 Bi- monthly treatment reviewStress, urge and mixed urinary incontinence by Dr Sarah JarvisUrinary incontinence (UI) is a huge, and largely hidden, problem, responsible for much needless embarrassment and can affect all aspects of a woman's quality of life. Urinary incontinence is defined as an involuntary loss of urine that has been objectively shown to cause social and hygiene problems.
The most common form of urinary incontinence is stress urinary incontinence (SUI) - approximately 1 in 3 women experience SUI symptoms in the UK. It is defined as the accidental leakage of urine during physical activities such as sneezing, coughing, laughing, lifting or exercise. Causes can include pregnancy, and childbirth, but women of all ages are affected.
Urge urinary incontinence (UUI) is defined as the complaint of involuntary leakage accompanied by or immediately preceded by urgency. If urination happens too frequently (the average is seven times a day), the bladder capacity to retain urine decreases, and frequency, nocturia and urge incontinence are the result.
Mixed urinary incontinence (MUI) is, as the name suggests, a combination of SUI and UUI. It is defined as involuntary leakage associated with urgency and also with exertion, effort, sneezing or coughing. Unfortunately, one often leads to the other, as women with stress urinary incontinence try to avoid episodes by more frequent urination, which predisposes to urge incontinence.
The degree of symptoms caused by one or the other cause varies between sufferers, and it is therefore important to identify the more predominant and bothersome symptoms and to treat them first. Treatment options for urinary incontinenceWhy the importance of differentiating between symptoms of stress and urge incontinence? Because they have different causes, their management and treatment is completely different. Management of SUI is aimed primarily at the sphincter muscles and the pelvic floor, and first line treatment is usually pelvic floor exercise. With encouragement and perseverance, success rates for this treatment can be encouraging, but many women fail to persevere with exercise. Vaginal cones and surgical treatment are also options.
Drug treatments for UUI have long been among the most popular options for treatment and have also historically been used in the treatment of SUI although they are not tested for this use. Recently a drug treatment, called duloxetine (Yentreve), has been developed specifically for women with moderate to severe symptoms of SUI. This treatment has been proven to reduce the frequency of episodes with corresponding improvements in quality of life. The main side effect is nausea, but generally tends to resolve within 30 days of treatment, and can be managed effectively.
Non-pharmacological therapy for UUI involves bladder retraining, which works on the principle that conscious effort to avoid urination re-establishes voluntary control of the bladder. There are several drug treatments available, including solifenacin (Vesicare) oxybutynin and tolterodine (Detrusitol) - drug treatment is a common choice for UUI.
For the large proportion of patients with MUI, maximal relief will be gained by identifying the most bothersome symptoms of incontinence. It is essential to recognise, for instance, that for many women, while urinary urgency is the most dramatic presenting symptom, it only precedes a small proportion of episodes. Clarifying the Diagnosis | Questions to clarify the cause(s) of incontinence
Yes to some or all of these questions suggests stress urinary incontinence - Do you mostly leak small amounts of urine?
- Do you leak urine without warning, or feeling that you need to pass urine, when you cough, sneeze or laugh?
- Do you leak urine without warning, or without feeling that you need to pass urine, when you move suddenly, run, lift, jump or do other exercise?
Yes to some or all of these questions suggests urge urinary incontinence: - Before (or possibly at the same time as) you leak urine, do you get a sudden urge to rush to the toilet?
- When you feel the urge to pass urine, do you have to rush to the toilet and sometimes leak before you get there?
- Do you need to get up to pass urine more than twice at night?
- Do you wet the bed?
- Do you sometimes leak a large volume of urine?
Yes to questions from both sets of questions above suggests mixed urinary incontinence |
Dr Sarah Jarvis
Dr Sarah Jarvis trained at Cambridge and Oxford Universities. She is now a GP, GP trainer in inner-city London, and a Fellow of the Royal College of General Practitioners (RCGP).
Dr Sarah Jarvis writes extensively in the medical and consumer press, and is a regular contributor to Good Housekeeping, Women's Health, Pregnancy and Baby and You magazines. She is the ITN lunchtime news resident doctor and the Radio 2 doctor, appearing on the regular health slot on Jeremy Vine's Radio 2 Monday afternoon show. She also appears regularly on GMTV and Radio 5 live.
Dr Sarah Jarvis has authored A Younger Woman's Diagnose-It-Yourself Guide to Health, Diabetes for Dummies, Pregnancy for Dummies (published in 2005) and a chapter on women's health in the recently published RCGP book advances in general practice.
Sarah has a particular interest in women's health. She is the RCGP spokesperson on women's health and the tutor for the women's health module of the RCGP/University of Bath distance learning programme. She has also acted as advisor to, and presented, the satellite television series The Maternity Guide.
SUI Case StudiesSimone Simone is 49 years old and married with two children. She is the owner of two health clubs in the UK, is a personal fitness trainer and was awarded UK's Fitness Professional 2002 - for raising awareness of good nutrition and active lifestyles.
Simone has lived with stress urinary incontinence (SUI) for seventeen years. After giving birth to her son in 1989, following a 36-hour labour, she noticed that she had a slight leakage of urine. This occurred when exercising and also had to be careful when coughing or sneezing. She had been told about pelvic floor exercises in hospital but had forgotten about them. After the birth of her daughter in 1991, Simone's condition worsened. She noticed, while teaching aerobic classes, that she was leaking urine during certain moves and eventually had to wear pads at every session. She thought it was normal and that she just had to live with it. Simone found ways of coping with her SUI, for example when she went shopping, she would have to plan in advance where all the toilets were and organise her shopping around these.
As a dynamic, successful businesswoman, Simone's confidence was seriously compromised. She felt embarrassed, devastated, stigmatised and was afraid of being intimate with her husband but didn't know what to do. She felt that the physical side of her marriage was traumatised, and as she comments some marriages would break down, but I was lucky to have such a strong relationship and understanding husband.
A few years later she had a very embarrassing episode and decided that she had to do something about her condition. She went to see her family doctor, who undertook a cough test and he told her that she had no control of her bladder. She did not want surgery so tried numerous non-invasive treatments from weighted vaginal cones, urethral shields and electrical stimulation.
Simone decided to find out more about SUI and really focus on her pelvic floor exercises. Using her skills as a personal trainer she devised her own unique holistic exercise regime that included modified Pilates exercises that she designed to match her condition. Today, so long as she continues regularly with her exercise regime, which includes pelvic floor work and maintains a healthy weight, unless she has a heavy cold, she manages her SUI. She no longer has to worry about where all the toilets are when she goes shopping or even when she ran the London Marathon. She admits however, these exercises, although effective to control her condition in most instances, they are time consuming and not always easy for everyone to fit into a busy day as she does. Simone hopes that by speaking out about her condition women will understand that they too have the right to not to have to live with SUI. KateKate first suffered from symptoms of stress urinary incontinence (SUI) after having a hysterectomy. She suffered in silence for 8 years. At first she ignored her symptoms because they were mild and because she believed they were a natural part of ageing. However, over the years her symptoms have become progressively worse and she finally sought medical help.
SUI had a huge impact on Kate's life. Kate had always been sporty and enjoyed going to aerobics. Since her symptoms have become steadily worse she feels unable to continue with her old exercise regime for fear of leaking. Kate is also nervous about the types of clothing she can wear.
Finally two years Kate became so fed up with the condition especially the unpredictability of never knowing when she was going leak, hat she told her doctor. She was referred to a physiotherapist who taught her how to do pelvic floor muscle exercises. For a while Kate managed her SUI by wearing pads and hoped the pelvic floor muscle exercises would help. When pelvic floor muscle exercises did not control her symptoms, Kate went back to her doctor and was prescribed the medication Yentreve (duloxetine) which is now helping her to control her leaks.
Since being diagnosed with SUI, Kate has felt relief to finally know what is happening to her. She has spoken about her SUI with friends and now realises that it is very common.
Kate says Women should not feel embarrassed about having SUI or feel like it is their fault. After talking to my friends about SUI I realise how common it is. Carol Carol was officially diagnosed with stress urinary incontinence (SUI) four years ago and her GP referred her to the hospital, where she was sent to a specialist nurse. She underwent urodynamics, which revealed that her SUI was worse than she thought. Carol first managed her condition by wearing pads but was referred back to her consultant who invited her to consider taking part in the trial of Yentreve (duloxetine), the first pharmacological treatment for SUI. Carol was also recommended to do pelvic floor exercises to help strengthen her pelvic floor.
Carol first started to experience SUI after the birth of her first child 23 years ago. She did pelvic floor exercises to strengthen the muscles and her condition improved greatly. However, the birth of her twins three years later triggered symptoms of SUI again, which continued to worsen over the years.
Carol used to leak 2-4 times a day, which significantly affected her quality of life. She was unable to go out dancing with her friends because she would leak if she danced. She also experienced SUI when she coughed, sneezed or laughed. Carol explains that, 'It was mortifying, as you can imagine. SUI significantly affected my confidence and social life and also had an impact on the sorts of clothes I wore. For example, I would never wear tight, light coloured clothing because it would show any leaks.'
Carol continues, SUI also deterred me from having intimate relationships and I also had to stop all forms of physical exercise because the impact of aerobics and running would cause me to leak. I once ran the Thomas Cook Six Mile Run for charity and crossed the line with urine running down my legs.
Carol's condition has improved significantly with Yentreve (duloxetine). She no longer leaks everyday but may leak occasionally if she causes excessive pressure on her bladder, for example, when she does high impact sport. Carol has regained her confidence now that her SUI is under control. I can go out socialising with my friends and even dance again safe in the knowledge that I won't leak. Treatment review library
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