Large numbers of women have urinary incontinence and it can affect all age-groups. Only a small number seek help because women often think incontinence is unavoidable, especially after having children or don't realise that effective treatments are available. Urinary incontinence can have a major impact on your quality of life affecting self-confidence, physical activity, and relationships.

What is Urinary Incontinence?

Incontinence is the leakage of urine from the bladder. There are different types of urinary incontinence and it's essential to get the diagnosis right so that you get the correct treatment.

• Stress incontinence: When urine leaks after coughing, sneezing or physical activity. SUI is caused by weakness of the muscles that hold the urine in the bladder.
• Urge incontinence: When you get a sudden urgent desire to pass urine that you can’t resist, and urine starts to pass before you can get to the toilet. Having to rush to the toilet urgently is called overactive bladder. Urge incontinence affects around 6% of women.
• Mixed incontinence: This is when there is both urge and stress incontinence.
• Overflow incontinence: This is when you can’t hold urine in a full bladder because the urinary tract is blocked or nerves supplying the bladder are damaged.

How is it diagnosed?

A bladder diary is a chart on which you write down how often you have to pass urine and also the amount of urine. You also record what drinks you have, and any leaks that occur. This can be a useful way of recording the bladder's behaviour and helps us to diagnose what kind of incontinence you have.

We will take a detailed account of your symptoms and perform a simple urine test in clinic. You will need to have an examination also. Usually, this is all that is needed to make a diagnosis and start treatment. Sometimes, additional tests may be recommended, such as urodynamics.

Urodynamics (or bladder pressure studies) is a test which measures the pressures inside the bladder while it is filling up and emptying. This shows how the bladder behaves and can help to diagnose the underlying problem. Not every patient will need urodynamics to diagnose the problem.

Treatments for Urge Incontinence

Common treatments for urge incontinence and overactive bladder include:

• Bladder retraining
• Oestrogens therapy
• Medications
• Botulinum toxin bladder injections
• Sacral Neuromodulation
• Surgery

Usually, simple things are tried to treat your symptoms first. Patients often respond well to “conservative measures” and tablets can make the bladder less sensitive. For people who do not get better with simple treatments, botulinum toxin injections can be very effective.

Treatments for Stress Incontinence

Stress incontinence can be managed in a number of ways. We will go through the benefits of each and any side effects or complications.

Pelvic floor exercises

Medication

Surgery with or without using nylon mesh (Tension free vaginal tapes or colposuspension)

Urethral injections

We usually recommend that you try pelvic floor exercises before considering operations. If further therapy is needed, we can discuss an effective surgical approach with you.

Which specialist should you see?

It is important to see a specialist who has expertise in dealing with incontinence. This will usually be an urologist or urogynaecologist.

The national institute of clinical excellence says: “The expertise of the surgeon is one of the factors that influence surgical outcomes. The best outcomes are achieved when surgeons and their teams have specialist training and regular practice in continence surgery.”

“Some procedures for incontinence are technically simple, yet potentially harmful if carried out incompetently or in inappropriate patients. Others are complex and require higher levels of expertise.”

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What is Bacterial Cystitis?

Bacterial cystitis is an inflammation of the bladder caused by bacteria entering the bladder. Most commonly the infection starts when bacteria enter via the urethra.

How common is Bacterial Cystitis?

Bacterial Cystitis occurs most commonly in women as compared to men and children. Between one or two out of every five women in the UK will get cystitis at some point in their life.

What are the risk factors for Bacterial Cystitis?

Bacteria may be introduced into the urinary system for many reasons. Women are more susceptible due to a shorter urethra and its proximity to the back passage (anus). Poor bladder emptying leaves residual urine in the bladder. This can lead to an increased amount of bacteria (or other micro organisms) in the bladder, urethra and kidneys. During pregnancy pressure from the uterus may result in incomplete emptying of the bladder, thus encouraging bacteria to grow. Prolapse of uterus or vagina can cause similar problems.

During catheterisation, trauma (damage) may occur to the urethra or bladder, which may increase the danger of infection. Abnormalities in the urinary system are rare but may lead to recurring infections. Abnormal vaginal flora may occur after the menopause increasing the risk of bladder infections. Sexual intercourse may introduce bacteria to, or cause bruising of, the urethra and cystitis-like symptoms. Sexually transmitted diseases (STD) such as Chlamydia and Gonorrhoea can cause symptoms similar to cystitis.

Use of perfumed hygiene products and certain types of underwear, can encourage infections.

Underlying conditions like diabetes can increase the risk.

What are the symptoms of Bacterial Cystitis?

• Burning or stinging pain when urinating (dysuria)
• Frequent need to pass small amounts of urine
• Feeling of urgency to pass urine even when the bladder is empty
• Blood in urine (haematuria)
• Mild fever and chills
• Painful sexual intercourse
• Dull pain in the lower back or abdomen
• Fatigue, generally feeling unwell, nausea

These symptoms affect routine life due to lack of sleep, pain, frequency. It can disrupt work and relationship especially if cystitis follows sexual intercourse. Repeated doses of antibiotics can lead to vaginal thrush.

How is Bacterial Cystitis Diagnosed?

With mild symptoms no investigations are required before starting the treatment. A specimen of mid-stream urine (MSU) should be collected in a sterile container provided by your GP. The GP will perform a simple urine test and may also send the sample to the hospital for a full culture test. Your GP will then prescribe the most suitable antibiotics required.

If repeated urinary tract infections occur, you may be referred to see a consultant urogynaecologist or urologist for further investigations.

How to prevent recurring infections?

• Maintain at least two litres of fluid intake a day. You should preferably drink water or diluted squash. Avoid alcohol, pure fruit juices, tea or coffee as they can irritate the bladder.
• Cranberry juice may help as it can prevent some bacteria from growing. You can take it regularly in between the cystitis episode to prevent infection.
• Avoid using high sugar product.
• Wear clothes made of natural materials such as cotton or linen. Do not wear thongs or items that are not natural cotton.
• Hygiene: Always wipe from front to back when using the toilet.
• Wash the anal area after a bowel movement.
• Empty your bladder as soon as you feel the need.
• Healthy diet increases your immunity and reduces the infections. Sugar encourages the growth of bacteria, so try and reduce the amount of sugar in your diet.
• There are some alternative preparations available like D-Mannose, Uva Ursi (Bearberry) supplements, Nettle Tea or Manuka Honey which may help prevent recurring infections.
• Oestrogen replacement treatment in the form of pessaries or topical cream may prove useful.
• Avoid the use of spermicidal products as it can destroy Lactobacilli (good bacteria). Wash the genital area prior to sex and urinate within 15 minutes afterwards to help flush away any bacteria.
• You may need to cease using feminine perfumed products

How is bacterial cystitis treated?

• Increase your intake of fluid to flush out the system and dilute the urine. Drink bland fluids such as water or fruit squash. Avoid alcohol, caffeinated, carbonated and acidic drinks, such as orange juice as these can irritate the lining of the bladder.
• Alkalising the urine helps to eradicate bacteria and soothe the bladder.
• Use Bicarbonate of soda, 5 ml (one teaspoon) in half a glass of water, 2 - 3 times a day. However, due to its high salt content it should only be taken for short periods of time. It should not be used in patients with high blood pressure or heart problems.
• Other urine alkalinisers such as sodium or potassium citrate are available from your pharmacy. Please check with your GP or pharmacist to ensure that these can be taken in addition to any other medication.
• To relieve pain take a simple painkiller such as paracetamol or ibuprofen. Hot water bottle helps to relieve discomfort. If symptoms continue for longer than 2 - 3 days, always consult your GP. If you are pregnant consult your GP straight away. Your GP will prescribe appropriate antibiotics for the infection.

Treatment for recurrent cystitis:

Women who get cystitis recurrently may be prescribed a course of antibiotics to keep at home which they can take at the onset of an attack. Sometimes a low dose of antibiotics is prescribed for three to six months to reduce the risk of infection. If you get cystitis after sexual intercourse you may be advised to take a single dose of antibiotics immediately afterwards to prevent an attack. It is important to have a urine sample sent off to the laboratory to confirm whether an infection is present and to discover which antibiotic is required. Recurring infections should be investigated and a referral to a consultant may be recommended. Recurrent infections can be treated with Intravesical treatments placed directly into the bladder via a small catheter. These include Cystitstat®, Uracyst®, iAluRil®, and Gepan® instillation.

Helpful links: www.cobfoundation.org

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Painful Bladder Syndrome (PBS) or Interstitial Cystitis (IC) is a chronic inflammation of the bladder wall. It is a disorder with symptoms of mild-to-severe bladder pain and an urgent and/or frequent need to urinate. There is an estimated 400,000 people in UK with IC/PBS, of whom 90% are females and 10% are males.

What causes IC/PBS?

The cause of IC/PBS is not yet known. Research continues to find the cause. Indications suggest the condition could be due to a defective bladder lining, or an autoimmune disorder. Normally, the lining protects the bladder wall from the toxic effects of urine. In about 70% of the people who have interstitial cystitis, the protective layer of the bladder is "leaky." This may let urine irritate the bladder wall, causing interstitial cystitis. Other possible causes may be an increase of histamine-producing cells in the bladder wall or an autoimmune response (when antibodies are made that act against a part of the body). IC/PBS may resemble a bacterial bladder infection, however short term antibiotics are not effective.

What are the main symptoms?

• An urgent need to urinate, (yet you may pass only very small amounts of urine each time) and increased frequency both in the daytime and during the night.
• Pressure, pain and tenderness around the bladder, pelvis and perineum (the area between the anus and vagina). This pain and pressure may increase as the bladder fills and decrease as it empties in urination.
• Pain during sexual intercourse

How can IC/PBS affect an individual's life?

• Many IC/PBS patients find that their life revolves around knowing where the nearest toilet is known as “Toilet Mapping”. This can be very restricting. Going out of the house require thought and planning. Some severe sufferers of IC/PBS can find themselves virtually housebound. This leads to social isolation and depression.
• Interrupted sleep pattern due to frequency and urgency of urination throughout the night and pain causes tiredness and poor performance.
• Constant pain especially after sex can affect relationship.

How is IC diagnosed?

IC is diagnosed by elimination. If the symptoms are suggestive of IC, diagnostic tests such as urodynamics (bladder pressure studies) or cystoscopy (looking inside the bladder with telescope) are performed to rule out other similar conditions like overactive bladder. Repeated midstream urine samples might be checked to rule out bacterial cystitis. It can take time to obtain a correct diagnosis as symptoms of IC/PBS can be similar to other conditions. There are periods when symptoms are not bothersome and patient can have almost normal life that alternate with periods of “flares” when symptoms are bothersome or even severe. There are triggers like bladder infections, gastrointestinal problems, sex and prolonged sitting, certain foods and beverages, including alcohol and coffee can worsen IC symptoms.

Treatment:

• Early evaluation and treatment can help. Effective treatment of other conditions like crohn’s disease, ulcerative colitis, diverticulitis, irritable bowel syndrome, painful menstrual periods or endometriosis is very important.
• Avoid any foods or drinks that aggravate bladder pain or urinary urgency and frequency during flares. It is not clear that these items should be avoided at other times. Some practitioners strongly recommend a highly restrictive "interstitial cystitis diet", although its benefit has never been studied. (You can follow diet advice given by interstitial cystitis network, www.icnetwork.com)
• As yet there is no cure for IC, so treatment approaches are designed to control symptoms. Each patient has his or her own unique subset of bothersome symptoms. Many a times you need specialist team to design therapies to alleviate each of your symptoms.
• Avoid alcohol, acidic foods and tobacco.
• Bladder distension under anaesthesia may be tried by some. It is unexplained why distension helps.
• Bladder instillation for interstitial cystitis (also called a bladder wash or bath), a procedure in which the bladder is filled with a therapeutic solution (usually containing a combination of agents) that is retained in the bladder for varying periods of time, from a few seconds to 2-3 hours. The treatment schedule varies depending on substance used. E.g Cystistat (sodium hyaluronate) and Uracyst (chondroitin). They are believed to replace the deficient GAG layer on the bladder wall.
• Medications for interstitial cystitis such as Elmiron (the first oral medication approved specifically for IC). Elmiron may reduce bladder discomfort and pain in some people with IC and may work by repairing the damaged bladder lining. Another oral medicine like an antihistamine called hydroxyzine or amitriptyline may help by blocking pain.
• Your doctor may also suggest that you take an over-the-counter pain medicine to ease pain.
• Transcutaneous posterior tibial nerve stimulation for Interstitial Cystitis in which doctors send mild electric pulses to a nerve in the foot through a small acupuncture needle.
• Bladder training for interstitial cystitis is a therapeutic technique where you void at designated times and use relaxation techniques and distractions to help keep to the schedule.
• Interstim for interstitial cystitis is a small pacemaker that sends impulses to the sacral nerve, which controls the bladder. It is usually reserved for those who have not responded to other treatments.
• Diet modification to treat interstitial cystitis may help alleviate symptoms because alcohol, tomatoes, spices, chocolate, caffeinated and citrus beverages, and high-acid foods can contribute to bladder inflammation. Smoking cessation to treat for interstitial cystitis is important.
• Alternative therapy can help to cope with chronic pain. Psychosocial support (psychotherapy) can be helpful in dealing with issues like stress, anxiety and depression associated with this long term condition. Relaxation techniques can relieve musculoskeletal tension, and may include meditation, progressive muscle relaxation, self-hypnosis, or biofeedback.
• Many patients with IC have tight and tender muscles and connective tissue in the pelvis, lower abdomen, thighs, groin, and buttocks. Pelvic floor physical therapy (PT) may be recommended to decrease tightness in these muscles. It can decrease bladder or pelvic pain as well as urinary urgency and frequency. This type of physiotherapy is specialised requiring therapist specially trained in pelvic soft tissue manipulation and rehabilitation.

About

What is an Overactive Bladder Syndrome?

Overactive Bladder (OAB) is a sudden and compelling need to relieve the bladder which is difficult to put off, often associated with the frequent need to go to the toilet during the night or the day, and may result in incontinence.

People experiencing these symptoms should not feel ashamed or embarrassed to talk to their doctor, because help is available. OAB can have a huge emotional and physical impact on people.

How common is Overactive Bladder Syndrome?

About 1 in 6 adults experience some symptoms of an overactive bladder. About 1 in 3 people with an overactive bladder have episodes of urge incontinence.

What causes overactive bladder syndrome?

Normally, the bladder muscle stay relaxed as the bladder gradually fills up. However, in people with an overactive bladder, the bladder muscle seems to give wrong messages to the brain. The bladder may feel fuller than it actually is. The bladder contracts too early when it is not very full, and not when you want it to.

Symptoms

What are the symptoms of Overactive Bladder?

Untimely contractions lead to symptoms like Urgency where you cannot wait to go to urinate, increased frequency more than 7-8 times a day, Night time frequency (nocturia) of more than 1-2 times every night interfering with your sleep and Urinary leakage mainly happening on the way to the toilet or without any warning. You may pass quite small volumes of urine.

Treatment

How can you help your symptoms?

Try these top tips to help you control your symptoms:

• Make this as easy as possible to go to Toilet when needed.
• Go to the toilet only when you need to. If you go to the toilet too often the bladder becomes used to holding less urine which causes worsening of symptoms.
• Drink normal quantities of fluids. This is usually about two litres of fluid per day - about 6-8 cups of fluid and more in hot climate.
• Avoid all Caffeine intake and fizzy drinks. In some people, alcohol may make symptoms worse.
• You may have weak pelvic floor muscles so ask your doctor or nurse about exercises you can do to strengthen them.
• Make sure you know where the toilets are when you are out and about.
• Try not to use toilet everytime when you go bursted.

Other Treatment

Bladder training (sometimes called bladder drill)

Bladder training is a very simple but effective treatment. It works in up to half of cases and makes it important part of the treatment. The aim is to slowly stretch the bladder so that it can hold larger and larger volumes of urine. For more information see the “Bladder Drill” section on this website.

Medication

If there is not enough improvement with bladder training alone, medicines also help. There are number of medicines available. They work by blocking certain nerve impulses to the bladder, which relaxes the bladder muscle and so increases the bladder capacity. Medication improves symptoms in some cases, but not all. The amount of improvement varies from person to person. Click here to know about medication.

Posterior Tibial Nerve Stimulation

This treatment involves inserting a very fine needle (like acupuncture) into a specific point near the ankle. A specific kind of electrical impulse is delivered to the patient through the lead set. The electrical impulses travel along the tibial nerve to the nerves in the spine that control pelvic floor function. For more information on this treatment please look at the “Tibial nerve stimulation” section on this website.

Surgery

Surgery is used in very limited cases of overactive bladder where symptoms have not responded to above mentioned treatments and symptoms are too bothersome.

Treatment with botulinum toxin A

This is an alternative treatment to surgery if other treatments including bladder training and medication have not helped your symptoms. Make sure that you discuss this procedure fully with your doctor and understand all of its risks and benefits before you go ahead with it. Click below to know more about this treatment.

Further help and information
www.bladderproblem.co.uk provides accessible information on how you can help to manage bladder conditions.

If you have any further questions, to make an appointment please contact.