by Dr. Nupur Yogarajah
Troublesome bladders causing frequent toilet trips and leakage are sometimes viewed as par for the course if you’ve had children or are post menopause. Sadly, this often leads to these particular groups of women avoiding seeking support, but there are options available to help people minimise the impact these symptoms can have on their quality of life.
Of course, it is not only the above groups of women that experience bladder related symptoms – they can occur in all adult age groups of women, regardless of whether or not they have had children. If you are experiencing incontinence you may also shy away from seeking help as you fear surgery may be your only option. However, there are plenty of non surgical treatment options for bladder issues.
Incontinence is largely divided into two categories: stress and urge. Stress incontinence is the involuntary leakage of urine when pressure in the abdomen increases, for example when you cough or sneeze. Urge incontinence is when you feel an urgent need to pass urine, and leakage occurring before you have the opportunity to access a toilet. Sometimes women can have elements of both stress and urge incontinence, called mixed incontinence.
Urge incontinence is strongly intertwined with overactive bladder syndrome (OAB) which gives the same sensation of urgency and is associated with having to visit the toilet very often (frequency) and also sometimes as night (nocturia). OAB can exist with or without leakage of urine.
The focus of this article will be on techniques to manage urge incontinence and OAB. The cause of this condition is over activity of the bladder muscle, known as the detrusor muscle. Unwanted leakage or incontinence occurs when the detrusor muscle contracts at times you don’t want it to.
The detrusor muscle is in a relaxed state as the bladder fills. As the bladder approaches the stage of needing emptying, receptors in the bladder muscle send a signal to your brain, conveying the sensation of needing to urinate.
In OAB and urge incontinence, this need to pass urine occurs too soon, giving you the sensation of urgently needing to visit the toilet even though the bladder is not full. The bladder is under the control of different nerves, some of which we can consciously control and others which we can’t (involuntary). It is the involuntary contraction of the detrusor muscle that leads to symptoms of leakage and urgency.
Lifestyle modifications to help with incontinence
Detrusor over-activity normally occurs for reasons unknown. Those who have had previous bladder surgery can sometimes be left with detrusor muscle issues, and some neurological conditions such as a stroke or multiple sclerosis can cause those who have them to develop urge incontinence.
However, the bulk of women who have incontinence have no underlying sinister cause, and often some simple lifestyle adaptations can assist in controlling symptoms.
Firstly caffeine can be a bladder irritant, and limiting your intake can have a calming effect on your OAB/urge incontinence. If you are drinking more than two caffeinated beverages a day, decrease your caffeine intake slowly over a few days to allow your body to get used to it. If you find it helps your symptoms but you miss your tea or coffee, look into decaffeinated versions.
Don’t forget caffeine is also hidden in soft drinks such as cola and diet colas, green tea, energy drinks, dark chocolate, and some over the counter painkillers. Alcohol can have a similar effect, and trialling cutting down, or avoiding it entirely when you will not have easy access to a toilet could help.
Re-training your bladder to cope with visiting the toilet less often and being able to hold larger volumes of urine can also help. Bladder training, also known as bladder drill, does take some commitment, but the effect it can have on your lifestyle can be dramatic and therefore worth it. It is most useful to do this with the guidance of a continence advisor or your GP. In many area patients can now directly self-refer to a continence clinic.
The general principle is to initially gauge how often you visit the toilet and the volume of urine you pass each time (measured with a jug). After your baseline is established, the training then focuses on you extending the time between your toilet visits. What you will notice as the weeks go on and you visit the toilet less frequently is the volume of urine you pass during each trip is more than your baseline and your sensation of urgency should hopefully improve. The goal will vary between women, but passing urine 5-6 times per day is a good target to work towards.1
The question of fluid intake is often raised when trying to manage OAB and urge incontinence. Fluid restriction is not advised and drinking six to eight glasses of water a day, or more in hot climates, is recommended to maintain adequate hydration.2
If you are troubled by waking at night to pass urine then you may want to look at ensuring you complete your daily fluid intake a couple of hours before bedtime.
Pelvic floor exercises are advised to assist in treating stress incontinence, so if you have mixed incontinence this can help you manage your symptoms. It is currently unclear if these exercises have any role in alleviating OAB or urge incontinence.3
However, as a general rule, performing regular daily pelvic floor exercises can help keep these muscles strong and is useful for all women, particularly those have been through or envisage they may go through a pregnancy and childbirth, as this area can be significantly weakened during this process.
If the above measures do not adequately control your symptoms and you are interested in pursuing medication then do visit your GP. The medications used for OAB/urge incontinence are focused on relaxing the bladder muscle to give you some relief from the rapid frequency of toilet visits and sensation of urgency.4
Some of the common side effects of these classes of drugs can be constipation and a dry mouth. Generally, though, these unwanted effects lessen over time and starting on a low dose and titrating upwards makes them more tolerable, although this means you may not see an immediate effect.
If the side effects are intolerable, it is often worth trialling another drug, as even though they largely come from the same group of medicines, some people tolerate one drug better than another.
In women who have been through the menopause, the decreasing oestrogen can cause thinning of the tissue in the vaginal area. This can sometimes lead to the feeling of urgency and bladder irritation as the openings of the bladder and the vagina are very closely located. In these circumstances, you may be offered an oestrogen cream to use in the area to help ease symptoms.
If the combination of lifestyle changes and medication has failed to control your symptoms adequately enough, then you can discuss specialist referral with your GP. Injections of botox into the bladder and nerve stimulation are not common management strategies, but may be required in some cases. Surgery is the last resort and rare for the management of OAB.
OAB and urge incontinence symptoms can sadly lead to significant effects for some women, and if you are experiencing symptoms which are having a damaging effect on your day to day life you are definitely not alone. Patients have told me that when their symptoms have been at their worst they have deliberately avoided public places and social events for fear of having a leakage accident, or not being able to get to the toilet on time.
These anxieties can cause embarrassment and isolation and hence this condition is recognised by the medical profession, with dedicated continence services available to offer support and advice. If you are suffering with these issues and have been unable to control your symptoms with lifestyle measures, then do reach out for help.