Urinary Problems

The bladder has two distinct roles:

1. To store urine: under normal bladder control, the urine is collected and stored in the bladder without leakage. As the bladder reaches capacity, messages are sent to the brain that tell you that you need to go to the toilet.

2. To release urine when passing urine: As the bladder fills to capacity increasing messages are sent to the brain to void (pass urine). When comfortable to void the bladder contracts and the urethra relaxes to allow voiding. Women pass urine much faster then men, at a rate of 30-50 mls a second.

For females, the usual bladder capacity is approximately 500mL. Most females will pass 350-700mL each time they pass urine, which is 4-7 times per day. Prior to the age of 60, one night waking to pass urine is normal, and after the age of 60, one extra void during the day or night is also considered normal. There should be no urgency, frequency, burning, or blood in the urine.

• Stress urinary incontinence: Urine leakage occurs during exercise, coughing, sneezing, laughing, lifting heavy objects, and/or other body movements that put pressure on the bladder. This type of incontinence is the most common and it occurs when the muscle that keeps the urethra closed during times of increased abdominal pressure isn’t functioning well and allows urine to leak.
  
• Urgency urinary incontinence (overactive bladder): Urine leakage is associated with an urgency to urinate. Some women feel this urge and others do not. This type of urinary incontinence occurs when the bladder contracts suddenly, often as the patient is moving toward the bathroom but before she can get there, causing urinary leakage.
  
• Mixed incontinence: This is a combination of stress urinary incontinence and urgency urinary incontinence.
  
• Functional incontinence: Urine leakage occurs in patients who may have normal bladder function and sensory cues but cannot reach a restroom in time because of physical or medical conditions that limit their ability to get to the bathroom.
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• Overflow incontinence: Urine leakage occurs when the bladder does not empty properly. As a result, the bladder stores too much urine at any given time, and some leaks out. ​

At your visit, A/Prof Mahmoud may:

• Ask questions about when and how often you experience incontinence
• Conduct a physical examination that can help identify other conditions that may influence your bladder, such as pelvic organ prolapse
• Ask you to cough with a full bladder to see if you leak urine
• Ask you to keep a bladder diary, in which you would record what you drink, as well as how much and how often. If you would like to bring one to your appointment, you can print it HERE.
  

A/Prof Mahmoud may also order diagnostic tests including:

• Urodynamic testing to gain information about your bladder and urethra
• Urine analysis and culture to detect a urinary tract infection or any blood in your urine
• 3D ultrasound to evaluate the status of your pelvic floor muscles
• Cystoscopy to examine the inside of the bladder and urethra

In women pregnancy, childbirth, obesity, and menopause often contribute to stress incontinence by causing weakness to the pelvic floor or damaging the urethral sphincter, leading to its inadequate closure, and hence the leakage of urine. Stress incontinence can worsen during the week before the menstrual period. At that time, lowered estrogen levels may lead to lower muscular pressure around the urethra, increasing chances of leakage. The incidence of stress incontinence increases following menopause, similarly because of lowered estrogen levels. In female high-level athletes, effort incontinence may occur in any sports involving abrupt repeated increases in intra-abdominal pressure that may exceed perineal floor resistance.

Overactive Bladder (OAB) is defined as frequency, which is more that 8 urinations in 24 hours, as well as a strong desire to void with or without urge incontinence (involuntary loss of urine with urgency). Approximately 15% of adults have OAB, with half of those actually experiencing urge incontinence.

The overactive bladder is characterised by urinary frequency (8 or greater voids in 24 hours) and urgency (a strong desire to void) with or without urge incontinence (involuntary loss of urine with urgency). This condition affects 15% of adults with women more commonly affected, and the incidence increases with age.

Causes:

Unstable bladder:

Involuntary bladder contraction resulting in urgency or incontinence and may be related to the bladder muscle contracting too quickly.  Common triggers include washing hands, putting the key in the door, anxiety

Hypersensitive bladder:

Urinary urgency and or pain or urge incontinence when the bladder does not contract. Some causes include infection, inflammation, foreign bodies or tumours.

Detrusor hyperreflexia:

When the unstable bladder is due to neurological disease  (ie. spinal cord injuries, parkinsons, alzhiemers, multiple sclerosis).

Diagnosis:

Diagnosis is made by a combination of history, examination and investigation by your doctor. Infection is usually excluded with a urine test. Your doctor may ask you to complete a 24-hour urinary diary. This is an excellent means of confirming how many times you void, the volume voided and the amount of incontinence experienced Your fluid intake may also be recorded. Women with a hypersensitive bladder classically pass small amounts of urine frequently. Women with an unstable bladder may have normal urinary frequency but experience significant urge incontinence. Urodynamics may be required to confirm the diagnosis.

Treatment Options:

Most therapies that address urgency urinary incontinence focus on decreasing the abnormal contractions in the bladder that lead to urinary leakage.

• Lifestyle changes
  Some lifestyle changes can help reduce symptoms of urgency urinary incontinence, including:
  • Keep your bladder empty by urinating every two to three hours
  • Limit fluids which worsen incontinence including alcohol, caffeinated beverages, and high-sugar beverages
• Pelvic Floor Physical Therapy
  Pelvic floor physical therapy helps rehabilitate and restore the pelvic floor muscles to their normal function. Your urogynecologist will evaluate your pelvic floor muscles at your initial consultation and provide a referral if necessary.
• Medications
  Medications are especially useful for treating an overactive bladder associated with urgency urinary incontinence; however, many patients with mixed incontinence will benefit from medical therapy as well.
  
  Some medications that may help with urinary incontinence include:
  • Local vaginal estrogen: Low-dose topical application of estrogen to the vagina may help rejuvenate and tone tissues in the urethra, reducing some symptoms of urinary incontinence.
  • Anticholinergic oral medications:  Oxybutynin, Solifenacin, Fesoterodine, Tolterodine, Darifenacin, and Trospium are daily oral medications used to treat urgency incontinence or overactive bladder.
  • Beta-3-agonists: Mirabegron is an oral medication that relaxes the bladder muscle and decreases abnormal or unwanted contractions. 
    
• Procedures
  If lifestyle changes and medications do not adequately improve a woman’s symptoms of urgency urinary incontinence, there are several minimally invasive procedures that are low risk and effective at treating refractory (non-responsive) urgency urinary incontinence.
  • Sacral Neuromodulation: This is a minimally invasive procedure, which can treat both urinary and anal incontinence. A thin wire is placed through the skin in the lower back, close to the nerve that supplies the bladder. This wire is connected to a neurostimulator (similar to a pacemaker) and delivers small impulses to the nerves that control the bladder.
  • Percutaneous Tibial Nerve Stimulation: Percutaneous tibial nerve stimulation is another way to regulate the nerves to the bladder. This procedure is less permanent than sacral neuromodulation and ideal for women who want to avoid a procedure in the operating room. Percutaneous tibial nerve stimulation utilizes a tiny acupuncture needle placed in the skin over the ankle to deliver electrical pulses to the tibial nerve. The procedure is done in the office weekly for about three months. It is painless and does not have any risks or side effects.
  • Botox®: Injections of onabotulinum toxin A (Botox®) into the muscle in the wall of the bladder reduces urinary leakage episodes in women with urgency incontinence.

Functional incontinence is a form of urinary incontinence in which a person is usually aware of the need to urinate, but for one or more physical or mental reasons they are unable to get to a bathroom. The loss of urine can vary, from small leakages to full emptying of the bladder.

Overflow incontinence occurs when the patient's bladder is always full so that it frequently leaks urine. Weak bladder muscles, resulting in incomplete emptying of the bladder, or a blocked urethra can cause this type of incontinence. Sometimes neurological diseases, diabetes or other diseases can decrease neural signals from the bladder (allowing for overfilling) and may also decrease the expulsion of urine by the detrusor muscle (allowing for urinary retention). Additionally, tumors and kidney stones can block the urethra. Spinal cord injuries or nervous system disorders are additional causes of overflow incontinence. Overflow incontinence is rare in women, although sometimes it is caused by fibroid or ovarian tumors. Also overflow incontinence can be from increased outlet resistance from advanced vaginal prolapse causing a "kink" in the urethra or after an anti-incontinence procedure which has overcorrected the problem. Early symptoms include a hesitant or slow stream of urine during voluntary urination. 

Pathway for the surgical treatment of pelvic organ prolapse:

• Prolapse is the protrusion of vaginal tissue within and outside of vagina 
• While 50% of women who have had children have prolapse only 12-20% women undergo prolapse surgery
• So not all prolapse requires surgery!!!
• Pelvic floor excercises can help with early prolapse
• Vaginal ring pessaries can help however less than 10% continue to use pessary after 5 years

Summary of pathway findings:

• Obliterative surgery is a safe and efficacious option for the elderly or medically compromised who are happy to sacrifice sexual activity.
• In reconstructive surgery consider addition of apical support to both anterior and posterior vaginal repair
• The vaginal native tissue repair (sutures) is the preferred treatment of anterior vaginal prolapse
• The vaginal native tissue repair (sutures) is the preferred treatment of posterior vaginal prolapse (rectocele)
• In those with post-hysterectomy (vault) prolapse sacral colpopexy is the preferred apical option with vaginal based colpopexy being a reasonable alternative.
• In those with uterine prolapse hysterectomy and hysteropexy (uterine preservation) are both reasonable options however based solely on medical grounds the vaginal hysterectomy with apical support is the preferred option.
• Bilateral salpingo-oopherectomy (BSO) should be discussed at the time of hysterectomy in post-menopausal women.
• At prolapse surgery, those with pre-operative urinary stress incontinence and occult stress urinary incontinence should consider concomitant continence surgery.