Pelvic Floor Clinic (Module 3): Urinary Incontinence

Welcome to Module #3. In this module we will look at bladder issues
and specifically will focus on urinary leakage or incontinence. Other bladder issues, such as retention, will
not be addressed in this video, as they are less common and require individualized assessment
for each patient. The objectives for this module are to 1) To
better understand how a normal bladder and lower urinary tract should function, 2) To
become aware of different types of problems with the bladder and lower urinary tract,
different treatment options for dealing with these issues and to better understand things
you can do to improve your symptoms. Urinary incontinence is a frustrating issue
and far too common, especially for women. Up to half of all women have issues with leakage
from their bladder at some point in their life. You may recall from module one, as we considered
associated factors, that incontinence tends to become more of a problem…
as we age, if we smoke, after having children, if things are passed
on genetically if we gain extra weight, if we have long-standing
issues with constipation and straining, if we are involved with activities involving
chronic high impact or lifting heavy things or if we take some type of medication that aggravates the bladder, as well as foods and beverages
that irritate the bladder. Before we look at different types of incontinence,
we will quickly look at the normal bladder. There are many parts of the urological system,
but we will focus onthe storage and emptying of urine, basic anatomy and how the normal
bladder should be working. That way it is easier to recognize if you
are having symptoms that are not considered normal. The bladder is really a reservoir or storage
tank for urine that is produced in your kidneys. The ureters – the 2 yellow tubes – drain
urine to the bladder from your kidneys, an ongoing process. The bladder varies in size and position depending
on how full or empty it is. It consists mostly of muscle – the detrusor
muscle which contracts and relaxes. It functions like a balloon that you inflate
and deflate. Normally the bladder is quite relaxed as it
fills and contracts when it empties the urine. After the kidneys filter everything you eat
and drink, this urine will go to the bladder to be stored there. At a certain level of fullness, you will feel
like you need to urinate. Urine drains from the bladder through the
urethra, which in women is quite short – about 4 cm in length. We stop the urine from draining by tightening
the pelvic floor muscles which intersect and encircle the urethra. When the detrusor muscle of the bladder contracts,
we relax the muscles around the urethra and allow the urine to drain out. The bladder thus empties as the urine drains
out, but there is always a small amount of urine left behind. This is normal. The walls of the urethra have many estrogen
receptors in them. When we are younger with estrogen in our system,
they are plump and moist and healthy and can stay closed better because of this. As we age and our estrogen declines, the urethra
may not be as plump and moist, and stay as securely closed. The whole system involving our bladder is
quite complicated. To understand it more easily, we will look
at 2 phases – the filling phase and the emptying phase. As the bladder begins to fill, the bladder
muscles begin to contract and you will feel the normal sensation of the desire to empty it. In the bathroom, we sit and consciously relax
the muscles around the urethra, or the external sphincter. The bladder muscle then pushes the urine out,
causing a rise in pressure in the bladder as the urine drains, as you can see by the
line going up in a wave. After, the cycle begins again with a nearly
empty bladder. The normal bladder holds about 350 to 650
ml (1 to 2 cups). You should be able to hold your urine for
about 3 to 4 hours and void generally about 6 to 8 times in a 24 hour time frame. Ideally, you should not need to waken to void,
but if you do get up once or twice, it is not unusual – likely because you are processing
fluids you consumed towards the end of the day. It is most helpful if you can keep track of
your normal pattern using a voiding diary. We will talk more about this in module # 5. Okay, now we will look at the different types
of incontinence. It is helpful if you can identify the symptoms
that describe you best, since different problems are managed in different ways. The top 2 on this list – stress and overactive
bladder – are the most common types of incontinence and many women have a bit of both, therefore
called mixed incontinence. The bottom three are less common bladder issues
but we will briefly discuss them as well. Stress incontinence is “the complaint of
involuntary leakage on effort or exertion – such as coughing or sneezing”. In this situation, the bladder generally functions
normally, that is – you don’t need to use the bathroom frequently and you are able to
easily hold the urges as they come. However, certain things that put pressure
on the bladder – coughing, jumping, running, sneezing, etc – provokes some leakage, from
a few drops, perhaps a gush or sometimes a large amount. Some women find that they may leak urine when
having intercourse – a very distressing thing to have happen. With any type of pressure on the bladder,
the urethra is unable to stay tightly closed (like the dotted line shows) and the muscles
around the urethra re unable to tighten enough to prevent the leakage of urine. It acts like a leaky tap. This can often be seen in younger women and
may worsen as women age. Rarely does it start in older women. You can see the treatment options for stress
incontinence here. Using the pelvic floor muscles that encircle
the urethra is an important option – actually important for every type of pelvic floor issue
that we see in the clinic, not just stress incontinence. A clinic pelvic floor physiotherapist will
briefly describe how to find and use these muscles for this purpose. Secondly, a pessary can be used for stress
incontinence and I will explain that to you. Surgery is available as an option and lastly,
there are healthy bladder habits that may likely be of help and stress incontinence
episodes may be less frequent. First, a physiotherapist will describe how
to find and use your pelvic muscles to prevent stress incontinence. The information about pelvic muscle exercises
is also found in the PREVIOUS module on pelvic organ prolapse – if you have already viewed it, feel free to fast forward through this segment. Hello, I am a pelvic floor physiotherapist
and I will briefly review how training the pelvic floor muscles can be useful for women
that have bladder leakage problems. As we have explained, the pelvic floor is
a hammock of muscles and ligaments that extend from the back to the front and from side to
side across the bottom of your pelvis. They attach to your pubic bone in the front,
to your tailbone at the back, and between your sitting bones on each side,
The three openings through the pelvic floor are the urethra, through which you pee, in the front, the vagina in the middle, and
the anus in the back. The pelvic floor muscles tighten to close
around these three openings to prevent any leakage of urine, stool, and gas. They keep us dry. They must also be able relax to allow us to
empty our bladder and bowels when we need to and have pain free intercourse. They help support our pelvic organs inside,
the bladder, the bowel and the uterus. These muscles also help us with our posture
as they work together with our deep abdominal muscles, deep low back muscles, and our breathing
muscle, the diaphragm. The pelvic floor plays a role in sexual function
as these muscles contribute to orgasm and our general awareness of sensation and enjoyment
if they are healthy. How can you find and feel your pelvic floor
muscles? Can you stop or slow the flow of urine halfway
through emptying your bladder? Please do not use this as an exercise, but
as just a test to see if you can find where these muscles are. If you can slow the flow, you are using the
muscles more towards the front of the pelvic floor that are around your urethra. Secondly, are you able to squeeze the muscles
around your vagina? Imagine squeezing a tampon or closing the
vaginal opening. These muscles are the one that are in middle
part of your pelvic floor. Are you able to tighten the muscles around
your anus, as if you are trying to stop passing gas? This is the part of the muscle group more
toward the back of the pelvic floor. If you are not sure if you are using the right
muscles, check this with your family doctor or whomever you will see in the pelvic floor
clinic. There are pelvic health physiotherapists you
can book appointments with as well. They can help you locate and exercise these
muscles. In Alberta, use this website link to locate
the physiotherapist closest to you. Private physiotherapy has fees attached. How do I do pelvic floor muscle exercises? When you try to do pelvic floor muscle exercises,
it is helpful to think about closing the three openings as your pelvic floor muscles lift
“up” inside. hink of closing an elevator door and the elevator
moving up towards your head. As you tighten the pelvic floor muscles, do
not tighten your legs, bottom, or tummy. Do not push down or hold your breath. As well, it is also just as important to completely
relax the muscles after the contraction. Think about the elevator coming back down
after lifting up. There are two different ways to do these exercises:
One way is by doing them slowly. Close the openings, and pull up and in slowly
holding for up to 10 seconds at a time. Relax completely after each one and repeat
this 10 times in a row. Another way is to do them is by quickly squeezing
and lifting them, holding them for only 1 second and then releasing them. This should be repeated up to 10 times. We suggest that you do these exercises regularly
every day, three times with 10 exercises per time as described above. Remember to both contract and relax. This should be done for the rest of your life. Start by doing these exercises in positions
that are easier for you to feel your pelvic floor muscles, such as lying down or sitting. When will you notice a difference? It can take 6 to 8 weeks to notice an improvement
in your pelvic floor function. You may notice that you no longer leak, or
leak much less, when you cough or sneeze or exercise because you can tighten your muscles
around your urethra. You may find that when the urge to void comes,
you can hold it back by tightening these muscles. Remember, though, that you are exercising
a muscle and like any exercise program, you must continue to keep the muscles strong. As the saying goes, “if you don’t use
it, you lose it”! Over time, the key in preventing urinary incontinence
is to get into the habit of contracting or squeezing your pelvic floor muscles BEFORE
you lift, cough, sneeze or laugh. We call this “The Knack”. Over time, you can train yourself to do this
automatically, but for a while, you will need to remember to deliberately squeeze prior
to these activities, to prevent squirts of urine. It is important to avoid heavy lifting and
lift with good posture. In all your tasks, always tighten your pelvic
floor muscles right before any lifting/pushing/pulling of any kind. Then, breathe out slowly. And, don’t hold your breath as this increases
downward pressure on your pelvic floor. Now we will look at the use of a pessary to
help prevent leakage of urine. I have a few pessaries here that I will hold
up – note that all of these pessaries have a knob on one side of them. Pessaries are devices that are inserted into
the vagina, next door to the bladder and work by providing some support to the urethra – that
tends to open up with a cough or sneeze and cause leakage. Here you can see how the knob of the pessary
sits facing the neck of the bladder, preventing leakage with exertion. Pessaries can be used full-time or part-time,
depending on your needs. Many women can take care of them on their
own – they are simple to remove and to insert and can be cleaned with water and soap. It is necessary to be fitted by someone who
can find the right size and style that meets your needs. They must fit properly, or they may not work
as well. You must purchase the pessary that you are
fitted with and sometimes you may need to purchase more than one in the fitting process
as we find the one that works best for you. You need to try a pessary in everyday life
to determine how well they work. They are a good option for stress incontinence
that many people don’t know about. Combined with strengthening your pelvic floor
muscles, you may find you rarely leak at all. Some women insert tampons for certain activities, and find they may also be helpful in decreasing leakage. There are also disposable pessaries on the
market which some women find helpful. On the main menu, you will find an additional
segment on pessaries and how they can be used. Please look at that for more information on
using pessaries for stress incontinence. Another option for treating stress incontinence
is to have a surgical procedure. Now we will meet Dr. Magali Robert who will
provide you with some information on surgeries for stress incontinence. There are various types of surgeries for stress
incontinence, but we will consider two main categories. The first aims at providing support to the
urethra using some type of sling. The other category of surgery consists of
bulking or plumping up the urethra so that it is tighter, preventing urine loss. The first category of surgery aims to provide
some support underneath the urethra, using a supporting sling. The supporting mesh sling is placed between
your urethra and vagina and can help make you dry. These surgeries are called a tension free
vaginal tape procedure (or TVT) or a transobturator tape procedure (or TOT). These are our most common surgeries and they
are done through a small vaginal incision. We can also do incontinence surgeries through
the abdomen, but these are less common. Here we can see how the sling provides support
under the urethra, thereby preventing leakage when there is any stress or pressure in the
pelvic region. Bulking the urethra is a procedure used for
stress incontinence. A bulking solution is injected around your
urethra to plump it up so it stays closed better – somewhat like how some women plump
up their lips! After the procedure, you can get up and go
back to your normal activities right away. However, the success rates of this procedure
are lower than other surgeries, and you may need to come back for more injections in the future. Your surgeon can advise you if this is a good
choice for you. Here again we see another view of the bladder
and urethra, and the bulking solution that is injected into either side of the urethra,
bulking it up to help keep the urethra closed, to prevent leaking .
The success rates are higher with surgery than other treatments but they also come with
possible complications. The decision to have surgery must be decided
by balancing these issues – better success versus potential complications. The most significant post-surgical complication
include a risk of having difficulty emptying your bladder and needing to catheterize (or
put a tube into your bladder) to help it empty. You may have more overactive bladder symptoms
(which will be covered next). The meshes that we use for the slings are
permanent. Your surgeon will discuss the implications
of mesh with you. If you are considering surgery, you may have
some specialized testing before surgery, to determine if you may be at higher risk of
problems or to help identify other bladder issues. This and other concerns will be discussed
in detail when you see your surgeon. Remember that surgeries are rarely done if
you are planning to have more children. Surgeries for stress incontinence can be done
in combination with prolapse surgeries. And it is important to know that these surgeries
do NOT workfor symptoms of overactive bladder and may worsen urgency. They are only done for stress incontinence. The last option we will talk about for stress
incontinence is “healthy habits” for the bladder. It is important to note that the things we
mention here may not completely cure stress incontinence, but in general are good habits
for optimal bladder functioning for everyone. One healthy habit is being a healthy weight. For some women, this may mean weight loss. There is now strong evidence that as little
as a 10% weight loss can have cause an important improvement in your urinary incontinence. Weight loss involves reducing your food intake
and exercise. It may be difficult to exercise if it causes
leakage but on the other hand it will also improve it in the long run. Aim to empty your bladder about every 3-4
hours. Avoid pushing to pee – let the bladder muscle
push the urine out, so take your time on the toilet. Ensure you are drinking the fluids you should
– we will go into more detail on this when we discuss the next type of incontinence. This next, very common, type of incontinence
– overactive bladder – can be very distressing. People sometimes say their bladder is controlling
their life! Women will describe having very sudden, very
strong urges to void – and may or may not make it to the toilet without some leakage. Some people notice this whenever they get
close to home – they can hardly make it in the door! Sometimes hearing water running prompts this
sensation. People also describe that they are going to
the bathroom very frequently – much more than every 3 to 4 hours. Sometimes you will need to get up frequently
at night to void and have trouble getting to the bathroom on time. For some women, wetting the bed can also be an issue. There are some other things which may cause
symptoms of an overactive bladder such as a bladder infection or bladder stones. But for most women OAB is a result of messages
between the bladder and the brain getting slightly mixed up. Here again we see there are several things
that can help with this type of incontinence. We will review all of them. But first and foremost is pelvic muscle exercise
treatment. When the urge to void comes, you should be
able to hold your urine by using your muscles. A physiotherapist just reviewed this previously. Next we will again consider healthy habits
for the bladder, adding a few more on. What do we recommend that you drink? All research indicates you should aim for
6 to 8 cups total fluids per day – of which water is the best. If you are working hard physically and it
is hot, you may need more. If you are sitting a lot, slightly less may
be better. Your urine should be a pale yellow color,
not dark in color, nor clear. (Note, that if you are taking vitamins, the
color of your urine will be darker). Don’t drink too much, or you will put additional
stress on the bladder and have a harder time controlling it. Drinking too little increases your risk for
bladder infections, and your strong urine can irritate the bladder wall, causing you
to feel the urge to void more frequently – but you may only have a few tablespoons of urine
inside. Your bladder needs fluids to function properly. Certain things you drink or eat may irritate
your bladder. Caffeine is the biggest culprit as so many
people drink beverages with caffeine on a regular basis. Caffeine causes your bladder to fill more
rapidly, and also irritates the bladder wall – increasing the sense of urgency. Try to reduce your caffeine intake, ideally
to nothing. Regular coffee has about 150 mg of caffeine
– tea about 50 – decaf coffee about 5 mg. However, decaffeinated drinks can be quite
acidic and may not be a good substitute. Acidic juices/fruits – including tomato
products – will also aggravate your bladder if you consume large amounts of them. A glass of orange juice will provide your
daily needs for vitamin C – but more than that may irritate your bladder. Cranberry juice is also an irritant, as is
alcohol and highly spicy foods. If spicy food irritates your mouth and causes
your eyes to water, it likely irritates your bladder as well. There may even be other food products as well
– in excess – that may act as irritants such as artificial sweeteners if you use them
frequently. Try “double voiding” if you feel that
you are not emptying completely. After your urine flow stops, lean forwards
and back, side to side, even stand and sit back down. Do what we call a “pee pee dance”. Then lean forwards and allow the stream to
start again. It may not be as strong or last as long, but
you may be able to empty more completely. The ingredients of cigarettes irritate the
bladder wall and cause it contract. Most smokers develop a chronic cough and smoking
is also one of the main causes of bladder cancer. There are urge control techniques that you
can utilize when the urge hits you suddenly and strongly. Urge control techniques make take some practice,
but with time, may be very effective in preventing leakage. The urge to void comes usually in a wave,
builds to a peak and fades away. Firstly – do not run to the toilet – you
cannot outrace your bladder! Rather, sit down and relax – think of something
different, tale some deep breaths. Do a series of pelvic muscle contractions
and hold that urine back. The urge will subside- like a wave does – and
then, if it has been an appropriate length of time, walk to the bathroom with control
– OR – wait until later to go. This can be very effective, and especially
so with time and practice. Bladder retraining is another technique that
can be useful if you find you are running to the bathroom frequently. The goal of bladder retraining is to increase
the interval between trips to the bathroom, so your bladder becomes accustomed to holding
more over time. You will need a schedule you can be in control
of, with a watch or phone that gives you a signal. If you usually pee every hour, start at about
that interval. For the first week, go to the bathroom during
waking hours at this regular interval. Try and stick to it! For the following weeks, try and increase
this interval each week for a longer time – 15 to 30 minutes – and again, stick to it. Continue until you are able to hold for longer
intervals with ease. This has been shown to be an effective way
of retraining your bladder. At night, just try and sleep through. Here you may find that keeping track of your
voiding schedule can be assisted by using a bladder diary – mentioned earlier. We will talk more about this useful tool in
module 5. There are quite a few medications that can
be useful to assist you in your efforts to resist the symptoms of overactive bladder. Dr. Robert will discuss how these medications
work for you. You can think of your overactive bladder as
a highly sensitive bladder that reacts too quickly. It is controlled by your nervous system, which
will tell it what to do. The signals come from your brain and spinal
cord to the bladder. Medications try and block these signals and
relax the bladder so that it can hold more and become less sensitive. This means that you will void less often and
won’t feel the need to void all the time. The medications will work best if you have
followed the other suggestions mentioned. The medications must be taken every day; they
do not work well if you choose to only take them once in a while. The medications are in three categories: anticholinergics,
antispasmodics and adrenergic receptor activators. Not everyone will get a good result with each
medication. You may need to try several to find one that
works best for you. Your prescribing physician or nurse will discuss
which choice may be best for you and also discuss any side effects that you may experience,
such as dry mouth, dry eyes and occasionally constipation. If these medications do not work, than another
choice is Botulinum toxin, or Botox. This essentially relaxes the bladder by paralyzing
some of the muscles of the wall. However, it needs to be injected right into
the bladder wall – it is not a pill you take, but Botulinum wears off, and you will
need to get repeated injections. This can vary from 3 months to even yearly,
depending on your results. Vaginal estrogens may also help your symptoms. As your estrogen levels drop as you age, the
urethra and bladder become more easily irritated and you may feel that you need to urinate
all the time. By adding estrogen locally into the vagina
and making the tissues healthier, these sensations will decrease. Sometimes using vaginal estrogen is enough
to control your symptoms and regain control. There are various forms of vaginal estrogen
– creams, a tiny vaginal pill or an estrogen ring. There are also some other reasons that some
women have symptoms of urgency and frequency. A common one is a bladder infection. If bladder infections are a problem for you,
there are other suggestions that will apply to you. Do you have any symptoms of stress incontinence
or of overactive bladder? Perhaps you have some of both? Then you have mixed incontinence, and may
need to use treatment options for both of them. Some options are specific to each type like
surgeries only for stress incontinence and medications only for overactive bladder. Other treatment options, like strengthening
your pelvic floor muscles are helpful for both types. Now we will take a quick look at the other
less common types of bladder issues. The first is “overflow Incontinence”. Some people pride themselves on having excellent
bladder control and rarely having to use the bathroom and go only once or twice a day. Some people are so busy that they forget to go! Certain occupations make it difficult to take
bathroom breaks – being a nurse, doctor, teacher, cashier, and so on. The bladder can stretch over time as we continue
to make it wait to empty. However, this may result in an overstretched
huge bladder. This type of bladder may not function normally, and may no longer give you the normal sensations to void. Sometimes, you may no longer feel any urge
to go – and all of a sudden, you are wet. The bladder does its own thing and spills
over when it gets full enough. This can also happen when the urethra becomes
blocked, perhaps due to prolapse issues that were described in the last module. There are also medications you may be on that
make it hard for you to urinate. Overflow incontinence cannot be “fixed”
surgically or with medications. The best way to deal with it is to empty your
bladder on a timed schedule – say, every 3 hours– so it won’t get so overfull and
spill over without warning. If this does not help then you made need to
be taught how to self-catheterize (use a small tube to empty your bladder). Not emptying your bladder well can increase
your chance of having a bladder infection. Functional incontinence has less to do with
the bladder, and more to do with the difficulty in getting to the bathroom – due to some
disability that might slow you down. This could be requiring a cane or walker,
or perhaps a wheelchair. You can’t get there as fast! You can understand how this will make any
bladder issue worse! Even arthritis in your hands may delay you
from opening the zipper fast enough and so on. It is so important to have your pelvic floor
muscles strong, so you can hold on better, and also to ensure you use the bathroom on
a regular basis, and not wait too long. There are also ways to make access easier,
such as using a commode for night. There are community resources available to
help you so you can obtain various medical supplies and equipment – such as commodes
– that can make your life easier and your ability to get to the bathroom a reality. In Alberta, here are two links for you. Some bladders do fine during the day – but
not so well at night. We call night time issues “nocturia”. Getting up at night, especially if it prevents
you from falling asleep again, can be a tremendous bother and affect your quality of life a great
amount. As I said earlier, it is ideal to sleep through
the whole night. Some women wake up and void once or twice,
but can fall asleep right away and this is not a huge problem. But if you are frequently getting up, interrupting
your sleep, it is most difficult to cope with. It is actually normal to produce more urine
at night as you age, therefore you may be getting up more often than you did when you
were younger. Here are some strategies that may help. We suggest you limit your fluid intake in
the evening. Your kidneys process the fluids you drink,
and if you drink late into the evening, they will be working while you sleep, causing your
bladder to fill and to wake you up. If you stop drinking earlier, there won’t
be as much fluid to process. As well, we may retain fluid in our lower
limbs due to gravity or circulation issues. When you lie down to sleep, this fluid can
more easily make its way back to your kidneys and ultimately, your bladder. If you go for a walk in the evening and then
elevate your lower limbs, this fluid may drain back sooner – and you may empty your bladder
once or twice more in the evening, but less at night when you are trying to sleep. If you wear compression stockings, keep them
on until you go to bed, so they can prevent some of the fluid from collecting in your
lower limbs. If you have swelling in your legs, starting
to wear stockings may help. If this does not help, then speak to your
family physician for other options. And finally, some people get up to void – simply
– because they wake up. It becomes a habit. “I am awake – I might as well get up and
pee”. It this describes you, try not to get up,
but roll over and go back to sleep and break this pattern – if you don’t really need
to pee. Or – you may choose to wait for 15 min every
time you wake up. If after 15 min you still need to pee, then
get up and go. Keep doing this and within a month you should
be getting up only once or twice. If you do wake up, start doing pelvic muscle
exercises before you roll over, continue to do them as you sit and regain control, then
walk the bathroom with better control. This also works well with the first trip to
the toilet in the morning. If you require pads to keep your clothes dry
from leakage, we want to remind you to use pads designed for urine. As creatures of habit, we may use pads we
have always used – but many pads are designed only to hold blood from menstruating. Incontinence pads hold a much larger volume,
wick the urine away from the pad surface and turn it to a gel. They help prevent odour and reduce the irritation
to your skin and tissues. Incontinence pads and products are widely
available at stores of all kinds. There are other products that will help you
to keep your perineal area clean without irritating it, like soaps do. There are also creams to help protect your
sensitive tissues as well. Bladder issues such as incontinence can be
a big problem for many women and can greatly affect your quality of life. It is important to try and determine the main
type of incontinence that is affecting you. Then you must be clear on what specific types
of treatments work for the different types of incontinence. Make the changes that you can to help with
your issues – strengthen your pelvic floor muscles, drink adequate and proper fluids
and so on. Clearly, some of the solutions are YOUR responsibility
– we can make you aware, but only you can control things such as your fluid intake,
your weight, etc. However, there are options that will help
you like medications, pessaries or surgery – and you need to consider if you wish to
pursue these. This information is designed to provide women
with bladder issues with information needed to make changes in lifestyle issues that may
help you deal better with your symptoms. Feel free to review these modules as often
as you like. The next module talks about bowel evacuation
disorders. Even if that is not a problem for you now,
you never want it to be. We strongly encourage you to view it as well
to help you understand how best to deal with it or how to help prevent it.

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