Urinary incontinence is the accidental leakage of urine and it’s a very common problem, particularly for women,” says Bernie Leamy, a senior physiotherapist with the HSE, who also works in a private practice at Physio4Women in Kilkenny.

“Years ago, women accepted incontinence as the normal consequence of pregnancy, childbirth and ageing. Thankfully, women are now becoming more open about their symptoms and are seeking help. Incontinence, if not treated, can have severe social consequences on many aspects of a person’s life.

“Relationships can be affected and the fear of leakage can make everyday things, such as school runs, shopping, socialising and exercising, a nightmare,” explains Bernie.

She believes that many women don’t want to admit they have incontinence and therefore don’t buy the sanitary wear especially designed for it.

“Many women will also avoid wearing light-coloured trousers at all times for fear of leakage. The embarrassing smell of urine is often the biggest reason why women seek help.”

It is important not to suffer in silence.

“With more women doing activities nowadays such as Zumba, running, circuits, kettlebells and so on, there is a greater tendency for women to seek help about issues of incontinence. Getting help early is essential, before symptoms progress,” says Bernie.

Types of incontinence

There are several types of urinary incontinence: stress, urge, mixed and overflow incontinence.

Stress incontinence (abdominal pressure increases): “This is where a person leaks urine when there is an increase in abdominal pressure. Examples of this are when you cough, sneeze, lift, play sport, run or dance. Stress incontinence is the most common form of incontinence and is more prevalent among women rather than men. Pregnancy and childbirth can stretch and weaken the pelvic floor muscles that support the bladder neck. In particular, delivery elements such as baby’s head circumference, weight of the baby, instrumental delivery, such as forceps or vacuum, a tear or an episiotomy are also significant in terms of risk factors for pelvic floor weakness.

“Other causative factors include being overweight or obese, having a chronic cough or being postmenopausal,” says Leamy.

Urge incontinence(overactive/unstable bladder): “Urge incontinence is often referred to as an overactive or unstable bladder. In this case, patients experience a sudden and intense urge to urinate followed by an involuntary leakage of urine. They may also experience nocturia, which means getting up to urinate more than two times per night. Causes of urge incontinence include bladder abnormalities, nerve damage, poor bladder habits or neurologic conditions such as MS, stroke or Parkinson’s.”

Mixed urinary incontinence: “Some women have both stress and urge incontinence. This is referred to as mixed incontinence.”

Overflow incontinence: “This is when the bladder is unable to empty out completely and patients may experience dribbling of urine and a feeling that they have not completely emptied their bladder. Patients may also feel as if they have to strain to pass urine.”

Physiotherapy – first line of treatment

It is always advisable to discuss your symptoms with your GP and, if agreed, to explore the conservative route initially.

“Physiotherapy is regarded as the first line of treatment for urinary incontinence, unless there is an issue such as a significant prolapse or bladder abnormality that needs to be dealt with surgically. Physiotherapy is extremely effective for symptoms of stress incontinence. In the case of urge incontinence, if physiotherapy alone doesn’t yield a full recovery, medication can be added to the treatment. Surgery should be the last option,” explains Leamy.

Stress incontinence – what to do

Losing weight and avoiding smoking or anything that may contribute to a chronic cough is advisable. You should start doing pelvic floor exercises accurately and on a regular basis (see below).

Pelvic floor exercises

“It’s estimated that 80% of women perform pelvic floor exercises incorrectly,” says Bernie.

“If they’re not done right, then no improvement of symptoms will occur. Pelvic floor exercises are done by tightening the pelvic floor or vaginal muscles, ie tightening the back and front passage.

“In times gone by, women were often advised to stop the flow of urine midstream. This is no longer advised as it can lead to bladder infection and interrupt the reflex activity of the bladder.”

Patients can keep this image of stopping midstream in mind when trying to practice pelvic floor exercises.

“It is also important to make sure that other muscles, such as inner thigh muscles, gluteal muscles, are not contracting and that the patient is not holding their breath,” adds Bernie.

A woman with this condition should also start doing the knack exercise.

“This is when you tighten the pelvic floor as you cough or sneeze, which prevents leakage.”

Exercise one: Slow-hold contraction. This is where the pelvic floor muscles are contracted and held for a count of five to 10 seconds, depending on the patient’s ability.

Exercise two: The fast flicker. This is where the patient contracts the pelvic floor for one second and relaxes for one second. Repeat this up to 10 to 20 times, depending on ability.

Where to do the exercises: Crook lying is best, ie lying on your back with knees bent up and feet on the floor or bed. You then don’t have to work against gravity. Progressing on from this, you can do pelvic floor exercises while sitting and standing.

“Three sets of exercises should be done daily incorporating the slow-holds and fast flickers,” says Bernie.

Urge incontinence

If a woman has urge incontinence, she needs to speak to her GP and describe her symptoms. Her GP may refer her to a physiotherapist who specialises in incontinence issues. A full history and assessment will be carried out by the physiotherapist and a treatment plan put in place. Her treatment will probably involve bladder retraining, pelvic floor rehabilitation and possibly electrical stimulation. In the meantime, simple steps such as avoiding bladder irritants like caffeine can be helpful. Medication can also be beneficial in certain cases. If further investigations are required, urodynamic testing can be arranged. Urodynamic testing involves evaluating the bladder’s function and efficiency.

See read more here

See www.hse.ie for what’s available for incontinence treatment in the public health service

You can find a list of private practice physiotherapists across the country on www.iacp.ie

Note: ICL readers will be testing incontinence pads in a future issue.

Top tips

• Don’t suffer in silence.

• Lose excess weight.

• Reduce/eliminate intake of caffeine and alcohol (bladder irritants).

• Avoid going to the toilet “just in case”.

• Get into the habit of doing pelvic floor exercises.

• Constipation can cause straining, which can lead to a weakened pelvic floor.

• Following pregnancy and childbirth, it is worth seeking advice from a physiotherapist to help recover the pelvic floor and prevent incontinence.

We asked Bernie Leamy to comment on two readers’ stories.

Case study one

Sheila is a 58-year-old mother of three, who had surgery after experiencing leakage for many years.

The surgery has not been 100% successful and she still “dribbles a bit” after urinating.

This woman could ask to be seen by a women’s health physiotherapist, where a proper assessment of her pelvic floor*, together with other factors, could be assessed and a treatment program put in place.

She may have a slight inability to completely relax the urethral sphincter (valve at the urethra) as she passes urine, which may lead to some residual urine remaining in the bladder, which she then leaks afterwards.

Remember, it’s important to sit comfortably on the toilet seat. Don’t “hover” as this will prevent the pelvic floor from relaxing completely, leading to incomplete emptying of the bladder. She should also avoid bladder irritants like caffeine and alcohol.

Case study two

Anne is 56, has four children and has both stress and urge incontinence. She finds that if she drinks water “it passes through her”.

“As soon as I open the door of a loo it’s a battle as to who wins. Me or the wee,” Anne says.

This lady has mixed incontinence. It is really important that she doesn’t just put up with these symptoms or see them as a natural part of ageing.

Having had four children, it is highly likely that she has a weakened pelvic floor and she may have developed poor bladder habits over the years.

Initially, her symptoms may have been stress incontinence alone resulting from a weakened pelvic floor. Very often women with stress incontinence end up going to the toilet “just in case” without actually needing to go. The bladder then gets used to emptying small volumes of urine frequently.

The reflex activity of the bladder can be affected and urge incontinence may develop.

This lady should do very well following an assessment of her condition by a specialist physiotherapist and subsequent appropriate treatment.

Treatment may include bladder retraining**, pelvic floor exercises and electrical stimulation***, if required. In some cases, anti-cholinergic medication may be required to stop the bladder’s tendency to empty involuntarily.

*The pelvic floor forms a hammock-like support at the base of the pelvis and supports all the organs of the pelvis – the bladder, bowel and uterus. It also forms a seal around the urethra, the tube that comes out of the bladder.

**Bladder retraining involves learning, over time, to go to the toilet at scheduled times rather than every time you feel like going.

***Electrical stimulation involves painless electric currents being used in a tampon probe to strengthen the pelvic floor muscles.