Female Urogenital Tract
Female urinary incontinence, defined as the involuntary or accidental loss of urine sufficient to cause a problem, is a deeply distressing problem, which affects over 30% of women at some stage in their lives. It is a symptom not a diagnosis. Sadly, most sufferers are reluctant to discuss the problem due to embarrassment or accept it as part of the aging process. It may be transient such as with a bladder infection, or progressive as often occurs with advancing age. The control of voiding is complex and involves basic and higher neurological centres as well as good functional anatomy. For example, someone with a spinal injury or an emotionally disturbed child may become incontinent, just as well as a woman who has had a bad labour and delivery. What type of specialist ends up managing the patient depends on the perceived cause, although there is a great degree of overlap.
Accurate diagnosis is important. The most common types of incontinence likely to present to a gynaecologist are:
This is the most common type of incontinence in women, which occurs when sudden extra pressure (stress) is put on the bladder. In normal circumstances the pressure at the bladder neck would increase to balance the external pressure and maintain continence. The external pressure may be coughing, laughing or in extreme cases, simple movement.
The association with age, childbirth, chronic constipation, genital prolapse and unfortunate genetics amongst other causes is more pronounced. The weakness is that of the pelvic floor in general and the bladder neck in particular.
Prevention includes avoidance of causative factors such as constipation and it is generally believed that pelvic floor exercises may help. Bladder neck surgery may be advised after full assessment. Surgery could be as basic as a TVT or more complex and may include repair of an associated prolapse.
This is the next common form of incontinence. The desire to void cannot be suppressed and the bladder empties involuntarily. It bladder is often said to be "overactive", unstable or sensitive. It is often associated with increased voiding frequency and waking at night to void. It may be associated with urinary leakage during sex, especially during orgasm.
The causes of urge incontinence are not known but can be associated with stress, caffeine, urinary infection, caesarean delivery and nerve related conditions such as Parkinson's disease.
Treatment includes lifestyle changes, drugs, bladder retraining and very rarely surgery. Botox is now being tried in intractable cases and should not be considered as standard treatment.
It common for women to have a mixture of stress and urge incontinence. Objective diagnosis of urinary symptoms is by urodynamic investigations once other causes like infection; stones or tumours of the pelvis are excluded.
This type is associated with obstruction at the urethral level or lack of bladder sensation such that it does not empty. There may be constant dribbling and/or frequency.
Other types are the so-called functional and transient incontinence and that due to fistula formation.
Diagnosis and management
A thorough history, examination and a test to exclude a urinary infection are important to making the correct diagnosis. Any other test will depend on the working diagnosis but may include an ultrasound scan, special kidney x-ray (IVP), CT scan/MRI, pregnancy test or urodynamic investigations.Treatment and management will be tailored to the cause.