Bladder weakness has a substantial effect on quality of life but is often viewed as a stigmatising condition – so not everyone asks for professional help...

Bladder weakness usually occurs when the muscles in the pelvic floor or sphincter become damaged or weakened resulting in leakage of urine. Bladder weakness should be distinguished from overactive bladder (OAB), where the detrusor muscles in the walls of the bladder contract too often leading to frequency of urine excretion. Both bladder weakness and overactive bladder can cause urinary incontinence.

Types of urinary incontinence

Urinary incontinence is the involuntary leakage of urine. The most common types are:

Stress incontinence: Involuntary leakage of urine on exertion or effort or on laughing, coughing or sneezing. It occurs when the pressure inside the bladder as it fills is greater than the capacity of the urethra to remain closed. This can happen in cases of bladder weakness where the pelvic floor muscles or the sphincter are damaged or weakened – for example, during pregnancy or following childbirth – and if there has been damage to the area during surgery (e.g. hysterectomy in women; prostate surgery in men). Neurological conditions affecting the brain and spinal cord (e.g. Parkinson’s disease and multiple sclerosis), certain medications and obesity can also cause stress incontinence.

Urge incontinence: Involuntary urine leakage, accompanied by, or immediately preceded by, a sudden and compelling desire to urinate that cannot be deferred. In urge incontinence there is involuntary contraction of the detrusor muscles in the bladder walls, which can be caused by urinary tract infections or tumours of the bladder, constipation or neurological conditions such as Parkinson’s disease, stroke, multiple sclerosis, spinal cord injury and dementia. Mild cognitive impairment is not a risk factor for incontinence but does increase the impact. Other possible causes include drinking too much caffeine or alcohol. 

Mixed incontinence: Involuntary leakage of urine associated with both urgency and exertion, effort, sneezing or coughing.

Overflow incontinence (or chronic urinary retention): Often caused by blockage or obstruction of the bladder. While the bladder may fill up as usual, an obstruction will mean that the bladder cannot be emptied completely. At the same time pressure from the urine remaining in the bladder and building up behind the obstruction causes frequent leaks. Prostatic disease in men and pelvic tumours in women are a common cause. Overflow incontinence can also be caused by surgery to the bowel or spinal cord, bladder stones, constipation and certain medications. Stool impaction may be implicated in older people.

Total incontinence: Occurs when the bladder cannot store any urine at all, which can lead to passing large amounts of urine constantly or passing urine occasionally with frequent leaking. Total incontinence can be caused by injury to the spinal cord, or a fistula between the vagina and ureter or bladder or urethra.

How common is urinary incontinence?

It is difficult to estimate how many people suffer from urinary incontinence because of differences in its definition and many people not wanting to admit they have continence problems. Urinary incontinence is twice as common in women as men. 

A 2015 postal survey of women in one UK general practice¹ reported that 40 per cent of respondents experienced urinary incontinence but only 17 per cent had sought professional help, the perception being that incontinence was part of the natural ageing process. 

While urinary incontinence is often thought to be a problem mainly of middle-aged and older women, particularly amongst those who have had babies, it can also affect young women, including those who have not had a baby. A 2012 questionnaire-based Australian study of 1,002 healthy young women aged 16-30 years recruited on university campuses and at health clinics reported that one in eight said they had had urinary incontinence.²

The prevalence of urinary incontinence in men is largely unknown. Studies have produced figures ranging from 5.3 to 45.8 per cent of the population.³ All types of urinary incontinence become more common with age and are two to three times more common in those living in institutional care than in the general population.⁴

Why are women more at risk than men?

Particular risk factors for women include pregnancy with vaginal delivery, particularly where forceps are used and the baby is heavy. Caesarian section does not necessarily confer protection against urinary incontinence but does reduce it.⁵ Oral oestrogen therapy and hysterectomy also increase risk. Some studies show that urinary incontinence starts at the time of the menopause but the association between menopause and urinary incontinence is uncertain.⁶

Medications

Some medications can disrupt the normal process of storing and passing urine and increase the amount of urine produced. When reviewing a patient’s medication it is worth bearing in mind that angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, calcium channel blockers, diuretics, some antidepressants, sedatives, antipsychotics and HRT may all contribute to or exacerbate urinary incontinence.

Management

A specific diagnosis of urinary incontinence should always be made, particularly if the person has or is at risk of an underlying medical condition that could be causing the symptoms (see ‘When to refer’, below). If a pharmacist refers the person to his/her GP, they should suggest that they fill in a bladder diary while waiting for an appointment. It might be worth recommending an OTC self-check UTI test, particularly if any of the symptoms suggest it. 

Treatment will depend on the type and cause of the urinary incontinence. Pads and collection devices should only be offered on a temporary basis until a diagnosis is made and a management plan is in place. Should they be needed on a longer-term basis, an annual review should be recommended to check for skin integrity, any medication or lifestyle changes, and absorption efficiency. 

Many women of all ages choose to use pads, pants and pant liners as insurance protection during the day and/or night, perhaps when going to a special occasion, during physical activity or sport, or if suffering from a cough or cold when they know such symptoms will increase their risk of urinary incontinence. When wearing them it is important to avoid skin irritation by avoiding harsh soaps and using a no-rinse product to clean and protect the skin.

Stress incontinence

The National Institute for Health and Care Excellence (NICE) suggests the following management approach for women:

• A three-month trial of pelvic muscle floor exercise (eight contractions three times a day), to be continued if successful. The GP may refer the patient to a specialist for these exercises (e.g. a continence adviser, nurse specialist in urogynaecology or physiotherapist specialising in women’s health). A patient information leaflet on pelvic floor muscle exercises can be found here. Pelvic floor muscle exercises may also be useful for men who have undergone surgery for removal of the prostate gland
• Vaginal cones (small weights) can be used to help with pelvic floor muscle training. Starting with the lightest weight cone, they are inserted into the vagina and held in place using the pelvic floor muscles. They can be uncomfortable to use but may help stress or mixed incontinence
• Electrical stimulation and/or biofeedback can be considered in women and men who cannot contract the pelvic floor muscles:

• Electrical stimulation involves inserting a probe into the vagina in women or anus in men. An electric current runs through the probe, which helps strengthen the pelvic muscles while the person is exercising them. It can be difficult or unpleasant to use but may be beneficial for people unable to exercise their muscles without it
• Biofeedback is a way to see how well a person is doing with pelvic floor exercises. A small probe can be inserted into the vagina in women or anus in men, or electrodes attached to the abdomen or anus. These sense when the muscles are squeezed and the information is sent to a computer screen

• Drug treatment (duloxetine) should not be used first-line but may be used second-line in women who do not want or are unsuitable for surgery. Counselling about the adverse effects of duloxetine is important.

Pelvic floor exercises can also for be used for men with stress incontinence and in those who have undergone radical prostate therapy. They are also useful in both men and women who have stress incontinence due to stroke or MS. 

Urge incontinence or overactive bladder (OAB)

Lifestyle changes (see later) should be recommended. Bladder training is first-line treatment and should be used for a minimum of six weeks. This typically involves pelvic muscle training, scheduled voiding intervals with stepped increases and suppression of urge with distraction or relaxation techniques. The aim is to reduce the number of visits to the toilet both in the day and at night, to increase the ability to defer visits to the toilet and to improve the ability of the bladder to hold urine.

Double voiding is a useful technique to help ensure the bladder is empty. Double voiding involves sitting to urinate and then waiting for 20-30 seconds to urinate again.

Anticholinergic medicines reduce involuntary detrusor contractions and increase bladder capacity. Oxybutynin has traditionally been used first-line, but all antimuscarinics are equally effective. Oxybutynin should be avoided in the elderly as it may adversely affect cognitive performance. Newer antimuscarinic drugs such as darifenacin, solifenacin, tolterodine and trospium are alternatives. Extended-release or transdermal oxybutynin are other possibilities. Fesoterodine and propiverine are more recent antimuscarinics also licensed for this use.

Mirabegron is a beta-3 receptor agonist that acts in detrusor smooth muscle, designed to promote detrusor relaxation. It is recommended for people in whom antimuscarinic drugs are contraindicated or clinically ineffective, or who have unacceptable side-effects. 

Patients on anticholinergics should be reviewed every four weeks and referred for change of treatment if there is no benefit. Those who are stable on drug treatment should be reviewed annually (every six months if >75 years). About half of patients taking anticholinergics for overactive bladder report symptom control, but side-effects such as dry mouth and constipation may mean that many discontinue them. 

Concerns have also been raised about the risk of dementia with some anticholinergics, so this should be considered when conducting any kind of medicines review.

Mixed incontinence

In mixed urinary incontinence, treatment should be directed towards the predominant symptom but may involve a combination of approaches (e.g. pelvic floor exercises and bladder training). An antimuscarinic medicine should be started if these are not effective.

General lifestyle advice

Simple lifestyle changes can improve symptoms whatever the type of urinary incontinence.

The following can help:

• Drinking plenty of fluid overall. Drinking too little can concentrate the urine and irritate the bladder. In addition to water, people should choose low or no caffeine drinks including fruit and herbal teas, and decaffeinated coffee 
• Limiting or avoiding alcohol and caffeine. Alcoholic drinks and drinks containing caffeine (coffee, tea, cola drinks) can irritate the bladder and result in the need to pass urine more frequently
• Drinking less in the evening with more fluid intake earlier in the day. Avoid drinking liquids for two hours before bedtime. This will reduce the chance of needing to get up in the night to pass urine
• Emptying the bladder. Going to the toilet before long journeys or in situations where the toilet cannot be easily reached
• Avoiding constipation as this can put pressure on the bladder. Increasing the mount of fibre helps
• Losing weight if obese or overweight 
• Cold and allergy medicines containing decongestants and antihistamines can affect the bladder muscles and might be best avoided.

References 

1. ncbi.nlm.nih.gov/pubmed/25273552 
2. ncbi.nlm.nih.gov/pubmed/22801671
3. ncbi.nlm.nih.gov/pubmed/29477718
4. ncbi.nlm.nih.gov/pubmed/26914118
5. ncbi.nlm.nih.govpubmed/28626856
6. ncbi.nlm.nih.govpubmed/28681849