder neck descends with the efforts and loses its anatomical angle. This descent prevents the urethra from being compressed during straining, causing urine to escape – urethral hypermobility. It is the most frequent type in women, representing 49% of all types of incontinence.
• Urge Incontinence: involuntary contractions of the bladder occur. In other words, it is a “nervous bladder” – medically known as Overactive Bladder – which cannot be controlled by the brain. It is worsened by nervousness, cold weather, stimulants such as coffee and alcohol, carbonated beverages, diabetes mellitus, lumbar disc herniations and some neurological diseases. This type of incontinence would represent 22%.
• Mixed incontinence: in which the two previous types can be seen at the same time. It accounts for 29% of all types of incontinence.
• Incontinence due to intrinsic weakness of the urethral sphincter: it occurs because the sphincter is incompetent and is always open, allowing urine to pass at all times.

What are the risk factors?

1. Age: it has been sufficiently demonstrated that the prevalence – frequency – of cases of urinary incontinence increases progressively with age, since the tissues will lose elasticity due to the decrease in collagen, which is the substance that provides consistency to the muscle-ligamentous structures.
2. Childbirth: especially vaginal childbirth, during which there may be a greater tearing of tissues and greater suffering of the pelvic floor musculature and ligaments, even affecting the innervation of the urethral sphincter. It has also been seen that urinary incontinence is more frequent among multiparous women (women who have had several deliveries). In this case, stress incontinence tends to predominate.
3. Obesity: a clear relationship has been established between body mass index and urinary incontinence, since overweight increases intra-abdominal pressure, pushing the viscera towards the pelvis and causing a stretching, and therefore a weakness of the muscles, ligaments and nerves of the pelvic floor. On the other hand, it has been seen that in women who have undergone surgery for morbid obesity, the prevalence of incontinence decreased from 61% to 12%. The most frequent type of incontinence is usually stress incontinence.
4. Persistent constipation: due to straining, there is an overdistension of the ligaments of the pelvic floor, which can even damage the pudendal nerve, favoring the appearance of urinary incontinence, with stress incontinence being more predominant.
5. Various urogynecological factors: such as urinary tract infections, especially if they are repeated, prolapsed pelvic organs, such as the bladder and uterus or womb.
6. Neurological diseases: such as dementia, Alzheimer’s disease, multiple sclerosis, embolisms and hemorrhages, also known as cerebrovascular accidents, stroke or CVA. They are all causes of urgency urinary incontinence. Sometimes, the presence of a herniated disc at lumbar level can be the consequence of urge incontinence; the reason is that the nerves of the bladder originate in the lumbar spine, and a pinching of these nerves can cause an overactive bladder that causes bladder spasms and consequent urinary incontinence.
7. Diabetes Mellitus: also causes spasms or involuntary contractions of the bladder causing urgency urinary incontinence.
8. Medications: of the diuretic type, or to lower blood pressure -antihypertensives-.
9. Exciting substances: such as alcohol, coffee and colas, which favor the appearance of involuntary contractions of the bladder with the consequent urge incontinence.
10. Familial predisposition: there may be a genetic component, in terms of the quality of the muscular and ligamentous tissues of the pelvic floor.
11. Physical exercise: some exercises, such as abdominal exercises or jogging, by increasing the pressure of the abdominal viscera on the pelvis, may favor the appearance of incontinence. It is not uncommon to see incontinence in young sportswomen, even if they have not been pregnant.
12. Menopause: at this time there is a decrease in estrogen – female hormones – and therefore a loss of connective tissue, which is what gives resistance or strength to the ligamentous tissues.

What is a neurogenic bladder?

It is a clinical situation derived from a lesion of the nervous system, either by affectation at the level of the brain, of the spinal cord or, at the level of the nerves. Depending on where the injury occurs, or the degree of the same, the clinical consequences will be different.

What is the treatment for a neurogenic bladder?

It will vary from conservative treatment (intermittent bladder catheterization, pelvic floor rehabilitation, medication with anticholinergics, botulinum toxin, etc.) to surgical treatment; the surgical technique to be used will depend on the type and degree of involvement.

How does urinary incontinence affect a woman’s quality of life?

Incontinence can cause the woman to isolate herself, as she notices that the urine leaks give off an odor, and she is afraid that the people around her will notice the situation, so she begins to avoid social engagements.

Also, a British study showed that stress urinary incontinence altered the sex life of 28% of the women studied.

Urge incontinence makes many women unwilling to go to certain places where public toilets are not available, methodically planning the places where they can go.

Does urinary incontinence get worse as you get older?

Unfortunately, yes. We have already seen that menopause alters the ligamentous structures and weakens them. At the same time, problems of old age, such as diabetes or dementia, will aggravate incontinence.

Can postpartum urinary incontinence be prevented?

During pregnancy and childbirth, a number of changes occur in the structure of the pelvic floor tissues that are sometimes responsible for the subsequent onset of genital prolapse and urinary incontinence.

However, a pelvic floor muscle training program based on instruction by means of a simple booklet has been shown to be ineffective in terms of compliance. What is clear is that the exercises will have to be directed by physiotherapy professionals, being effective in this case and managing to prevent, to some extent, urinary incontinence.

How is it diagnosed?

• First of all, by physical examination: with a full bladder, coughing or straining will be ordered, and in this way it will be checked whether or not there is stress incontinence. At the same time, it will also be determined if there are genital prolapses.
• A urine culture will be requested to rule out that there are no germs and we are facing a urinary tract infection.
• It may be interesting to perform an ultrasound to visualize the bladder. Sometimes there are surprises, such as the presence of stones -lithiasis- in the bladder, which irritate it and favor infections and bladder spasms.
• A mandatory test in the diagnosis of female urinary incontinence is the performance of a Urodynamic Study. In this test the bladder is gradually filled with serum and the behavior of the bladder is recorded at all times, appreciating if there are involuntary contractions that may indicate the presence of an overactive bladder. The woman will also be asked to cough to see if there is stress incontinence. Finally, the woman will be asked to urinate to assess the behavior of the urethral sphincter. With this test, if urinary incontinence is present, it will be possible to label which group it belongs to and, therefore, which treatment is the most appropriate for each particular case.

What is the treatment for stress urinary incontinence?

If the incontinence is of a mild nature, pelvic floor muscle rehabilitation exercises can be tried with the intention of strengthening the pelvic floor muscles and improving leakage. This training implies that it must be maintained over time, as if it were a gymnastics any.

In addition, certain lifestyle habits must be modified, such as: losing weight, quitting smoking, not doing certain physical exercises, avoiding constipation, etc.

If the incontinence is more important, surgery may be proposed. Many techniques have been used, and not always with good results. Nowadays we have less aggressive techniques that can be performed under local anesthesia; they also require a minimal incision at the vaginal level and a hospital stay of a few hours. By means of these techniques we place a small polypropylene tape or mesh that acts as a hammock on which the urethra rests when straining, thus preventing urine leakage. The results are good, in a percentage of around 85% at 5 years.

How is incontinence due to urethral sphincter incompetence treated?

One of the surgical techniques used consists of placing a tape under the urethra that applies more tension, so that it somehow compresses the urethra enough to achieve continence.

Another system used is the injection, under the mucosa of the urethra, of different types of substances that manage to create swelling on the urethral lumen, closing it and, therefore, preventing urine leakage. This technique is performed with a little sedation and is practically ambulatory. The success rate is about 75% at 3 months and 45% at 3 years.

Are vaginal cones useful?

These cones, of graduated weight, are introduced into the vagina and the woman is expected to retain them by contracting the pelvic musculature while walking or coughing. If she is able to retain it, she will move on to another cone of greater weight, and so on progressively. This is an attempt to rehabilitate the pelvic musculature. A system similar to this is the Chinese balls.

What is electrostimulation used for?

Through low intensity electrical stimulation we try to strengthen the pelvic floor muscles. The equipment can be portable, and the exercises can be performed by the woman herself at home.

What is an artificial sphincter?

As its name suggests, it is a prosthesis consisting of a clamp that is placed around the sphincter of the urethra, attached to a reservoir of liquid and a mechanism that activates it, which is called a pump. When the activation pump, which is usually placed in the labia majora, is squeezed, the liquid from the reservoir passes into the cuff, which, when filled, compresses the urethra, thus preventing urine leakage. When you want to urinate, you only have to deactivate it, so that the liquid in the clamp returns to the pump.

This mechanism is used in rebellious cases where other techniques have failed.